Blood Sweat and Tears: Challenging GYN Cases Eliza Buyers, MD

Transcription

5/5/15
Blood, Sweat, and Tears: Challenging
Gynecology Cases
Colorado AAP Annual Meeting
May 8th, 2015
Eliza Buyers, MD, FACOG
Pediatric and Adolescent Gynecology
Children’s Hospital Colorado
Disclosures
•  Eliza Buyers is a Merck Nexplanon trainer.
Learning Objectives
•  Initiate work up and management of common
adolescent gynecologic issues including:
evaluation and management of dysmenorrhea and
abnormal uterine bleeding, and contraindications
to contraception or therapies that contain
estrogen.
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Case #1: Chloe
15 year old with painful periods (10/10 pain). Has
tried a heating pad, ibuprofen with little relief.
Misses 1-2 days of school each month.
•  Medical History
•  Gynecologic History
•  Age of menarche/ interval/ duration
•  Pain/cramps - 1-10 scale
•  Timing of pain ! before/with periods only
•  Amount of bleeding - product use
•  Associated symptoms (n/v/d…), other (acne, breast pain…)
•  Impact on activities -> school attendance
•  H.E.A.D.S.S.
• Depression, suicidality, self-harm, anxiety -> “stress”
• Sexual history (including pain, abuse)
• Substance use, eating disorder?
-Social history is for diagnosis, but also can guide treatment.•  ROS: GI and GU, other; Family history
•  What has been tried?: Exercise, heat, NSAIDs, lifestyle changes…
Dysmenorrhea
•  Pain begins before or with bleeding, lasts 1-3 days.
•  Usually does not occur until cycles are ovulatory; but, can
occur with any bleeding especially if heavy.
•  Can have associated nausea, vomiting, diarrhea, headache,
dizziness, back pain.
•  Occurs in 60-93% of teens.
Primary: recurrent lower abdominal pain that occurs during
menstruation in the absence of pelvic pathology.
Secondary: painful menstruation in the presence of pelvic
pathology.
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Differential Diagnosis: Dysmenorrhea in Teens
GYN
• Endometriosis
• Ovarian cyst
• STD, PID (new/current, or old/adhesions)
• Adenomyosis; fibroids; obstructive anomaly; Copper IUD use,
Chronic Pelvic Pain, other GYN
★ Non-GYN ★ (along with GYN causes, or on their own)
• Musculoskeletal, Neurogenic
• GI: Appy, Constipation, IBS, Celiac, Lactose intolerance…
• GU: UTI, other
Many other GYN and non-GYN causes of cramping pain…
Ø Can diagnose as (primary) dysmenorrhea once these excluded.
Ø Diagnosis usually by history alone, AND response to treatment.
Treating Menstrual Problems
Ø Lifestyle, heat, OTC NSAIDs.
Ø First-line medical therapy: hormonal (progestin effect).
²  Significant barrier: labeled/marketed as birth control.
•  Key message- this is medical therapy.
OK to
stop
periods!
EFFECTIVE
Treatment
Won’t
have sex
sooner
Conditions Treated By Hormonal Therapy
Painful periods
Chronic pelvic pain
Heavy periods
Acne
Irregular bleeding
Hirsutism
Infrequent periods
PCOS
Breast pain
Menstrual headaches
Prevention of Ovarian CA
Things made worse on menses
Prevent Endometrial CA
Patient preference
Ø Key message: medical therapy.
§ Teens and OCPs: non-contraceptive purpose (82%) more
common than pregnancy prevention (67%).*
§ 33% of teens use OCPs only for only non-contraceptive
reasons. (Compare to 14% (1.5 million) of all aged women)
*Jones, 2011.Beyond Birth Control:The Overlooked Benefits of Oral Contraceptive Pills. Guttmacher Institute.
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Follow-up Question
•  Chloe is 15 years old. If she came to see you with
the same concerns when she was only 12 years
old, what would you do?
Consider:
•  Menstrual age
•  Impact on school/activities
•  Benefit of treatment (= highly effective) vs. risks of
treatment (?) vs. no treatment.
Oral Contraceptive Pills
Differences in Pills: very few
Which pill?
§  Significant differences in side-effects (of “modern,” <35 ug EE)
not supported by randomized, double-blinded studies.
§  Reassure and educate – OK to switch (analogy: toothpaste).
Other Considerations
• 3rd generation progestins are less-androgenic (more
improvement in acne), less weight gain & bleeding irregularity.
• Issues of ? Increased VTE risk with 3rd generation pills:
²  Healthy, non-OCP users: 1-4 per 10,000 women years.
²  OCP users: 3 - 9 per 10,000 women years.
²  Likely higher end of range for 3rd generation progestins.
• Are ultra-low dose estrogen (20ug, 10ug EE) pills safer?
•  Good question, see above for VTE risk counseling.
Oral Contraceptive Pills: Examples
What can vary…
Example(s)
Estrogen Dose
• All “low dose”, or < 35 ug
• Ultra low dose (20, now 10)
Sprintec contains 35 ug EE
Levora or Seasonique contains 30 ug EE
Aviane contains 20 ug EE (very low dose)
Lo Lo-estrin contains 10 ug EE
Type of Progestin
• 11 available,
• 3 (or 4) “generations”
• 3rd gen: less androgenic
(1) Norethindrone: Microgestin/Lo-estrin 1/20 or 1/35
(2) Levonorgestrel: Levora, Seasonique, Aviane
(3) Norgestimate: Sprintec (3) Desogestrel: Reclipsen
(4) Drospirenone: Yaz, Yasmin
Progestin Dose
Depends on potency of progestin used
Monophasic Formulation
E/P dose same in each pill
Aviane (LNG/EE), Microgestin, Levora, Sprintec
Triphasic Formulation
TriSprintec (Norgestimate/EE) E+P dose varies each week
Regimen (#Active/#Placebo) Traditional pills: 21/7
21/7, 24/4, 84/7 (Seasonique) Placebos may have iron, or low dose estrogen
Continuous (Lybrel: LNG/EE)
★Any pill OK for extended or continuous use★
Progesterone only pill (“mini-pill”): Nora-Be 0.35mg, Mirconor (norethindrone)
Progesterone tx (not packaged as “a pill): norethindrone acetate (Aygestin)– usu. 5mg
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Oral Contraceptive Pills
Ø  Use Quick Start (= start now, today)
Ø  Dispense 3 months, refill 2 years
Ø  Consider picking 1-2 generics as your “go to” OCP.
•  Examples:
• 
• 
• 
• 
Sprintec (35ug EE, norgestimate)
Apri (30ug EE, desogestrel)
Seasonique (30ug EE, levonorgestrel)- extended dosing
Aviane (20 ug EE, levonorgestrel)
Ø Option of extended/continuous dosing with any pill.
Ø Expect breakthrough bleeding; always option to adjust.
Case #2: Alyssa
15 year old with 2 years of heavy
and irregular bleeding.
Periods are sometimes every 2 weeks, but has also
gone 4 months with no period.
Bleeding lasts 3 days - 6 weeks. Flooding at times.
•  BMI is 98th percentile.
•  Acne on face and back is bothersome.
•  Family history of obesity and Type 2 DM.
What’s a Normal Menstrual Period?
AAP & ACOG. Menstruation in girls and adolescents: using
the menstrual cycle as a vital sign. Pediatrics, 2006.
Menarche (median age)
12.43 years
Cycle interval
Typically 21-45 days
Flow length
≤ 7 days
Product Use
3-6 pads or tampons per day
Too much?
•  Check CBC. (ferritin)
•  If history concerning
and/or anemia->
work-up bleeding d/o.
Too frequent, infrequent, chaotic?
Ø  This is anovulatory bleeding!
§ Is there a reversible/treatable
cause of anovulation?
§ Anovulation is also the cause of
amenorrhea.
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Menstrual Cycle
Ovulatory
•  Until ovulation: endometrium is exposed to estrogen alone
(proliferation, proliferative phase).
•  After ovulation, combination of estrogen and progesterone.
•  No pregnancy, estrogen and progesterone fall -> menstruation.
Anovulatory
Ø  No ovulation, no progesterone: continual endometrial
proliferation (=> AUB, or amenorrhea).
Ø  Continuous OCP’s, continuous progestin: over time, induces
thin, atrophic endometrium.
Abnormal Uterine Bleeding
Terms that describe patterns or bleeding and indicate
ovulatory dysfunction:
•  Abnormal uterine bleeding associated with
anovulation: more often than every 21 days, excessive
amount, or excessive length (>7 d).
•  Oligomenorrhea: cycles are 45-90 days apart.
•  Amenorrhea: primary- no period by age 15, or >3 years
since breast development; secondary - > 90 days without
a period.
Management of abnormal uterine bleeding associated with ovulatory dysfunction.
Practice Bulletin No. 136. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2013;122:176–85.
Abnormal Bleeding in Teens: Basic Evaluation
More Common Causes (anovulation), NOT a Complete List!
Pregnancy
Physiologic/ immaturity HPO axis
Hypothalamic (stress, exercise, eating d/o)
Urine HCG
History and exclusion of
other causes
HISTORY
Thyroid dysfunction
TSH
Hyperprolactinemia
Prolactin
PCOS – 2 years post-menarche
-consider-
•  Medications ! Anatomic causes
•  Ovarian insufficiency (few/no periods- consider FSH)
•  Poor controlled DM, Cushing’s, Late-onset Congenital Adrenal
Hyperplasia, ovarian/adrenal tumor; prolactinomas, other pit. tumor.
Ø If prolonged and/or heavy: Check CBC, consider ferritin.
•  Helps guide need for treatment (along with impact on QOL).
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Lab Evaluation
•  TSH
•  Prolactin
Physical Exam and History
•  Total & free testosterone
•  Height, Weight
•  DHEAS
•  Menstrual history
•  Androstenedione
•  Hirsutism, Acne, Pubertal exam •  17 OH progesterone
•  LH/FSH
•  Family history of diabetes
+ Labs for Obesity
PCOS Review
Ø No universally accepted definition of PCOS and several expert
generated diagnostic criteria.
§ NIH criteria; need both 1) hyperandrogenism and 2)
oligomenorrhea/amenorrhea to make diagnosis.
§ All approaches exclude secondary causes of
hyperandrogenism and ovulatory dysfunction.
§ Diagnosis very difficult in adolescents because overlap with
normal physiology, and no definitive diagnostic profile.
Follow-up Question
Alyssa has failed life style interventions for several years. She
is also very against being on any form of birth control for
religious purposes. She denies sexual activity.
What is the next step in the management of this patient?
1) If she goes > 3 months without a period, give a progestin
withdrawal to protect her endometrium.
2) Continue to support her through diet and lifestyle
interventions.
3) Discuss the use of metformin.
4) All of the above are reasonable options.
PCOS Treatment in Teens
§ Ovulatory dysfunction (AUB, or oligo/amenorrhea)
²  Risk of endometrial hyperplasia (cancer)- now & future.
•  Progestin (OCP, or in other form) is protective.
•  Minimum: progesterone withdrawal q 3 months.
§ Acne- OCP (3 months for results), other acne tx options.
§ Hirsutism - hair removal, OCP (6 mo for result), spironolactone.
