Disorders of Menstruation in Adolescent Girls




Abnormal menstruation in adolescent girls can cause psychological and physical strain from excess, unpredictable, painful, or even absent bleeding. Care providers who understand what is normal and what is concerning can educate and often reassure the young woman and her family. When there is an abnormal or concerning scenario, they can initiate investigations and/or treatment in an expedient fashion to limit psychosocial and/or physical morbidity. This article provides pediatricians, family doctors, nurse practitioners, and adult gynecologists with the knowledge and understanding of the common complaints, differential diagnoses, and treatment strategies.


Key points








  • Distinguishing whether the teen is ovulatory or not can be helpful in narrowing the differential diagnosis.



  • The menstrual cycle can take several months to become regular and ovulatory. Reassurance may be all that is necessary but treat if interfering with activities or depleting the teen (physically and/or emotionally).



  • Primary physiologic dysmenorrhea is usually not present at menarche; it accompanies the establishment of ovulatory cycles. Take NSAIDs proactively and be suspicious of endometriosis if properly administered nonsteroidal antiinflammatory drugs (NSAID) in combination with Combined Contraceptives (CCs) fail to control dysmenorrhea. Similarly, be suspicious of outflow obstruction if dysmenorrhea is intractable, if menarche is painful or if puberty is near complete and no menses has occurred.



  • CCs offer many benefits but teens and/or parents often have misinformation about safety and side effects that must be addressed.



  • Functional amenorrhea is a diagnosis of exclusion and is caused by an imbalance of stress, diet, and/or exercise. These factors can also cause irregular menses.



  • It can be difficult to identify polycystic ovarian syndrome (PCOS) patients during adolescence.



  • With true menorrhagia, take bleeding history from teen and her family.






Introduction


Abnormal menstruation in adolescent girls can cause psychological, emotional, and physical strain from excess, unpredictable, painful, or even absent bleeding. This article discusses these common complaints and describes variations of normal, including the maturation of the hypothalamic-pituitary-ovarian (HPO) axis, but goes on to provide indications for reassurance alone versus active intervention. ( Figs. 1 and 2 ) show broad differential diagnoses for common symptoms. It is important for readers to recognize that these key figures and their list of underlying conditions are meant to guide the clinician’s history, physical examination, and the choice of investigations. Treatment options are organized according to symptoms and presenting complaints in Table 1 , which can be referenced regardless of the underlying disorder. The article elaborates on hypothalamic/functional amenorrhea, polycystic ovarian syndrome (PCOS), and primary dysmenorrhea, and applies or adapts the previously described basic principles of history, physical examination, investigations, and treatment to these conditions. To avoid missing the diagnosis, inherited bleeding disorders are discussed.




Fig. 1


Abnormal uterine bleeding in adolescents: heavy, prolonged, and/or irregular (those noted with an asterisk can also present as secondary amenorrhea). CNS, central nervous system.



Fig. 2


Primary amenorrhea. GnRH, gonadotrophin-releasing hormone; MRKH, Mayer Rokitansky Kuster Hauser syndrome; PCOS, polycystic ovarian syndrome.


Table 1

Medicinal treatment options for problematic menstrual bleeding (symptom based)


































Heavy (and/or Prolonged) Flow Irregular: Infrequent and Unpredictable Irregular: Frequent (± Prolonged) Painful/Crampy
CCs CCs CCs CCs
Antifibrinolytic Cyclic oral progestins Antifibrinolytic
NSAIDs (proactive) Maybe do nothing if ≥4 cycles/y NSAIDs ± acetaminophen
LAP LAP LAP
Course of oral progestin (if isolated prolonged bleed; discussed later)

Options need not be tried in the order listed.

Antifibrinolytics are tranexamic acid or aminocaproic acid.

Abbreviations: CCs, combined contraceptives (eg, oral pill, transdermal patch, vaginal ring); LAPs, long-acting progestins (ie, depomedroxyprogesterone acetate or levonorgestrel intrauterine system); NSAIDs, nonsteroidal antiinflammatory drugs.




