Common menstrual concerns in the adolescent

Introduction

Abnormal uterine bleeding (AUB) is the most common complaint among adolescents reporting to a gynecologist. They may present with bleeding that lasts for several weeks at a time or concern that they go months between periods. Young girls and their caretakers can have difficulty assessing what constitutes normal menstrual cycles or patterns of bleeding. Although some irregularity is expected around menarche, it can be hard to assess what is concerning for a more severe problem. The American College of Obstetricians and Gynecologists (ACOG) has provided guidance on what constitutes normal menses in young girls and adolescents ( Table 9.1 ). Please refer to Chapter 8 for further discussion of normal menses.

TABLE 9.1
Normal Menses
From American Academy of Pediatrics Committee on Adolescence; American College of Obstetricians and Gynecologists Committee on Adolescent Health Care, Diaz A, Laufer MR, Breech LL. Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Pediatrics . 2006;118(5):2245-2250.
Menarche (median age) 12.43
Mean cycle interval 32.2 days in first gynecologic year
Menstrual cycle interval Typically 21–45 days
Menstrual flow length 7 days or less
Menstrual product use Three to six pads or tampons per day

Abnormal uterine bleeding

AUB refers to bleeding from the uterine corpus that is abnormal in volume, regularity, frequency, or duration and occurs in the absence of pregnancy.

Menstrual irregularities refer to a deviation in what is considered normal menstrual bleeding in adolescents or adult women. The most common menstrual irregularities are described in Table 9.2 .

TABLE 9.2
Menstrual Irregularities
From American Academy of Pediatrics Committee on Adolescence; American College of Obstetricians and Gynecologists Committee on Adolescent Health Care, Diaz A, Laufer MR, Breech LL. Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Pediatrics . 2006;118(5): 2245-2250; Committee on Practice Bulletins—Gynecology. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012;120(1):197-206. (Reaffirmed 2021); Munro MG, Critchley HO, Fraser IS. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? Am J Obstet Gynecol . 2012;207(4):259-265.
Amenorrhea (pronounced ey-men-uh-REE-uh )

  • Absent menstrual periods

  • Primary amenorrhea: No menses by age 15 or 2–3 y post thelarche

  • Secondary amenorrhea: No menses for at least 6 mo in a nonpregnant patient who has already achieved menarche (started having periods)

Heavy menstrual bleeding (HMB) See section on HMB
Irregular menstrual periods Cycle-to-cycle variation of more than 20 days
Shortened menstrual bleeding Less than 2 days in duration
Intermenstrual bleeding Episodes of bleeding that occur between normally timed periods, also known as spotting

Prevalence

Menstrual cycles are often irregular during adolescence. Immaturity of the hypothalamic-pituitary-ovarian (HPO) axis during the early years after menarche often results in anovulation, and cycles may be somewhat irregular. However, 90% of cycles will be within the range of 21 to 45 days, although short cycles of less than 20 days and long cycles of more than 45 days may occur. By the third year after menarche, 60% to 80% of menstrual cycles are 21 to 34 days long, as is typical of adults.

There is a paucity of data in regard to the prevalence of specific menstrual irregularities (see Table 9.2 ) in the adolescent population. A cross-sectional study with 848 girls aged 12 to 18 years looked to characterize the menstrual cycle (regularity and menstrual flow length) in this population. A total of 41.3% of the girls reported irregular cycles and 17.2% reported menstrual flow length of >6 days. Irregular cycles were noted to be more prevalent among young teens ages 12 to 14 (44.6%) than among teenagers ages 15 to 18 (39.2%). Also, a higher percentage of younger teens ages 12 to 14 reported longer menstrual flow (22.9%) compared with the teenagers ages 15 to 18 (13.7%).

Etiology/pathophysiology of AUB

Causes of AUB are numerous and often multifactorial. , In an effort to create a universally accepted system of nomenclature to describe AUB in nonpregnant women, a new classification system was introduced in 2011. This system classifies AUB into heavy menstrual bleeding (HMB) or intermenstrual bleeding (IMB). From there, causes are broken down into two main categories. The PALM acronym refers to structural causes of AUB, and the COEIN acronym is reserved for nonstructural causes of AUB (See Video 9.1, Causes of Irregular Menstrual Bleeding).