§ Screen for Depression - high comorbidity.
§ Future fertility: counsel that great options if needed when wants
kids. Contraception now.
§ Metabolic risk (DM, CVD, Sleep apnea, Fatty Liver, HTN…)
²  10% loss of body weight results in significant sx improvement.
²  Consider metformin in addition to lifestyle changes.
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Follow-up Question
Alyssa did not use the progestin as prescribed and after 4
months of amenorrhea, she started to bleed heavily.
Last week she was seen in the ER; her previously normal
hematocrit was now 28 and she was started on “an OCP taper”
which she agreed to use due to the anemia.
She is here to see you today because she is still bleeding on
OCP’s. What option can be used to manage her bleeding?
1)  Restart the “OCP taper”
2)  Use an OCP along with norethindrone acetate
3)  Option 1 or option 2
AUB (Due to Anovulation) Treatment
“The endometrium that develops in the milieu of unopposed estrogen is fragile, vascular,
and lacking sufficient stromal support. As one area of bleeding begins to heal, another area
begins to slough, which results in erratic bleeding patterns.”
•  No randomized trials evaluating use of progestin and/or OCPs for
bleeding associated with anovulation. (Cochrane 2012)
•  OCP’s (v. placebo) improved menstruation and physical functioning in
women with DUB. (Ob Gyn 2000)
•  Levonorgestrel IUD has been shown to be effective in treating AUB.
(JAMA 2004)
Recommendations:
Ø Diagnose and address underlying cause of anovulation if possible.
Ø Hormonal therapy (progestin) is mainstay of treatment: OCPs, OCP
“taper,” OCP+ progestin, progestin alone are all options…
Ø If still bleeding: stress compliance (and try more progestin).
Ø Bleeding after “long term” progestin use? Atrophy may be cause, so
can try additional estrogen; If on OCP’s, take 5 days break.
Case #3: Michaela
Healthy 14 year old with severe
dysmenorrhea and moderate acne. Not
sexually active.
Wants OCP’s to manage these
concerns.
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Follow-up Question
Before starting OCP’s, you counsel Michaela about the small
but known increased risk for DVT/VTE with all OCP (and patch,
ring) use.
Which of the following family history would prompt you to offer
(not just discuss) testing for a hereditary thrombophilia?
1)  Dad is known to have Factor V Leiden.
2)  Dad had a DVT at age 45 after a knee replacement.
Thrombophilia testing never done.
3)  Family history unknown because patient is adopted, so
recommend testing.
Screening for Thrombophilia
Before Starting OCP’s
Ø It is not recommended to test all prospective users.
§  I.e., do not routinely test if history is unknown.
§  “Strong” family history?: no evidence-based recommendation to
test if affected relative is not sibling or parent.
Ø Consider/discuss testing if there is a first-degree relative with
DVT or thrombophila (Factor V Leiden, Prothrombin 20210, and
beta-2 glycoprotein).
Ø However, a negative thrombophilia test result does not
exclude an increased risk of VTE as the risk can be increased
in unaffected family members as well as in those affected.
Ø In many instances an alternative effective contraceptive is
acceptable and thrombophilia testing is unnecessary.
U.S. Medical Eligibility Criteria (USMEC)
Is this a safe option?
•  CDC convened experts to adapt the WHO criteria for safe
contraception use to U.S. standards of care and best evidence.
•  > 60 medical Conditions on 2 pages:
•  Green 1,2 = OK to use
•  Red 3,4 = don’t use
•  Note: it’s mostly green
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USMEC: Estrogen-containing Methods (“CHC”)
2 : Advantages generally outweigh theoretical or proven risks
•  Family history of first degree relative with VTE
3 Theoretical or proven risks usually outweigh the advantages
4 Unacceptable health risk (method not to be used)
•  Personal history of thromboembolic disease
•  Known thrombogenic mutations
•  Migraine with aura
•  Less than 3 weeks post-partum
•  Lupus with vascular disease, nephritis, + APA antibodies
•  Ischemic heart disease, CAD, congestive heart failure
•  DM with vascular complications
•  Uncontrolled, severe HTN
•  Poor liver function
•  Complicated organ transplantation
•  Current, active gallbladder disease
VTE Risk
One approach:
Ø  Discuss that non-users have a risk of VTE.
Ø  Use of OCP increases risk of VTE. Don’t use USMEC Category 3&4.
Ø  Overall risk very, low - especially in healthy teens.
Ø  As with any treatment, benefits need to outweigh risks.
Risk of venous thromboembolism among users of drospirenone-containing oral
contraceptive pills. Committee Opinion No. 540. ACOG. Obstet Gynecol 2012;120:1239–42.
Summary
Ø The menstrual cycle is a vital sign.
Ø Primary dysmenorrhea: pain occurs with period, and pain is
absent when menses is suppressed.
Ø Abnormal Uterine Bleeding
•  In teens, usually due to anovulation.
•  Check urine HCG. Get a good history. Consider TSH and
Prolactin. Consider PCOS, metabolic factors.
Ø There are some contraindication to estrogen-containing
contraception; very few to progestin-only options.
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Patient questions, resources,
feedback…any reason:
Eliza Buyers, MD, FACOG
direct/cell: 720-272-2886
patient scheduling: 720-777-2667
[email protected]
[email protected]
Pediatric and Adolescent
Gynecology Team
At Children’s Colorado
Stephen Scott
Tricia Huguelet
Eliza Buyers
11
Hormone Therapy for Period Problems
What are the options for dealing with my periods?
Many girls and teens have problems with their menstrual periods. Sometimes periods are painful,
cause heavy bleeding, or are very irregular. Sometimes periods can interfere with a girl’s normal activities like sports or school. The good news is that there are safe and effective options to
manage this problem.
Hormonal therapy is a first-line, medical option for treating painful, heavy, or irregular periods.
It is also safe and effective for girls and teens. These options are packaged as “birth control” but
your provider is recommending them to treat your medical condition.
Here are the most important hormonal options for treating menstrual problems. Based on your
specific situation, we may recommend certain one(s) today.
Comparing medical choices to treat heavy, painful, or irregular periods:
Treatment Choice
How to Use
Pill
Take 1 pill every
day
Vaginal Ring
Change every
month
Skin Patch
Depo-Provera
Progestin IUD
Implant
Change every week
What to expect after the first 3-6 months
• Lighter and regular periods.
• Less cramping and less pain.
• Clearer skin.
• No weight gain.
• Can be used in a certain way to have a period
only every 4 months, or to have no periods at all.
Shot every 3
months
• Lighter or no periods after 6-9 months of use.
• May cause increased appetite.
Doctor places inside
the uterus. IUD
works for 5 years.
• Lighter or no periods.
• No weight gain.
Doctor places under
skin of arm.
Implant works for
3 years.
• May have no periods, or irregular bleeding.
• No weight gain.
Birth Control Pills (also known as “the pill”): The pill contains the same hormones made by the female body: estrogen and progesterone.
The hormones in the pill 1) prevent an egg from being produced, and 2) keep the lining of the
uterus thin. These effects reduce pelvic pain, cramping, and bleeding. There are many brands
of pills available, but all of them have these positive effects.
The pill also can be taken in such a way as to have fewer periods (for example, a period every
3 months), or so there are no scheduled periods at all. Reducing or eliminating periods is a safe
option when using hormonal therapy.
The pill also has other benefits. It regulates the menstrual cycle. It improves acne, and it can
help prevent the growth of unwanted hair on the face and body if that is an issue for you. The
pill also prevents uterine and ovarian cancer. The pill has no effect on your future fertility (the
ability to have a baby later on) and does not cause weight gain.
The vaginal ring and the contraceptive patch contain the same medicine in birth control pills
and work in the same way. The ring needs to be changed once per month. The skin patch is
changed once every week.
Depo-Provera:
This medicine contains only the hormone progestin. It works to prevent ovulation and
also makes the lining of the uterus very thin. There may be bleeding during the first few
weeks or months of using Depo, but, with its continued use, it is very likely that there will
be no menstrual bleeding at all. This is a safe and expected benefit of Depo. For this
option, you will need to come into your provider’s office every 3 months for a quick and easy injection.
Levonorgestrel IUD:
The IUD sits inside the uterus and releases a small amount of the hormone progestin. This IUD
is a very effective treatment option for women of all ages who have pelvic pain, cramps,
and/or heavy bleeding; it works for 5 years, but can be removed at any time. There may be
some irregular bleeding during the first 3-6 months, but then periods are lighter, shorter, or
may go away altogether. The IUD is inserted during a pelvic exam; the procedure takes only a
few minutes and can cause some temporary discomfort. Current IUDs are designed very
differently than those of the past, and so this is a safe and effective option for teens of any age.
The Sub-Dermal Implant: The implant is a toothpick size device that goes under the skin of
the upper, inner arm. It releases the hormone progestin, which stops ovulation and makes the
lining of the uterus very thin. It lasts for 3 years but can be removed at any time; it is very
quick and easy to insert. Some teens will have infrequent or no bleeding with the implant, but
some will have more frequent and unpredictable bleeding. The change in menstrual bleeding is
expected and is not dangerous when using this option. There are ways to treat the bleeding that
occurs while using the implant if needed.
Please talk to us about any concerns that you may have. We can help you find the best option for
now and make changes if needed. With your help, we are confident that we can help safely and
effectively manage this medical problem.
Pediatric and Adolescent Gynecology: 720-777-2667
____________________________________________________________________________________________________________________
Eliza Buyers MD, FACOG; Stephen Scot, MD; Patricia Huguelet, MD
Pediatric & Adolescent Gynecology
January 2013
Approved by the Patient Family Education Committee
©2013 Children’s Hospital Colorado, Aurora, CO
childrenscolorado.org • Anschutz Medical Campus • 13123 East 16th Avenue • Aurora, CO 80045 • 800-624-6553
Article
genital system disorders
Menstrual Disorders
Susan Hayden Gray, MD*
Author Disclosure
Dr Gray has disclosed
no financial
relationships relevant
to this article. This
commentary does
Practice Gap
1. Dysmenorrhea, amenorrhea, and abnormal vaginal bleeding affect the majority of
adolescent females, impacting quality of life and school attendance. Patient-centered
adolescent care should include searching for, assessing, and managing menstrual concerns.
2. Polycystic ovary syndrome (PCOS) is the most common endocrinopathy in young
adult women, and pediatricians should recognize, monitor, educate, and manage their
patients who fit the medical profile for PCOS based on any/all of the three sets of
diagnostic criteria.
contain a discussion of
an unapproved/
investigative use of
a commercial product/
device.
Objectives
After reading this article, readers should be able to:
1. Define primary and secondary amenorrhea and list the differential diagnosis for each.
2. Recognize the importance of a sensitive urine pregnancy test early in the evaluation of
menstrual disorders, regardless of stated sexual history.
3. Know that polycystic ovary syndrome is a common cause of secondary amenorrhea in
adolescents and may present with oligomenorrhea or abnormal uterine bleeding.
4. Recognize that eating disordered behaviors are a common cause of secondary amenorrhea
and irregular bleeding, and treatment of the eating disordered behavior is the best
recommendation to ensure resumption of regular menses and long-term bone health.
