Most people know menstruation is normal vaginal bleeding that is part of the monthly cycle which prepares the body for a possible pregnancy. But you may have some questions about the regular—or irregular—ebb and flow of your cycle.

Tamara N. Kolev, MD, Assistant Professor, Obstetrics, Gynecology and Reproductive Science, Icahn School of Medicine at Mount Sinai, explains how mundane activities can affect your cycle and why one or two irregular periods is nothing to worry about.

Is it normal to have irregular periods? When should I worry about them?

Your menstrual cycle tells us about your overall health and hormone balance. Most people find that the time from the first day of one period to the first day of the next is about the same every month. This time span, called a cycle, can be anywhere from 22 to 35 days. Women on birth control tend to have periods that are shorter, lighter, or—depending on the birth control—disappear altogether.

If you have an irregular period once or twice, that’s probably fine. But, if you notice that you’re continually having irregular periods, it’s better to get evaluated to diagnose the underlying reason and get your body back in balance.

Why am I bleeding in between periods?

There are several reasons why some women have minor bleeding (spotting) between periods. It could be as simple as too much stress, too little sleep or certain medications.    The cause could also be a physical condition, such as fibroids, cervical or uterine polyps, or a chromosomal abnormality, all of which are generally non-cancerous (benign).If you’re at all concerned, you should check in with your primary care doctor or gynecologist.

If I exercise regularly, will my period be lighter–or will I even skip a period?

Exercise can help regulate your periods. When you exercise, your body releases hormones such as endorphins and serotonin, which can also help with menstrual pain, cramps, and mood disturbance. But if you exercise too much—especially if you also don’t eat enough—you may skip a period because your body needs a certain amount of body fat to produce estrogen and maintain the hormonal balance required to have normal periods.

What about diet and weight gain, will either—or both—affect my period?

Gaining or losing a few pounds shouldn’t affect your menstrual cycle. But if your weight changes dramatically, especially if it happens quickly, it can affect your periods. Along the same lines, if you’re not getting enough calories and nutrients to maintain a healthy hormonal balance and produce enough estrogen, your periods may become irregular or may skip a month altogether.

In terms of your daily eating habits, there is growing evidence that what you eat can affect premenstrual syndrome symptoms, such as mood swings, bloating, and fatigue. It can help to eat foods that are rich in omega-3 fatty acids, vitamin D, and calcium or take vitamin D or calcium supplements. Doctors also recommend reducing your intake of fat, salt, and caffeine. Additionally, not having enough iron in your system can make your periods shorter and less regular.  And if you have heavy bleeding when you menstruate, that may lower your iron level.

Alcohol use and smoking can also affect your period. While a glass or two of wine shouldn’t cause fluctuations, heavy drinking can disrupt your hormones and lead to late or irregular periods. Heavy smoking can shorten your menstrual cycle and make periods heavier and more painful.

How will stress and lack of sleep affect my period?

When your body is under stress, it can go into fight-or-flight mode, which may signal the body to overproduce certain stress hormones. This could change your overall hormonal balance. Lack of sleep, in particular, affects both stress hormones and melatonin levels. Melatonin is a hormone that helps to regulate the start of your period and the length of your cycle.   For this reason, changes in melatonin levels can affect your cycle. You may find your periods delayed, or they might skip a month altogether.

When should I see a doctor?

Typically, if you often have bleeding between periods or especially heavy bleeding, you should get it checked out. For premenopausal women, if you don’t have a regular cycle, or if you miss your periods regularly or for several months, you should be evaluated, even if you think the reason is excessive diet or exercise or not getting enough sleep. In general, if you’re at all concerned, make an appointment with your gynecologist for a check-up.

Can I get pregnant during my period?

If it’s truly your period, then no, you cannot get pregnant while menstruating. However, if you’ve been having irregular bleeding between periods, you may be unsure if the bleeding is a real period or if you are bleeding during ovulation. If you are bleeding while ovulating, then you could get pregnant.

Will my period change as I get older?

Yes. After menarche (onset of menses) your period may be irregular and unpredictable. But as you get older, certainly by your 20s, it should become more regular. As you get older, and you approach menopause, your periods will likely start to spread apart and become lighter and less regular. If, instead, they get heavier or more frequent, then it’s important to have that evaluated.

Menstruation can be uncomfortable. But, for some, “that time of the month” is also a period of extreme pain accompanied with heavy bleeding and pelvic discomfort. Affecting 2 to 10 percent of premenopausal women, endometriosis is often difficult to diagnose and can hamper the day-to-day living of those with the condition.

In this Q & A, endometriosis specialist Susan S. Khalil, MD, Assistant Professor of Obstetrics, Gynecology and Reproductive Science at the Icahn School of Medicine at Mount Sinai, explains the condition, its symptoms, and why early  diagnosis and treatment is important.

What is endometriosis?

Endometriosis is a condition in which there is an ectopic implantation of the endometrium. In layman’s terms, the lining of the uterus is implanted in sites outside of the uterus. Implantation can be in the fallopian tubes, the ovaries, or inside the belly. It can also be in areas of the body very distant from the reproductive organs, such as the lungs or even the brain. The condition typically effects women who are still having their period.

