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ОглавлениеI used to dread the time when my period arrived, but now I’m desperate to have one … what can I do?
Irregular periods are something I hear about frequently in clinic and get a lot of messages about online. Sometimes absent for months on end, they can cause a lot of stress, often because women worry they’re going to struggle to get pregnant eventually. There’s been a lot of media interest in polycystic ovarian syndrome (PCOS) lately, and while it’s a common cause of a disrupted cycle, many people don’t realise the impact that our hectic lifestyles can also have on periods. Most women tell me that they always had a regular cycle right from the word go, but that more recently they’ve gone completely haywire.
This is something that happened to me, and I had absolutely no idea of why. I’d thought my body was normal, so why had it started misbehaving? What I didn’t appreciate (and was never taught in medical school) was that my body was warning me that my intense exercise regime, lack of sleep and through-the-roof stress levels were putting it under incredible strain and destroying any hope of a normal menstrual cycle. Let me explain how and why these things alter your period and, while I’m at it, I will also give you a good rundown of PCOS.
How irregular is irregular?
Many people believe that anything that is not a twenty-eight-day cycle is irregular, but if your period comes, for example, every twenty-six to thirty days, that’s regular for you. As doctors, when we use the term ‘irregular’, we are talking about a cycle that has no rhyme or reason. This means you generally cannot predict when your period is going to come, and the variation in cycle length is usually more than ten days (i.e. If your shortest cycle is twenty-five days and the longest is sixty, the variation is thirty-five days). ‘Amenorrhoea’ is the term used when you don’t have a period for at least three or six months (depending on your source). It is also very common and something that causes a great deal of anxiety.
‘Lazy ovaries’ are not ‘a thing’
I’ve heard of people being told they are not having periods because of ‘lazy ovaries’, which is a bit unfair, as those poor little ovaries are trying their hardest to ‘keep calm and carry on’. Your menstrual cycle is not just controlled by your ovaries; they rely on getting the appropriate signals from the brain – the hypothalamus and anterior pituitary gland being the two areas that make the hormones that communicate with the ovaries to stimulate oestrogen and progesterone production. Many things can interfere with this communication, changing your menstrual cycle as a result.
Causes of irregular or absent periods
I’m sure a number of the issues outlined below will resonate with a lot of you, and if they do, I suggest you hotfoot it to Part Five for a more thorough insight into these factors.
Note: it may sound obvious but the first thing you need to check for when you’re not having a period is … pregnancy.
Hypothalamic amenorrhoea (HA)
Also called functional amenorrhoea, this is one of the most common topics I am contacted about via email and social media, usually by women who say things like; ‘I haven’t had a period for over a year and I just can’t understand why. I exercise five times a week and I’m on a really healthy diet.’ Although I have no statistics to back this up, I would estimate that it is more common in young, fit women heavily invested in a healthy lifestyle. Unfortunately, the current fashion for an athletic physique, combined with the ‘more-is-more’ attitude of society and our hectic lifestyles leave little room for the simple things in life – like hormone production. That is why women get HA; and I can usually tell this straight away from the Instagram profiles of the many women who message me about this problem – their bodies have quite simply run out of steam.
While we may not be very good at consciously prioritising the essentials, our bodies do this automatically as a way of helping us to survive. As over-the-top as it sounds, your body would prefer to keep your heart beating, rather than give you a period, so your brain shuts off production of the hormones that stimulate your ovaries, which stops ovulation. And since the entire purpose of your menstrual cycle is for you to get pregnant, Mother Nature is particularly clever, recognising that a stressed-out woman does not need the added stress of having a baby. From an evolutionary point of view, this is a survival tactic for both mother and baby.
The main triggers for hypothalamic amenorrhoea that I see on a recurrent basis are stress, diet and overexercising – or, usually, a combination of all three.