5. Know the differential diagnosis of abnormal uterine bleeding and describe the
preferred treatment, recognizing the central importance of iron replacement.
6. Understand the prevalence of primary dysmenorrhea and its role in causing recurrent
school absence in young women, and describe its evaluation and management.
7. Understand the need for discussion of menstrual and reproductive health with young
women who have special health-care needs and their families.
The onset of menstruation in young women is a milestone with personal, cultural, and
medical ramifications. Menarche heralds the onset of fertility, which can be cause for both
celebration and trepidation for the patient, her family, and
clinicians. It behooves both general and specialist pediatricians to be comfortable discussing what is normal and what
Abbreviations:
is not normal about menstruation. Young women who have
special health-care needs and their families deserve particular
AIS:
androgen insensitivity syndrome
attention. Both the American Academy of Pediatrics and the
DHEAS: dehyroepiandrosterone-sulfate
American College of Obstetricians and Gynecologists enFSH:
follicle stimulating hormone
courage pediatricians to think of menstruation as a “vital
GnRH: gonadotropin-releasing hormone
sign” for women. (1)(2) Irregular, absent, or overly painful
IUD:
intrauterine device
periods should be evaluated, closely monitored, and manLH:
luteinizing hormone
aged proactively.
MRKH: Mayer-Rokitansky-Küster-Hauser syndrome
NSAID:
OCP:
PCOS:
TSH:
nonsteroidal anti-inflammatory drug
oral contraceptive
polycystic ovary syndrome
thyroid stimulating hormone
Patient-Centered Care of Menstrual Disorders
In both the evaluation and treatment of menstrual disorders,
it is critical to keep in mind the patient’s perspective on her
symptoms. It is extremely valuable to hear from the patient
*Clinical Instructor in Pediatrics, Harvard Medical School; Attending Physician, Division of Adolescent and Young Adult Medicine,
Boston Children’s Hospital, Boston, MA.
6 Pediatrics in Review Vol.34 No.1 January 2013
Downloaded from http://pedsinreview.aappublications.org/ by guest on April 8, 2015
genital system disorders menstrual disorders
what her expectations of menses are, and where she has
derived these expectations. In conditions ranging from
polycystic ovary syndrome (PCOS) to endometriosis, the
patient’s quality of life has been shown to be much more
strongly linked to her own perception of her symptoms
than to her doctors’ assessment of their severity. Periods
perceived as heavy, painful, or abnormal can be a significant cause of school absence and decreased work productivity. What many patients and families desire as much as
relief from menses or menstrual pain is predictability. Setting realistic expectations from the onset of medical treatment goes a long way in improving quality of life.
The presence of menses can be a challenge to the families of young women who have special health-care needs,
and particular sensitivity is warranted. The onset of menstruation may raise what can be uncomfortable questions
about fertility and sexual activity (voluntary or otherwise)
for the families of these young women. Patients and families appreciate and deserve the opportunity to talk openly
about these subjects.
Epidemiology/Normal Menses
The median age of menarche in the United States is 12.4
years, with African-American girls experiencing menarche
slightly earlier on average than non-Hispanic white and
Mexican-American girls, as determined in the third National Health and Nutrition Evaluation Survey. (3) The
usual sequence of events leading up to menarche includes
thelarche (Tanner [sexual maturation rating] stage 2 breast
development) at a median age of 10.2 years and pubarche
(Tanner stage 2 pubic hair) at a median age of 11.6 years,
but recent studies have revealed that girls are developing
breasts and pubic hair earlier than in past generations although the age of menarche has remained more constant.
(4) Some girls, particularly African-American girls, may experience pubarche before thelarche. Early pubarche, especially accompanied by obesity and insulin resistance, is
associated with later development of PCOS.
The definition of precocious puberty remains controversial because of mixed data about how ethnicity and adiposity
affect development. Generally, the presence of breast development or pubic hair before age 8 years is considered precocious, although girls whose BMI is greater than 85% or
who are African-American or Mexican-American may have
earlier development. In one study, 27% of African-American
girls had signs of pubertal development at age 7 years, compared with 7% of white girls. (5) Menarche occurring after
age 14.1 years occurs in only 5% of girls in the United States;
the definition of primary amenorrhea is failure to achieve
menarche by age 15 years. Failure to progress from thelarche
to menarche within 3 years is also cause for concern.
It was thought previously that hypothalamic axis immaturity in the first gynecologic year was common, and
therefore menstrual irregularity was to be expected.
More current data indicate that even in the first gynecologic year, amenorrhea for more than 3 months is uncommon in healthy girls in the United States and
should be investigated if there are other issues apparent,
or if the pattern persists into the second year. A normal
menstrual cycle (counting from the first day of one
menstrual period to the first day of menses of the next
cycle) is 21 to 35 days in adults but has a slightly wider
range of normal in adolescents during the first 2
years after menarche. A normal period lasts from 3 to
7 days. Bleeding lasting 8 or more days is considered
prolonged.
Review of Menstrual Physiology
The menstrual cycle is divided commonly into three
phases: follicular (proliferative), ovulation, and luteal (secretory) (Figure). The follicular phase may vary in length,
but the luteal phase is 14 days during normal ovulatory
cycles. Ovulation is the event that defines regular cycles
and triggers the prostaglandin cascade, which is associated with primary dysmenorrhea.
Gonadotropin-releasing hormone (GnRH) secretion
in the hypothalamus is pulsatile and stimulates the pituitary gland to secrete luteinizing hormone (LH) and follicle stimulating hormone (FSH), which stimulates
follicle growth in the ovary. A dominant follicle in the
ovary secretes increasing amounts of estrogen, which
causes the endometrial lining to proliferate. A feedback
loop develops in which increasing amounts of estrogen
result in decreasing LH and FSH levels; but above a certain estrogen level, the negative feedback is reversed and
LH release from the pituitary is stimulated. This “LH
surge” triggers ovulation.
After ovulation, the remaining follicular cells in the
ovary luteinize and become the corpus luteum. This corpus luteum secretes estrogen and progesterone, which
has the effect of stabilizing the endometrium and causing
differentiation into glandular tissue to produce the
spongy lining needed for implantation of a fertilized
ovum. If fertilization and implantation do not occur, human chorionic gonadotropin is not produced, and the
corpus luteum involutes. The withdrawal of progesterone
(and estrogen) levels derived from the corpus luteum is
the trigger for the shedding of the endometrial lining,
or menses. In anovulatory girls, menstrual periods occur
from a proliferative endometrium because of waxing and
waning of estrogen levels.
Pediatrics in Review Vol.34 No.1 January 2013 7
Figure. The normal menstrual cycle, with relationship among
levels of gonadotropins, physiologic activity in the ovary,
levels of ovarian steroids, and changes in the endometrium.
Reprinted with permission from Braverman PK, Sondheimer
SJ. Menstrual disorders. Pediatr Rev. 1997;18(1):18.
Amenorrhea
Primary amenorrhea is clinically defined as the lack of
menses by the age of 15 years or by more than 3 years
after the onset of secondary sexual development. Lack
of any secondary sexual characteristics by age 13 years
also is abnormal and should be investigated. Secondary
amenorrhea is defined as 3 months of amenorrhea after
the achievement of menarche. Underlying conditions may
overlap in primary and secondary amenorrhea (Table 1).
Careful history and physical examination are crucial to
diagnosis. It cannot be overstated, however, that a sensitive pregnancy test must be part of the initial evaluation
of any patient with amenorrhea, regardless of the reported sexual history. Besides pregnancy, disordered
eating patterns and weight changes are among the most
common reasons for amenorrhea. Review of a growth
chart is important in considering the possible causes.
The differential diagnosis of primary amenorrhea includes genital tract abnormalities, as well as endocrine
causes (which also may cause secondary amenorrhea), including hypothalamic/pituitary, ovarian, thyroid, or adrenal abnormalities. The assessment of the patient should
include a detailed history and physical examination, laboratory testing, and radiologic imaging in some cases.
The patient and parent should be asked about a past
medical history of chronic illness, tempo of any pubertal development, weight gain or loss, exercise habits, and stressors.
Family history should focus on any potential endocrine disorders in first-order relatives, including thyroid disease, diabetes, PCOS, and infertility. The parent should be asked also
about any family history of constitutional delay of menses.
Sexual history should be obtained confidentially, because
pregnancy is a rare but possible cause of primary amenorrhea
and the most common cause of secondary amenorrhea.
Social stressors may contribute to primary or secondary
amenorrhea, and asking about academic pressure, family
conflict, mood disorders, body image, and eating behaviors
is important. Clinicians should ask about history of medication use, including any antipsychotic medication, contraceptive use (adolescents often forget or deny use unless asked
specifically), and illicit drug use. The review of systems
should include discussion of acne or unwanted hair growth,
weight changes, mood changes, disordered eating attitudes
and behavior, change in bowel habits, abdominal pain, headaches, visual changes, galactorrhea, and vaginal discharge.
The review of a growth chart identifies patients who are
overweight or underweight for height. Girls who are overweight for height and not growing appropriately are more
likely to have an endocrinopathy (hypothyroidism, Cushing syndrome), whereas patients underweight for height
may have a deficit of calories (eating disorder or bowel disease such as inflammatory bowel disease or celiac disease).
The patient who has exceptionally short stature (final
height predicted to be less than 5 ft in the patient who has
normal parental heights), with or without other features
such as webbed neck, widely spaced nipples, shield chest,
and high arched palate, and primary amenorrhea raises
concerns about Turner syndrome (45,X) or mosaicism
(46,XX/45,X). Consultation with a geneticist or endocrinologist may be warranted.
Physical examination should include assessment of
height, weight, and BMI in addition to routine vital signs.
The clinician should examine the patient’s skin thoroughly. Peripheral visual fields should be checked by confrontation and the fundi examined. The clinician should
Table 1.
Differential Diagnosis of Amenorrhea
Primary Amenorrhea
Central (hypothalamus/pituitary;
hypogonadotropic hypogonadism
with low FSH)
Ovarian (hypergonadotropic
hypogonadism with high FSH)
Genital outflow tract
Other
a
Constitutional delay
Chronic illnessa
Functional hypothalamic
amenorrheaa
Kallmann syndrome
Laurence-Moon-Biedl and
Prader-Willi syndromes
Tumors (craniopharyngioma
and prolactinoma)
Infiltration (hemochromatosis)
Infarction
Iatrogenic (radiation, surgery)
Congenital hypopituitarism
Turner syndromea
Gonadal dysgenesis
Primary ovarian insufficiency
Oophoritis
Galactosemia
Tumor
Radiation, chemotherapy
Imperforate hymena
MRKHa
Transverse vaginal septum
Vaginal agenesis
Androgen insensitivity
Intersex disorders
Pregnancy
PCOS (uncommon)
Thyroid disease
Cushing syndrome
Addison disease
Secondary Amenorrhea
Functional hypothalamica
amenorrhea
Chronic illness
Tumors (prolactinoma)
Oophoritis
Radiation, chemotherapy
Uterine synechiae (Asherman
syndrome)
Pregnancya
PCOSa
Contraceptive use
Hyperprolactinemia due to
medication or illicit drug use
Thyroid disease
Late-onset congenital adrenal
hyperplasia
Cushing syndrome
Addison disease
a
Most common diagnosis in each category; the other diagnoses are not listed in order of prevalence.
test for, or at least ask about, the presence of smell (anosmia is associated with Kallmann syndrome). The thyroid
gland should be palpated for enlargement. Tanner staging
should be recorded and tracked over time, and breast examination should verify whether there is any galactorrhea.
