When You Shouldn’t Go with the Flow

Erratic or heavy periods raise questions

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“When your period is interrupting normal, daily life – like missing school or not participating in sports or activities – that requires some evaluation, and potentially, intervention,” says Dr. Kristina Haley, a pediatric hematology/oncology specialist and co-director of the OHSU Spots, Dots and Clots clinic in Portland.

Even though half the human race experiences them, there can still be a lot of confusion about periods, or menstruation, and what is and is not “normal.” Depending on your frame of reference, you may be assuming your experience is typical when it isn’t.

“When your period is interrupting normal, daily life – like missing school or not participating in sports or activities – that requires some evaluation, and potentially, intervention,” says Dr. Kristina Haley, a pediatric hematology/oncology specialist and co-director of the OHSU Spots, Dots and Clots clinic in Portland.

What is normal?

Girls typically have menarche, the first occurrence of menstruation, around age 12. For the first two years, there often isn’t a pattern to the cycle or the flow.

“It’s very normal to have irregular cycles the first couple of years,” says Dr. Maureen Baldwin, an OB-GYN specialist and co-director of the OHSU Spots, Dots and Clots clinic in Portland. “Missing up to a few menstrual cycles a year is within normal for any age group, but especially with teens. It doesn’t need evaluation—unless they are having sex and could be pregnant.”

After those early years, periods usually become more predictable, Haley said, though it can take up to six years to settle into a consistent pattern. Blood flow typically lasts four to five days and repeats about once a month. Each woman’s cycle, or the number of days from when one period starts until the next one starts, can vary. The average is 28 days.

Tracking the calendar is easy, but it can be harder to determine if the amount of blood is normal. Baldwin says there is research about the average milliliters of blood, but who is going to weigh their pads to check that each month? Instead, she simply asks if patients feel their flow is heavy, because a study proved a woman’s perception of this is often correct.

What is abnormal?

Baldwin rates heavy and prolonged periods as the most important signs for medical evaluation.

“Periods that last more than seven days are a red flag, regardless of age,” she says.

Haley added that soaking through pads very quickly or needing to double-up on protection is unusually heavy for any age group as well. Heavy and/or prolonged periods can lead to an iron deficiency or anemia, which can cause fatigue and challenge a girl’s ability to participate in sports or perform in school.

With irregular periods, Baldwin says counting the cycle correctly is important and often misunderstood by women. A few days either way of the expected cycle date isn’t relevant, but having randomly occurring periods (for example, 14 days after the last one and then 40 days before the next one), warrants evaluation.

“With young girls, irregularity is common, but if it’s been more than a couple of years of irregularity, they should get an evaluation by a health care provider,” Baldwin says.

Another concern for young girls is failing to start a period. Baldwin says if a girl has reached 16 years old without a period, this is another reason to check in with a provider.

“The first evaluation is a discussion and possibly a blood test,” Baldwin says. “We then start with attempting treatment, which is nearly always successful. If that doesn’t work, we might do a pelvic ultrasound next to rule out structural problems or ovarian cysts.”

Symptom of a bleeding disorder?

In general, about 20 percent of females with heavy menstrual bleeding have an underlying bleeding disorder. Close to 40 percent of the adolescent patients who come to the OHSU Spots, Dots and Clots Clinic for help with heavy periods test positive for a bleeding disorder.

There are several kinds of bleeding disorders, which relate to how the blood clots. In her pediatric practice, Haley typically sees patients with congenital or inherited blood disorders. In girls, heavy periods can be a sign that the blood isn’t clotting properly.

“it’s not uncommon for us to see an adolescent with a blood disorder, and then we find the mom also has heavy periods, so we refer her to an adult hematologist,” Haley says. “They’ll say, ‘I always had periods that lasted 10 days, but so does everyone else in my family, so I thought it was normal.’”

Bleeding disorders, if mild, may not be obvious unless there is a bleeding challenge, like an injury, Haley says. However, with girls, every month presents a bleeding challenge, so heavy flow can be a sign for further investigation. A blood test can help determine if a disorder is present.

“It’s important to know that abnormal periods don’t necessarily mean there is a bleeding disorder,” Haley says. “In 2006, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics recommended that health care providers start using the menstrual cycle as a sort of vital sign. Screening for a bleeding disorder should be part of the evaluation for heavy menstrual bleeding.”

Finding a manageable solution

Baldwin offers several solutions to patients who struggle with heavy menses or irregularity.

“I start by asking the patient what is the most important thing for her –- predictability or lots less?” Baldwin says. “With the heavy bleeders, they usually pick a lot less. Most teens want to know when they will bleed.”

One option for treatment is tranexamic acid, a nonhormonal method of management. Baldwin says the patient takes six pills a day for five days while having her period. The pills help to decrease period bleeding by 30-40 percent. Not all insurance providers cover this method, Baldwin cautioned.

Another option is a combination of estrogen and progestin hormones that provide regularity, predictability and decrease period bleeding by 50-60 percent for most women, Baldwin described. A third choice, she added, is progestin-only medications, which can decrease period bleeding by as much as 80-90 percent and have fewer contraindications for women with other medical problems.

For young girls, Baldwin says doctors avoid using estrogen medicines for the first year after menarche to allow for complete bone fusion. However, there is no minimum age after periods start for placing an intrauterine device, she noted.

The results of a survey commissioned in Britain recently revealed that 44 percent of girls worldwide do not know what is happening to them the first time they have their periods. Fifty percent of the girls surveyed were too shy to tell anyone else about starting their period.

“Women don’t always talk about their periods and they don’t know how their experience compares to others, so it’s important for providers to ask questions,” Haley notes.

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Assemble a period pack for school

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Stock a small travel bag with:

  • pads and/or tampons
  • pantyliners
  • baby wipes
  • spare pair of underwear


Keep a pair of black leggings and an extra sweatshirt that can be tied around her waist in the locker. Depending on your child’s school rules, include over-the-counter pain medicine like ibuprofen. If students aren’t allowed to self-administer medicine,fill out the paperwork for it to be available for your child at the school health room.

Attending to school for female teens

The teen years are full of awkward experiences for everyone, but females get the added embarrassment factor of the unexpected or heavy period causing blood stains through clothes. The humiliation factor can be high and horrifying to a young girl, even if no one notices or teases. At the OHSU Spots, Dots and Clots Clinic, the physicians noted many of their patients were missing school, leaving early or taking online classes because of their menstrual flow.

“One reason seems to be that girls often don’t have adequate access and time for bathroom breaks to change pads at school,” Haley said. “We write notes to schools and help girls think about how to be prepared so they don’t have to go home. Many of these girls don’t have a medical problem; they have a period. If a girl is missing school due to pain or bleeding that is prolonged or perceived as heavy, let’s evaluate her.”




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