Stress
You’ve probably heard of cortisol, the stress hormone. It influences production of female hormones by telling your brain that you’re under stress (even if you don’t realise it) and to halt ovulation until you’ve overcome it. Unfortunately, we are so used to living our lives in ‘turbo-power mode’ that we’ve forgotten what it’s really like to press the pause button, or even that it exists. I frequently meet real-life superwomen. They typically have several children, a zoo-worth of animals and a husband who isn’t very domesticated. And often an irregular cycle. Recently, I called one of these superwomen into my room and apologised that the clinic was running late. She said, ‘Oh, don’t worry; it’s been lovely to sit and read a magazine and have some time to myself …’ So before she’d even sat down I was pretty certain of what the problem was, although it can be a tricky one to solve because so many women have lost sight of how important it is to take that critical time for themselves.
Dietary factors
If you’re not eating enough to be able to provide the energy requirements of your own body, you’re not going to be able to sustain a healthy pregnancy. So here again, your brain shuts the system down, saving the energy and nutrients that would otherwise be used on ovulation. Fat tissue is one of the sites of oestrogen production, so women with very low body fat may not produce enough oestrogen, which is made from a specific type of fat called cholesterol. Fat tissue is also able to send signals to the brain to tell it whether there is enough of the stuff to maintain a pregnancy. Female hormones are made of fats, so if your diet is devoid of good, healthy fats, your body doesn’t have the right ingredients to make the goods.
I recently had a difficult conversation with a patient who had become a vegan right around the time that her periods stopped, but she was convinced that couldn’t be the reason why, because to her, veganism was the healthiest diet out there. However, any extreme change in diet can lead to nutrient deficiency (see Chapter 14).
Overexercising
Adrenaline is the ‘fight-or-flight’ hormone that is going to save you from that wild bear. Nowadays, there are very few bears or other life-threatening mammals running around, but your body doesn’t know the difference between thrashing it out on the treadmill or running from said bear. Your body senses this exertion as a stress and says to your ovaries, ‘Hold your horses! This woman is in danger – do not ovulate.’ It’s common for long-distance runners to lose their periods, but it’s not just running that can be a problem. Any intensive exercise can have the same effect. Many women that I see are training like athletes, then running off to their full-time jobs, families and social commitments and it can be too much for their bodies to cope with. They can also be putting themselves in a calorie deficit if they’re not eating enough, which takes us back to dietary factors. All of this – and how to address it – is discussed further in Chapter 15.
Post-Pill amenorrhoea
After stopping the contraceptive Pill you will have your usual bleed, assuming you stopped at the end of the pack. But when is your next period going to come? That’s the million-dollar question. Some people will go back to having a regular cycle pretty much straight away. Others sit and wait … and wait … and wait some more. And in my experience, this is much more common than the textbooks say. But if the Pill is out of your system after a day or so, why does this happen? There is no single answer. It’s likely to be a combination of three factors:
The Pill essentially takes over your natural hormones, so it can take some time for them to get back into sync to the point where they can resume ‘business as usual’.
The triggers for hypothalamic amenorrhoea (see here), which I find to be very common.
The possibility of an underlying problem such as PCOS, which has been masked by the Pill.
Premature menopause
Also referred to as premature ovarian failure/insufficiency (POF/POI), premature menopause is actually a misnomer. You run out of eggs when you go through the menopause, whereas with POF/POI your ovaries stop responding, despite still having eggs on the shelf. I can’t even count the number of times I’ve had women come and cry in my clinic room, convinced this is happening to them when their period has gone AWOL. It takes a very simple blood test to confirm or refute the diagnosis (oestrogen levels will be low and FSH will be through the roof) and, thankfully, it’s pretty uncommon, affecting about 1 in 100 women before the age of forty, and 5 in 100 before forty-five (the average age in the UK for menopause being about fifty-one years). It tends to run in families, so asking your mum when she went through the menopause is helpful.
Hormonal diseases
PCOS is the most common hormonal disorder that can affect your periods and is discussed at length below. Diseases associated with hormones that seem unrelated to your ovaries can also have a dramatic impact due to the interconnection of the hormonal system as a whole. Thyroid disease (high or low levels) is particularly common in women, and changes in thyroid hormones have both a direct and indirect effect on female hormone levels, which can change the timing of your periods and also how heavy they are (see here). A thyroid blood test can be done by your GP, and this can reveal thyroid problems in many women. Type 1 diabetes (where your body is unable to make insulin) and type 2 diabetes (where your body becomes less responsive to insulin) are both associated with irregular cycles due to the interaction of insulin and female hormone production.9, 10 Type 2 diabetes can also be associated with PCOS, as described below. There are, of course, other hormonal diseases which, although less common, will be checked with blood tests.