Abdominal palpation should be performed to detect constipation or the presence of any masses.
An external genital evaluation should be performed to
detect clitoromegaly (clitoral glans wider than 0.5 cm)
and patency of the introitus. All that is necessary for an
internal examination in virginal patients may be passage
of a saline moistened cotton-tip swab to assess the depth
of the vagina (7–8 cm is average for a postpubertal young
woman). If there is any question of an anatomic abnormality, pelvic ultrasonography should be performed at
a center experienced with prepubertal patients.
Genital Outflow Tract Anomalies
The range of congenital abnormalities includes external
anomalies such as imperforate hymen and transverse vaginal septum with normal müllerian structures, as well as
müllerian anomalies such as uterine and vaginal agenesis.
Appropriate and consistent visual examination of the vaginal introitus in the newborn and at health maintenance
visits should prevent the late diagnosis of imperforate hymen. Early detection can help avoid the “classic”
presentation of imperforate hymen in a postpubertal young
woman: cyclic abdominal pain, midline abdominal mass,
and purplish bulging seen at the introitus of the vagina
(a hematocolpos, which may be remarkably large). Such
late-found cases require gynecologic intervention in an operating room or controlled setting, as opposed to a simpler
procedure when the patient is diagnosed as a newborn.
Transverse vaginal septum presents similarly but may
be harder to identify because the external examination
may appear normal. A swab cannot be passed a normal
length in the presence of a low transverse septum, but
a high septum may not be detected without direct visualization or pelvic imaging.
Vaginal agenesis rarely occurs as an isolated finding and
usually is associated with other müllerian anomalies. MayerRokitansky-Küster-Hauser syndrome (MRKH) includes
vaginal agenesis and, usually, uterine and fallopian tube
agenesis as well. On external examination, the vaginal opening ends in a blind pouch. Girls with MRKH go through
puberty at the usual tempo because they have normal ovaries, but they do not attain menarche. Because they have
normal ovaries, they can have children by oocyte retrieval,
fertilization of the egg in vitro, and a gestational carrier.
Young women born with androgen insensitivity syndrome (AIS) are genetically males (46,XY), but their androgen receptors do not respond to testosterone in the usual
way. They have serum levels of testosterone comparable
with adolescent males, but do not have body hair and do
have breast development due to peripheral aromatization to
estrogen. Because they are 46,XY, they possess müllerian
inhibitory substance, which inhibits formation of the uterus
and vagina. Although they have female-appearing external
genitalia, they possess testes, which most patients elect to
have surgically removed after puberty because of the increased risk of cancer. There are rare, partial forms of
AIS in which female patients present as somewhat virilized.
Patients with vaginal agenesis are able to create a vagina
with the use of manual dilators with expert coaching and
education. The young woman must be able to choose
whether she wants to and, if so, at which age she wishes
to begin. Although there are surgical procedures such as
bowel vaginas and other complex approaches, the drawbacks are excess vaginal discharge and the need for ongoing dilatation. Online resources and support groups, such
as at www.youngwomenshealth.org, may provide a needed
source of information and emotional support for girls with
MRKH, AIS, and other rare conditions.
Other Causes of Amenorrhea
For girls with primary amenorrhea unrelated to outflow
tract anomalies, the diagnostic evaluation is similar to that
for girls who experience secondary amenorrhea. Because
pregnancy is a common cause for secondary amenorrhea,
the first test to perform is a sensitive urine pregnancy
test. The next steps are to obtain levels of FSH, LH,
thyroid stimulating hormone (TSH) or free thyroxine,
and prolactin. Other laboratory tests to consider include
levels of androgen (total and free testosterone and
dehydroepiandrosterone-sulfate [DHEAS]) to screen
for hyperandrogenism, and possibly pelvic ultrasonography. Free testosterone levels should only be drawn if
the laboratory is known to provide high quality results.
Elevated levels of FSH indicate hypergonadotropic hypogonadism, whereas low levels indicate hypogonadotropic
hypogonadism.
Hypergonadotropic hypogonadism implies ovarian
insufficiency, and the most common cause is gonadal
dysgenesis, most frequently due to Turner syndrome.
Turner syndrome usually presents with delayed puberty
and primary amenorrhea, but secondary amenorrhea is
possible, especially in patients born with a mosaic chromosome pattern. Other causes of ovarian insufficiency
include autoimmune and radiation- or chemotherapyinduced oophoritis, as well as galactosemia. Autoimmune
oophoritis may be associated with other autoimmune
conditions, such as diabetes mellitus, adrenal insufficiency, thyroid disease, celiac disease, and vitiligo.
Hypogonadotropic hypogonadism implies that either
the hypothalamus or the pituitary gland is the root of the
problem. The most common cause of hypogonadotropic
hypogonadism is functional hypothalamic amenorrhea,
but this is a clinical diagnosis, and a diagnosis of exclusion, so diagnostic evaluation, including levels of FSH,
LH, TSH, and prolactin, is warranted as well as screening
for eating disorders and sometimes for celiac diseases.
Although rare, tumors may impinge on the pituitary, so
it is important to ask all patients about the occurrence of
headaches, visual changes, and galactorrhea, and to check
for galactorrhea on examination. The most common pituitary tumor is a prolactinoma. A craniopharyngioma also
can present with poor growth and amenorrhea, as can
pituitary infiltration by hemochromatosis.
Laurence-Moon-Biedl and Prader-Willi syndromes
present with obesity, developmental delay, and amenorrhea due to hypothalamic dysfunction. Kallmann syndrome presents as amenorrhea with anosmia. Kallmann
syndrome is a disorder of neuronal migration, whereby
GnRH neurons do not migrate to the hypothalamus;
thus, the olfactory bulbs also do not develop properly.
Functional hypothalamic amenorrhea, or secondary
amenorrhea due to suppression of GnRH pulsatility in
which no anatomic or organic disease is known, can be
caused by stress, weight loss, or exercise. This condition
may result in a low estrogen state, which places young
women at risk for failure to achieve peak bone mass. This
disorder is often, but not always, associated with being
underweight and with eating disorders. Secondary amenorrhea may precede significant weight loss in anorexia
nervosa, and weight gain beyond the point where menses
were lost frequently is required for resumption of menses.
Normal-weighted bulimic patients who are purging frequently also may experience amenorrhea.
Female athletes are at risk for developing the “female
athlete triad,” consisting of energy insufficiency, amenorrhea, and low bone density. Use of oral contraceptives
(OCPs) can induce withdrawal bleeding but has not been
shown to be effective at increasing bone density in athletes or in those with anorexia nervosa.
The role of leptin is being investigated actively, because leptin administration recently has been demonstrated to promote resumption of menses. Trials of
androgens and estrogens together and transdermal estrogen alone have demonstrated promising effects in small
studies. Increased energy availability, meaning weight
gain in most cases, has been shown to have long-term
and significant positive effects on bone density.
Because of the serious long-term sequelae for bone
health, young women with prolonged functional hypothalamic amenorrhea who do not or will not increase
their energy availability should be referred for multidisciplinary assessment to a nutritionist, a mental health professional, and a health-care provider who are well versed
in eating disorders and bone health. (6)
PCOS is the most common endocrinopathy in young
adult women; some researchers estimate that the condition affects up to 10% of American women of reproductive age. Young women with PCOS present with
amenorrhea or oligomenorrhea and signs of hyperandrogenism, including hirsutism and acne. They are often, but
not always, overweight.
There are three sets of criteria for diagnosis of PCOS:
the 1990 National Institutes of Health consensus criteria,
the 2003 Rotterdam criteria, and the 2006 Androgen Excess Society criteria. (7)(8)(9) The National Institutes of
Health criteria include patients with anovulatory menses
and clinical or biochemical evidence of hyperandrogenism,
with or without polycystic ovaries on ultrasonography,
in whom other diagnoses (eg, late-onset congenital adrenal hyperplasia and thyroid disease) have been excluded.
The Androgen Excess and PCOS Society guidelines
also include those patients who experience normal menses
but have biochemical or clinical hyperandrogenism
and also polycystic ovaries on ultrasonography. Most
pediatric clinicians use one of these two definitions, with
clinical or biochemical hyperandrogenism being sine
qua non.
Evaluation for PCOS includes measuring LH, FSH,
TSH, and prolactin levels to exclude other disorders, as
well as obtaining serum levels of testosterone (a normal
total testosterone excludes a testosterone-producing tumor), free testosterone (elevated in most patients with
PCOS), and DHEAS.
In patients with virilization (eg, clitoromegaly, deep
voice, notable hirsutism), a first morning 17-hydroxyprogesterone to rule out late-onset congenital adrenal hyperplasia and evaluation for a tumor is warranted. Pelvic
ultrasonography may be a useful adjunct to laboratory
testing, although ideally the procedure should be performed in a center with pediatric expertise. In the case
of significantly elevated concentrations of DHEAS or total testosterone, other androgen levels, such as androstenedione and dehydroepiandrosterone, may be drawn,
and consultation with an endocrinologist is suggested.
In rare situations of high testosterone levels combined
with genital anomalies, chromosome studies should be
considered to rule out intersex conditions.
PCOS is associated with abnormal LH pulsatility and
secretion beginning in the premenarchal period, ultimately resulting in increased androgen production from
the ovaries and adrenal glands, as well as anovulation. Because anovulation leads to irregular buildup of the endometrial lining, the initial presentation of PCOS may be as
heavy (previously known as dysfunctional) uterine bleeding.
PCOS is associated with insulin resistance in more
than one half of patients and is an independent risk factor
for later development of type II diabetes and the metabolic syndrome. Current recommendations are that patients who have PCOS and an elevated BMI should
undergo lipid testing and an oral glucose tolerance test
every 1 to 2 years.
Because of prolonged periods of unopposed estrogen
stimulation and endometrial proliferation resulting from
anovulation, older women with PCOS also are at increased risk of endometrial cancer. This risk can be reduced through early detection and treatment to ensure
more regular endometrial shedding. Lifestyle modification including exercise and weight loss can improve menstrual regularity in some women.
Pharmacologic treatment for PCOS includes three options: cyclic use of progestins to induce withdrawal bleeding; use of estrogen-containing contraceptives (pills,
transdermal patch, or vaginal ring) to reduce ovarian androgen production and increase steroid hormone binding
globulin; and use of metformin to lower circulating
insulin levels and reduce ovarian steroid hormone
production.
It is important to note the potential reproductive ramifications of these therapies. Estrogen-containing contraceptives are the best option for sexually active young
women who do not desire a pregnancy and those with
hirsutism and acne; metformin use is particularly helpful
for those with glucose intolerance. Metformin promotes
ovulation, so this drug should not be the sole therapy in
sexually active teenagers. Some young women choose to
use both therapies. Spironolactone often is used as an adjunct treatment to reduce androgen effects on the hair
follicle in girls with hirsutism; spironolactone’s use as
monotherapy is not recommended because it is teratogenic and causes menstrual irregularity unless used in
conjunction with an estrogen-containing contraceptive.
