Periods Gone Rogue: Navigating Perimenopause Menstrual Irregularities
From Predictable to Perimenopause: Understanding Your Changing Menstrual Cycle
Ladies, let’s talk about your period—because, let’s be honest, she’s been with you for a while now. For years, she’s (mostly) followed the rules, showing up on time, staying for a few days, and then graciously exiting until next month. But lately? She’s acting a bit out of sorts. Early, late, heavy, light, skipping months, showing up twice—it’s like she’s lost the script.
Welcome to perimenopause, the hormonal rollercoaster leading up to menopause.
You're not alone if your menstrual cycle feels like it’s lost its GPS. Let’s break this often frustrating time down and explore more about the inner workings of the perimenopausal period.
First, Let’s Talk About the “Normal” Menstrual Cycle
The menstrual cycle is a meticulously choreographed dance between your brain, ovaries, and uterus, that can be broken down into four distinct phases.
Phase 1: The Menstrual Phase (AKA the “Out with the old” Phase)
This is where the cycle begins—Day 1 of your period.
Your uterine lining, which was all prepped and ready to host a potential pregnancy, gets the eviction notice when no fertilized egg shows up to rent the space. Cue the shedding of that lining, which you know as your period.
What’s happening hormonally?
Estrogen and progesterone levels are at rock bottom, which is why you might feel tired, cranky, or ready to eat an entire pint of ice cream while binge-watching your favorite show.
Phase 2: The Follicular Phase (Days 1-14, AKA “Let’s Get Ready to Ovulate”)
The follicular phase overlaps with your period at first and continues for about two weeks.
During this time, your pituitary gland in the brain signals your ovaries by sending out follicle-stimulating hormone (FSH) to recruit a few follicles (tiny sacs that each hold an egg).
One follicle emerges as the star of the show, growing bigger and bigger as estrogen levels rise. This surge in estrogen thickens your uterine lining, rolling out the red carpet for a potential pregnancy.
If you’re feeling energetic, clear-headed, or just plain amazing during this phase, you can thank your rising estrogen for the glow-up.
Phase 3: Ovulation (Around Day 14 in a 28-day cycle)
Around Day 14 of a typical 28-day cycle, ovulation happens. Your ovary releases an egg from the dominant follicle, as the pituitary gland releases a surge in luteinizing hormone (LH) triggering ovulation, and it begins its journey down the fallopian tube. This is your fertile window.
How do you know you’re ovulating? Some women notice subtle signs like a twinge of pain on one side (called mittelschmerz), increased cervical mucus (a clear, stretchy consistency like egg whites), or even an extra dose of confidence (thanks again, estrogen).
Luteal Phase (Days 15-28, AKA “The Waiting Game”)
After ovulation, the now-empty follicle transforms into a structure called the corpus luteum, which starts pumping out progesterone. This hormone helps stabilize the uterine lining, creating a cozy environment in case a fertilized egg comes along.
If pregnancy doesn’t happen, the corpus luteum packs up and disintegrates, leading to a drop in progesterone. This hormonal dip is what triggers your next period.
For some women, this phase comes with PMS—bloating, irritability, cravings, or just feeling like you want to cry over a cute puppy video. Totally normal (and relatable).
Rinse and repeat.
This predictable cycle happens until your ovaries start their retirement plan.
And other thoughts on perimenopause :)
Insert PERIMENOPAUSE…
The Menstrual Cycle Goes Off Script
Perimenopause usually starts in your late 30s or 40s and can last anywhere from a few years to over a decade (yes, really). During this time, your ovaries start senescing—which is a fancy word for getting old and tired.
The number and quality of your eggs decline, ovulation becomes hit or miss, and your hormones go on an unpredictable joyride.
“Fun fact: You are born with all the eggs you will ever have, starting with about 6 million during fetal development and reducing to 1-2 million at birth. By puberty, only around 300,000 - 400,000 eggs remain. This number continues to decline with age and menstrual cycles, impacting both the quantity and quality of eggs over our lifetime.”
So What’s Actually Happening to my Cycle in Perimenopause?
