Almost 20 years ago, in 2006, the American College of Obstetricians and Gynecologists identified the menstrual cycle as the fifth vital sign. Yet despite this important designation, many patients are still belittled or dismissed when they visit their doctor with menstrual or hormonal concerns.

A healthy cycle typically occurs every 21 to 35 days, measured from the first day of bleeding to the next cycle’s first day. Variation from cycle to cycle should not exceed seven to nine days for the same patient. Menstrual bleeding should last no longer than seven days and should not be especially heavy, defined as soaking through more than one pad or tampon per hour. Bleeding outside the normal period—such as spotting between periods or after intercourse—also warrants attention. In the years surrounding menarche (a girl’s first period) and perimenopause (the transition leading up to menopause), a broader range of normal may be expected. 

If cycles fall outside these parameters—whether due to irregular length, excessive variability, prolonged bleeding, heavy flow or unexpected bleeding—patients should seek evaluation from their healthcare team.

Why Menstrual Health Matters

Despite the paradigm shift that menses is not simply a lifestyle feature but a vital sign of internal bodily function, many patients are still not taken seriously when they raise concerns about women’s health. When a patient reports chest pain, the doctor responds with additional questions, a physical exam, and often laboratory testing or imaging. It would be unthinkable to treat someone for a heart attack, pneumonia or reflux, for example, without first determining the cause of the chest pain.

But when it comes to women’s health, patients are often offered blanket solutions—such as birth control, hysterectomy or uterine ablation—without first investigating the underlying cause of the period problem. Patients depend on healthcare professionals to help identify both causes and appropriate solutions when something goes wrong with their body. Women do not always want a one-size-fits-all approach. While birth control, hysterectomy or uterine ablation may sometimes be appropriate, a treatment offered without first determining the cause may not be sufficient for every patient.

Understanding the Causes

Menstrual changes can stem from a wide range of factors. Some are linked to normal life stages, including menarche, perimenopause, pregnancy and breastfeeding. Others are unrelated to the reproductive system, such as thyroid disorders, abnormal prolactin levels, certain medications or inherited bleeding disorders. 

Some causes of menstrual dysfunction are specific to the organs of the reproductive tract—the uterus, ovaries, cervix and fallopian tubes. These may be structural, such as fibroids, adenomyosis, endometriosis and uterine scars, which are typically benign; polyps, which can occasionally be precancerous; and other growths that may be cancerous or precancerous, though these are less common. Among the most common causes of menstrual changes are hormonal influences on the cycle, including polycystic ovary syndrome (PCOS) and increased stress on the reproductive system from overexercise or reduced caloric intake, which can lead to hypothalamic dysfunction.

Girls and women should be able to describe their typical menstrual pattern to their doctors and note any changes whenever concerns arise. Medical professionals should follow up with clarifying questions to help narrow down possible causes of abnormal menstruation. Pelvic ultrasound can assess the uterus and ovaries and detect structural abnormalities. Comprehensive lab testing can evaluate for excessive blood loss or anemia, bleeding disorders, pregnancy, menopause, thyroid or prolactin abnormalities, PCOS and hypothalamic dysfunction, providing valuable information for any patient with abnormal periods.

Taking Menstrual Health Seriously

Recognizing menstrual changes as important indicators of overall health reinforces the period’s status as the fifth vital sign. By tracking cycles, investigating underlying causes, and using imaging and lab testing when appropriate, healthcare professionals can ensure patients receive care tailored to their individual needs. Women’s concerns about menstrual health deserve the same diligence, attention and respect as any other vital sign, underscoring the importance of individualized evaluation and treatment.

Dr. Danielle J. Miller is a family medicine physician and the founder of Luz Medicine. In addition to caring for patients at all ages and stages of life, she and her team work closely with patients seeking answers related to infertility, miscarriage, abnormal menses and perimenopause. All care at Luz is rooted in deep listening; partnering with patients; providing comprehensive workups; and offering holistic, personalized support to help resolve medical issues. For more information, call/text 717-844-9003, email [email protected] or visit LuzMedicine.com.