Abnormal Vaginal Bleeding
Abnormal vaginal bleeding is reported commonly during
adolescence. Pediatric practitioners must know what is
normal in order to assess patients accurately. A normal
period usually lasts 3 to 7 days. Bleeding that lasts 8 days
or longer is considered abnormal. The normal interval
between menses in adolescents may be between 21 and
45 days in young adolescents, although 21 to 35 days
is more common.
Menorrhagia means a large quantity of bleeding, metrorrhagia means irregular bleeding, and menometrorrhagia means heavy and irregular bleeding. When
patients say that they have “heavy” bleeding, however,
it is important to ask them whether they mean bleeding
that is in large quantity, frequent, or associated with pain,
because these symptoms have different implications.
Studies reveal that both adolescent patients and their
clinicians can significantly underestimate as well as overestimate the amount of vaginal bleeding, so it is important to obtain objective evidence of blood loss regardless
of the history (eg, complete blood count).
The differential diagnosis of abnormal vaginal bleeding is broad (Table 2). The term “dysfunctional uterine
bleeding” has been replaced by “abnormal uterine bleeding.” Abnormal uterine bleeding refers to irregular and
sometimes heavy bleeding due to a delay in maturation
of the negative feedback loop whereby rising estrogen
levels suppress FSH secretion. This maturational delay results in a constantly proliferative endometrium with irregular shedding. Abnormal uterine bleeding is the most
common cause of abnormal bleeding in adolescents, but
it is a diagnosis of exclusion, and the differential diagnosis
also should include pregnancy (including complications
such as ectopic pregnancy and miscarriage), bleeding disorders, pelvic infection, and endocrinopathies such as
PCOS and thyroid disease.
In evaluating the patient with abnormal vaginal bleeding, it is important to consider the possibility of pregnancy first, because pregnancy complications presenting
with bleeding, such as ectopic pregnancy, can be life
threatening. All patients should be asked privately
whether they have ever had sex, coerced or voluntary,
but pregnancy testing should be obtained universally because patients may fear the consequences of disclosure.
Patients who have ever had sex should be asked specifically about contraceptive use and about history of any
sexually transmitted infections, and should be tested
for gonorrhea and Chlamydia trachomatis infection by
using simple urine nucleic acid amplification tests. Regardless of stated history, pediatricians should have
a low threshold for performing these tests for unexplained bleeding because the prevalence of Chlamydia
is so high in adolescent women.
The patient’s menstrual history can then help narrow
down other possibilities. Patients should be asked about
the date of menarche and the pattern of bleeding since
that time. For patients who have had heavy flow from
the time of initial menses, a bleeding disorder such as
von Willebrand disease is more likely. Regular cycles accompanied by premenstrual symptoms and dysmenorrhea usually imply ovulatory bleeding. Regular, cyclic,
but heavy flow is suggestive of a hematologic cause. Irregular cycles suggest anovulatory cycles, which may be
due to an underlying endocrinopathy such as PCOS or
hypothyroidism, a condition that causes functional hypothalamic amenorrhea. Intermenstrual bleeding suggests
anatomic disease (cervicitis due to sexually transmitted
infections must be ruled out) or breakthrough bleeding
associated with use of hormonal contraception.
The review of symptoms should include questions
about weight changes, exercise habits, bleeding tendencies,
acne, hirsutism, headaches, visual changes, chronic illness,
bowel habits, and urinary symptoms (younger patients may
confuse hematuria with vaginal bleeding). Family history
of bleeding tendencies (especially during childbirth
and surgical procedures), endocrinopathies, and infertility should be elicited. Patients should be asked specifically
(and confidentially) about contraceptive use, including
intrauterine devices (IUDs). Clinicians also should ask
about antipsychotic and antiepileptic medications that
may cause irregular bleeding, and aspirin and other anticoagulants, which may worsen bleeding.
Physical examination should include orthostatic vital
signs for those with heavy bleeding. Young women
Differential Diagnosis of Abnormal Vaginal Bleeding in the
Adolescent Girl
Table 2.
Abnormal uterine bleeding
Pregnancy-related complications
Threatened abortion
Spontaneous, incomplete, or missed abortion
Ectopic pregnancy
Gestational trophoblastic disease
Complications of termination procedures
Infection
Pelvic inflammatory disease
Endometritis
Cervicitis
Vaginitis
Bleeding disorders
Thrombocytopenia (eg, idiopathic
thrombocytopenic purpura, leukemia,
aplastic anemia, hypersplenism, chemotherapy)
Coagulation disorders (eg, von Willebrand
disease, other disorders of platelet function,
liver dysfunction, vitamin K deficiency)
Cervical problems
Cervicitis (including cystic fibrosis)
Polyp
Hemangioma
Carcinoma or sarcoma
Uterine problems
Submucous myoma
Congenital anomalies
Polyp
Carcinoma
Use of intrauterine device
Breakthrough bleeding associated with
hormonal contraceptives
Ovulation bleeding
Ovarian problems
Cyst
Tumor (benign, malignant)
Endometriosis
Trauma
Endocrine disorders
Hypo- or hyperthyroidism
Adrenal disease
Hyperprolactinemia
PCOS
Vaginal abnormalities
Carcinoma or sarcoma
Laceration
Foreign body (eg, retained tampon)
Systemic diseases
Diabetes mellitus
Renal disease
Systemic lupus erythematosus
Medications
Hormonal contraceptives
Anticoagulants
Platelet inhibitors
Androgens
Spironolactone
Antipsychotics
Reprinted with permission from Gray SH, Emans SJ. Abnormal vaginal bleeding in the adolescent. In: Emans SJ, Laufer MR, eds. Emans, Laufer, and
Goldstein’s Pediatric and Adolescent Gynecology. 6th ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2011:159–167.
may be remarkably tolerant of severe anemia and show no
signs other than resting tachycardia or orthostatic hypotension. Providers should examine the skin for acne, hirsutism, and acanthosis nigricans suggestive of PCOS as
well as petechiae or bruising to suggest bleeding disorders. The thyroid gland should be palpated. Palpation
of the abdomen should begin in the epigastric area and
progress downward, assessing for a uterine fundus that
would suggest undetected pregnancy. Pelvic and bimanual examination is indicated for sexually active patients
to screen for cervicitis and pelvic inflammatory disease.
In virginal patients who have longstanding ongoing
bleeding or bleeding resulting in anemia, assessment
can be managed by external genital examination with passage of a cotton-tip swab to assess vaginal patency, as well
as transabdominal pelvic ultrasonography.
Laboratory testing should consist initially of a urine
pregnancy test and a complete blood count, including
platelet and reticulocyte count, and TSH level. In both
the initial evaluation and in follow-up treatment, for girls
who have normal hemoglobin level and hematocrit, the
content of hemoglobin in the reticulocyte is a sensitive
indicator of iron deficiency and can give clinicians more
information about the tempo of bleeding or recovery of
iron stores. Other laboratory testing may be indicated depending on the severity and nature of the symptoms.
For those patients with hemorrhage from menarche or
serious bleeding at any time, coagulation studies including prothrombin time/international normalized ratio,
partial thromboplastin time, and Von Willebrand panel
are indicated. For those patients with previous amenorrhea or irregular bleeding, screening for endocrinopathies
should be conducted by measuring FSH, LH, TSH, and
possibly prolactin, as well as androgen levels for girls with
signs of hyperandrogenism on examination. For girls presenting with focal pain or a pelvic mass, abdominal ultrasonography also is warranted.
Treatment of abnormal vaginal bleeding is based
largely on the severity of anemia, in addition to management of any comorbid conditions. The preferred treatment of vaginal bleeding in adolescence is medical;
surgical intervention rarely is indicated. All treatment
of vaginal bleeding resulting in anemia must include iron
replacement, although this therapy can be overlooked
easily during the acute presentation and management.
The general goal of treatment is to stabilize the endometrium by providing estrogen for initial hemostasis and
progestins for endometrial stability. The most convenient
and effective option in most cases is treatment by using
combined OCPs (Table 3). Sudden withdrawal of either
estrogen or progestin may trigger ongoing bleeding, so
treatment for several months usually is warranted.
Long-term follow-up for conditions predisposing to abnormal bleeding, such as PCOS, is necessary as well.
For adolescents who have contraindications to the use
of estrogen, such as a history of blood clot, uncontrolled
hypertension, migraine with aura, immobility, or chronic
illness, management of abnormal bleeding with cyclic
progestins often is possible, although sometimes more
challenging. Progestin-eluting IUDs may be an option
in some cases.
Menstrual suppression by using GnRH analogs is desirable in some conditions, but because of the initial agonist
phase, withdrawal bleeding often occurs at 3 weeks before
amenorrhea is established. For this reason, prophylactic use
is better than use in an acute emergency. Antifibrinolytics
such as tranexamic acid interfere with the breakdown of
blood clots and thus stop or slow down bleeding; these
agents may be an option in some adolescents with bleeding
disorders; consultation with a hematologist is suggested.
Dysmenorrhea
Dysmenorrhea is common in young women worldwide
and occurs in the majority of adolescents. Primary, or
functional, dysmenorrhea is pain that occurs in the absence of pelvic disease, whereas secondary dysmenorrhea
is secondary to a pathologic process. Primary dysmenorrhea is more common than secondary dysmenorrhea, but
clinicians should be familiar with “red flags” on history
and examination that should lead them to pursue a diagnosis other than functional pain.
Primary dysmenorrhea usually presents in the second
or third gynecologic year, when ovulation becomes more
regular. Pain may be reported in the lower abdomen,
back, or upper thighs. The pain may be associated with
headache, nausea, or diarrhea. The symptoms are caused
by prostaglandin E2 and F2a secretion in the uterus after
an ovulatory cycle, resulting in increased uterine contractility and upregulation of pain receptors.
Nonsteroidal anti-inflammatory drugs (NSAIDs),
such as ibuprofen and naproxen, inhibit cyclooxygenase, an enzyme necessary for prostaglandin synthesis.
NSAIDs are used commonly to treat dysmenorrhea
and have been shown to be effective in randomized controlled trials. It is important to know that acetaminophen
does not act on this pathway and is much less effective for
the treatment of primary dysmenorrhea. Traditional recommendations for rest, exercise, and proper nutrition
have not been shown to be effective.
Primary dysmenorrhea may result in significant school
absence and lost productivity, so aggressive and evidencebased treatment is warranted. If appropriate doses of
NSAIDs (Table 4) do not control symptoms after two
to three cycles, a trial of OCPs may be indicated. OCPs
reduce menstrual pain by eliminating ovulation and by
thinning the endometrial lining; when ovulation does
not occur and the endometrial lining is thinner, the synthesis of prostaglandins is reduced. In severe cases, extended cycle OCP regimens (eg, 84 active pills, followed
by 7 placebos) may be used to eliminate menses. Young
women with dysmenorrhea often try over-the-counter medications, including ibuprofen and naproxen, and complementary therapies such as vitamins and herbal remedies.
