Introduction
The menstrual period is a key marker of health. In fact, many professional medical organizations recommend that the menstrual cycle be considered a vital sign, as timely identification of abnormal menstrual patterns can assist in early identification of potential health issues. Treating menses as a vital sign also highlights its importance and significance to patients, caregivers, and other health care providers.
Despite the fact that 1.8 billion people across the world menstruate each month, stigma around periods still exists. Gender inequality, discriminatory social norms, cultural taboos, poverty, and lack of basic services like toilets and menstrual products can cause menstrual health and hygiene needs to go unmet. Practitioners play an important role in reducing stigma and increasing sexual and reproductive health education by providing holistic care when it comes to assessing menstrual health. This chapter will review what is considered a “normal” menstrual cycle in adolescence and will share practical tips on how to take a complete, holistic menstrual history. Situations considered out of the range of normal will also be discussed.
Physiology
Fig. 8.1 describes the normal physiology of the menstrual cycle.
What’s “normal” for adolescents?
Menarche
The age of menarche varies globally. Many variables have been identified as potential contributors to the timing of menarche; for example, higher weight/body mass index (BMI), more robust nutritional status, and higher socioeconomic status have all been linked with earlier onset of menarche around the world. Physical activity, sleep quality, and emotional stressors may also be important contributors to pubertal timing. Onset of both puberty and menarche appears to occur later in lower-income countries (LICs), likely secondary to suboptimal nutritional status. , , The median age of menarche across well-nourished individuals in high-income countries (HICs) has been relatively stable for several decades, at 12.4 years of age ( Table 8.1 ). Interestingly, new data show a possible trend to a lower median age of menarche of 11.9 years of age. Studies have also shown that Black adolescents begin puberty and menstruation earlier than their White peers, whereas Latinx youth have menarche between the two. The effect of structural racism on age of menarche has not been well researched and should be prioritized. ,
| Menarche |
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| Menstrual Cycle Interval |
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| Menstrual Flow Length/Volume |
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a Adapted from references , , .
Cycle length
Menstrual periods are often irregular in adolescents in the years after menarche. The positive stimulatory feedback mechanism of estrogen on luteinizing hormone (LH) does not mature until 2 to 5 years after menarche, which can lead to irregular periods. In general, cycles become more regular after 2 to 3 years post menarche with 50% to 80% of the cycles being anovulatory and irregular during the first 2 years after menarche. That said, 10% to 20% of cycles remain anovulatory up to 5 years after menarche. 
A menstrual cycle length between 21 and 45 days (mean 32 days) during adolescence is considered normal (see Table 8.1 ). The length of the interval between the onset of menses and the establishment of ovulatory cycles is associated with the age of menarche; those who are younger at the time of menarche achieve regular ovulatory cycles in a shorter period as compared with those who experience later menarche. For example, in those who undergo earlier menarche (i.e., less than 12 years old), 50% of their cycles are ovulatory within the first year of menarche, and almost all of their cycles are ovulatory by year 5 post menarche, whereas it can take over 5 years for all cycles to be ovulatory in individuals who had later-onset menarche.
Menstrual blood flow/volume
Individuals experience different amounts of vaginal bleeding during their menstrual periods, and quantifying volume of blood loss can be challenging. The average blood loss during the menstrual period is 40 mL (normal range between 25 and 69 mL), and blood loss >80 mL per period is considered heavy menstrual bleeding (HMB). A regular disposable tampon or pad fully soaked holds approximately 5 mL of blood, whereas an extraabsorbent tampon/pad holds about 10 mL. Those using menstrual cups can more easily measure blood loss. The absorbency of reusable period underwear has not been well established. It is important to note that HMB at menarche can be the presenting sign for teens with inherited bleeding disorders; coagulopathies are found in 20% of patients presenting with HMB. Heavy bleeding can also seriously affect an adolescent’s quality of life from a physical, social, emotional, and material point of view. , ,
Other symptoms
It is considered “normal” for individuals to have some associated symptoms sometimes before or during their period. Many individuals have dysmenorrhea—recurrent, crampy lower abdominal/pelvic pain that occurs during menses. The majority of dysmenorrhea in adolescents and young adults is primary and is associated with a normal ovulatory cycle and no pelvic pathology. Primary dysmenorrhea is mitigated by prostaglandin release and prostaglandin-mediated uterine contractions. Menstrual cramps may also be affected by volume of blood flow. Although everyone’s experience varies, some common symptoms reported are lower back pain, bloating, sore breasts, headache, changes in bowel habits, fatigue, and mood swings. 
Even if symptoms reported are considered “normal” or nonpathologic, any individual with period complaints needs to be supported and treated appropriately. Periods need not interfere in someone’s functioning. Table 8.1 and Table 8.2 describe “normal” vs. “abnormal.”
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Period tracking
Adolescents should be encouraged to track their menstrual periods in some form, whether it be on a paper calendar or journal or electronically. This allows the individual and their health care provider to note patterns in cycle interval length, total bleeding days, amount of bleeding, and any other symptoms they want to better understand in relation to their menstrual cycle. Many patients use electronic apps to track their menses. Some apps can track a multitude of things ranging from premenstrual syndrome (PMS) symptoms, cycle length, menstrual flow, sexual health, and fertility. Although these apps can help teens track important variables for their menstrual health, practitioners should be aware of the potential privacy concerns. There are also reports that some apps allow parents and peers to track a teen’s data without their knowledge. If they choose to use a period-tracking app, it is essential that adolescents research the security features to ensure that their personal health data are not being collected, shared, and/or sold without their explicit consent.
Period products
Many menstruators around the world do not have the luxury of choice when it comes to period products. For those who do, many factors contribute to their decision making ( Table 8.3 ), including product cost. Period poverty—the financial and material barriers to accessing menstrual products—affects nearly a quarter of all students in the United States. It is essential that practitioners are sensitive to their patients’ social and financial circumstances and understand how this may affect their menstrual hygiene practices.
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