Checking the calendar and realizing your period hasn’t shown up this month can bring up a lot of questions. If your cycle is usually predictable and you’re in your forties, you may be wondering what your body is trying to tell you, and if this means you’re in perimenopause (the transitional phase leading up to menopause).
While perimenopause is a common reason for missed periods at this stage of life, it’s not the only possibility.
Aside from
pregnancy, your cycle can be affected by stress, changes in your weight, or underlying health conditions.
Here are the most common reasons for a missed period in your forties and how to tell whether it might be perimenopause or something else entirely.
The most common sign of perimenopause is unpredictable menstrual cycles, says Rhiana Saunders, MD, a reproductive endocrinologist and infertility specialist at Aspire Houston Fertility Institute in Texas. “Normally, as women approach menopause, they may notice their cycles change to shorter intervals, from every 28 to 30 days to 23 to 25 days,” she says.
These
shorter cycles can last for a long time and happen because the
follicular phase (the first part of the menstrual cycle before you ovulate) is shrinking, explains
Anupama Rambhatla, MD, a board-certified obstetrician-gynecologist and reproductive endocrinology and infertility specialist in Newport Beach, California. Cycles can also become longer.
If a cycle is 35 days long, that could seem like a missed period.
Eventually, as the ovaries no longer respond predictably to the hormones your brain releases, your menstrual cycles can become even more irregular, and your periods begin to skip months at a time.
Changes in the menstrual flow are also common during perimenopause. Some women notice much heavier periods than they’re used to, which can lead to fatigue or symptoms of anemia (low red blood cell levels), says Dr. Saunders.
Beyond changes to your cycle, perimenopause often brings other telltale signs, such as:
- Stronger premenstrual symptoms (PMS), like breast tenderness, bloating, mood swings, and irritability
- Hot flashes or night sweats, which happen when lower estrogen levels affect how the brain regulates body temperature
- Trouble falling or staying asleep
- Vaginal dryness
But everyone experiences perimenopause differently. Some people find their symptoms minor and manageable, and for others, their quality of life is significantly affected.
A missed period doesn’t always mean perimenopause, even if you’re in your forties. Several reasons that have nothing to do with approaching menopause can affect your menstrual cycle in this stage of life, says Eric Liberman, DO, a board-certified obstetrician-gynecologist based in Teaneck, New Jersey. Some reasons for a missed period include the following.
Pregnancy
It may seem obvious, but pregnancy is still one of the most common reasons for a missed period in your forties.
Even if your cycles have already started changing, it’s still important to check for pregnancy first, if it’s a possibility. “Pregnancy is easily diagnosed with a
pregnancy test,” Dr. Liberman says.
Hormonal Imbalances
“The endocrine system is a fine-tuned communication system that allows certain organs to communicate with each other using
hormones as chemical messengers,” says Liberman. An imbalance in any hormone, even one not directly related to reproduction, can create a ripple effect that disrupts your menstrual cycle.
Thyroid conditions are a common example, says Liberman. The thyroid helps regulate metabolism and energy use, but thyroid hormones also play a role in reproductive function. When thyroid levels are too low (
hypothyroidism) or too high (
hyperthyroidism), your period may become irregular or stop altogether.
Polyendocrine metabolic ovarian syndrome (PMOS) — formerly known as PCOS — is another hormonal condition that can affect your cycle, Liberman says. Women with PMOS often have higher-than-normal
testosterone levels, which can prevent ovulation (the release of an egg).
Without ovulation, the menstrual cycle doesn’t happen regularly, leading to skipped or widely spaced periods.
You may also experience missed periods if your
prolactin levels are too high.
Prolactin is the hormone that helps the body produce breast milk after pregnancy, but levels can rise even when someone isn’t pregnant or breastfeeding.
Certain medications, stress, or problems with the pituitary gland can increase prolactin and interfere with
ovulation, leading to missed periods.
Weight Changes
Fat cells contain an enzyme that converts certain hormones into estrogen.
When someone carries extra body fat, and they’re not in menopause or perimenopause, they may produce more estrogen, says Liberman. “These increased levels of estrogen trick the body into thinking you are pregnant and prevent the release of an egg,” he says, and without the release of an egg, your body doesn’t produce enough progesterone, which is needed to trigger a period.