Structural causes of AUB (PALM) could be the result of uterine p olyps, a denomyosis, l eiomyoma (also known as fibroids ), and m alignancy. Nonstructural causes of AUB are the case for the majority of adolescent patients—COEIN—and include c oagulopathy, o vulatory dysfunction, e ndometrial causes such as sexually transmitted infections, and i atrogenic reasons such as breakthrough bleeding from a contraception or side effect of hormone therapy. The N is the “not yet classified” subcategory where causes that do not fit well into any of the previously mentioned subcategories are located; an example of this would be arteriovenous malformations.

One of the most common reasons for AUB in the adolescent is ovulatory dysfunction. The differential diagnosis for anovulation in adolescents is broad and can be divided into physiologic versus pathologic causes. Physiologic causes of anovulation include the process of puberty or an immature HPO axis does not have the necessary hormonal feedback needed to regulate menses. Pregnancy or breastfeeding, which increases prolactin levels, can also result in anovulation.

Pathologic causes can be the result of elevated androgens such as in polycystic ovary syndrome (PCOS), congenital adrenal hyperplasia (CAH), or androgen-producing tumors. Hypothalamic dysfunction, which can occur because of eating disorders such as anorexia nervosa, and elevated prolactin from pathologic causes such as pituitary tumor, thyroid disease, and premature ovarian insufficiency (POI) are also possible causes. Iatrogenic causes stem from treatment of other ailments such as radiation to the brain or pelvis or chemotherapy with toxic effects to the ovaries. And finally, certain drugs or medications can cause increases in the prolactin level and/or menstrual disturbances such as risperidone.

See Video 9.2, Causes of Heavy Menstrual Bleeding.

Clinical presentation and classical signs

The presentation for AUB will vary depending on the etiology. Determining the etiology of AUB is essential in choosing the most appropriate and effective management for the individual, and it is accomplished by obtaining a thorough history and physical examination and ordering relevant laboratory and imaging tests ( Table 9.3 ).

TABLE 9.3
Evaluation of Abnormal Uterine Bleeding in Adolescents
History
  • •

    Menarche/gynecologic age

  • •

    Menstrual history (regular or irregular pattern, typical interval, duration, use of sanitary products per day, associated cramping); a if applicable, when did change in pattern occur and details of current episode

  • •

    Impact on quality of life

  • •

    Any history of past brain or pelvic radiation, chemotherapy

  • •

    Medications (specific attention to those that might cause AUB; e.g., anticoagulants, NSAID use, hormonal contraceptives)

  • •

    Sexual activity status, trauma, assault b

  • •

    See HMB section for specific HMB questions

  • •

    Review of systems:

    • •

      Symptoms of anemia: headache, dizziness, syncope, fatigue, pica

    • •

      Symptoms of pathologic causes of anovulation: unwanted hair growth, severe acne, eating habits, headaches, nipple discharge, constipation, diarrhea, cold or heat intolerance, hot flashes

    • •

      Associated symptoms: fever, chills, pelvic pain, vaginal discharge

Physical Examination
  • •

    Temperature, blood pressure, heart rate, BMI, assessment of hemodynamic stability (if indicated)

  • •

    Dermatologic

  • •

    Signs of anemia and bleeding disorders (pallor, bruises, petechiae, ecchymosis)

  • •

    Signs of hyperandrogenism (acne, hirsutism)

  • •

    Signs of insulin resistance (acanthosis nigricans)

  • •

    Thyroid examination

  • •

    Abdominal examination (evaluate for presence of mass, hepatosplenomegaly)

  • •

    Sexual maturity rating (breast and pubic hair)

  • •

    External genitalia examination

  • •

    Speculum examination/bimanual (if clinically indicated and patient is able to tolerate)

Laboratory Tests
  • •

    Pregnancy test

  • •

    Assessment of anemia from blood loss: CBC, ferritin level

  • •

    TSH

  • •

    Testing for other causes as indicated:

    • •

      Bleeding disorder evaluation (see later)

