Summary
Menstrual disorders such as irregular, heavy or painful periods are common in adolescent girls and may affect quality of life, disrupt sports and social activities and are known to cause school absences in one in four girls. Immaturity of the hypothalamo–pituitary–ovarian (HPO) axis in post-menarchal years is the leading cause for menstrual dysfunction and visits to the emergency department in this age group [1]. Several terminologies have been used to describe menstrual dysfunction, but the International Federation of Gynaecology and Obstetrics (FIGO) system, describing normal and abnormal uterine bleeding (AUB) is the most universally preferred classification [2].
5.1 Introduction
Menstrual disorders such as irregular, heavy or painful periods are common in adolescent girls and may affect quality of life or disrupt sports and social activities and are known to cause school absences in one in four girls. Immaturity of the hypothalamo–pituitary–ovarian (HPO) axis in post-menarchal years is the leading cause for menstrual dysfunction and visits to the emergency department in this age group [Reference Smith, Quint and Hertzberg1]. Several terminologies have been used to describe menstrual dysfunction, but the International Federation of Gynaecology and Obstetrics (FIGO) system, describing normal and abnormal uterine bleeding (AUB), is the most universally preferred classification [Reference Munro, Critchley and Fraser2].
Most menstrual disturbances in adolescence require reassurance and simple measures that can be offered at the primary care level. Referral to a specialist paediatric and adolescent gynaecologist may be required particularly if simple measures fail to control symptoms, in cases of coexisting complex medical conditions or for girls with learning difficulties.
The chapter covers assessment and management of normal and abnormal variations in menstruation in adolescents with key recommendations.
5.2 Normal and Abnormal Variation in Menstruation in Adolescents
The average age of menarche in the United Kingdom has declined from 13.5 in early 1900s to 12.3 years in 1990s [Reference Morris, Jones, Schoemaker, Ashworth and Swerdlow3]. Menarche occurs in the setting of a maturing HPO axis and menstrual cycles tend to be irregular due to anovulation. Cycle length can therefore be variable and erratic although 90% will be within the range of 21–45 days. In the first 2 years post menarche, about 50% of the menstrual cycles are anovulatory; by the third year, these are 21–34 days long in 60%–80%, as is typical of adults. At 5 years, 25% of cycles will continue to be anovulatory, the number decreasing further over the next several years to 20% [4]. Table 5.1 depicts the normal and abnormal variation in patterns of menstruation in adolescents. Understanding of this variation in menstrual patterns is vital to provide adequate explanation and reassurance to the young girls and their guardians and carers.
Table 5.1 Normal and abnormal menstrual patterns in adolescents
| Parameter | Normal | Abnormal |
|---|---|---|
| Cycle length | 21–45 days |
|
| Duration of menses | <8 days | Prolonqed: >8 days |
| Amount of bleeding | Usually 30–40 mL, i.e. ~3–6 soaked tampons or pads each day | Heavy: >80 mL or any excessive loss that interferes with physical, social, emotional and/or material quality of life |
| Painful periods |
| Persistent pain not responding to simple medical treatment may have an underlying pelvic pathology, such as endometriosis or Müllerian anomaly |
Delayed or absent ovulation, either physiological or due to polycystic ovary syndrome (PCOS), results in the lack of progesterone and thus its protective effect on the endometrium. The excessive and unopposed oestradiol from ovarian follicles makes the proliferated endometrium prone to unpredictable menstrual bleeding.
5.2.1 Abnormal Uterine Bleeding (AUB)
FIGO recommends the use of the term abnormal uterine bleeding to describe any aberration of menstrual volume, regulation, duration and/or frequency in a woman who is not pregnant. HMB is the commonest presentation of AUB in adolescents. A history of excessive bleeding may include prolonged period lasting >7 days, ‘flooding’ episodes, use of multiple sanitary pads or high-flow absorbent pads, soaking through pads or tampons within 2 hours, soiling of clothes and bedsheets overnight or presence of anaemia. Table 5.2 depicts the FIGO classification system for AUB based on these four parameters [Reference Munro, Critchley and Fraser2].