Pediatric clinicians should therefore ask specifically about previous treatments before prescribing additional medications.
Before assuming a patient has primary dysmenorrhea,
the clinician should consider possible causes of secondary
dysmenorrhea. Patients who continue to experience significant pain despite 3 to 6 months of OCP use have a
significantly higher risk of endometriosis (presence of endometrial tissue outside the uterus) and should be referred
to a pediatric gynecologist for evaluation. Laparoscopy is
the only definitive way to diagnose endometriosis, but often it is difficult to recognize this condition in pediatric
patients.
Table 3.
Suggested Combined OCP Regimens for Abnormal Bleeding
Use a monophasic OCP such as:
• Norgestrel 0.3 mg/ethinyl estradiol 30 mg (Lo/Ovral, Low-Ogestrel, Cryselle).a
• Levonorgestrel 0.15 mg/ethinyl estradiol 30 mg (Nordette, Levlen, Levora, Portia).a
For all patients:
• Advise the patient to keep a menstrual calendar.
• Ensure iron stores are addressed. Patients typically need several months of oral iron supplementation to replete iron stores,
and then should be instructed in maintenance of iron needs.
• If OCPs are used for treatment and then discontinued, consider cyclic progestin therapy to prevent recurrences.
A. For mild bleeding—menses slightly prolonged or cycle slightly more frequent, without anemia (Hgb normal):
• May be observed for several cycles and provided treatment with iron and NSAIDs such as ibuprofen or naproxen sodium.
• Consider treatment with OCP or progestin.
• If choose to treat with OCP: 1 pill daily for 21 d, followed by 1 wk of placebo pills or 1 hormone pill continuously for 84day cycles or longer.
• Continue this regimen for 3–6 mo.b
B. For moderate bleeding—menses lasting >7 d or cycle frequency <3 wk and mild anemia (Hgb 10–11 g/dL):
• If the patient is not bleeding significantly at the time of the visit, is not already on hormonal therapy, and anemia is mild:
1 pill a day for 21 d is a reasonable first step.
• If patient is bleeding moderately at time of visit: 1 pill twice a day until bleeding stops, followed by 1 hormonal pill a day
for at least 21 d is a reasonable first step.
• If bleeding is under control, continue cyclic 21 day or may elect extended cycles for 3–6 mo.b
• Follow serial Hgbs, as needed; if bleeding persists, may need to continue twice-daily pill for a short interval.
C. For severe bleeding with moderate anemia (Hgb 8–10 g/dL)
• Consider inpatient admission unless patient’s bleeding is slowing and family is reliable, has transportation, and is reachable
by phone.
• For severe bleeding: 1 pill four times a day for 2–4 d, with antiemetic as needed 2 h before each pill; followed by 1 pill
three times a day for 3 d; and then 1 pill twice a day for at least 2 wk. (For this regimen, prescribing OCPs “four times
a day” should be written as “1 pill every 6 hours” and “3 times a day” as “1 pill every 8 hours” in order to maintain
hormonal concentrations.)
• For bleeding that is slowing and Hgb >9 g/dL: 1 pill twice a day can be initiated as a first step.
• Follow closely with serial Hgb; if anemia or bleeding persists, may need to continue twice-daily hormonal pill and
eliminate pill-free interval until Hgb has returned to normal.
• Once Hgb has normalized, cycle using 21 once-daily pills and 5–7 d of placebo or extended cycles for 6 mo.b
D. Severe bleeding with severe anemia (Hgb £7 g/dL, orthostatic vital signs):
• Admit for inpatient management. Transfusion needs are individualized on the basis of Hgb, orthostatic symptoms, amount
of ongoing bleeding, and the ability to gain control of the bleeding.
• Most patients can be treated with OCPs: 1 pill every 4–6 h until bleeding slows (usually takes 24–36 h), with antiemetics
as needed; 1 pill four times a day for 2–4 d; 1 pill three times a day for 3 d; 1 pill twice a day until hematocrit is >30%.
• Occasionally intravenous conjugated estrogens (Premarin) 25 mg every 4 h for 2–3 doses are used in severe acute
hemorrhage. It is very important to remember that the estrogen will stop the bleeding but if a progestin is not added, a rebleed from estrogen withdrawal will occur when the IV estrogen is discontinued.
• Consider antifibrinolytic therapy.
• Once Hgb has normalized, cycle using 21 once-daily pills and 5–7 d of placebo or use extended cycles for 6–12 mo.b
Reprinted with permission from Gray SH, Emans SJ. Abnormal vaginal bleeding in the adolescent. In: Emans SJ, Laufer MR, eds. Emans, Laufer, and
Goldstein’s Pediatric and Adolescent Gynecology. 6th ed. Philadelphia, PA: Lippincott, Williams, and Wilkins; 2011:159–167. Hgb¼hemoglobin.
a
Mention of brand name does not imply endorsement of a particular product.
b
It is important to reconsider a patient’s need for birth control before discontinuing OCP therapy.
Other red flags include pelvic pain or bleeding that occurs midcycle and pain associated with vaginal discharge,
all of which may be associated with pelvic infections.
Clinicians should have a low threshold for sending nucleic
acid amplification testing for gonorrhea and C trachomatis
and doing a speculum and bimanual examination to screen
for pelvic inflammatory disease. Pelvic examination also may
reveal evidence of an IUD; non-hormone-containing IUDs
may increase menstrual pain significantly. Again, urine pregnancy testing is always worthwhile because adolescents may
mistake bleeding in early pregnancy for a period.
In adolescents who have dysmenorrhea from menarche
that progresses steadily, genital tract abnormalities with
obstruction should be considered, as well as endometriosis.
Medications Used to Treat
Dysmenorrhea
Table 4.
Propionic Acid Group:
• Ibuprofen
• Naproxen sodium
• Naproxen
Fenamate Group:
• Mefenamic acid
400–600 mg Q 4–6 H
550 mg load, then
275 mg Q 6 H
500 mg load, then 250 mg
Q 6–8 H
500 mg loading dose, then
250 mg Q 6 H
Reprinted with permission from Braverman PK, Sondheimer SJ.
Menstrual disorders. Pediatr Rev. 1997;18(1):25.
Other causes of pelvic pain not associated with menstrual
problems are beyond the scope of this review.
Young Women With Special Health-Care
Needs
Young women with special health-care needs and their families may need particular care with respect to normal menstruation as well as menstrual disorders. When possible, the
patient’s concerns should be expressed privately and remain
confidential. It is important that pediatric practitioners not
assume that young women with disabilities, cognitive or
otherwise, are not sexually active. Patients’ ability to consent to sexual activity should be assessed and discussed
openly with parents when appropriate. Many parents have
fears about their daughters’ vulnerability to coerced sex and
deserve the opportunity to discuss these concerns.
Normal menses may cause problems of hygiene for
girls with limited cognitive skills or limited mobility.
Painful menses cause unnecessary suffering, and some
conditions (eg, seizures, headaches) may be triggered
or worsened by menstrual changes. Treatments to decrease, eliminate, or make bleeding more predictable
should be “safe, minimally invasive, and nonpermanent”
according to the 2009 American Congress of Obstetricians and Gynecologists Committee Opinion on menstrual manipulation for adolescents with disabilities.
(10) Total amenorrhea may be difficult to obtain, and
some patients and families may decide that it is easier
to manage bleeding that is predictable but potentially
longer, rather than bleeding that is sporadic and irregular.
NSAIDs may play a useful role in reducing pain and
bleeding, as may combined OCPs, used traditionally or
in extended or continuous regimens. For young
women with limited mobility, the potential increased
risk of deep vein thrombosis with estrogen use should
be weighed, although the absolute risk is low. Transdermal contraceptive patches may have a higher associated
risk of blood clot. Medroxyprogesterone injection also
may be of limited use in these patients due to the potential
additive risk of low bone density with immobility, as well as
weight gain that may further limit mobility.
Progestin implants offer long lasting and reversible
contraception and sometimes can result in amenorrhea
but carry a risk of unpredictable bleeding, as do progestin
eluting IUDs, and both may require placement under anesthesia. Hysterectomy and endometrial ablation are
more likely to result in amenorrhea but would be recommended only in very unusual circumstances.
Summary
• The presence of normal menses in young women
should be considered a vital sign; heavy, painful,
absent, or irregular menses should be investigated.
(Based on some research evidence as well as
consensus.) (1)(2)
• Patients who are pregnant usually present with
secondary amenorrhea but may present with irregular
or heavy menstrual bleeding. A sensitive urine
pregnancy test should be performed early in the
evaluation of these complaints, regardless of stated
sexual history. (Based on expert opinion.)
• Menstrual complaints such as heavy bleeding and
dysmenorrhea are a frequent cause of school absence
in girls and should be evaluated and treated. (Based on
some research evidence as well as consensus.) (1)(2)
• Polycystic ovary syndrome (PCOS) is a frequent cause
of secondary amenorrhea or oligomenorrhea but also
can present with anovulatory and frequent menses.
(Based on expert opinion.)
• Functional hypothalamic amenorrhea is associated
commonly with stress, weight change, chronic illness,
and intense athletic activity. Patients with eating
disorders have an energy deficit, as do many of those
experiencing intense athletic activity, and are at risk
for hypothalamic amenorrhea.
• The morbidity associated with prolonged amenorrhea
is low bone density due to inadequate estrogen
production. Use of oral contraceptives (OCPs) alone
appears not to restore bone density in girls with
anorexia nervosa. The best recommendation is
increased energy intake and weight gain when
underweight. (Based on some research evidence as
well as consensus.) (6)
• Young women with special health-care needs need
assessment and counseling about sexuality and
reproductive health. Clinicians should be aware of how
cognitive or mobility issues affect menstrual hygiene
and should present options for medical management
of menses to improve quality of life. (Based on expert
opinion.) (10)
ACKNOWLEDGEMENTS. The author wishes to thank
Ms Alison Clapp for her assistance with review of the literature, as well as Drs S. Jean Emans and Gregory F. Hayden
for their helpful suggestions regarding this article.
References
1. Diaz A, Laufer MR, Breech LL; American Academy of Pediatrics
Committee on Adolescence; American College of Obstetricians and
Gynecologists Committee on Adolescent Health Care. Menstruation in girls and adolescents: using the menstrual cycle as a vital
sign. Pediatrics. 2006;118(5):2245–2250
2. ACOG Committee on Adolescent Health Care. ACOG Committee Opinion No. 349, November 2006: Menstruation in girls
and adolescents: using the menstrual cycle as a vital sign. Obstet
Gynecol. 2006;108(5):1323–1328
3. Chumlea WC, Schubert CM, Roche AF, et al. Age at menarche
and racial comparisons in US girls. Pediatrics. 2003;111(1):110–113
4. Sun SS, Schubert CM, Chumlea WC, et al. National estimates of
the timing of sexual maturation and racial differences among US
children. Pediatrics. 2002;110(5):911–919
5. Herman-Giddens ME, Slora EJ, Wasserman RC, et al. Secondary sexual characteristics and menses in young girls seen in office
practice: a study from the Pediatric Research in Office Settings
network. Pediatrics. 1997;99(4):505–512
6. Gordon CM. Clinical practice. Functional hypothalamic amenorrhea. N Engl J Med. 2010;363(4):365–371
7. Zadawski J, Dunaif A. Diagnostic Criteria for Polycystic Ovary
Syndrome: Towards a Rational Approach. Oxford, England: Blackwell Scientific Publications; 1992
8. Rotterdam ESHRE/ASRM-Sponsored PCOS consensus workshop group. Revised 2003 consensus on diagnostic criteria and
long-term health risks related to polycystic ovary syndrome
(PCOS). Hum Reprod. 2004;19(1):41–47
9. Azziz R, Carmina E, Dewailly D, et al; Androgen Excess Society.
Positions statement: criteria for defining polycystic ovary syndrome as
a predominantly hyperandrogenic syndrome: an Androgen Excess
Society guideline. J Clin Endocrinol Metab. 2006;91(11):4237–4245
10. American College of Obstetricians and Gynecologists Committee on Adolescent Health Care. ACOG Committee Opinion
No. 448: Menstrual manipulation for adolescents with disabilities.