What causes the condition, and can it be prevented?

The cause of endometriosis is largely unknown, but there are a few different theories. One is that, in some women, blood from menstruation flows backward into the belly instead of flowing downward, causing incorrect implantation. Another is “de novo” formation, meaning that it just happens on its own. Yet another theory is that local cell changes can lead to endometriosis.

There is no cure for endometriosis, but there are treatments. And early diagnosis leads to less invasive methods of managing the condition.

I think I have endometriosis. What are the symptoms?

The most common symptoms of endometriosis are pelvic pain and painful periods.

If you are wondering how much period pain is too much, remember that your period should not routinely interfere with your ability to go to work or school, or to go about the activities of daily living. If you are missing out on these activities due to your period, please see a gynecologist.

Patients with endometriosis may also experience unexplained painful urination, painful bowel movements, and painful intercourse. Occasionally, women will get evaluated for the condition if they are having difficulty getting pregnant. Based on your symptoms, endometriosis can be suspected, but the condition is confirmed through laparoscopy.

I was diagnosed with endometriosis. Can I still get pregnant?

Yes, you can get pregnant. However, you may require some assistance. For instance, some people with the condition may need to undergo minimally invasive surgery to remove endometrial tissue.

There is a wide spectrum of severity with endometriosis. While many women actively pursue treatment or diagnosis because they are having difficulty conceiving, there are also pregnant women whose diagnosis is only discovered during routine examination.

What are the treatment options for the condition? Will I need surgery?

Generally, the treatment for endometriosis includes medication and, for some, a surgical option.

Common medications prescribed for the condition depend on the patient’s primary goals, which may include pain control or suppression, or pain control while trying to conceive. The medications include hormonal agents with progesterone only, a combination of estrogen and progesterone, and gonadotropin-releasing hormone (GNRH) agonists or antagonists. The treatments are tailored to the patient when they are evaluated.

If patients need surgical intervention, laparoscopy is one option. It can be used to diagnose endometriosis and to remove growths and scar tissue from the reproductive area. The procedure is often regarded as a fertility-sparing operation that also helps to reduce the pain associated with endometriosis and improve quality of life.

How important is early treatment, and diagnosis, of endometriosis?

Early treatment and diagnosis is important to maintain fertility and manage pain symptoms. It also helps with identifying patients who have endometriosis, and patterns in their family history.

At Mount Sinai, we offer a team-based approach that includes various services, such as pelvic floor therapy, acupuncture, dietary management, and pain management. All of these services are intended to make endometriosis a more livable condition for patients as well as to provide them with a good framework for support.

Menopause, also called the “change of life,” can be difficult to navigate. Fortunately, doctors can help. For answers to some commonly asked questions, we spoke with Elissa M. Gretz–Friedman, MD, Director of the Menopause Center at Mount Sinai and an Assistant Professor of Obstetrics, Gynecology and Reproductive Science at the Icahn School of Medicine at Mount Sinai.

Can my doctor help with my hot flashes?

If you are having hot flashes which are disruptive to your life, talk to your doctor about your concerns as they can offer a number of options that may provide relief. Typically, your physician will start with the least invasive approach, which is often a discussion of lifestyle changes that may help, such as dressing in layers, keeping your home on the cooler side, and drinking ice water. Also, hot flashes are more common in women who are clinically obese, so your physician might recommend weight loss.

Some hot flashes are triggered. While it varies from woman to woman, these triggers can include alcohol, hot or spicy drinks, or even stress. Keep an eye on when your hot flashes occur and, if you find that an action or beverage sets them off, do your best to avoid it.

If lifestyle changes don’t help, doctors may suggest certain over-the-counter therapies including black cohosh and S-equol, which contain plant-based compounds that mimic estrogen, or Relizen®.

My menopausal symptoms are severe. Should I consider hormone therapy?

Menopause hormone therapy (MHT) involves taking medication that contains estrogen, the female hormone your body stops producing during menopause. It is the most effective treatment for hot flashes, vaginal discomfort, and other menopausal symptoms, and is typically prescribed to women who have severe symptoms. If you have not had a hysterectomy, it will be recommended that you take a combination of estrogen and progesterone. The progesterone is necessary to prevent developing cancer of the uterus.

Women who are less than 60 years old and less than 10 years from their final menstrual period are good candidates for hormone therapy. Before prescribing this therapy, a physician will take your medical and family history and perform a physical exam. You will also need an up to date mammogram.  It isn’t safe to take MHT if you’ve had hormone-related cancers such as breast or endometrial cancer or have a history of undiagnosed bleeding or blood clots in the legs or lungs, coronary artery disease or stroke, or liver disease. Certain women that are very high risk for breast cancer are also not good candidates for estrogen and progesterone.

In addition to helping with menopausal symptoms, hormone replacement can decrease your risk of colon cancer or type 2 diabetes. And, it increases your overall life expectancy.

Are there options besides hormone therapy for my severe symptoms?

