Menstrual disorders and abnormal uterine bleeding are common concerns of young women. Complaints include menses that are: too painful (dysmenorrhea), absent or occur irregularly (amenorrhea or oligoamenorrhea), or prolonged and heavy (menorrhagia, or excessive uterine bleeding). In providing optimal reproductive care, the medical provider must be able to distinguish between normal developmental patterns or symptoms requiring education and reassurance from pathologic conditions requiring prompt assessment and treatment. This article discusses the normal menstrual patterns seen in adolescent females and provides an evaluation and management approach to primary and secondary dysmenorrhea.
Key points
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The time between menarche and the establishment of ovulatory menstrual cycles is variable but may take as long as 2 to 4 years.
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Primary dysmenorrhea is a clinical diagnosis rarely requiring extensive diagnostic tests and is generally responsive to graded management using nonsteroidal anti-inflammatory drugs (NSAIDs) and combined oral contraceptives.
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Excessive uterine bleeding can be seen as a consequence of physiologic anovulation from an immature hypothalamic-pituitary-gonadal axis but when it occurs soon after menarche bleeding diathesis must be considered.
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When evaluating dysmenorrhea, the history and physical examination provide important clues to etiologic factors and guide the diagnostic evaluations that may be needed.
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Evidence is available to support the use of both NSAIDs and hormonal treatments for the management of primary dysmenorrhea.
Introduction
Menstrual disorders and abnormal uterine bleeding are common concerns that bring young women to the physician’s office. Complaints include menses that are too painful (dysmenorrhea), are absent or occur irregularly (amenorrhea or oligoamenorrhea), or are prolonged and heavy (menorrhagia, or excessive uterine bleeding). In providing optimal reproductive care to these adolescents, the medical provider must be able to distinguish normal developmental patterns or symptoms requiring education and reassurance from pathologic conditions requiring prompt assessment and treatment. This article is a discussion of the normal menstrual patterns seen in adolescent females with an evaluation and management approach to primary and secondary dysmenorrhea.
Introduction
Menstrual disorders and abnormal uterine bleeding are common concerns that bring young women to the physician’s office. Complaints include menses that are too painful (dysmenorrhea), are absent or occur irregularly (amenorrhea or oligoamenorrhea), or are prolonged and heavy (menorrhagia, or excessive uterine bleeding). In providing optimal reproductive care to these adolescents, the medical provider must be able to distinguish normal developmental patterns or symptoms requiring education and reassurance from pathologic conditions requiring prompt assessment and treatment. This article is a discussion of the normal menstrual patterns seen in adolescent females with an evaluation and management approach to primary and secondary dysmenorrhea.
Normal menstrual patterns in adolescents
Normal menstrual cycles require the maturation of the complex feedback system of the hypothalamic-pituitary-gonadal (H-P-G) axis. The mature system involves orderly and sequential release from the pituitary of luteinizing hormone (LH) and follicle-stimulating hormone (FSH), in response to gonadotropin-releasing hormone from the hypothalamus. This results in the growth and maturation of follicles in the ovary, oocyte maturation, and estrogen and progesterone secretion. In the initial follicular phase of a normal menstrual cycle, increasing levels of FSH stimulate the maturation of an ovarian follicle as well as the secretion of estrogen. Estrogen, in turn, stimulates endometrial proliferation. In an ovulatory midcycle, the rising level of estrogen switches from a negative feedback mechanism on both LH and FSH to a positive mechanism. The resulting surge of LH precipitates the release of an oocyte from a mature follicle. The second half of the menstrual cycle, the luteal phase, is characterized primarily by secretion of progesterone as well as estrogen by the corpus luteum formed by the residual follicle. This results in falling levels of FSH and LH, and some additional growth but also stabilization of the thickened endometrium. In the absence of pregnancy and implantation, after about 10 to 14 days, the corpus luteum involutes, and estrogen and progesterone levels decline, resulting in endometrial shedding, or menstruation. In most adult women, this cycle averages 28 days but can vary from 24 to 35 days and typically lasts 4 to 6 days.