Obstet Gynecol. 2009;114(6):1428–1431
Suggested Reading
Braverman PK, Sondheimer SJ. Menstrual disorders. Pediatr Rev.
1997;18(1):17–25, quiz 26
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1. A mother brings in her daughter because of a concern that she has never menstruated. The patient is thin,
athletic, and has a normal physical examination (including genital inspection). At what minimum age does
this concern warrant further investigation?
A. 13 years.
B. 14 years.
C. 15 years.
D. 16 years.
E. 17 years.
2. A 14-year-old girl comes in with a history of monthly cyclical abdominal pain. On examination, you note
midline tenderness in the area below the umbilicus, and a purplish bulging at the vaginal introitus. Of the
following, the most likely diagnosis is:
A.
B.
C.
D.
E.
Androgen insensitivity syndrome.
Chlamydial infection.
Crohn disease.
Hematocolpos.
Ovarian torsion.
3. A 15-year-old girl comes in for evaluation of infrequent menstrual periods. On examination, you note a BMI of
35 and acne. Otherwise, her examination is unremarkable. Of the following, what is the most likely laboratory
abnormality associated with this patient’s presentation?
A. Elevated follicular stimulating hormone (FSH).
B. Elevated free testosterone.
C. Elevated gonadotropic releasing hormone (GnRH).
D. Elevated prolactin.
E. Elevated thyroid stimulating hormone.
4. A 16-year-old girl is seen with a complaint of excessive bleeding with menses (menorrhagia). Of the following,
which component of the history and examination most suggests von Willebrand disease?
A. Anovulatory cycles.
B. Heavy flow from time of initial menses.
C. Breakthrough bleeding in between periods.
D. Previous oral contraceptive use.
E. Tenderness on bimanual examination.
5. Of the following, which is the most appropriate first-line therapy for primary dysmenorrhea?
A.
B.
C.
D.
E.
Acetaminophen.
Ibuprofen.
Metronidazole.
Oral contraceptive trial.
Relaxation techniques.
Menstrual Disorders
Susan Hayden Gray
Pediatrics in Review 2013;34;6
DOI: 10.1542/pir.34-1-6
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Menstrual Disorders
Susan Hayden Gray
Pediatrics in Review 2013;34;6
DOI: 10.1542/pir.34-1-6
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Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of
Pediatrics. All rights reserved. Print ISSN: 0191-9601.
CLINICAL REPORT
Menstruation in Girls and
Adolescents: Using the Menstrual
Cycle as a Vital Sign
Guidance for the Clinician in Rendering
Pediatric Care
AMERICAN ACADEMY OF PEDIATRICS
Committee on Adolescence
AMERICAN COLLEGE OF OBSTETRICIANS AND GYNECOLOGISTS
Committee on Adolescent Health Care
ABSTRACT
Young patients and their parents often are unsure about what represents normal
menstrual patterns, and clinicians also may be unsure about normal ranges for
menstrual cycle length and amount and duration of flow through adolescence. It
is important to be able to educate young patients and their parents regarding what
to expect of a first period and about the range for normal cycle length of subsequent menses. It is equally important for clinicians to have an understanding of
bleeding patterns in girls and adolescents, the ability to differentiate between
normal and abnormal menstruation, and the skill to know how to evaluate young
patients’ conditions appropriately. Using the menstrual cycle as an additional vital
sign adds a powerful tool to the assessment of normal development and the
exclusion of pathological conditions.
INTRODUCTION
Young patients and their parents frequently have difficulty assessing what constitutes normal menstrual cycles or patterns of bleeding. Girls may be unfamiliar with
what is normal and may not inform their parents about menstrual irregularities or
missed menses. Additionally, girls often are reluctant to discuss this very private
topic with a parent, although they may confide in another trusted adult. Some girls
will seek medical attention for cycle variations that actually fall within the normal
range. Others are unaware that their bleeding patterns are abnormal and may be
attributable to significant underlying medical issues with the potential for longterm health consequences.
Clinicians also may be unsure about normal ranges for menstrual cycle length
and for amount and duration of flow through adolescence. Clinicians who are
confident in their understanding of early menstrual bleeding patterns may convey
information to their patients more frequently and with less prompting; girls who
have been educated about menarche and early menstrual patterns will experience
less anxiety when they occur.1 By including an evaluation of the menstrual cycle
as an additional vital sign, clinicians reinforce its importance in assessing overall
health status for both patients and parents. Just as abnormal blood pressure, heart
rate, or respiratory rate may be key to the diagnosis of potentially serious health
conditions, identification of abnormal menstrual patterns through adolescence
may permit early identification of potential health concerns for adulthood.
www.pediatrics.org/cgi/doi/10.1542/
peds.2006-2481
doi:10.1542/peds.2006-2481
All clinical reports from the American
Academy of Pediatrics automatically
expire 5 years after publication unless
reaffirmed, revised, or retired at or
before that time.
The guidance in this report does not
indicate an exclusive course of treatment
or serve as a standard of medical care.
Variations, taking into account individual
circumstances, may be appropriate.
Key Words
menarche, menstruation, adolescent
Abbreviation
PCOS—polycystic ovary syndrome
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright © 2006 by the
American Academy of Pediatrics and American
College of Obstetricians and Gynecologists
PEDIATRICS Volume 118, Number 5, November 2006
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2245
NORMAL MENSTRUAL CYCLES
Menarche
From the early 1800s to the mid-1950s, menarche occured at increasingly younger ages in the United States,
but there has been no further decline in the last 40 to 50
years. This finding also has been seen in international
studies of other developed urban populations.2 The US
National Health and Nutrition Examination Surveys
have found no significant change in the median age at
menarche over the past 30 years except among the
non-Hispanic black population, which has a 5.5-month
earlier age at menarche than it did 30 years ago.3 Age at
menarche varies internationally and especially in less
developed countries; in Haiti, for example, the mean age
at menarche is 15.37 years.4,5 This knowledge may be
especially pertinent for practitioners with a large number of immigrant families in their patient population.
Although onset of puberty and menarche typically occur
at a later age in females from less well-developed nations, 2 large studies have confirmed that a higher gain
in body mass index (BMI) during childhood is related to
an earlier onset of puberty.6,7 This earlier onset of puberty may result from attainment of a minimal requisite
body mass at a younger age. Other possible explanations
for the perceived trend in timing and progression of
puberty are environmental factors, including socioeconomic conditions, nutrition, and access to preventive
health care.8
Despite variations worldwide and within the US population, median age at menarche has remained relatively
stable, between 12 and 13 years, across well-nourished
populations in developed countries. The median age of
females when they have their first period or menarche is
12.43 years (see Table 1).3 Only 10% of females are
menstruating at 11.11 years of age; 90% are menstruating by 13.75 years of age. The median age at which black
female adolescents begin to menstruate is earlier (12.06
years of age) than the median age for Hispanic (12.25
years of age) and non-Hispanic white (12.55 years of
age) females.3 Although black girls start to mature earlier
than non-Hispanic white and Hispanic girls, US females
complete secondary sexual development at approximately the same ages.9
Menarche typically occurs within 2 to 3 years after
thelarche (breast budding), at Tanner stage IV breast
development, and is rare before Tanner stage III development.10 Menarche correlates with age at onset of puberty and breast development. In girls with early onset
TABLE 1 Normal Menstrual Cycles in Young Females
Menarche (median age): 12.43 years
Mean cycle interval: 32.2 days in first gynecologic year
Menstrual cycle interval: typically 21–45 days
Menstrual flow length: !7 days
Menstrual product use: 3–6 pads/tampons per day
2246
of breast development, the interval to menarche is
longer (3 years or more) than in girls with later onset.11–13 By 15 years of age, 98% of females will have had
menarche.3,14
Traditionally, primary amenorrhea has been defined
as no menarche by 16 years of age; however, many
diagnosable and treatable disorders can and should be
detected earlier, using the statistically derived guideline
of 14 to 15 years of age.3,14 Thus, an evaluation for
primary amenorrhea should be considered for any adolescent who has not reached menarche by 15 years of
age or has not done so within 3 years of thelarche.
Accordingly, lack of breast development by 13 years of
age also should be evaluated.15
Cycle Length and Ovulation
Menstrual cycles are often irregular through adolescence, particularly the interval from the first to the second cycle. According to the World Health Organization’s
international and multicenter study of 3073 girls, the
median length of the first cycle after menarche was 34
days, with 38% of cycle lengths exceeding 40 days.
Variability was wide: 10% of females had more than 60
days between their first and second menses, and 7% had
a first cycle length of 20 days.16 Most females bleed for 2
to 7 days during their first menses.17–19
Early menstrual life is characterized by anovulatory
cycles,20,21 but the frequency of ovulation is related to
both time since menarche and age at menarche.21–23
Early menarche is associated with early onset of ovulatory cycles. When the age at menarche is younger than
12 years, 50% of cycles are ovulatory in the first gynecologic year (year after menarche).
By contrast, it may take 8 to 12 years after menarche
until females with later-onset menarche are fully ovulatory.23 Despite variability, most normal cycles range
from 21 to 45 days, even in the first gynecologic year,16–18
although short cycles of fewer than 20 days and long
cycles of more than 45 days may occur. Because long
cycles most often occur in the first 3 years postmenarche, the overall trend is toward shorter and more
regular cycles with increasing age. By the third year after
menarche, 60% to 80% of menstrual cycles are 21 to 34
days long, as is typical of adults.16,18,24 An individual’s
normal cycle length is established around the sixth gynecologic year, at a chronologic age of approximately 19
or 20 years.16,18
Two large studies, one cataloging 275 947 cycles in
2702 females and another reporting on 31 645 cycles in
656 females, support the observation that menstrual
cycles in girls and adolescents typically range from 21 to
approximately 45 days, even in the first gynecologic
year.25,26 In the first gynecologic year, the fifth percentile
for cycle length is 23 days and the 95th percentile is 90
days. By the fourth gynecologic year, fewer females are
having cycles that exceed 45 days, but anovulation is still
significant for some, with the 95th percentile for cycle
length at 50 days. By the seventh gynecologic year,
cycles are shorter and less variable, with the fifth percentile for cycle length at 27 days and the 95th percentile
at only 38 days. Thus, during the early years after menarche, cycles may be somewhat long because of anovulation, but 90% of cycles will be within the range of 21
to 45 days.16
ABNORMAL MENSTRUAL CYCLES
Prolonged Interval
A number of medical conditions can cause irregular or
missed menses in adolescents. Although secondary amenorrhea has been defined as the absence of menses for
6 months, it is statistically uncommon for girls and adolescents to remain amenorrheic for more than 3
months or 90 days—the 95th percentile for cycle length.