Polycystic ovarian syndrome (PCOS)
This is the most common hormonal disorder seen in women, with some studies suggesting that up to 1 in 5 of us is affected. It is diagnosed based on the presence of two out of the following three characteristics known as the Rotterdam Criteria:
Irregular or absent periods
Signs of excess male hormones including excess body/facial hair or acne or high levels on a blood test
Polycystic ovaries seen on an ultrasound scan
PCOS does not typically cause pain. Polycystic ovaries are often seen on scans to investigate lower abdominal pain, but are not the cause of this pain.
What causes PCOS?
PCOS is a syndrome (i.e. a collection of symptoms), so it’s not the same cause in everyone. It is a complex mash-up of your in-built genetics, epigenetics (which is how genes are turned on and off) combined with environmental aspects of how we live our lives now.
One of the key features of PCOS is insulin-resistance, which is found in about 70 per cent of sufferers. This is when your body is able to make plenty of insulin (one of the key hormones responsible for keeping your blood sugar under control), but your tissues are less sensitive to it, and therefore you have to ramp up production to maintain the same response. The problem is that insulin forces your ovaries to convert oestrogen to the male hormone testosterone, which stops ovulation (goodbye regular periods) and gives you all the fun hormonal side effects (hello acne, excess hair, mood swings …). Blood tests and ultrasound scans are carried out to confirm it and rule out other causes of the symptoms.
So what causes PCOS in those who are not insulin resistant? The adrenal glands. As well as making cortisol, and the fight-or-flight hormones adrenaline and noradrenaline, they also make testosterone and its precursors, resulting in the same effect on your ovaries.
Management of PCOS
A lot of women are understandably disappointed to hear that there is no cure for PCOS. But there are plenty of ways to treat the symptoms, both through lifestyle changes and prescribed medication:
Lifestyle intervention
Every guideline I’ve ever come across for PCOS cites ‘lifestyle intervention’ as the first-line treatment, although doctors have not always been famed for giving the best lifestyle advice. Thankfully, times are changing and there is a new wave of doctors coming on to the scene, led by the likes of my friends Dr Rupy Aujla, Dr Hazel Wallace and Dr Rangan Chatterjee (see Resources), all of whom dish out great lifestyle tips via their social-media platforms and chart-topping podcasts, so check them out.
Several years ago, a hugely overweight twenty-two-year-old came to clinic for advice about PCOS as she was planning on getting pregnant in the next few years. I spent about fifteen minutes talking to her all about lifestyle interventions that she could undertake. I gave her so many in-depth, practical tips and tricks that she could use to improve her PCOS and, in turn, her long-term health in general, which is so important for anyone planning a pregnancy, with or without PCOS. My heart sank though when she looked at me and said, ‘But can’t you just prescribe me a tablet to sort it all out?’ Granted, these interventions are not easy, requiring some hard work and diligence at times, but you will reap the benefits in the long term because they can reduce the risk of the complications of PCOS, including type 2 diabetes and heart and vascular diseases, which are some of the major causes of death and chronic-health issues in the Western world.
Here is a summary of the advice that I give to my patients (see Part Five, here for more details).
Weight loss Many patients are surprised when I tell them I’m not going to ask them to lose weight. Weight loss is one of the most effective ways to help the symptoms of PCOS (reducing fat reduces insulin resistance, which is the main driver of the condition), making your cycles more regular, increasing the chance of a healthy pregnancy, improving acne and reducing the risk of diabetes and heart disease in the future.11 However, being told to lose weight is psychologically tough and, I believe, makes the whole disease much more traumatic to deal with. I prefer instead to focus on improving diet and exercise which, if done correctly, will result in both improved symptoms and weight loss without this being a depressing focal point.