In adolescent girls, structural problems (P, polyp; A, adenomyosis; L, leiomyoma; M, malignancy) are rare, and the reported incidence of these is 1.3%–1.7% [Reference Smith, Quint and Hertzberg1]. Anovulatory cycles (AUB-O) are the leading cause of menstrual irregularity and HMB in adolescents. AUB due to anovulation can also be a result of polycystic ovary syndrome, thyroid disorders and hypogonadotrophic hypogonadism such as eating disorders or athletic triad.
Coagulations disorders (AUB-C) appear to contribute to HMB in 5%–36% of adolescents. A possibility of inherited and acquired bleeding disorders should be considered when evaluating an adolescent with AUB, especially if the symptoms commenced with onset of menarche. Von Willebrand disease is the most common coagulopathy, with prevalence reported between 5% and 28% among hospitalised adolescents with HMB in different studies. The LoVIC study conducted in Dublin showed that 40% of girls and women with low VWF reported absence from school or work for a couple of days due to HMB; 50% of the study participants had required iron replacement therapy by the time they had a clinical review for HMB; and 70% of women reported their HMB to date back to menarche [Reference Lavin, Aguila, Dalton, Nolan, Byrne and Ryan5]. A retrospective cohort study conducted by Jacobson et al. showed that despite recommendation by the American College of Obstetrics and Gynaecology, fewer than 20% of adolescent girls who presented with HMB were screened for Von Willebrand disease [Reference Jacobson, Vesely, Koch, Campbell and O’Brien6], thus highlighting the need for clinician awareness of the high prevalence of this condition in girls with abnormal menstruation.
Platelet dysfunction and immune thrombocytopaenia purpura (ITP) may also present with AUB post menarche. Platelet dysfunction includes a heterogeneous group of disorders including Glanzmann thrombasthenia and Bernard–Soulier syndrome. History of spontaneous nose bleeds, easy bruising, prolonged bleeding after dental procedures or minor wounds, petechiae and family history of bleeding disorders should be asked for.
Endometritis can also cause irregular heavy bleeding and can be present in association with pelvic inflammatory disease or sexually transmitted infections. Pregnancy and sexually transmitted infections must be considered as a differential diagnosis in adolescents with AUB. It is important to sensitively ask about sexual history. Clinicians should seek an opportunity to speak to the girl in private as often adolescent girls are accompanied by parents or care-takers making it difficult to have an open discussion. All hormonal methods of contraception including oral, implant, depot medroxyprogesterone acetate or the levonorgestrel intrauterine system can be associated with irregular or breakthrough bleeding.
5.2.1.1 Management of Abnormal Uterine Bleeding
Evaluation of menstrual patterns and HMB by keeping a menstrual diary may be helpful for young adolescents. This could be achieved by using simple, free to use, helpful period tracker and period flow apps.
Serious pathology is rare in adolescents with AUB and often investigations are normal. Most cases may be managed with advice and simple medication. Although patients referred to secondary or tertiary care may have tried simple medical treatments, many general practitioners are reluctant to manage menstrual dysfunction in adolescents in the primary sector and there is a need for continuous education and training.
5.2.2 Heavy Menstrual Bleeding in Adolescents
5.2.2.1 History and Evaluation of HMB in Adolescents
HMB is the commonest presentation of AUB in adolescents. Thorough history taking and appropriate investigations (Table 5.3) should be the focus for identifying the underlying cause as has been already outlined.