Thus, it is valuable to begin evaluation of secondary
amenorrhea after the absence of menses for 90 days.
Therefore, girls and adolescents with chaotically irregular cycles with more than 3 months between periods
should be evaluated, not reassured that it is “normal” to
have irregular periods in the first gynecologic years.
Irregular menses may be associated with many conditions, including pregnancy, endocrine disorders, and
acquired medical conditions, because all of these conditions are associated with derangement of hypothalamicpituitary endocrine function (see Table 2). Commonly,
polycystic ovary syndrome (PCOS) causes prolonged intervals between menstrual periods, especially in patients
with signs of androgen excess. The pathogenesis of PCOS
is unclear; many experts believe that PCOS results from
primary functional intraovarian overproduction of androgen. Others believe that excessive luteinizing hormone secretion from the pituitary gland, which stimulates a secondary ovarian androgen excess, has a role in
causing the disorder. Still others hypothesize that PCOS
may be related to hyperinsulinism. Whatever its origins,
TABLE 2 Causes of Menstrual Irregularity
Pregnancy
Endocrine causes
Poorly controlled diabetes mellitus
Polycystic ovary syndrome (PCOS)
Cushing disease
Thyroid dysfunction
Premature ovarian failure
Late-onset congenital adrenal hyperplasia
Acquired conditions
Stress-related hypothalamic dysfunction
Medications
Exercise-induced amenorrhea
Eating disorders (both anorexia and bulimia)
Tumors
Ovarian tumors
Adrenal tumors
Prolactinomas
PCOS accounts for 90% of hyperandrogenism among
females and, by definition, is characterized by amenorrhea and oligomenorrhea. Before the diagnosis is confirmed, hyperprolactinemia, adrenal and ovarian tumors, and drug effects (such as those caused by danazol
and several psychotropic medications) must be ruled
out. Additionally, although uncommon in the general
population, congenital adrenal hyperplasia should be
ruled out by a negative 17-"-hydroxyprogesterone test
result (serum concentrations less than 1000 ng/dL).27
Treatment of PCOS should target menstrual irregularities, hirsutism if present, obesity, or insulin resistance.
Menstrual irregularities can be caused by disturbance
of the central gonadotropin-releasing hormone pulse
generator as well as by significant weight loss, strenuous
exercise, substantial changes in sleeping or eating habits,
and severe stressors. Menstrual disturbances also occur
with chronic diseases, such as poorly controlled diabetes
mellitus; with genetic and congenital conditions, such as
Turner syndrome; and with other forms of gonadal dysgenesis. The diagnosis of pregnancy always should be
excluded, even if the history suggests the patient has not
been sexually active.
Excessive Menstrual Flow
A female’s first period usually is reported to be of medium flow, and the need for menstrual hygiene products
is not typically excessive. Although experts typically report that the mean blood loss per menstrual period is 30
mL per cycle and that chronic loss of more than 80 mL
is associated with anemia, this has limited clinical utility
because most females are unable to measure their blood
loss. However, a recent study in adult women confirms
that the perception of heavy menstrual flow is correlated
with a higher objective volume of blood loss.28
Attempts to measure menstrual blood loss on the
basis of number of pads or tampons used per day or
frequency of pad changes are subject to variables such as
the individual’s fastidiousness, her familiarity or comfort
with menstrual hygiene products, and even variation
among types and brands of pads or tampons.29 Most
report changing a pad approximately 3 to 6 times a day,
although external constraints such as school rules and
limited time between classes may make menstrual hygiene more problematic for adolescents than adults.
Menstrual flow requiring changes of menstrual products
every 1 to 2 hours is considered excessive, particularly
when associated with flow that lasts more than 7 days at
a time. This type of acute menorrhagia, although most
often associated with anovulation, also has been associated with the diagnosis of hematologic problems, including von Willebrand disease and other bleeding disorders,
or other serious problems, including hepatic failure and
malignancy.30–33
The prevalence of von Willebrand disease is 1% in the
general population. Von Willebrand disease is the most
2247
common medical disorder associated with menorrhagia
at menarche.34 As many as 1 in 6 girls presenting to an
emergency department with acute menorrhagia may
have von Willebrand disease.30 Therefore, hematologic
disorders should be considered in patients presenting
with menorrhagia— especially those presenting acutely
at menarche. Hormonal treatment, in the form of estrogen therapy, may affect hematologic factors and mask
the diagnosis. Blood collection to screen for hematologic
disorders should be obtained before initiating treatment.
Evaluating the patient may include referral to a hematologist or a specialized hemophilia treatment center for
appropriate screening.
ANTICIPATORY GUIDANCE
Because development of secondary sex characteristics
begins at ages as young as 8 years, primary care clinicians should include pubertal development in their anticipatory guidance to children and parents from this age
on. Clinicians should take an ongoing history and perform a complete annual examination, including the inspection of the external genitalia. It is important to educate children and parents about the usual progression
of puberty. This includes the likelihood that a child’s
initial breast growth may initially be unilateral and
slightly tender. Breast development will likely then become bilateral, but some asymmetry is normal. Young
females and their parents should understand that the
progression of puberty also includes the development of
pubic hair, which will increase in amount over time and
become thicker and curlier. Additionally, clinicians
should convey that females will likely begin to menstruate approximately 2 to 2.5 years after breast development begins, keeping in mind that recent studies have
suggested that the onset of both breast development and
menarche may occur slightly earlier for black girls than
for white girls.35 Young females should understand that
menstruation is a normal part of development and
should be instructed on use of feminine products and on
what is considered normal menstrual flow. Ideally, both
parents and clinicians can participate in this educational
process.
EVALUATION
Once young females begin menstruating, evaluation of
the menstrual cycle should be included with an assessment of other vital signs. By including this information
with the other vital signs, clinicians emphasize the important role of menstrual patterns in reflecting overall
health status. Clinicians should ask at every visit for the
first date of the patient’s last menstrual period. Clinicians
should convey that the menstrual cycle is from the first
day of a period to the first day of the next period and
may vary in length.
Both the American Academy of Pediatrics and the
American College of Obstetricians and Gynecologists
2248
recommend preventive health visits during adolescence
to begin a dialogue and establish an environment where
a patient can feel good about taking responsibility for her
own reproductive health and feel confident that her
concerns will be addressed in a confidential setting.36,37
These visits are also an opportunity to provide guidance
to young females and their parents on adolescent physical development based on data that define normal pubertal development, menarche, and menstrual cyclicity.38 Even during visits with adult patients who interact
with adolescents or have children, education about appropriate expectations and normal patterns for the adolescent menstrual cycle may be helpful guidance in the
decision to consider evaluation.
Asking the patient to begin to chart her menses may
be beneficial, especially if the bleeding history is too
vague or considered to be inaccurate. Although uncommon, abnormalities do occur. Confirming normal internal and external genital anatomy with a pelvic examination or ultrasonography can rule out significant
abnormalities. Therefore, one might consider the menstrual cycle as a type of vital sign and an indicator of
other possible medical problems. Using menarche or the
menstrual cycle as a sensitive vital sign adds a powerful
tool to the assessment of normal hormonal development
and the exclusion of serious abnormalities, such as anorexia nervosa, inflammatory bowel disease, and many
other chronic illnesses. Menstrual conditions that suggest the need for further evaluation are listed in Table 3.
Because menarche is such an important milestone in
physical development, it is important to be able to educate young females and their parents regarding what to
expect of a first period and about the range for normal
cycle length of subsequent menses. Girls who have been
educated about early menstrual patterns will experience
less anxiety as development progresses.1 It is equally
important for clinicians to have an understanding of
bleeding patterns of young females, the ability to differentiate between normal and abnormal menstruation,
TABLE 3 Menstrual Conditions That May Require Evaluation
Menstrual periods that:
● Have not started within 3 years of thelarche
● Have not started by 13 years of age with no signs of pubertal development
● Have not started by 14 years of age with signs of hirsutism
● Have not started by 14 years of age with a history or examination suggestive
of excessive exercise or eating disorder
● Have not started by 14 years of age with concerns about genital outflow tract
obstruction or anomaly
● Have not started by 15 years of age
● Are regular, occurring monthly, and then become markedly irregular
● Occur more frequently than every 21 days or less frequently than every 45
days
● Occur 90 days apart even for one cycle
● Last !7 days
● Require frequent pad/tampon changes (soaking more than 1 every 1–2
hours)
and the skill to know how to evaluate the young female
patient appropriately.
AAP COMMITTEE ON ADOLESCENCE, 2005–2006
Jonathan D. Klein, MD, Chairperson
Michelle S. Barratt, MD
Margaret Blythe, MD
Paula K. Braverman, MD
*Angela Diaz, MD
David S. Rosen, MD
Charles J. Wibbelsman, MD
LIAISONS
Miriam Kaufman, MD
Canadian Paediatric Society
Marc R. Laufer, MD
American College of Obstetricians and Gynecologists
Benjamin Shain, MD
American Academy of Child and Adolescent
Psychiatry
STAFF
Karen Smith
ACOG COMMITTEE ON ADOLESCENT HEALTH CARE, 2005–2006
*Marc R. Laufer, MD, Chair
*Lesley L. Breech, MD, Vice Chair
Jacqueline E. Darroch, PhD
Jennifer E. Dietrich, MD
LeighAnn C. Frattarelli, MD
Eduardo Lara-Torre, MD
Federico G. Mariona, MD
Michelle D. Vichnin, MD
Nichole A. Zidenberg, MD
LIAISONS
Trina M. Anglin, MD
US Bureau of Maternal and Child Health
Lorrie Gavin, MPH, PhD
Centers for Disease Control and Prevention
Melanie A. Gold, DO
American Academy of Pediatrics
Richard S. Guido, MD
American Society for Colposcopy and Cervical
Pathology
CONSULTANTS
Richard R. Brookman, MD
John Santelli, MD, MPH
STAFF
Luella Klein, MD
Janet Chapin, RN, MPH
Lisa Goldstein, MS
*Lead authors
ACKNOWLEDGMENTS
The committees would like to thank Lesley Breech, MD;
Angela Diaz, MD; S. Paige Hertweck, MD; Paula Adams
Hillard, MD; and Marc Laufer, MD; for their assistance in
the development of this document.
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Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital
Sign
American Academy of Pediatrics, Committee on Adolescence, American College of
Obstetricians and Gynecologists and Committee on Adolescent Health Care
Pediatrics 2006;118;2245
DOI: 10.1542/peds.2006-2481
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2006 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital
Sign
American Academy of Pediatrics, Committee on Adolescence, American College of
Obstetricians and Gynecologists and Committee on Adolescent Health Care
Pediatrics 2006;118;2245
DOI: 10.1542/peds.2006-2481
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/118/5/2245.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2006 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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