Your Period: When Is It OK to Skip and When Is It Not?

Skipping periods frequently comes up during discussions with my patients. It seems like most women who have regular periods are reluctant to skip them for a medical indication, usually having the perception that there will be a negative health consequence, while the ones who have never had regular periods perceive it as normal. The truth is that they're both wrong.

The best way to understand skipping periods is to understand a little about a normal menstrual cycle. Basically, in order to have a regular cycle, you have to ovulate. The first half of the cycle (starting with the onset of your period), your body goes through a complex sequence of hormonal signaling to promote the maturation of an egg. During that time, your ovaries produces a lot of estrogen, which stimulates the growth of the endometrium (the lining of the uterus). Midway through, you ovulate, and your ovaries then switch gears and start producing not only estrogen but also progesterone. I think of progesterone as the brakes--it tells the endometrium to stop growing and to mature for a possible pregnancy instead. If you do not conceive that cycle, after 14 days, the ovaries' hormone production system poops out, and your hormone levels drop abruptly. This triggers your period to start because hormones are no longer available to support the endometrium.

Whether or not it's OK to skip periods is really a matter of whether or not your endometrium is getting progesterone exposure. Before menopause, regardless of ovulation, most women's ovaries will continue to make some estrogen. If that continues over time without any progesterone (i.e., no braking signal), the lining can get overgrown, and eventually the over-stimulated endometrial cells can start showing changes that can lead to cancer. This is more problematic in overweight women because it turns out that fat cells also produce some estrogen (a weaker type than is made in the ovary).

What I usually tell my patients is that if we have a good reason for them not having periods, then it's OK, and all of those good reasons involve progesterone exposure. This includes having long-term progesterone therapy, such as with the Depo Provera shot, Implanon, or Mirena IUD. It is also true for patients who are on birth control pills, as these contain a type of progesterone as well, in combination with estrogen. In the case of the pill, most packs are designed to give patients a monthly period by providing either 4 or 7 days of a placebo (sugar pill), which mimics the end of an ovulatory cycle--triggering a period by abrupt withdrawal of hormones. By skipping those placebo pills, a woman can safely skip her period. This is how extended-cycle pills like Seasonique and Lybrel work (Seasonique gives you a period at the end of 3 months; Lybrel skips your period every month). With all of these medications, because of the continuous progesterone exposure, the endometrium becomes very thin--the brakes are always on--so there is no "build-up" of tissue as many patients fear. In the case of some, such as the Mirena, you might stop your period entirely simply because there is no significant amount endometrium to shed.

However, skipping periods naturally is not OK. It indicates some problem with a woman's hormonal signaling, which is causing her not to ovulate and, therefore, not to produce progesterone. While this is not unusual in the late 40's as women approach menopause, it is clearly abnormal before that time. As I explained earlier, most women continue to produce estrogen, and this can have disastrous consequences for the uterus. In addition to the worst-case scenario, cancer, long-term "unopposed estrogen exposure" (meaning all estrogen, no progesterone) can also cause women to have very heavy periods or even periods more than once a month. Aside from problems with the uterus, when we evaluate women for skipping their periods, we sometimes find other hormonal problems, such as thyroid disorders, which can have implications for a woman's general health. For all of those reasons, if you do not have regular periods, you should see a doctor to help you figure out why. This is particularly true if it has been going on for a long time; if you just skip one cycle and then go back to your usual thing the next month, don't sweat it.

In a nutshell, progesterone is good, and you can use it to your advantage if you want to skip periods. But if you're not using it and skipping periods anyway, that's not good; see your doctor.

Choosing Your New OB/Gyn

Finding a good doctor can be challenging, and I think that finding an OB/Gyn can be even harder than other types of doctors. I like my internist, but I only see her about once a year and don't have to discuss super personal issues with her. Your relationship with your OB/Gyn is likely to be different, especially if you're pregnant. If you're lucky, your friends will have a great recommendation who takes your insurance. If not, here are some things to consider when looking for your new doc:

1. Does the doctor have the smarts? Your OB should have completed a full 4 year residency program. Beyond that, it's great if he or she is board certified. If not, you might inquire why; board certification in our specialty is a complicated process that takes several years to complete. A recent residency graduate will likely be "board eligible" after passing the written board exam, meaning s/he hasn't had the chance to complete the oral exam yet. Board eligibility lasts 6 years, so if a doctor has been in practice for several years and is not board certified, this might be a red flag (but not always--a few years ago one of my partners completed his annual recertification a few days late, and he was technically not certified for the next 12 months).

2. Do you like the office? You will likely have as much interaction with the office staff as you will with the doctor. You want to make sure that they are pleasant on the phone and willing to help you make an easy transition into the office (sending you new patient forms in advance, getting records transferred, etc.). You also need to find an office whose hours work with yours.

3. What hospital affiliation(s) does the doctor have? This is particularly important for OB patients. If you have a specific hospital in mind for delivery, obviously you want a doctor who works there. This also goes for anyone who might need surgery. It is particularly important if your insurance plan covers different percentages at different hospitals.

4. Who covers for the doctor after hours? Even solo practitioners do not work 24 hours a day, 365 days a year. You want to make sure that there is a clear plan for coverage if your doctor is unavailable and that you are comfortable with the arrangement.

5. What services are available at the office? Some practices add to convenience by providing some additional services in-house, such as ultrasonography, bone density scanning, or minor surgeries.

No matter how much homework you do, you won't really know if a doctor is right for you until you have at least one office visit. Perhaps the most important part of the doctor-patient relationship is that intangible "bedside manner" thing we all talk about but no one can quantify. A good OB/Gyn is someone you can discuss the most intimate aspects of your life, though you probably won't be ready for that at the first appointment. Often patients bring to us concerns that they are unable to discuss with their best friends or spouses. If your new OB/Gyn seems squeamish or judgmental, it's time for you to move on. If you find him to be professional and concerned about your needs, you've found your new doctor!

What's an OB/Gyn and Why Do I Need One?

I find that my patients often don't really understand the differences between me and their other doctors or what I actually do on a day-to-day basis. Maybe that's because we do many different things all at once. At the most basic level, an obstetrician-gynecologist is a physician who specializes in the female reproductive tract. We take care of women and girls of all ages, from childhood to old age. Obstetrics refers to pregnancy care; gynecology is all the other aspects of reproductive health. We see women for both preventive care, such as routine prenatal care or the annual well-woman exam, as well as for problems, such as complicated pregnancies or abnormal pap smears. Unlike many other types of doctors, we provide both nonsurgical, medical treatment of conditions as well as perform surgery when indicated. We serve both as women's primary care physicians and as consulting specialists for other types of doctors (more on that below).

Despite wearing so many different hats, the biggest thing that sets us apart from other types of doctors is that taking care of female problems is all we do. Unlike family practitioners or internal medicine physicians, who spend three years learning about many, many different body systems, OB/Gyns spend their four years of residency training learning only about the female reproductive system, which makes us uniquely able to handle those problems. Although many women choose to see their family doctor for routine exams, there are often times when a gynecologist is more suited to address their reproductive health concerns. Because women's health is all we do, we are often able to make a diagnosis or develop a treatment plan that works in a visit or two for a problem that has perplexed a family doctor for months. For that reason, it is often helpful to establish a relationship with an OB/Gyn before you actually need one. Similarly, I always recommend to my patients that they have a relationship with a primary care doctor as well. Just as I am better able to handle your female problems, your PCP is better able to handle just about any other concern. It's best to have both of us on your side.

The truth is that being a woman is complicated. We all need our own specialist.