| History | Menarche |
| Cycle length, duration and amount of bleeding | |
| Symptoms of anaemia | |
| Symptoms of easy bruising, nose bleeds | |
| Period cramps/pelvic pain | |
| Symptoms of hypothyroidism | |
| H/o acute weight loss, weight gain | |
| Acne, hirsutism, scalp hair loss | |
| Medical/surgical history | |
| Family h/o bleeding disorders | |
| Sexual history | |
| Social history | |
| Medication including hormonal contraception | |
| Examination | BMI |
| Signs of hyperandrogenism | |
| Pelvic examination in sexually active patients only if indicated | |
| Laboratory | Full blood count |
| Serum ferritin | |
| Coagulation profile | |
| Von Willebrand factor screen | |
| Hormone profile: FSH, LH, oestradiol, testosterone, SHBG, prolactin, thyroid function tests if indicated | |
| Genital swabs if infection suspected: culture and sensitivity as well as NAAT testing for chlamydia and gonorrhoea | |
| Imaging (usually not first-line) | Pelvic ultrasound scan |
| MRI may be necessary if Müllerian anomalies are suspected |
In a young girl who presents with HMB, haematological investigations should include a full blood count, blood film, coagulation profile including Factor XI as well as screening for Von Willebrand factor deficiency. Specialist haematologist input should be requested if results are abnormal for both a short- and long-term management plan. Other tests such as serum ferritin and thyroid function tests should also be considered.
5.2.2.2 Management of HMB in Adolescents
AUB may present as an acute emergency or may result in chronic bleeding. In acute AUB prompt assessment for signs of hypovolaemia and hemodynamic instability are of utmost importance (flowchart is shown in Figure 5.1). Blood transfusion with or without clotting factor replacements may be necessary if there is haemodynamic instability or if haemoglobin is <70 g/L.
Figure 5.1 Flowchart management of Acute HMB in adolescents.
After the initial resuscitation, management should be aimed at identifying the underlying cause and planning an effective long-term treatment. Tranexamic acid is the first line of treatment followed by high-dose oral progestogens. Oral high-dose oestrogen-based hormonal therapy or intravenous conjugated oestrogen is third line but not routinely practised in the United Kingdom due to high thrombosis risk. Coagulation disorders like Von Willebrand disease need management with the help of the haematology team. Treatment options include antifibrinolytics, desmopressin, Von Willebrand factor/factor VIII concentrates and recombinant factor VIIa (rFVIIa) in cases of intractable bleeding.
Medical management forms the mainstay of long-term management although most of the evidence relating to medical management of HMB is in adult women and has been extrapolated for use in adolescents.
5.3 Non-pharmacological Management
Non-pharmacological management may not help in the control of bleeding but it is important to advise girls about the importance of regular exercise and healthy diet to maintain a healthy body weight and prevent anaemia. A high body mass index could further cause ovulatory dysfunction and irregular and heavy periods.
5.3.1 Non-hormonal Medical Management of Heavy Menstrual Bleeding
5.3.1.1 Tranexamic Acid
Tranexamic acid is an antifibrinolytic agent which is used in the treatment of excessive bleeding in a variety of situations. It inhibits plasmin and can also improve platelet function. Oral tranexamic acid has an established role in HMB and is effective in reducing menstrual loss by up to 50%. It has been licensed for use in children over 1 month of age [Reference Williams and Creighton7]. Tranexamic acid can be used both in acute and long-term management of AUB. It is associated with an increased risk of thrombosis and hence should not be used if there is active thromboembolic or severe renal disease, or history of thromboembolic disease in first-degree relatives; and should also be used with caution alongside combined hormonal contraceptives due to the increased risk of thrombosis. Tranexamic acid can be used in adolescents with bleeding disorders.
The recommended oral dose for treatment of HMB is 1 g three times a day for up to 4 days. The maximum dose is 4 g/d. It is recommended to start tranexamic acid on day 1 of the period till reduction in loss is observed or for up to 4 days [Reference Williams and Creighton7,Reference Maybin and Critchley8]. Tranexamic acid is also available as a syrup or as an intravenous preparation. Both oral and intravenous tranexamic acid can be used in the management of severe acute bleeding.
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