If you are not a good candidate for hormone therapy, there are alternative medications that we use for treatment of bothersome hot flashes and other severe symptoms of menopause. These are selective serotonin reuptake inhibitors (SSRIs) or serotonin and norepinephrine reuptake inhibitors (SNRIs). While these medications are typically used to treat depression and anxiety, they have also been shown in lower doses to help reduce hot flashes. The most common SSRIs used to help with menopausal symptoms is paroxetine, which is approved by the U.S. Food and Drug Administration for this indication. Citalopram and escitalopram have also been prescribed for this use.  Helpful SSNIs include venlafaxine and desvenlafaxine. Gabapentin–a medication primarily used for nerve pain in those with shingles and seizures–has also been used for hot flashes, especially those that occur primarily at night, since it may make you tired.

What is a menopause specialist? Do I need to see one?

Menopause specialists are physicians with special training to address the issues of women in midlife. They are certified through examination by the North American Menopause Society and stay up to date on the newest research about midlife women’s health.

You do not necessarily need to see a certified menopause specialist as a matter of routine. But, if you are not getting the help you need to treat your symptoms, a specialist may be able to provide additional advice. We have a number of menopause specialists at Mount Sinai listed on our website and you can find a list of specialists throughout the country on the North American Menopause Society website.

Puberty isn’t the only hormonal change that your body will undertake. If you are a woman between mid-40s and mid-50s, menopause—also known as the ‘change of life’—is a significant, and natural, part of aging. While you are only ‘officially’ menopausal when you haven’t had a period in 12 months, menopause itself is a process that takes years and can affect your body in a variety of ways.

In this Q &A, Elissa M. Gretz-Friedman, MD, Director of the Menopause Center at Mount Sinai and an Assistant Professor of Obstetrics, Gynecology and Reproductive Science at the Icahn School of Medicine at Mount Sinai, explains the basics of menopause and its symptoms.

What exactly happens during menopause?

Basically, your ovaries exhaust their supply of eggs. Women are born with all the eggs they will have for their lifetime.  When this happens the ovaries will stop producing estrogen and progesterone. Estrogen affects almost every system in the body so this is a big change.  While most women experience menopause as part of healthy aging, some women may reach it early due to chemotherapy or if their ovaries are surgically removed for various reasons. Some younger women who go into early menopause due to chemotherapy may regain their menses after treatment ends.

It’s important to remember that, generally, menopause is a process, not an “on-off” switch. Before you reach menopause, you’ve probably been in what we call the menopause transition, or perimenopause, for five to ten years.

What should I expect in the years leading up to menopause?

Every woman experiences perimenopause differently. Most go through two phases. In early perimenopause, the level of estrogen in your body may  rise and fall unevenly, which could cause a variety of symptoms, the most common being irregular periods. Women may find that the length of time between periods varies from one month to the next. For instance, you could have a 21-day cycle followed by a 35-day cycle. When your estrogen level is higher, you may experience increased bleeding or breast tenderness.

During the last one to three years of this process, called late perimenopause, your period might become lighter. You might have spotting between periods and the time from one period to the next may grow longer.  They will be 60 days or even six or nine months apart.  Any one of these menses could be the last.  You are post menopausal  when you have not had a period for one year.

How will my body react to menopause?

Hot flashes are the best known and most common symptom of menopause with about three-quarters of menopausal women experiencing the symptom. These uncomfortable feelings of warmth can last for two to four minutes and are often followed by sweating. Hot flashes can happen at any time during the day or night, and you may have several  or many during a 24-hour period. Nighttime hot flashes might awaken you from sleep.

Other possible symptoms include anxiety, heart palpitations, or vaginal dryness, which can cause pain during sexual intercourse. Some women experience cognitive changes, such as difficulty learning new tasks, forgetfulness, and brain fog. You may also find it difficult to sleep.

The cognitive issues usually resolve after menopause. The vaginal symptoms will continue to worsen the longer you get from your last menstrual period.

Once you reach menopause, your doctor will begin to monitor you for osteoporosis, a disease that can leave your bones more brittle and fragile, making them more likely to break from a fall.  Menopause is a risk factor for osteoporosis as lowered sex hormones—like estrogen—affect the bone remodeling process. Menopause related-bone loss will accelerate significantly in the two years just before and the two years after your final menstrual period.  Bone loss will continue even after that point, but your bone density will not change as quickly.

Will menopause affect my libido? And, can I stop using birth control once I am menopausal?

Many factors can affect your libido, including stress level, sleep, partner issues—and menopause. The vaginal dryness that some women experience due to menopause can lead to painful intercourse which, in turn, can affect your libido. Fortunately, lubricants, vaginal moisturizers, and vaginal estrogen—which is safe to use in most women and can help restore the vaginal tissues—are helpful. Lubricants and vaginal moisturizers are available over the counter, but you will need to talk to your primary care physician or gynecologist for a vaginal estrogen prescription.

Also, while it is rare to become pregnant in your late 40s, it is not unheard of. It is recommended that women continue to use birth control until officially menopausal.