Diet There are a lot of people pushing extreme PCOS diets online, particularly focused around low-carb/ketogenic (high-fat, low-carb) diets, which I don’t subscribe to at all. The rationale behind them is sound, and data supports short-term effectiveness.12 But we don’t know for sure if these diets have a direct impact in the long term, and they’re hard to stick to, so I don’t recommend them unless a patient is insistent on trying. I also don’t want to promote faddy eating in young, impressionable women, who are already at a higher risk of eating disorders.13 Low-carb diets also run the risk of resulting in a low-fibre intake, which is associated with a higher risk of PCOS.14To get enough fibre, you need to eat carbs. Carbs are not the devil, but the devil is in the detail. You need to eat good-quality, high-fibre carbs such as oats, brown rice and fruits and veggies that are also packed with other precious nutrients that your body needs for all the complex chemical processes such as ovulation. Good-quality fats (see here) are also essential because female hormones are made from cholesterol that is a fat. If you don’t have the building blocks, you can’t make the goods. The Mediterranean diet really is the one that has it all (see here for more on that).
Exercise Probably one of the questions I am most frequently asked online is: ‘What’s the best exercise for PCOS?’ And my honest answer is: the one you’re going to stick with – because dealing with PCOS is about being consistent. And exercise doesn’t have to happen in a gym either; so for many people, something as simple as going for a walk at lunchtime or getting off the bus a few stops early may be exactly what they need and what fits with their schedule. If you want to get geeky about it, one of the main aims of exercise for PCOS is to slightly alter body composition to increase lean muscle and decrease fat tissue (see Chapter 15). Muscle is much more sensitive to insulin compared to fat, and also needs more energy, so improves your metabolism.
Relaxation Life is stressful. Stress increases cortisol, which increases insulin resistance and testosterone levels. If you can remove the driver, you can break the cycle. Realistically, we can’t take all the stress out of our lives – and nor should we, as a certain amount of stress is good for us – but we have to look for ways to manage it. Depression and anxiety levels are also known to be higher in women with PCOS,15 so self-care is very important. Exercise is a great way of addressing self-care and helping you to relax.
Sleep Lack of sleep makes you more insulin resistant, as well as causing cravings for sweet, fatty, high-calorie, low-nutrient foods and caffeine, all of which spike cortisol. And the vicious PCOS cycle continues to turn. I find that exercise helps me sleep better, so as you can see, all the things in this section go hand in hand.
Medication
This isn’t an exhaustive list, but these are the three types of medication that I get asked about the most:
The Pill The combined oral contraceptive Pill (COCP) will not ‘balance your hormones’. While it is entirely acceptable to use the Pill to ensure you have a regular monthly bleed, or as contraception, it will not treat the underlying cause of your irregular cycle. Once you decide to stop taking the Pill your periods will likely still be irregular, unless you’ve made some serious lifestyle changes. I see a lot of patients in clinic who are very disappointed to hear this as they’re under the impression that by using the Pill, their PCOS is cured; it isn’t. The Pill just forces the body to bleed on the week off.Many women are not keen on taking the Pill, but it is advised to have at least four periods per year to reduce the risk of the uterine lining becoming too thick and irregular which can, in the long run, increase the risk of endometrial cancer. The other advantage of the Pill is that it helps your body to make something called ‘sex hormone-binding globulin’, which mops up excess testosterone, so helping with acne and excess hair.
Metformin This is a diabetes medication that reduces insulin resistance. A lot of women tell me they hate it though because it can cause awful stomach cramps and diarrhoea. While metformin can be effective for improving ovulation, body weight and composition, it works best when used in conjunction with lifestyle modification.16
Inositol This is a dietary supplement that can be bought over the counter. Of all the many supplements that have been proposed for use in PCOS this one seems to get the most coverage online and, thankfully, has the biggest evidence base, relatively speaking. I’ve seen a really positive effect from inositol in quite a few women; however, although lab studies suggest it may reduce insulin resistance, and there has been a handful of small human studies to show it can improve menstrual-cycle regularity, reduce testosterone and even increase the chance of pregnancy,17 there haven’t yet been any big trials to prove exactly how effective it is, the best type to use or the optimum dose, so it’s not something that’s routinely recommended by many gynaecologists just yet.