Ovulatory menstrual cycles occur at varying rates following menarche. Within 2 years of menarche, 18% to 45% of female patients will have established regular ovulatory cycles. This increases to 45% to 70% by 2 to 4 years following menarche and to 80% by 5 years. Dysmenorrhea generally occurs during ovulatory cycles, explaining why most dysmenorrhea in adolescents usually has onset 6 to 12 months following menarche. Dysmenorrhea can occur less frequently, however, even with anovulatory cycles. Studies have shown that girls who experience menarche earlier generally establish ovulatory cycles within a shorter time than those girls whose menarche occurs later in age.
Before the establishment of ovulatory cycles, follicular development that does not result in ovulation still can produce levels of estrogen that stimulate endometrial proliferation. Eventually the negative feedback effect of this level of estrogen will reduce gonadotropins, resulting in falling levels of estrogen and a withdrawal bleed. In this situation, the lack of progesterone to stabilize the endometrium can result in cycles that are prolonged and excessive. This anovulatory excessive bleeding is physiologic and will usually resolve with maturation of the H-P-G axis and the establishment of ovulatory cycles.
Typical parameters for uterine bleeding considered to be excessive include a duration lasting more than 7 days, reports of perceived flow that is heavier than normal (quantified as more than 80 mL/cycle), cycles occurring less than every 24 days or more than 35 days, and any bleeding between normal cycles.
Dysmenorrhea, or painful menses, is a commonly experienced symptom in women of reproductive age. When severe enough, it can result in restrictions in normal functioning, such as attending school or work. There are 2 commonly defined categories of dysmenorrhea: primary and secondary. Primary dysmenorrhea refers to pain during menses in the absence of any specific pathologic state and is characterized by recurrent, crampy, bilateral lower abdominal pain. Secondary dysmenorrhea refers to pain during menses that can be explained by an organic pathologic condition or any disorder that is determined to be responsible for the reported symptoms of pain with menstruation.
Epidemiology
Dysmenorrhea is considered the most common symptom of all menstrual complaints, especially during middle and later adolescence. Prevalence rates range from 67% to 90% in young women between the ages of 17 and 24 years. A systematic review conducted by the World Health Organization (WHO) in 2006 found the prevalence of menstrual pain in reproductive-aged women to be between 17% and 81%. This review, however, found that severe dysmenorrhea was reported in only 12% to 14% of community-based samples of women in the United Kingdom. Despite that many of these studies use different populations and criteria for assessing the severity of symptoms, these ranges are similar to many previous studies and confirm the high prevalence of this symptom.
Risk factors for dysmenorrhea include younger age (<30 years), early age of menarche (<12 years), nulliparity, and low body mass index (<20). The higher rates of dysmenorrhea among women with a strong family history of dysmenorrhea have been postulated to be the result not only of genetic factors but also possibly through conditioned behavior learned from one’s mother or sisters or similar family lifestyles. Family history of dysmenorrhea, onset of menarche before age 12 years, and reports of irregular or heavy menstrual flow or longer duration of menstrual bleeding episodes have also been reported as increased risk factors for dysmenorrhea. A limited number of studies also suggest a positive association between depression and/or somatization and dysmenorrhea. The mechanism for this is poorly understood but it is postulated that mental distress can disrupt several neuroendocrine responses, such as impairment of follicular development, progesterone synthesis, prostaglandin activity, and adrenaline and cortisol release. A recent meta-analysis from Britain did not find significant differences in reports of dysmenorrhea by race or ethnicity, and no consistent data have been reported for obesity, alcohol or tobacco use, education, or marital status as risk factors.
