TRPI Interview with Sarah Prager, MD, MAS, UW Medicine Professor
January 3rd, 2025
SN: I’m Suha, I’m one of the co-founders for The Red Poppy Initiative and, actually Natalie, you should introduce yourself, and you can introduce the project as well.
NZ: Of course! My name is Natalie, I’m also one of the co-founders for The Red Poppy Initiative and I use she/her pronouns. We also have another co-founder, whose name is Elizabeth, but she couldn’t join us today unfortunately. So, obviously you’ve seen our organization through our emails, but just as a quick recap, our organization is dedicated to destigmatizing menstruation within Washington state so more women and other people can learn more about menstruation and it can be more accessible to everyone. So that’s going to be the purpose of this interview, so we can learn from a professional in this field such as you [Sarah Prager,] and more people can gain public access or knowledge about menstruation. Alright, with that said, would you like to introduce yourself?
SP: Sure! My name is Sarah Prager, I use she/her pronouns, I am an OB/GYN and complex family planning subspecialist, I work at the University of Washington and focus primarily on reproductive health issues.
SN: Alright, with that being addressed, shall we move onto the questions?
SP: Sure.
SN: First and foremost, what is a period, and what does it entail?
SP: A period is the shedding of the endometrial lining which happens for many reproductive aged people with a uterus, on a regular basis, when they are not using contraception, and when they are not pregnant or breastfeeding. And it is just one part of a cycle that [is] sort of changes in reproductive hormones, that first prepare a uterus to carry a pregnancy, and then if a pregnancy doesn’t result, the shedding of the uterine lining.
NZ: Great start to this interview! Just to add onto this question, would you mind detailing generally, at what age people would get their period and what symptoms, physical or emotional, might occur when one gets their period?
SP: The age when people start getting their period can vary a lot. It can be as early as eight or nine years old; it can be as late as 14-16 years old, but generally speaking, in the United States, it is closer to around 11 or 12.
SN: On that note, sort of straying away from the cycle itself, but more what affects it, how can hormonal imbalances affect one’s period and how can we see this in physical symptoms?
SP: The- Well, having a regular menstrual cycle is dependent on having hormones that interact in a very regular manner, and when there are irregularities with that, it can result in periods being longer or shorter or irregular or heavier or more painful or any number of things. It’s quite common for the first six years after the first menstrual cycle for those cycles to be more irregular and sometimes heavier for young people and generally speaking, some of that normalizes over time. However, there are a number of conditions that can lead to those hormones behaving in an irregular fashion, which can result in irregular periods or missed periods, or frequent periods, or any number of things.
SN: Is there any way people that menstruate can counteract these hormonal imbalances?
SP: Sort of, I mean, most of the time if people take hormonal contraception that often suppresses the regular hormones that somebody is experiencing in their body such that the typical menstrual cycle doesn’t occur, or it impacts the lining of the uterus so that it doesn’t build up. Even if hormones are still cycling normally, and that can change one’s experience of the bleeding part of the period, and often some of the other things as well, but not always.
NZ: So, as you said earlier, because within like around the first six years, there will be irregularities regarding one’s period. I was actually wondering at what point should a person, whether it’s like within those six years or after the six years serve to be concerned about, I guess, hormonal imbalances or physical imbalances that may indicate that they want to see a doctor about their period, or that there might be physical issues regarding their period.
SP: The simple answer is that if at any time it is causing distress, then that is a good time to go see a doctor. Whether it’s because periods are very crampy or they’re very unpredictable, or they’re super heavy, or they haven’t started yet and somebody is, you know, getting into later High School, etc., or it comes very early, any of those things are reasons to go and seek care from a clinician. In terms of, when should one be concerned? It kind of depends. So sometimes people just constitutionally are going to have an earlier or a later cycle, and just knowing their family history and what has happened to other women and people in their family with the uterus can sometimes help them predict when to expect their own cycle to start. And of course, if somebody is missing periods and they’re sexually active, they should always think about taking a pregnancy test. But again, sort of the fallback is, if it’s causing just any kind of distress, then it’s worth seeing somebody about it so that either they can be reassured, or a workup can happen.