Introduction


Abnormal menstruation in adolescent girls can cause psychological, emotional, and physical strain from excess, unpredictable, painful, or even absent bleeding. This article discusses these common complaints and describes variations of normal, including the maturation of the hypothalamic-pituitary-ovarian (HPO) axis, but goes on to provide indications for reassurance alone versus active intervention. ( Figs. 1 and 2 ) show broad differential diagnoses for common symptoms. It is important for readers to recognize that these key figures and their list of underlying conditions are meant to guide the clinician’s history, physical examination, and the choice of investigations. Treatment options are organized according to symptoms and presenting complaints in Table 1 , which can be referenced regardless of the underlying disorder. The article elaborates on hypothalamic/functional amenorrhea, polycystic ovarian syndrome (PCOS), and primary dysmenorrhea, and applies or adapts the previously described basic principles of history, physical examination, investigations, and treatment to these conditions. To avoid missing the diagnosis, inherited bleeding disorders are discussed.




Fig. 1


Abnormal uterine bleeding in adolescents: heavy, prolonged, and/or irregular (those noted with an asterisk can also present as secondary amenorrhea). CNS, central nervous system.



Fig. 2


Primary amenorrhea. GnRH, gonadotrophin-releasing hormone; MRKH, Mayer Rokitansky Kuster Hauser syndrome; PCOS, polycystic ovarian syndrome.


Table 1

Medicinal treatment options for problematic menstrual bleeding (symptom based)


































Heavy (and/or Prolonged) Flow Irregular: Infrequent and Unpredictable Irregular: Frequent (± Prolonged) Painful/Crampy
CCs CCs CCs CCs
Antifibrinolytic Cyclic oral progestins Antifibrinolytic
NSAIDs (proactive) Maybe do nothing if ≥4 cycles/y NSAIDs ± acetaminophen
LAP LAP LAP
Course of oral progestin (if isolated prolonged bleed; discussed later)

Options need not be tried in the order listed.

Antifibrinolytics are tranexamic acid or aminocaproic acid.

Abbreviations: CCs, combined contraceptives (eg, oral pill, transdermal patch, vaginal ring); LAPs, long-acting progestins (ie, depomedroxyprogesterone acetate or levonorgestrel intrauterine system); NSAIDs, nonsteroidal antiinflammatory drugs.




The common presenting complaints


Care providers for adolescent girls are likely to be confronted with concerns over periods that are perceived as too heavy or prolonged, too painful (dysmenorrhea), irregular (unpredictable, too frequent, or infrequent), and/or nonexistent (primary or secondary amenorrhea). There are many suggested sets of terminology but, to avoid misinterpretation, this article uses lay language descriptors and the term abnormal uterine bleeding (AUB). When it comes to heavy flow, it is often helpful to first elicit evidence of ovulation (classic premenstrual molimina such as breast tenderness, headaches, cyclic mood changes, and cycle regularity). When cycles are regular and ovulatory, but still heavy, the problem is more likely the teen’s inability to manage idiopathic heavy flow or a bleeding disorder. In contrast, anovulatory cycles, or cycles triggered by infrequent ovulation, can be heavy and/or prolonged. When ovulation is absent or infrequent, the underlying cause is often endocrinopathy; imbalance or syndrome at the hypothalamus, the pituitary, or at the ovary (see Fig. 1 ). Infections of the lower genital tract (or a retained tampon) tend to cause intermenstrual bleeding, and pregnancy must be considered with almost every change in menstrual cycle or abnormal vaginal bleeding presentation.




  • Key point/pearl



  • Distinguishing whether the teen is ovulatory or not can be helpful in narrowing the differential diagnosis.