This hormone pattern can sometimes lead to heavier bleeding later on because the lining of the uterus continues to thicken from the continuous estrogen instead of shedding on a regular schedule, says Liberman.
Saunders says that conditions related to being
underweight or having low body fat, whether from intense athletic training, like marathon running,
eating disorders, or not eating enough calories, can affect ovulation as well.
Many women experience missed or
irregular periods when their
body mass index (BMI) drops below 18.5, she says.
In these cases, the brain tries to conserve energy and doesn’t release the hormones that allow for ovulation and menstruation.
Stress
If you’re wondering how stress can affect your period, it has to do with cortisol, the main stress hormone.
Ongoing stress raises cortisol levels, which can interfere with the hormones that regulate ovulation and menstruation.
During stressful times in life, your cycle may become irregular or pause until your cortisol levels are better regulated.
Finding ways to manage stress, such as with exercise, therapy, meditation, or other relaxation techniques, may help your cycle return to its usual pattern.
Certain Medications
Consider looking at your medicine cabinet if your menstrual cycles have changed. Some medications can affect cycle timing and bleeding patterns, says Dr. Rambhatla, including hormonal birth control, certain
antidepressants and antipsychotic drugs, and high-dose steroids.
If your periods started changing after you began a new medication, speak with the healthcare professional who prescribed it to see whether the medication could be playing a role.
Other Medical Conditions
Sometimes, a missed period can be a sign of an underlying health issue.
While these aren’t the most common causes, they’re worth being aware of:
- Hormone-Producing Tumors Certain rare ovarian tumors, like granulosa cell tumors, can produce estrogen on their own, which can interfere with your normal cycle.
- Asherman’s Syndrome Scar tissue that forms inside the uterus after certain procedures can physically block menstrual flow, making it seem like periods have stopped.
- Chronic Illnesses Poorly controlled diabetes, autoimmune diseases, or other long-term health conditions, can put enough strain on your body to disrupt the hormones that regulate your cycle.
- Uterine or Ovarian Conditions Ovarian cysts, fibroids, or polyps can change your bleeding patterns, often making periods unpredictable.
Many of these causes are treatable, which is why ongoing missed periods should be checked out by a healthcare provider.
When missed periods occur alongside symptoms like hot flashes, night sweats, poor sleep, or mood changes, perimenopause is often the more likely explanation, says Rachel Pope, MD, a board-certified obstetrician-gynecologist based in Ohio and associate professor of obstetrics and Gynecology at Case Western Reserve University School of Medicine.
While medical conditions like PMOS or thyroid disorders can affect your cycles, Dr. Pope says they usually come with different patterns or clues.
Use the table below to compare perimenopause with other common causes of missed periods in your forties:
Any change in your menstrual pattern is a good reason to see your gynecologist, says Earl Peeper, MD, a board-certified obstetrician-gynecologist based in New Orleans.
“In our forties, periods can become very unpredictable, and keeping track of what is happening through a journal or an app can help a woman pick up new patterns,” says Pope. Having this information ready can make it easier to discuss management and treatment options with your gynecologist.
Seek medical care right away if you notice missed periods that alternate with random, heavy bleeding, such as passing clots, soaking through pads or tampons, or if your cycles are becoming unusually close together, says Liberman. This is especially important if you have certain risk factors, including:
- Obesity
- PMOS
- High blood pressure
- Diabetes
- Family history of certain cancers (uterine, colon, ovarian, or breast)
- Prior use of tamoxifen (a hormone-blocking medication used in breast cancer treatment)
- Inherited gene mutation, such as Lynch syndrome or BRCA
If you’ve already reached menopause — meaning you’ve gone a full 12 months without a period — discuss any new spotting or bleeding, even if it’s light, with your gynecologist, Liberman says.
On the flip side, if you’re in your mid-to-late fifties or older and still having regular vaginal bleeding without ever going a full year without a period, that’s also worth mentioning to your provider.
Conditions like polyps in the uterus or fibroids can cause ongoing bleeding and may be delaying your transition to menopause.
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