Pathophysiology
Primary dysmenorrhea results from excessive production of prostaglandins at the time of ovulatory menses. In the second half of an ovulatory cycle, the withdrawal of progesterone from the normally involuting corpus luteum causes the release of phospholipids, in particular omega-6 fatty acids, which, in turn, are initially converted to arachidonic acid, and then to prostaglandins. This production of prostaglandin results in increased intrauterine pressure and abnormal uterine contractions. In addition, vasoconstriction of uterine vessels results in decreased blood flow, ischemia of the uterine muscles, and increased sensitivity of pain receptors, all of which cause pelvic pain. Endometrial blood flow has been shown to decrease during these uterine contractions, suggesting that the resulting ischemia is responsible for the pain. Prostaglandins are also converted to leukotrienes that, along with the prostaglandin F2-alpha, are also responsible for the systemic symptoms, such as nausea, vomiting, headache, and dizziness, that may accompany menstrual cramps. The requirement for ovulatory cycles to be present for primary dysmenorrhea to occur in part explains why most adolescents will not develop dysmenorrhea with initial menarche but may have pain after they have established more regular menses several months after menarche.
Patient evaluation overview
Primary dysmenorrhea generally coincides with onset of ovulatory cycles. Localized symptoms include lower abdominal pain or pelvic pain, with or without radiation to the lower back or thighs. The pain generally begins with the onset of the menstrual period and can last anywhere from 8 to 72 hours in duration. Additionally, common systemic symptoms are headache (59%), dizziness (28%), fatigue (67%), nausea (55%) or vomiting (24%), and back pain (56%).
As with any physical complaint referable to the genitourinary system in an adolescent, the evaluation of menstrual pain must include a comprehensive history as well as a physical examination with components determined by the history. This is important to rule out any possible pathologic causes for the menstrual pain, as well as to determine the best approach for management. In the sexually active female, it is essential to include a comprehensive sexual history, which is best done separately from the parents, to assure confidentiality of the information obtained.
Clinical assessment
History
The history should include questions in the following areas:
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Menstrual history
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Specific therapies attempted and their success
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Family history of dysmenorrhea
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Sexual history
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Review of systems (ROS) focusing on systemic, gastrointestinal (GI), genitourinary (GU), musculoskeletal, and psychosocial areas
Box 1 provides specifics areas in the history that need to be considered.
Menstrual history
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Age at menarche
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History and characteristic of menstrual cycles
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Interval between periods
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Typical duration of menses
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Nature of flow
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Dates of most recent menses: last menstrual period (LMP) and previous last menstrual period
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The pediatrician may need to educate the teen that the LMP begins on the first day of menses, and not on the last day.
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Pattern of menses (irregular vs regular)
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History of when menstrual pain developed following menarche
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Characteristics of menstrual pain (location, nature, timing related to onset of menses, duration, associated systemic symptoms, and severity)
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Extent of functional impairment of activities, such as school, work, typical activities
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Whether lower abdominal cramping is present at other times in the menstrual cycle
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Acuity or chronicity of reported pain
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Any therapies that have been used in the past and the response to these
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Including medications (types, specific doses and duration of treatment), conservative measures (heating pads, exercise) and complementary alternative treatments, such as supplement, herbal remedies, vitamins.
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Family history of dysmenorrhea
Sexual history
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History of sexual activity
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Age of coitarche
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Numbers of prior sexual partners
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History of any sexually transmitted infections
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Presence of dyspareunia
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Contraceptive use, presently and in the past.
ROS
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Probe for any systemic symptoms or symptoms that may indicate a pathologic cause of menstrual pain.
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Generalized systemic symptoms, such as fatigue, dizziness, or premenstrual physical or emotional symptoms
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GI symptoms, such as vomiting, diarrhea, pain on defecation, (these may be present in primary dysmenorrhea or may be seen in endometriosis)
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GU symptoms
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Musculoskeletal symptoms, particularly in the hip and pelvic are (to rule out possible trauma or tumor as cause of pain)
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Psychosocial history (to evaluate for substance abuse, especially tobacco smoking, and stress, anxiety, or history of sexual abuse).
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