    • •

      STI screening with gonorrhea and chlamydia if sexually active

    • •

      Free/total testosterone, DHEAS, 17 hyrdoxyprogesterone prolactin if PCOS suspected

    • •

      Liver function tests

Imaging
  • •

    Pelvic ultrasound depending on clinical judgement

AUB, Abnormal menstrual bleeding; BMI, body mass index; CBC, complete blood count; DHEAS, dehydroepiandrosterone sulfate; HMB, heavy menstrual bleeding; NSAID, nonsteroidal antiinflammatory drug; PCOS, polycystic ovarian syndrome; STI, sexually transmitted infection; TSH, thyroid-stimulating hormone.

a Can use a menstrual calendar app for patients being expectantly managed.

b It is best to ask sensitive questions privately.

Evaluation/testing

A thorough history is perhaps the most important component and should be taken in a systematic manner, while taking the clinical setting into consideration.

Direct information regarding the timing, length, and heaviness of the cycle should be elicited:

  • 1.

    When did you start your period?

  • 2.

    How often do you bleed?

  • 3.

    How many days do you bleed for?

  • 4.

    How many pads or tampons do you use per day or per hour?

All the components of a physical examination are important depending on your clinical setting. However, attention should be paid to vital signs, checking the skin for any signs of unwanted hair growth, acne, thyroid abnormalities, Tanner staging, and an external genitalia examination. Speculum examination is often not necessary and may not be well tolerated in this population. The external genital examination can be accomplished via labial retraction in a down and out manner to evaluate the introitus, and in some cases, this technique exposes the distal third of the vagina. Refer to Chapter 4 for further information on pediatric gynecologic examination.

Laboratory tests for AUB with associated ovulatory dysfunction (AUB-O) include a pregnancy test, a complete blood count (CBC) to evaluate for anemia and platelet quantity, screening for thyroid hormone (as thyroid abnormalities are associated with menstrual abnormalities), and sexually transmitted infections (when appropriate). Bleeding disorder screening should also be performed if indicated (discussed later). Structural abnormalities account for only a small minority of cases of AUB in this population; thus clinical evaluation should guide the inclusion of a pelvic ultrasound. Although the transvaginal is considered the most accurate route to assess the female reproductive structures, the majority of adolescent patients will not tolerate it, and thus transabdominal pelvic imaging is the imaging modality of choice in nonsexually active females.

See Fig. 9.1 for important aspects to look for during the physical examination and Table 9.3 for detailed history, laboratory, and imaging testing for abnormal uterine bleeding.

Fig. 9.1
Physical Exam

Treatment

Determining the etiology of AUB is essential in choosing the most appropriate and effective management for the individual ( Table 9.4 ).

TABLE 9.4
AUB Treatment
Etiology Management
C oagulopathy a Hormone therapy
O vulatory Dysfunction
O varian Failure, Premature a Hormone therapy
P rimary Pituitary Disease a Treat underlying disease
T hyroid Disease Treat underlying disease
I atrogenic: chemotherapy/radiation Hormone therapy
M edications Discuss alternatives, hormone therapy
Hyper A ndrogenic anovulation (PCOS,CAH) a Hormone therapy
Hyperpro L actinemia Treat underlying disease
H ypothalamic dysfunction (anorexia nervosa) Treat underlying disease
E ndometrial (e.g., STIs) Treat underlying disease
I atrogenic (e.g., BTB with contraception) Optimize hormone therapy, offer alternatives
N ot yet classified Treat underlying disease
OPTIMAL-H is an acronym that can be used to remember causes of ovulatory dysfunction.
BTB, Breakthrough bleeding; CAH, congenital adrenal hyperplasia; PCOS, polycystic ovarian syndrome; STI, sexually transmitted infection.

a Consider collaboration with hematology and endocrinology as indicated for optimal management of disease.

Hormone therapy

Hormone therapy comprises two main categories ( Tables 9.5 and 9.6 ):

  • 1.

    Combined hormonal therapy with estrogen and progestin

  • 2.

    Progestin therapy only

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Feb 15, 2025 | Posted by in GYNECOLOGY | Comments Off on Common menstrual concerns in the adolescent

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