What is normal, and the maturation of the hypothalamic-pituitary-ovarian axis


Although there may be trends toward earlier puberty, the average age at menarche has been fairly stable between ages of 12 and 13 years in Canada and the United States. More than 90% of adolescent girls have had menarche by 14 years of age. It is generally accepted that most menarchal bleeds are the result of endometrial proliferation from estrogen. Both thelarche and leukorrhea are evidence of estrogen exposure and precede menarche by 1 to 2 years. Menarche is an anovulatory bleed; often the result of erratic sloughing of the proliferative endometrium as opposed to a synchronous slough 2 weeks after ovulation, which explains why, for many young teens, the bleed can be prolonged and heavy but, at the same time, usually fairly painless (discussed later). It is also generally agreed that the HPO axis needs time to mature, averaging 6 months to 3 years before regular ovulatory cycles are established. The earlier menarche occurs, the sooner cycles regulate. During these months immediately after menarche, teens can experience cycles consistent with ovulatory dysfunction: irregular and unpredictable (frequent or infrequent), heavy and prolonged, but intervals between menses are seldom greater than 3 months. It is well recognized that teens and their parents may have misinformation or misguided expectations about what is normal. Education and reassurance are sometimes all that is necessary if the girl is otherwise coping. They may report her to be irregular if the cycle is not exactly every 30 days and they may report her to be experiencing heavy bleeding because she is having menstrual accidents but she is still learning how and when to use pads/tampons. Regular ovulatory cycles typically occur every 21 to 34 days and blood loss is less than 80 mL. Trying to determine which teens are experiencing abnormally heavy flow (and among them, which may have an inherited bleeding disorder [discussed later]) can be challenging. Looking for anemia and clarifying the number of saturated pads/tampons required in a day and the number/size of clots can be helpful but how it affects the girl’s life is paramount. However, having to change a pad/tampon every 1 to 2 hours and greater than 7 days’ moderate/heavy flow is likely excessive. Whether the teen is merely experiencing HPO axis maturation, or whether she has an underlying disorder, treatment should be indicated if the problem is causing distress or dysfunction. The American College of Obstetricians and Gynecologists’ committee on Adolescent Health care has a useful summary of the menstrual cycle as a vital sign, which outlines expectations and causes for concern, and Wilkinson and Kadir reviewed adolescent menstrual disorders in a supplement of the Journal of Pediatric & Adolescent Gynecology that is dedicated to this topic and inherited bleeding disorders.


Menstrual Cramps (Dysmenorrhea)


With the establishment of ovulatory cycles, the teen may begin to experience dysmenorrhea. Primary dysmenorrhea refers to prostaglandin-mediated physiologic menstrual cramping typical of ovulatory cycles. Dysmenorrhea is typically absent from the first several menses because they are often anovulatory, and it is concerning when the menarchal bleed is very painful because it can be the result of obstructed outflow (discussed later).




  • Key point/pearl



  • The menstrual cycle takes 6 months to 3 years on average to become regular and ovulatory.



  • Reassurance may or may not be all that is necessary even if symptoms are considered a physiologic variant. Treat if interfering with activities or depleting the teen (physically and/or emotionally).



  • Underlying disorders (see Fig. 1 ) such as disordered eating, PCOS, pregnancy, and bleeding disorders can be present during the first few years after menarche. Immaturity of the HPO axis is a default diagnosis.



  • Primary physiologic dysmenorrhea is usually not present at menarche; it accompanies the establishment of ovulatory cycles.



  • Helpful patient/parent information is available:





Interpreting and Using the Figures


Fig. 1 provides a broad differential for heavy bleeding, prolonged bleeding, and/or irregular bleeding. The conditions noted by an asterisk (*) can also cause secondary amenorrhea. Secondary amenorrhea traditionally was a term reserved for cessation of menses of 6 months or more. Many clinicians now advocate for the criterion to be only 3 months or 90 days. Although there is less chance of disorder, this more lenient criterion affords more opportunity for early recognition of pregnancy, eating disorders, and so forth. Fig. 2 provides a broad differential for primary amenorrhea, which may or may not be accompanied by delayed or arrested puberty. Although definitions vary, delayed puberty in a girl refers to absence of breast development (thelarche) by age 13 years. Neither figure includes the hypothalamic-pituitary-adrenal axis, but conditions such as congenital adrenal hyperplasia, Cushing, and tumors (adrenal gland and ovary) need to be considered when there is significant androgenization/virilization or other stigmata. Chronic illness can include disorders such as type 1 diabetes, renal failure, and inflammatory bowel disease. Both hyperthyroid and hypothyroid disease can affect the HPO axis functionality and thus both figures mention thyroid endocrinopathy. Both figures list premature ovarian failure (POF), which can be idiopathic or caused by gonadal dysgenesis/agenesis (ex Turner syndrome), fragile X premutation, cancer therapies (chemotherapy, radiation), autoimmune oophoritis, and so forth. Autoimmune POF often coexists with other autoimmune conditions in the patient and/or her family. Primary ovarian insufficiency is an entity in itself but for the purposes of this article it should be considered a mild form of POF or a state of transition. Remember that these figures are meant to guide the history, physical examination, and choice of investigations.