NZ: So, on that note of like, causing distress, I think that’s a great point to make. As for me personally, like when I have my period, sometimes I’ll get, like, really painful periods. And I know, like within my family, that it’s a pretty common trend regarding the woman in my family- having really painful periods. So, for other women who may be experiencing painful periods, but do not think it’s like a concern that necessitates going to a doctor for it, what are some things that a woman can do in order to maybe ease the pain of their periods?
SP: There are a number of different things that can sometimes help. Exercise sometimes helps, although it can be hard to exercise when you’re already feeling crampy. Using a heating pad or a hot water bottle or getting in a hot bathtub, those things can help as well. If those are not working, then non-steroidal, anti-inflammatory medications like ibuprofen or naproxen, Aleve, that kind of a thing, is often quite helpful as well. And then going on hormonal contraception often can make periods lighter or go away, which then improves or eliminates the cramping associated with periods as well.
SN: What is the biggest misconception you think people generally have about menstruation?
SP: Honestly, one misconception that I hear a lot is that it is necessary to have periods in order to be healthy, that it is a sort of flushing out of the system that is required. And, the reality is that if somebody is using a medication like a hormonal contraceptive to suppress a period that is 100% safe and healthy. There’s nothing magical or particularly helpful about having a menstrual cycle. If they want to suppress it, if somebody is not menstruating and they are not actively suppressing it, then it is helpful to figure out why that is happening. Is it pregnancy, is somebody very underweight, do they have an eating disorder of some kind, or is there some other consideration going on that they should be aware of? But I often hear that people are concerned about suppressing periods, or, you know, short or longer periods, because it is some how unhealthy, and that is not true.
NZ: Just to follow up on that question- do you think these like misconceptions regarding menstruation come from a societal stigma around menstruation, or, I guess generally, what as a society can we do to kind of clear up this misinformation and these misconceptions about menstruation?
SP: I do think it relates to societal norms and expectations, and, historically, that was the only way people knew that they weren’t pregnant. And so, I understand why there is, you know, sort of this deep-seated evolutionary tie to health or normalcy. Having a menstrual cycle also very much signifies youth. I guess being of reproductive age and being healthy and able to bear children, which again, historically, has been a lot of how women are valued. I think all of that has been changing to a certain extent over time, but it’s only been 60 years, 70 years since we’ve even had the development of the pill. I mean, it wasn’t widely available until, well, it was developed in 1960 it wasn’t super available until 1968 and it wasn’t legal for unmarried women until 1972, I think, in the United States. So, you know, we have a relatively short history of being able to impact menstrual cycles very much. And so, you know, certainly it takes longer than that to combat millennia of expectations and evolution.
SN: Okay, we were talking a lot about the pill and ways to suppress your period and I kind of wanted to know more about that. So, when we’re talking about suppressing a period, does that mean that, like, we’re stopping the menstrual cycle as a whole, or we’re just, like, stopping, like the physical symptoms of the menstrual cycle, and we just can’t see it.
SP: It’s a little bit of both. If you’re talking about what we think of as the regular birth control pill, which is a combination of both estrogen and progestin hormones, those work by suppressing ovulation. They suppress the ovary actually releasing the egg. There’s a lot of other feedback that is happening, and the way that it is suppressing the ovary is by not allowing for normal changes in estrogen and progestin and other reproductive hormones in the body. The end result of that is for many people, that periods become lighter or happen less frequently, if at al. The main goal is to prevent pregnancy, but secondarily, they can also have positive impacts of making periods less impactful for people. The menstrual cycle as we think of it, is being eliminated because it requires those changes in the hormones in order to trigger normal menstruation. People on a birth control pill, often, particularly in the beginning, will still have bleeding on a regular, or somewhat regular basis. We tend to think of that more as like withdrawal bleeding, because the way a lot of birth control pills are designed to be taken is 21 days of active hormones and then seven days of inactive pills. And during that inactive period, the body starts to try to kind of kick back into gear, and it’s the withdrawal of the birth control hormones that allows for that bleed to happen. But now we also often continue those pills without planning for monthly bleeding. The original design of the pill was not done because it’s healthier. It was done to mimic a menstrual cycle, to make it more acceptable to people. And so, trying to, again, as I said before, trying to eliminate this menstrual bleeding is perfectly safe and healthy and can have a lot of really beneficial effects for people.