Luteal Out-of-Phase Cycles:
Normally, progesterone rises after ovulation. But in perimenopause, ovulation doesn’t always happen when it should (or at all). Without ovulation, progesterone doesn’t get the memo to rise, so estrogen takes over, leading to unpredictable bleeding, spotting, or skipped cycles.
Estrogen Rollercoaster:
Some months, estrogen soars, leading to heavy, long periods. Other months, it plummets, causing lighter, shorter, or missed periods.
Shorter or Longer Cycles:
Your cycle might shrink from 28 days to 21 or extend to 40+ days.
Some months, you may even have two periods! Think back to the phases of our menstrual cycle. Essentially, one menstrual cycle gets superimposed over the next, the timing of the cycle gets all out of sync, and the result is multiple periods in a short duration of time.
Skipped Periods:
You might go months without a period, only for it to return with a vengeance.
Heavier Periods:
When ovulation is irregular, your uterine lining can build up more than usual—so when your period does show up, it can feel like it’s back with a vengeance.
Make it stop!
If your periods have become erratic, uncomfortable, or disruptive, you don’t have to suffer in silence. There are ways to manage the madness:
Lifestyle Strategies
Balance Blood Sugar: Avoiding big insulin spikes can help with hormone stability. Focus on whole foods, protein, and healthy fats.
Supplements like Myo & D-chiro inositol have been shown to help with ovarian health and stabilize blood sugar spikes. Ask me if I think this might be right for you!
Regular Exercise: Strength training, walking, and yoga can help regulate hormones and ease symptoms.
Manage Stress: Cortisol (your stress hormone) can make perimenopause symptoms worse. Deep breathing, mindfulness, and good sleep hygiene can help.
Medical Options
Birth Control Pills: Low-dose oral combined contraceptive pills can help regulate cycles, control heavy bleeding, and ease hormonal swings.
Progesterone Therapy: If you’re skipping ovulation, adding micronized progesterone or a synthetic progestin-only pill can help stabilize the uterine lining.
Menopausal Hormone Therapy (MHT): If your symptoms are significant (hot flashes, night sweats, mood swings), MHT may help. However, MHT offers underwhelming relief when it comes to perimenopausal menstrual cycle chaos.
IUDs: Progestin-releasing IUDs like Mirena can lighten or stop periods altogether while preventing pregnancy.
Minor Surgical Procedures: Endometrial ablation is a minimally invasive surgical procedure that uses radiofrequency to effectively destroy the lining of the uterus (endometrium) to reduce or stop heavy menstrual bleeding. Some gynecologists offer these in their offices making them a great choice for many women in dire straights over their cycles, especially those that do not wish to use hormone-containing solutions.
Hysterectomy: Usually reserved for bleeding that just will not relent or for those with other pathologic concerns (i.e. fibroids, endometrial hyperplasia), this surgery, done robotically, laparoscopically, vaginally, and rarely abdominally, removes the uterus and often the cervix. Tandem removal of the ovaries would be called a hysterectomy plus oophorectomy.
Supplements & Alternative Therapies
Magnesium & Vitamin B6: Can help support mood and hormonal balance.
Adaptogens (Ashwagandha, Rhodiola): May help regulate stress hormones.
Acupuncture: Some women find it helpful for cycle regulation and symptom relief.
When to See a Healthcare Professional
Perimenopause is normal, but some period changes aren’t. Call your HCP if you experience:
Extremely heavy bleeding (soaking through a pad or tampon every hour).
Bleeding after sex or between periods.
Periods that last longer than 10 days.
Sudden onset of very irregular cycles before age 40 (could be premature ovarian insufficiency).
Final Thoughts: You’re Not Alone
Perimenopause is a transition—a recalibration, not a malfunction. Yes, it can be frustrating, exhausting, and at times, downright weird—but it’s also a sign of the next chapter in your life. And the good news? You don’t have to navigate it alone. Whether through lifestyle changes, hormone therapy, or just knowing what the heck is going on, there are ways to smooth out the ride.
So if your period is pulling a disappearing act—or making an over-the-top comeback—just know: it’s not you, it’s your peri. And we’ve got options to help.
— Jackie Piasta, WHNP-BC, MSCP
