What is it that I want you to know before we begin?

In order to understand if your period is irregular, it's really important to understand what causes the period and just your normal hormones. And it's so sad because we learn so many things in school, like geometry. We don't even learn about our bodies.

This is not hard to understand, and I'm going to break it down for you really quickly in a way that you can grasp. So I want you to think about the parts that make up your reproductive system when it comes to your hormones. In your period is your brain, your Ovaries, and your uterus.

So from the brain, you have the hypothalamus, which is the control center of the brain, and it sends signals out to the pituitary gland. The pituitary gland is really what releases all the controlling signals that goes to various other parts of the body, whether it's the adrenal glands, ovaries, or testes, the thyroid. It is the real kind of hormone dispersal system.

And then you have the Ovaries. Inside the ovaries, there are small eggs, and the ovary has the ability to make hormones. I will always say the ovary is a hormone generating factory.

And then you have your uterus. The uterus actually has different layers to it, and the innermost layer is the endometrium. And the endometrium is the part that regenerates every Month and then sheds what you know is your period.

And there are cells, there's a basal layer of that endometrium. And what that does is has the ability to regenerate new cells every single month. And this all works in conjunction in a normal cycle.

So what I want you to first understand is I want to take all this to the ovary. So if we think about the ovary, we like to think about inside the ovary. I use the analogy that you have a vault where all your eggs are kept.

So when you're born, that vault is full. Throughout your life, eggs come out of the vault, and when the vault is empty, you're in menopause. So born with all your eggs, you're going to run out of them.

What happens every single month from the time you're a baby inside your mother's womb, you are losing eggs. So an entire group of eggs is released from the vault. Each egg grows inside a follicle.

So we use egg and follicle interchangeably, so the brain will send out follicle stimulating hormone, or FSH, once you start puberty. But all of those times when you were a baby, up until you had puberty, you had a group of eggs. Each microscopic egg in a follicle come out of the vault and they just died.

So you were losing eggs that whole time. When puberty starts, the brain starts sending out FSH. Now, FSH is follicle stimulating hormone, and it works to stimulate a follicle to grow.

And this is actually starting the whole process. The process is actually not mature at the very beginning. So a follicle starts growing and making some estrogen, but you don't fully ovulate.

And those are those couple years of early puberty where you're growing breasts and secondary sex characteristics, but you don't have a period yet. Once you ovulate, you're going to start having a period. So FSH gets an egg to grow.

As that egg grows, it makes estrogen. Estrogen, in a normal cycle, grows the lining of the uterus. This is called the follicular phase, the time when a follicle is growing, when that egg is mature, and it's making enough estrogen to tell the brain, I am mature.

This is 200 peakograms of estrogen for 50 hours. The pituitary gland now sends out another hormone called LH, or luteinizing hormone. LH first is released in a big surge, which allows that follicle to open up to rupture and allow the egg out.

That's ovulation. And then what happens is that follicle reforms and luteinizing hormone comes from the pituitary gland, impulses the entire luteal phase, and this follicle now becomes a corpus luteum. It's a cyst making progesterone.

And this progesterone does what we call stabilizes the endometrium. So now it compacts down and it gets ready for an embryo to implant. So implantation happens after a set amount of progesterone exposure, usually like five to nine days.

So progesterone opens and closes that implantation window. Now, if you are not pregnant, that corpus luteum can only live for about twelve to 14 days. It dies, progesterone drops, that's the signal to the uterus to have a period.

Boom. So gets rid of all that old endometrium and it starts fresh. If a pregnancy comes in, the pregnancy makes HCG, which is what you detect on a pregnancy test, and that HCG rescues the corpus luteum, allowing it to continue to make progesterone.

And that's the way the body knows you're pregnant. But this is what's supposed to happen every single month, and so many things can go wrong.

And this is why I always say your period is a vital sign. It's actually telling us a lot about your body. The caveat to that, if you're on birth control pills, birth control with an IUD, you've gotten a shot, the implant, that's all masking your normal hormones.

And I'm not saying that's a bad thing, that's a personal choice. It's very effective, certain types of contraception, but then your period is not a vital sign. So that means if we want to understand how it works, we have to come off of that contraception and see how our period comes back.

So the period is only a vital sign when you're not using contraception. I will have patients say, oh, yeah, my periods are perfect and regular, but they've been on the pill for 20 years, so of course they're perfect and regular. That's what the pill does.

So you have to be off contraception to understand what your body is doing. Issues at all of these levels can cause irregularity or abnormal periods, so let's just break them down. A regular period is bleeding that is regular and predictable for you.

So if you have bleeding every single month between 27 to 30 days, that's perfect, that's regular within a couple of days of the start for you. Now, if your bleeding is irregular, it can be as mild as a change from your baseline, or it can be something that is dictated as abnormal, even if it's in the normal range. So if you Google a normal period, you are going to see people say anywhere from 25 to 35 days is normal.

That does not mean your period should come 25 days. One month, 35 days, the next 25, the next 37. That is actually irregular, and I will call that irregularly regular because it's not coming, but it is coming abnormally.

So when I think of ovulation issues, I think of them as on a spectrum, and we're going to go through this very fast. So we'll have perfectly regular periods, then we have slightly abnormal ovulation, which actually is a luteal phase defect. This is where, if you're tracking when you ovulate and when your luteal phases, it is less than that eleven day ratio.

