"What daily hormone supplement do
you recommend to improve an irregular menstrual cycle?
"
SS
Irregular menses, as measured from the start of one
menses to the start of another, seem to occur in two
patterns:
Onset of menses varies irregularly from about 3 weeks
to 6 weeks but not skipping a month altogether. It
is called metrorrhagia if many of the menses are less
than 4 weeks.
Onset of menses varies from 4 weeks to 3-6 months
having perhaps only 2-6 menses a year. This is called
oligomenorrhea, infrequent menses.
Oligomenorrhea, the infrequent, irregular menses pattern
is caused by lack of ovulation. However, it may further
be subdivided into a low estrogen type in which there
are no follicles being developed and a high estrogen
type in which the follicles are developed but they
are arrested so none of the eggs are released (ovulated)
from the ovary.
To answer the question above, we really need to identify
what type of irregular menses is involved as well
as the goals of treatment. For example, is the goal
just to have a more predictable menstrual flow or
is it to try to time intercourse in order to improve
the chances of conception? Is the goal to be more
regular so that a rhythm method of contraception works
or to plan work or leisure events so as to avoid interruption
by a mense?
What are some of the causes of irregular, more frequent
menses (metrorrhagia)?
Causes of the metrorrhagia irregular menses pattern
are unknown or are more likely related to stresses
and ingested medications or substances that disrupt
corpus luteum function or even act as anticoagulant
blood thinners. Caffeine may act this way and disrupt
corpus luteum function. Heavy caffeine consumers tend
to have twice the risk of short cycle length (less
than 24 days) (1). Their cycles are not heavier but
they are often more frequent.
Cigarette smoking is another agent that can shorten
menstrual cycles (2). Cigarettes seem to shorten the
follicular phase but heavier smoking also may shorten
the luteal phase. Both heavy smoking and even smoking
just 10 cigarettes or more a day may cause menstrual
cycles to be shorter in length, as well as more variable
in their lengths than nonsmokers.
Acute or excessive alcohol ingestion, getting drunk
on occasion, is also known to alter menstrual patterns
(3). Sometimes it shortens cycles while at other times
it can cause a delay of menses. The alcohol is thought
to affect the liver's ability to properly metabolize
estrogen and progesterone.
What makes a woman not ovulate at all and have low
estrogens?
There are many things that can block ovulation in
women. Stress is the most common cause. Eating disorders
such as bulimia and anorexia also cause low estrogen
and menstrual delay (4). If there are no menses at
all, this is called hypothalamic amenorrhea. The mechanism
for this is not totally known but probably has to
do with alteration of brain proteins and hormones
so that the normal ovulatory releasing factors do
not work. When the brain releasing factors do not
stimulate follicle development, there are few estrogens
produced and a woman is then at risk for osteoporosis
at a young age. This is why physicians prescribe estrogens
in this condition, i.e., to prevent bone loss.
Recreational running does not seem to change menstrual
cycle length (5), but strenuous endurance running
can disturb cycle length (6) and make a woman anovulatory.
Long distance runners and other strenuous sports have
been well known to cause anovulation of the low estrogen
type. There has even been a suggestion that being
a vegetarian may increase the risk of anovulation
(7, 8).
What causes irregular, infrequent menses and high
estrogens?
While the most common cause of irregular delayed menses
is due to stress type hypothalamic amenorrhea, the
next most frequent type is due to polycystic ovarian
syndrome. This is a complex condition of the ovaries
in which follicles seem to grow and produce estrogen
but the egg does not get released. This results in
a high estrogen condition but infrequent menses. When
the period does start, it often can be a very heavy
one that persists for days or even weeks. The continuous,
high estrogens cause the uterine lining to grow and
proliferate and eventually it gets too thick and then
sloughs off causing a menstrual like bleed. Because
of the chronic and continuous estrogen stimulation,
most doctors feel that a menstrual period should be
induced with hormones (progesterone/progestin) so
that a woman is not at risk for endometrial cancer.
Women who have polycystic ovarian syndrome (PCOS)
will frequently have abnormal carbohydrate metabolism
called insulin resistance or even develop diabetes.
Additionally, excess hair growth due to extra testosterone
occurs in many women with PCOS.
What is the best non-prescription treatment to make
menses more regular?
For a metrorrhagia type of irregular menstrual pattern,
it is important to give up tobacco, alcohol and cut
caffeine servings down to 2 or less per day. Try to
minimize any medications that you do not have to take.
If menses are mildly irregular and you are trying
to time conception, taking a phytoestrogen supplement
on a daily basis may help stabilize the menstrual
cycle length.
For a low estrogen, irregular menstrual problem,
the key treatments are:
stress reduction and/or relaxation techniques
elimination of overly strenuous physical exercise
eliminate any eating disorders such as purging, bulimia,
or anorexia
take supplemental, measured estrogens such as phytoestrogens
in soy or clover products
For a high estrogen irregular menses pattern such
as that found in PCOS, weight reduction using a low
carbohydrate diet is essential. Even a 10% weight
loss will help restore normal menstrual patterns in
obese women who are anovulatory (9).
What are the best prescription treatments for menstrual
irregularities?
Oral contraceptives (OCPs) are the most commonly used
hormonal treatment for irregular menses. They do not
correct the underlying problem that causes the irregularity
but they will regulate the pattern very precisely
to the same day of the week each cycle. In general,
oral contraceptives are very safe and will not cause
an alteration in the body even after taking for a
very long time. Some women cannot take birth control
pills, however, so other treatments are also used.
Women with irregular menses due to hypothalamic factors
can take a sequential hormone regimen. In this regimen,
estrogen is given each day and then progesterone is
given for 10-14 days each month in order to induce
a withdrawal bleed. This regimen will not protect
against pregnancy should ovulation occur so if a pregnancy
is desired, this may be the best regimen.
For polycystic ovarian syndrome most physicians will
prescribe oral progestins or progesterone to take
for 10 days every two months if there has not been
a spontaneous menses. This is thought to protect against
the development of endometrial cancer or hyperplasia
from the long term elevation of estrogens.
Carbohydrate metabolism abnormalities are often successfully
treated with a combination of diet and medications,
and the menstrual irregularities may disappear. Metformin,
a drug which reduces high insulin levels has been
shown to make women with PCOS resume normal menses
in almost 90% of cases (10 ). This is a dramatic breakthrough
in treatment and one worth seeing your physician about
if you have PCOS.
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