Abnormal uterine bleeding: the generic assessment


History: Key Features





  • Explicit description of menstrual complaints, perceived menstrual cycle, and time elapsed since menarche: if heavy, try to establish how heavy by inquiring about the frequency required for changing pads/tampons, number and size of clots, and the duration of flow. Recall that changing pads/tampons every 1 to 2 hours and consistently greater than 7 days’ heavy flow is likely excessive. If irregular, try to establish how irregular by inquiring about the longest and shortest intervals between menses. Recall that normal menses occur every 21 to 34 days and although it can take up to 3 years to establish a normal regular cycle, irregularity should prompt inquiry guided by the disorders listed in Fig. 1 . For both heavy and irregular menses, try to ascertain whether the girl is ovulatory by asking about molimina such as breast tenderness, cyclic mood changes, and cramping. If painful, try to establish whether the pain is consistent with physiologic dysmenorrhea and treatments tried and how they were used (discussed elsewhere in the article). If absent (amenorrhea), establish whether it is primary (never menstruated), or secondary (>90 days warrants assessment). Other important clues include the mother’s age at menarche, any history of pelvic pain, the subjective impression of pubertal progression, and any chance of pregnancy.



  • Review of systems using Fig. 1 or 2 as a guide looking for symptoms of endocrinopathy or syndromes such as dieting, thyroid imbalance, or PCOS.



  • Sexual history and need for contraception.



  • Traditional past medical history, past surgical history, medications, smoking/risk taking, allergies, and related family history.



Physical Examination


Depending on the presenting complaint, clinicians should use Fig. 1 or 2 as a guide when looking for physical stigmata of endocrinopathy or syndromes such as short stature (Turner syndrome), underweight (eating disorder), goiter (thyroid condition), and hirsutism/obesity (PCOS).


Physical Examination: Key Features





  • Height, weight, body mass index (BMI) (calculate percentage and plot on growth chart), blood pressure (especially if the patient is obese or has PCOS features, and/or if combined contraceptives [CCs] will be prescribed).



  • Secondary sexual characteristics/Tanner staging, if applicable.



  • Abdominal examination.



  • If menses are absent, introital examination must be included and consider single-digit vaginal examination. Is there a vagina, patent hymen, leukorrhea? Leukorrhea is suggestive of current estrogen.



  • Speculum examination is not always indicated (recall, Pap smear is no longer indicated in teens, and urine can be sent for some sexually transmitted infection [STI] screening).



  • If there is intermenstrual bleeding, and/or the girl is sexually active, consider a speculum examination, but, if the teen is precoital, choose a narrow speculum (if deemed necessary).



Investigations and Diagnostic Tools


It is hoped that, through history and physical examination, the differential diagnosis has been narrowed, but the clinician usually needs to choose from the following list of investigations to confirm or refute plausible conditions.


Investigations and Diagnostic Tools to Consider





  • Urine human chorionic gonadotropin (HCG)



  • Complete blood count, ferritin




    • Anemia might corroborate abnormally heavy flow and raise the suspicion of a bleeding disorder or add justification for treatment




  • Thyroid-stimulating hormone (TSH) (free T4), plus or minus prolactin



  • Follicle-stimulating hormone (FSH), luteinizing hormone (LH)




    • High (menopausal) gonadotropin levels confirm gonadal or ovarian insufficiency or failure (discussed elsewhere in the article). If LH and FSH are both less than 1 the clinician can be confident that the problem is hypothalamic or pituitary dysfunction, but often low normal values are difficult to interpret.




  • Ultrasonography pelvis.



  • Clinicians should individualize the need for cervix and/or vaginal swabs, and pregnancy testing. Although urine can be tested for gonorrhea and Chlamydia , Trichomonas requires a vaginal swab.




    • Examples of accessory testing to consider:




      • If functional or hypothalamic amenorrhea, PCOS, or bleeding disorder is suspected, see the relevant parts of this article outlining other warranted investigations.



      • If there are central nervous system (CNS) symptoms or hyperprolactinemia, consider brain imaging.



      • If there is gonadal insufficiency or failure, order karyotype and consider referral (pediatric endocrine, pediatric/adolescent gynecology, genetics).



      • If there is profound or marked hyperandrogenism/virilization, consider serum androgens plus or minus adrenocorticotropic hormone (ACTH) stimulation and imaging adrenals. This situation is likely to warrant referral (pediatric endocrine or gynecology).



      • If there is intractable dysmenorrhea or primary amenorrhea suggestive of müllerian anomaly, consider MRI pelvis and referral (pediatric/adolescent gynecology or gynecology).





