Menstruation

Menstrual periods are an important sign of young adolescent females’ overall health; in fact, many providers consider menstruation the sixth vital sign. Health care providers must understand the differences between normal versus abnormal menses to determine when to provide reassurance or perform an appropriate workup. Further, family modeling and cultural differences in menstruation-related attitudes can affect how comfortable youth are with discussing menstrual-related symptoms or undergoing a pelvic exam.

Menarche is the age of period onset that typically occurs within 2 to 3 years after breast bud development (thelarche). The average age at menarche in the United States is 12.4 years. However, the age can vary among different nationalities and ethnicities. For instance, Black and Latina females tend to experience earlier puberty than their white and Asian counterparts. Puberty, and thus menarche, may also be affected by body mass index (BMI).

The following figure describes the three phases of the menstrual cycle: follicular, ovulation, and luteal:

(Source: Reproduced with permission from Menstrual Disorders. Pediatr Rev, Copyright © 1997 by the AAP).

Normal Menstrual Cycle in Adolescents

When asking about the last menstrual period, inquire specifically about the first day of the last period (many patients will otherwise report the last day). Normal menstrual cycles in adolescents are defined by the following parameters:

• Frequency: 21-45 days (mostly within 21-35 days): When asking about frequency, specify the time between the first day of one period and the first day of the next period. For instance, if the last two periods were February 2-9 and March 2-8, the frequency would be 28 days (February 2 to March 2). However, some patients may incorrectly say that they only have 3 weeks between periods (February 9 to March 2), which means 21 days without any bleeding.

• Menstrual flow duration: 2-7 days

• Menstrual product use: 3-6 pads or tampons per day; bleeding can be challenging to quantify because some patients change a pad/tampon with a spot of blood while others will wait until product is soaked through. Be concerned if a patient is changing a pad/tampon every 1-2 hours. Be sure to ask if the pad/tampon is soaked when changed and the type of product used (e.g., pantiliner or light/regular/heavy/superheavy pad/tampon).

Amenorrhea

Definitions for the types of amenorrhea are as follows:

• primary amenorrhea: no menarche by age 15 years or more than 3 years after thelarche

• secondary amenorrhea: no period for 3 consecutive months after menarche

• oligomenorrhea: fewer than four menses/year for first postmenarchal year, fewer than four menses/year at 5 postmenarchal years

Differential diagnosis: The differential diagnosis for primary and secondary amenorrhea can overlap.

Menstrual Irregularities

Definitions for menstrual irregularities are as follows:

• abnormal uterine bleeding: irregular bleeding, heavy bleeding, or both

• heavy menstrual bleeding: using more than six pads per day (switching pad every 1-2 hours or frequently soaking through clothes)

• prolonged bleeding: period lasts >7 days

• frequent bleeding: period occurs more often than every 21 days

Differential diagnosis: Although the differential diagnosis for menstrual irregularities is broad, it is important to assess the patient for signs and symptoms of anemia. A complete blood count (CBC) and iron studies should therefore be considered. Pelvic ultrasound may be helpful but is not required in the initial investigation of adolescent abnormal uterine bleeding.

Treatment: Treatment for menstrual irregularities varies depending on the underlying etiology and degree of anemia. The main goals of management are hemodynamic stability, correction of anemia, and maintenance of normal cycles. Management is largely based on severity of the bleeding and anemia. Severity of anemia and hemodynamic stability guide whether outpatient management is sufficient or referral to an emergency department for further evaluation and possible transfusion is warranted.

• If abnormal uterine bleeding is suspected in a patient with anovulatory cycles, consider oral contraceptives for menstrual regulation.

• Several combined oral contraceptive (COC) regimens have been evaluated for medical management of abnormal uterine bleeding. Although estrogen may improve hemostasis in adolescents with active bleeding, no consensus exists on whether to treat with COCs or progestin-only regimens.

• For patients with hemoglobin levels of 10-12 g/dL, management options include observation, nonsteroidal anti-inflammatory drugs (NSAIDs) to decrease flow, and hormonal therapy.

• For patients with hemoglobin levels <10 g/dL who are hemodynamically stable, consider treatment with continuous monophasic COCs (containing both estrogen and progestin) until hemoglobin is normalized. COCs can be dosed every 8-12 hours until bleeding stops, with the addition of antiemetics if nausea develops due to the high estrogen doses.

• Patients who are hemodynamically unstable or have hemoglobin levels <7 g/dL should be hospitalized and started on iron therapy and monophasic COCs every 6-8 hours for 2-4 days prior to tapering to a daily dose.

• Antifibrinolytics may be useful in cases of severe bleeding.

• If estrogen is contraindicated, consider a progestin-only pill or a progestin intrauterine device (IUD).

Dysmenorrhea

Definitions for dysmenorrhea are as follows:

• primary dysmenorrhea: painful periods in the absence of pelvic disease

• secondary dysmenorrhea: painful periods due to pathologic cause (e.g., sexually transmitted infections [STIs], endometriosis)

Etiologies of secondary dysmenorrhea:

• endometriosis

• congenital obstructive Mullerian malformations

• cervical stenosis

• pelvic inflammatory disease

• pelvic adhesions

• ovarian cysts

• uterine polyps or leiomyomata

• adenomyosis

History

• severity of pain: mild to severe, nausea, emesis, physical limitation, missed school days

• timing of pain: whether pain occurs only during the patient’s period or also occurs between periods

• sexual history: should be confidential, covering condom use, hormonal contraception use, history of STIs, history of pregnancy

• family history: painful periods, endometriosis, infertility

Evaluation

• consider a pelvic exam if the patient has secondary dysmenorrhea or is sexually active

• consider testing for STIs (including gonorrhea, chlamydia, and trichomoniasis)

• endometriosis (a cause of dysmenorrhea): diagnosed with a laparoscopic procedure

Treatment: Pain in primary dysmenorrhea is due to prostaglandin secretion in the uterus.

• NSAIDs (ibuprofen or naproxen) that inhibit cyclooxygenase, and thus prostaglandin synthesis, are considered first-line treatment.

• COCs (containing both estrogen and progestin) can also be considered (see Contraception in this rotation guide and in the Women’s Health rotation guide).

• Complementary therapies such as exercise and heat treatment may be encouraged.

• If taking COCs for 3 to 6 months does not improve symptoms, consider referral to an adolescent gynecologist for evaluation for endometriosis.