NZ: And I just had a follow up to that question about, like, I guess, the side effects of the menstrual cycle. I know a lot of people on social media or just within this, like, larger community of Washington nowadays talk about, like, being on a pill, especially when they’re in high school or early college, other than like, preventing pregnancy and those effects. Are there any like other reasons why people might want to be on the pill for like, hormonal reasons or acne reasons?
SP: Yeah! Lots of people, regardless of age, but often, particularly young people, start birth control pills not because they’re actively looking to prevent pregnancy, but because they want to have less painful periods or less heavy bleeding, because their bleeding is interruptive of their sports or school or whatever it might be, or because they have acne and birth control pills that are combination and contain estrogen also have a side effect, usually, of decreasing acne for people. So many people start them for those two reasons, for acne prevention and for less problematic periods, and then subsequently, if they stay on them long enough, are also using it potentially for pregnancy prevention. But I would say the many young people are starting pills, not for pregnancy prevention. And I would say older people, too are often using contraception for non-contraceptive benefits, and not necessarily, or even at all, for the contraceptive benefit. You know, they may have a same sex partner or not be engaging in sex with that can result in pregnancy or engaging in sex at all, but they still want to have the menstrual benefits.
NZ: Okay, wonderful! And I think with that said, I kind of want to transition this to more about the cultural implications of menstruation. So obviously, we’ve talked a lot about how culture, and I guess the history of menstruation, has affected people’s perceptions towards them. I also know from like background information that a lot of cultures also have their own taboos and stigmas. So, my question for you is, what do you think are some of the biggest, I guess, cultural stigmas regarding menstruation that kind of prevent discussions around like pregnancy prevention or just having, like safe periods?
SP: In a lot of cultures, historically, people who were menstruating were considered dirty, and so they weren’t allowed into places of worship, so they weren’t allowed to pray. They were excluded from community life during the time that they were menstruating. And, you know, considered other and different and unclean. So there has been historically, a very negative connotation about menstruation.
SN: We see you also do a lot of work regarding pregnancies and pregnancy prevention. I saw abortion on your UW page. At what stage in a woman’s period should they consider pregnancy?
SP: That’s a great question! We have now quite sensitive pregnancy tests that can identify a pregnancy right around the time that somebody would be missing a period if they had a regular four-week cycle or 28-day cycle. So, if somebody knows their cycle and knows they’re relatively regular and their period is not showing up when they expect it, taking a pregnancy test at that point could be useful to help them identify if they are pregnant. Prior to, you know, sort of 10 to 14 days after ovulation, a negative pregnancy test isn’t particularly reassuring, because there is a point during the cycle where fertilization could have occurred, meaning a sperm and an egg could have already met, but if it hasn’t yet implanted into the endometrium, it’s not yet producing human chorionic gonadotropin or HCG, which is the pregnancy hormone, and that is the hormone that we test to identify if somebody is pregnant. The medical definition of a pregnancy isn’t until implantation has occurred. So, like, technically, from a medical standpoint, somebody isn’t actually pregnant until implantation and that development of the HCG, but fertilization could have occurred, and we don’t have great ways of identifying fertilization.
NZ: And that’s a great point that you just made about stages after ovulation. So, I actually have a question about ovulation. I think, evidently, the stage of which you are ovulating is not as easy to track as when you’re menstruating, because you’re not necessarily bleeding. So, how do you think like, women or young girls or just anyone who menstruates, can better track when they’re ovulating or specific cycles in their like menstrual phase?