Also consider referral (eg, gynecology, pediatric gynecology, pediatric endocrine, genetics hematology, psychiatry, as indicated) for:



  • 1.

    Delayed or arrested puberty


  • 2.

    True eating disorder or elite athlete


  • 3.

    Inherited bleeding disorder


  • 4.

    Complex or confusing scenarios in which investigations or response to traditional therapies are unsuccessful



For more detailed reviews of delayed puberty, primary ovarian insufficiency, and POF in adolescents see Refs.


Treatment (in General)


Table 1 presents a symptom-based chart of several useful medicinal treatment options that can be used and referred to by clinicians almost independent of underlying condition. The following list elaborates further on these treatment modalities and a series of questions is provided to help the clinician choose from the various reasonable medications for any particular menstrual complaint/symptom.


Treatment Options (in General)





  • Nonsteroidal antiinflammatory drugs (NSAIDs): ibuprofen, mefenamic acid, naproxen sodium, ketorolac



  • CCs: daily pill, weekly patch, monthly vaginal ring




    • Consider extended cycle: gradually increase the number of consecutive weeks between hormone-free intervals (HFIs), when either the HFI or the withdrawal bleed are still problematic.



    • Consider shortening the HFI when either the HFI or the withdrawal bleed are still problematic. For example, 4 days off instead of 7.




  • Cyclic oral progestins: 5 to 10 mg of medroxyprogesterone acetate or 200 mg of progesterone X for 10 to 14 days. These progestins can be used to induce a withdrawal bleed in teens whose menstruation is heavy and prolonged but infrequent. A single course can also be useful as a medical dilatation and curettage for isolated anovulatory bleeds that continue for several weeks.



  • Depomedroxyprogesterone acetate (DMPA) 150 mg intramuscularly every 10–13 weeks.




    • Informed choice about weight gain, side effects (including irregular bleeding or amenorrhea), bone density




  • Levonorgestrel intrauterine system (LIUS)




    • Patient must be properly selected and counseled



    • Adolescent age is not a contraindication to intrauterine device or system



    • Nulligravid patients may experience more cramping and higher expulsion rate




  • Antifibrinolytics: tranexamic acid 1 to 1.5 grams p.o. 3 to 4 times/d, aminocaproic acid 2 to 4 grams p.o. 4 to 6 times/d.



Consider referral when there are contraindications to CCs or for LIUS insertion.


When using Table 1 , ask:



  • 1.

    What are the symptoms of priority? Heavy? Irregular? Painful?


  • 2.

    What are the patient’s preconceived ideas about, and past successes/failures with, methods?


  • 3.

    Can the patient/family afford it? Is subsidy available?


  • 4.

    Will the patient adhere to or accept it (eg, would she take a daily pill or accept an injectable method)?


  • 5.

    Are there any contraindications (eg, CCs and migraines with complex neurologic features, LIUS and current STI cervicitis)?


  • 6.

    Are there any other noncontraceptive benefits to be exploited (eg, CCs and acne or hirsutism)?


  • 7.

    Does the patient also need reliable family planning/contraception? Private time with patient alone should be part of the routine to allow for open discussion and to reinforce healthy sexual choices and advise dual protection (advised).


  • 8.

    Does the patient also need an iron supplement?




  • Other key points/pearls (for treatment in general)



  • NSAIDs work best if they are taken proactively (and combined when necessary with acetaminophen).



  • CCs offer cycle regulation, reduced flow, reduced cramps, and reduced acne/hirsutism with a single medication, but teens and/or parents often have misinformation or misperceptions about safety and side effects that must be addressed to facilitate compliance/adherence. For example, confidently reassure that CCs do not cause significant weight gain or cancer.



  • If planning to use CCs in an extended cycle fashion, slowly increase the number of consecutive weeks between HFIs. Continuous use from the outset often involves persistent breakthrough bleeding that frustrates the teen and leads her to abandon the treatment plan.



  • There is still a role for DMPA in properly selected and fully informed adolescents.



  • Pelvic examination is not a prerequisite for hormonal methods (except intrauterine).


Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Oct 2, 2017 | Posted by in PEDIATRICS | Comments Off on Disorders of Menstruation in Adolescent Girls

Full access? Get Clinical Tree

Get Clinical Tree app for offline access