Menstrual Disorders

83 Menstrual Disorders



Kamillah Wood, Sara B. Kinsman


Menstrual irregularity is one of the most common concerns that pediatricians address with their adolescent female patients. Being prepared to provide anticipatory guidance regarding the normal menstrual cycle will help ensure that adolescent females do not experience complications associated with dysfunctional uterine bleeding such as changes in lifestyle, anemia, hospitalization, and transfusions. When adolescent females and their caretakers are taught the risks of excessive menstrual flow, they may be more likely to call a pediatrician before an adolescent has developed a significant anemia. Teaching patients to keep a calendar of their menstrual cycles can help adolescent females to actively care for their own health and begin to communicate effectively with their providers about a number of related health topics, including dysmenorrhea, nutritional needs, and reproductive health needs.


Dysfunctional uterine bleeding (DUB) is menstrual bleeding that is not consistent with the expected timing or flow for average menstrual cycle. The normal menstrual cycle occurs every 28 days with a normal range from 21 to 35 days. Menstrual bleeding typically lasts 4 days with a normal range of 2 to 7 days. Typical blood loss is expected to be 30 mL of blood per cycle with the upper limit of normal being 80 mL per cycle. The average age for menarche in the United States is currently 12.3 years. Although anovulation is common in the first 12 to 24 months after menarche affecting approximately 50% of cycles, excessively frequent menses or high volumes of menstrual flow need to be managed carefully to avoid significant blood loss. Specifically, pediatricians can teach adolescent females and their caretakers that excess blood loss may result from when menstrual flow soaks more than six full pads or tampons per day, lasts for greater than 7 days, and occurs more frequently than every 21 days.



Eitology and Pathogenesis


The most common cause of DUB in young women is anovulation. A normal menstrual cycle starts on the first day of menstruation and begins with the follicular phase. During this phase, a developing ovarian follicle synthesizes estrogen, which promotes endometrial growth and proliferation. As estrogen levels continue to increase, estrogen provides positive feedback centrally to the pituitary gland, causing a surge in luteinizing hormone (LH) excretion. This results in release of the ovum from the follicle. The follicle forms the corpus luteum and the beginning of the luteal phase. Estrogen levels decrease, and the corpus luteum begins to produce progesterone. The progesterone promotes stabilization of the endometrial mucosa as well as glandular changes within the endometrial wall to provide an environment for implantation of a fertilized ovum. Without implantation, the corpus luteum cannot maintain production of progesterone, leading to sloughing of the endometrial lining or menstruation approximately 14 days after ovulation.


Anovulatory cycles result when the increase in estrogen during the follicular stage does not result in a surge of LH and therefore ovulation cannot occur. Because the endometrium is mainly exposed to estrogen without progesterone, it can become highly thickened, resulting in heavy, prolonged, or unsynchronized sloughing of the lining (Figure 83-1).


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Figure 83-1 Neuroendocrine regulation of menstrual cycle.



Clinical Presentation


The pediatrician should take a detailed history, including questions regarding the degree and pattern of vaginal bleeding. Asking these questions of the adolescent with the caretaker present can be helpful. Sometimes a dialogue between the adolescent and her caretaker may facilitate a fuller understanding of her bleeding pattern. Questions should include the age of menarche, the duration and amount of bleeding associated with the first few menses, the duration of menstruation subsequently, frequency, the color of menstruation, the presence of clots in the menstrual discharge, the number of pads or tampons used daily, and any need to change pads or tampons during the night. The presence of dysmenorrhea will also be helpful. Despite careful history taking, most adolescent and adult females cannot accurately account for the total amount of blood loss; however, aspects of this history will still inform the pediatrician’s laboratory evaluation.


In a confidential setting, the pediatricians should ask the adolescent directly about her sexual history, including consensual and nonconsensual sexual intercourse, history of sexually transmitted diseases, use of hormonal contraceptive methods or intrauterine devices (IUDs), and history of pregnancies or abortions. Questions of physical or sexual abuse are important, although adolescent females may need to be reminded that pediatricians are mandated reporters and will need to ensure the adolescent’s safety by reporting history of abuse to other helping adults.


The review of systems can assess for the presence of other etiologies that could cause DUB. The report of weight changes, oral lesions, or dental decay may raise concern for an eating disorder; visual changes, headaches, and galactorrhea may raise concern for a prolactinoma; acne, hirsutism, acanthosis nigricans, and obesity may raise concern for polycystic ovarian syndrome (PCOS); and nosebleeds, bruising, or petechiae may raise concern for bleeding dyscrasias.


The family history should include information regarding the history of heavy or prolonged menses, chronic anemia, bleeding disorders, PCOS, and endocrine disorders such as thyroid disease.


The pediatrician will also be interested in medication use, even those that a caretaker may not be aware of such as an oral contraceptive pill (OCP), IUD, or excessive aspirin use.


For the general physical examination, close attention to vital signs may reveal tachycardia or have orthostatic hypotension associated with severe anemia. In addition, the pediatrician should document visual field testing; thyroid enlargement; the presence or absence of galactorrhea; signs of androgen excess; and signs of extramenstrual bleeding, including bruising and petechiae.


The external genital examination can identify pubertal Tanner staging, clitoromegaly, and heavy ongoing vaginal bleeding that may be due to trauma or malodorous discharge that may be associated with a retained foreign body or anatomic abnormality. For young and nonsexually experienced adolescents, a pelvic examination may not be indicated or possible in the pediatrician’s office. If no significant concern for acute vaginal tear, foreign body, or anatomic etiology is present, the pelvic examination can be deferred.


For adolescents who are sexually active, direct observation of the source of bleeding from the vaginal mucosa or cervix may be helpful. Cervical testing for gonorrhea and chlamydia can be obtained. With a bimanual examination, the clinician can also assess the degree to which the adolescent is experiencing cervical motion tenderness, uterine tenderness, or pelvic fullness.


Laboratory evaluation should begin with a urine pregnancy test and complete blood count and differential. If there is a concern for a coagulopathy, prothrombin time, partial thromboplastin time, and a von Willebrand panel are indicated before starting hormonal treatment. Consultation with a hematologist may facilitate a comprehensive assessment of bleeding disorders. Endocrine evaluation, including thyroid-stimulating hormone, serum prolactin, free testosterone, FSH, LH, and estradiol can be helpful.


Ultrasonography is useful in adolescents who cannot undergo a full speculum examination and is indicated for adolescents who are pregnant or for whom an anatomic abnormality is suspected. Pelvic ultrasonography will be more sensitive than most pediatricians’ examination to exclude an anatomic abnormality.

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Jun 19, 2016 | Posted by in PEDIATRICS | Comments Off on Menstrual Disorders

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