THINGS YOU’VE ALWAYS WANTED TO KNOW, BUT WERE TOO AFRAID TO ASK
When should irregular periods be investigated?
There is no hard-and-fast rule. A sensible approach would be to see your GP if you are having periods less often than every three months, or if you’ve recently started having an irregular cycle. A lot of patients say they’ve always had an irregular cycle, but this should still be investigated as there may be a correctable cause.
I frequently receive messages from concerned mothers, such as: ‘My fifteen-year-old daughter has had irregular periods ever since they started three years ago and her GP won’t do anything about it.’ While it’s bound to be worrying, remember that it can be normal for teenagers to have irregular periods and may take about five years from when they start to settle down into a more regular cycle.18 So it’s not always wrong to leave things alone to see if they sort themselves out, but it very much depends on what else is going on and what other symptoms she may be having, so do discuss this with your GP if you are worried.
Are there any health risks associated with hypothalamic amenorrhoea?
First and foremost, the thing that most women are worried about is fertility. If you’re not ovulating, you can’t get pregnant. So if you want to have a baby in the near future, you need to speak to your doctor as soon as possible.
One of the biggest risks with HA, however – and many women are not aware of this – is the risk of brittle bones and heart disease that can arise due to a lack of oestrogen, which I would suggest is just as important as your fertility. I’m really passionate about ensuring this message filters through. We often tend to focus on short-term, tangible outcomes, forgetting the things we can’t see. ‘I’d rather look shredded now and deal with my bones when I get older,’ one patient told me. But that’s the problem. You can’t deal with your bones later. Peak bone strength in females occurs around the age of thirty, and if you’re not building it in those crucial teens and twenties you can’t catch up later. Build it now, for benefits down the line.
Does PCOS increase the risk of ovarian cancer?
This is the thing that everyone worries about. PCOS itself does not increase your risk of getting ovarian cancer,19 but obesity and diabetes, both of which are associated with PCOS, may do so. It’s important, therefore, to try and implement some of the lifestyle changes discussed here.
PCOS does increase the risk of endometrial cancer (cancer of the lining of the uterus),20 the greatest risk being to women who are less physically active, regardless of obesity or diabetes.21 So anything you can do to increase the amount of movement you do may reduce your risk, irrespective of whether you actually lose weight,22 which is another reason why I prefer to steer away from concentrating on weight loss as a specific goal.
I had a scan that shows I have polycystic ovaries – what are the implications of this?
‘Polycystic’ means having lots of cysts. With regards to your ovaries, this means you have loads of follicles that are trying to mature and break free. Up to 25 per cent of women have ovaries with a polycystic appearance,23 and it’s particularly common in younger girls who have started their periods in the last few years because their ovaries are literally bursting with eggs wanting to get out. However, it doesn’t automatically mean you have polycystic ovarian syndrome (PCOS), if you don’t have any of the other classic symptoms (see here).
THE GYNAE GEEK’S KNOWLEDGE BOMBS
Irregular or absent periods cause so much anxiety, so I hope this chapter will have put your mind at ease, giving you a few areas of your life to re-evaluate if this is a particular problem for you. The most important takeaways here are:
Lazy ovaries do not exist. If you stop having periods it’s because your ovaries aren’t receiving the right messages from the brain, or other hormones are influencing their activity.
Premature menopause is very rare and unlikely to be the cause of irregular or absent periods, but it is very easy to check for with a simple blood test.
Your body is very clever and is able to stop your periods if you are stressed, overexercising or not eating well, as a survival tactic to conserve energy for things that are more important than making hormones.
The contraceptive Pill will not cure PCOS. It will merely cause you to have a period every month, but when you stop the Pill, if you haven’t made any lifestyle changes, your body will resume the same cycle as before you started it.
Lifestyle changes including diet, exercise and stress management can have a massive positive impact on PCOS. They also reduce your risk of complications such as diabetes, heart disease and female cancers.