So eleven days or less of a luteal phase. Sometimes also, luteal phase spotting can be a sign of this. You might notice a shortening of your period.

Interval used to be 28 to 30 days, now it's 24 to 26. 2nd is when it's starting to just not come at a perfect interval, so that 25 to 30 day next is when they're getting longer. So now you're having a period every 40, 45, 60 days, then you're skipping full months over and over again, once every few months, and then you have Frank Amenarrhea.

So think about this whole spectrum where amenarrhea is. You're not bleeding at all, and different things can cause these issues. So what can cause irregular periods? From the uterus, you can have abnormal bleeding.

That's not actually a period, but it can be confusing. So things like polyps or fibroids or even scar tissue where blood gets trapped behind that can cause abnormalities in your bleeding. So we have, number one, anatomic uterine factors.

Number two is going to be ovarian. Ovarian factors, which can contribute to abnormal periods can be PCOS, which is polycystic ovarian syndrome. This is essentially when you have a lot of eggs inside your ovary, so that normal signal of FSH gets diluted and then the ovary doesn't ovulate at a regular, predictable interval.

What starts to happen in PCOS is the ovary shifts and starts making a lot of testosterone or androgens, and you get a constellation of other symptoms, like acne, hair growth, weight gain. That kind of feeds itself with this insulin resistance.

We also have low ovarian reserve or going into ovarian failure. But when you start getting into those low egg counts, you start to have more irregularity in your periods. At the pituitary level, you can have a few different things that can go wrong.

So you can have abnormalities in prolactin secretion and abnormalities in thyroid, because the pituitary gland sends out FSH, LH, prolactin, thyroid stimulating hormone, abnormalities in one can actually impact the other. So that's why we see prolactin and thyroid abnormalities impacting the ovary. And then we also have what we call hypothalamic amenarrhea, which is actually where you don't have secretion of FSH or LH, but it's derived from the layer above the hypothalamus, the control center of the brain.

And the reason here is it does not feel like the body can have a period. Malnutrition, eating disorders, over exercising, chronic stress, chronic disease, variety of different reasons why. But when the hypothalamus kind of shuts that part off, it can take years and years to recover.

So somebody who had an eating disorder in the past, I might see period abnormalities or lack of a period for years and years after recovery. So it's important not to delay seeking care. So when you're coming in and you have irregular periods, what is normally going to be the evaluation? The typical evaluation is going to be one looking at your hormones.

So that's going to be typically AMH for ovarian reserve, FSH and estrogen. That's going to tell us, are you an ovarian failure or hypothalamic TSH for thyroid and prolactin? So those hormones are going to help us get a basic sense, are we running out of eggs? Is our brain turned off? Is our ovary not responding? So that's going to help us understand what's going on from there. You may or may not need an anatomic evaluation.

As we said, polyps, fibroids, or even overgrowth of that endometrial lining from not ovulating or endometrial cancer can contribute. So ruling out cancer with an endometrial biopsy is something that is sometimes done. There's also clinical history just looking at your ovulatory pattern or looking at something called chronic an ovulation.

So there's an in between zone where none of these are perfect. Sometimes I think it's a mild hypothalamic disease. So you're stressed for one reason or another, so your brain's not sending out a strong enough signal of FSH.

That is something that can sometimes be overcome with medications to help you ovulate. You also have obesity or extra fat cells can actually cause chronic an ovulation. And the reason why is fat cells make a type of estrogen, and that estrogen fools the brain.

So now the brain doesn't send out a strong enough signal of FSH because it thinks an egg is growing. So losing weight, decreasing that estrogen, allows the brain to send out a stronger signal of FSH. And there's other rare ones like adrenal disease, things like Cushing's or congenital adrenal hyperplasia, typically presenting when you're younger with some other abnormalities.

But the truth is, your period is a vital sign. So if you're not on contraception and your period is not coming at regular, predictable intervals, you should get an evaluation, even if you're not trying to get pregnant, because your hormones are really essential to how you feel and to your daily life. If you're trying to get pregnant, you will hear this.

And this is one of the most important takeaways. If you're under age 35, you should try for a year before you see a fertility doctor. Or if you're over age 35, you should try for six months before you see a fertility doctor.

That is under the presumption that you have regular, predictable periods and you're able to have intercourse. If your periods are not regular, do not pass go. Go get an evaluation right away.

Some of these things are easily fixable. Some of these things take a while. Some of these I would advance you to fertility treatment right away, so you deserve to have the information that you need.

The last question I get asked all the time is about coming off birth control. So, Dr. Crawford, being on birth control impacts things.

How long do I need to wait? I usually say you should come off any type of hormonal contraception three to six months before you're ready to conceive so that we can see what your period pattern is. By the three month mark, you should really be having periods again. And if you're not, it's not that the birth control caused anything wrong.

It's that. Remember, the birth control was masking it. It was allowing your body to have periods.

But now the reality is being seen and it's time to get a workup, know what's going on and get treatment for it. So no type of contraception can cause these issues, but you're just not aware of it until later. So we don't want to be later in the game.

So if you stop any type of contraception, three months have gone by, your periods are not regular yet. Go see a fertility doctor or your OBGYN and start the workup.