SP: So, if somebody has regular cycles, then it can be easier to identify when they are ovulating, because ovulation happens relatively predictively about 14 days prior to menstruation. But of course, you can’t know, you know, 14 days ago, like in the future. You know, that’s not how we’re able to identify things. But if, like, for instance, if I have a regular 28-day cycle, then that also means that I’m ovulating around day 14 of my cycle. So, if somebody is having regular cycles, it can be easier to identify that. Some people get a little bit of pain when their ovary releases an egg, which is what ovulation is. Some people have a little bit of bleeding mid cycle, bleeding that is associated with their ovulation. That’s sometimes called middle-schmertz, which is a German word for, you know, middle period, basically. And there are ovulation predictor kits which measure luteinizing hormone, a different reproductive hormone, and people, you can use those for several days, and then when you see that there’s an LH surge, that means that ovulation is typically going to happen within the next 12 to 24 hours. However, I don’t typically recommend that people use that as a means to figure out when they are ovulating, because, you know, it’s kind of expensive and it’s a little bit academic in a way. I mean, most people who are using those are using them to try to identify when to have sex for the purposes of getting pregnant, not when to have sex for the purposes of avoiding pregnancy, although it can be used that way. There are some other changes that happen, like changes to cervical mucus, etc. But those are also a little bit more challenging to track. There are minor changes that occur in basal body temperature, and so some people have a special thermometer that can look at those minor changes, and when their temperature goes up a little bit mid cycle, that could be an indication of ovulation. So, there are some ways to tell, without fancy tests, but the easiest is if somebody has a regular cycle, and then you can kind of ballpark it.
SN: Okay, I had two questions, kind of stemming from this conversation. The first one was, when you’re in your luteal phase, is it possible to get pregnant? And my second one was, when pregnant, can menstrual bleeding still occur?
SP: Both good questions. The answer is that, for the most part, people are only fertile within about 12 or 24 hours of ovulation. So, if somebody is more than a day or two past that ovulation point in their luteal phase, then they largely cannot get pregnant. That’s why people use ovulation predictor kits to figure out that most fertile window, but sperm can survive in the reproductive tract, the female reproductive tract, for up to about a week, five or seven days. And so having unprotected intercourse, you know, within a week before ovulation, there can still be active, viable sperm when the egg is released, and pregnancy can result. So that’s one of the reasons why if a person has more than one partner and has had unprotected sex with more than one person within a particular time frame around ovulation, it can be impossible to determine without genetic testing who the sperm donor was.
SN: Okay. And my other question, when pregnant and menstrual bleeding still occur?
SP: Menstrual bleeding, no bleeding, yes. It wouldn’t be menstrual bleeding, but lots of people have a little bit of bleeding with implantation, some people have bleeding or spotting in early pregnancy. And this can confuse people to think that they’re having a menstrual cycle, when it’s not a menstrual cycle, but it is bleeding.
NZ: And to follow up with that, after someone has given birth to a child, how often will it take for menstruation, or like their period to come back after giving birth?
SP: That’s really dependent on a lot of different factors, primarily whether or not they’re breastfeeding. To what extent they’re breastfeeding. Are they fully or only partially breastfeeding? How much of the nutrition is for the baby is coming from breast milk? It also depends on, you know, what their bodily resources are. If they’re in a sort of nutrition rich environment, then their cycle is likely to come back sooner rather than later. If they’re in a nutrition poor environment, then a lot of their resources are going to be going toward supporting the new their newborn. So, there’s no easy way to answer that question, because there are so many variables that contribute to that before you even introduce things like, you know, hormones or other methods of preventing pregnancy that can also impact periods returning.
SN: Kind of straying away from talking about the biology of it- we’re kind of running out of time. So, I would like to conclude this interview with one question. It’s more open ended. But what do you wish more young people that menstruate knew about periods in pregnancy?
SP: I think I’ve already pretty much said it, but that if periods are bothersome, then there are a lot of ways to address that, and it’s completely safe to do that. So, I think periods often are
experienced as somewhere between an annoyance to being incredibly bothersome and sometimes unhealthy for people and either because of pain or heavy bleeding. And that just doesn’t have to be there are a lot of ways for most people to be able to positively impact what their experience with their periods are.
NZ: Okay, and that’s a wonderful way to conclude the interview. So, Dr Prager, thank you so much for attending this interview with us. I think we learned a lot, and we’re really excited to share this with other people for organizations advocacy.
SP: Thank you so much. You’re welcome. Good luck with your organization and let me know if you have other questions!
NZ: Yeah, of course. Thank you so much Dr. Prager and thank you for your time. We appreciate it.
SP: You’re welcome. Take care. Happy New Year.
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