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Symptoms associated with menstruation are among the most common concerns of adolescent women. However, the factual information that adolescent women need is not always available to them. Physicians can do much to correct the myths and misinformation that the teenager may have concerning her menstrual cycle. This paper addresses clinical office concerns about normal menstruation, dysmenorrhea, amenorrhea and dysfunctional uterine bleeding.
Les symptômes associés aux menstruations font partie des préoccupations les plus fréquentes des adolescentes. Cependant, celles-ci n’ont pas toujours accès aux renseignements factuels dont elles ont besoin. Les médecins peuvent participer énormément à corriger les mythes et la désinformation de l’adolescente face à son cycle menstruel. Le présent article traite des préoccupations abordées en cabinet au sujet des menstruations normales, de la dysménhorrée, de l’aménorrhée et de la ménométrorragie.
Symptoms associated with menstruation are among the most common concerns of adolescent women. Although televison advertisements about tampons and winged sanitary napkins abound, the factual information that the adolescent woman needs is not always available to her. Physicians can do much to correct myths and misinformation that the teenager may have concerning her menstrual cycle. This health note addresses clinical office concerns about normal menstruation, dysmenorrhea, amenorrhea and dysfunctional uterine bleeding.
Menarche is a late event in puberty. In North America, the average age of menarche is 12 years eight months, with a range of nine to 17 years of age. The first period occurs approximately two years after breast budding between Tanner stages 3 and 4 (1). If there is no budding by 14 and a half years, the physician can begin to think about delayed puberty because it is unlikely that menstruation will occur by age 17 years. Recently, Herman-Giddens et al (2) reported an earlier onset of pubertal changes in American girls, with breast bud formation in 14.7% of Caucasians and 48.3% of Afro-Americans by age eight years (2). Along with this early influence of estrogen, there are uterine changes that result in the production of a thin, odorless vaginal discharge. A doctor should discuss this phenomenon with the patients after the physical finding of breast budding to alleviate unnecessary worry about this discharge. This is also an appropriate time to teach about the expected sequence of body changes that will take place, encouraging the teen and her motherto continue the discussion together. A book list to help them do this can be found in Table 1. The first two years of periods are often anovulatory and, therefore, may be very irregular. It is not uncommon to have only one or two periods during the first year. On the other hand, some girls may have regular ovulatory cycles from the start. Increasing regularity occurs over the next five years (3). The actual ‘normal’ range from cycle to cycle can be from 21 to 45 days, with blood loss being from 20 to 80 mL total. In more practical terms, this is 10 to 15 saturated tampons or pads per cycle, with no more than six saturated tampons or pads in one day. Bleeding is heaviest during the first few days with rapid tapering after this (4). It is useful and reassuring for the teen to know the ranges of normal.
Table 2 lists the definitions of common menstrual complaints. History taking and physical examination involved in sorting out menstrual problems are often very sensitive and embarrassing for some. Some approaches that may help the office clinician obtain pertinent information follow. Approaches to these problems are then outlined.
It is often necessary to get a family menstrual history from the parent because it is unlikely that the teen will know this information. Important information includes fertility or bleeding problems, virilized relatives, medications taken during pregnancy as well as significant emotional and psychiatric history of the family. There must also be time for a comfortable, private interview with the teen during which the legal limits of confidentiality can be explicitly explained (see reference 5). Only then can a doctor obtain a detailed history concerning sexual activity, pregnancy, sexually transmitted disease (STD) risk and drug use (both licit and illicit), all of which can affect the menstrual cycle. The history should also include serious illnesses and treatments, age at menarche, date of last normal menstrual cycle, frequency, duration and quantity of flow as well as the presence and timing of any menstrual pain. Because the control of chronic conditions – such as diabetes melitus, inflammatory bowel disease, cystic fibrosis and juvenile arthritis – can affect menstruation, an assessment of this control is important. Medications, in particular carbamazepine, phenobarbitol and phenytoin, increase the incidence of breakthrough bleeding. Poor nutrition, both over and under, laxative abuse, stress and depression can play havoc with regular cycles. More continues to be learned about the effects of extensive physical exercise on hormones causing amenorrhea.
The physician should then explain the need for the general physical examination as well as areas of special concern, ie, the need to determine Tanner staging, hymenal patency, clitoromegaly, vaginal discharge or lesions, hirsuitism, and neurological testing. A pelvic examination may not be necessary at this time if the history and physical have determined the cause of the complaint. A pelvic examination should be done if there is any suspicion of a mass; concern about the presence or normalcy of the vagina, cervic or uterus; or, if the teen is sexually active, concern about pregnancy or STD. The paediatrician may wish to defer the pelvic examination to a colleague who is more experienced in doing pelvic examinations. Even if no pelvic is done, many physicians will have the mother, a nurse or whoever the adolescent requests present while doing a genital examination. The issue of chaperones still depends largely on community practice but should be determined by the request and comfort of the patient and doctor.
It is most comforting if the doctor talks to the patient during the examination, explaining the procedures and normal findings. Keep the patient as covered as possible, using both a gown and a sheet. After the examination, allow the patient to dress privately before discussing the findings, need for further assessment and tests with her and, with her permission, with her parents. If the patient refuses the examination, ask about her specific concerns and try to alleviate them. It may be necessary to reschedule the examination. Sometimes the adolescent will request a female doctor for the genital or pelvic examination. Be flexible.
Secondary dysmenorrhea usually occurs later, well after the establishment of regular ovulatory cycles. It can result from such conditions as STDs, pregnancy complications, endometriosis, or uterine or vaginal congenital anomalies, and is treated by addressing the underlying etiology.
Primary dysmenorrhea commonly occurs as cycles become ovulatory. The foundation of therapy is education and reassurance. If the teen can continue her normal activities, encourage her to do so. It may not be possible to refrain from using medication. Ask her to record when she takes medicine. This is useful to determine the severity of the pain and that the proper dose has been used, as well as to make the teen aware of medicine intake. First-line use of acetaminophen may be adequate. Because such primary dysmenorrhea is the result of prostaglandin-medicated uterine hyperactivity, antiprostaglandins such ibuprofen can be helpful. If it is not, naproxen sodium or mefenamic acid (Ponstan, Parke Davis) can be used. A three-month trial of the medication at the correct dose is in order before changing medications (Table 3). Finally, if the pain is incapacitating, oral combined birth control pills may be used. The majority of young women will be helped by one of the above regimens. If the patient continues to have significant dysmenorrhea despite a sufficient trial of nonsteriodal anti-inflammatories (NSAIDS) and oral contraceptives, further evaluation for pelvic pathology is in order. The role of endometriosis in adolescent dysmenorrhea is beginning to be recognized. It is probably the most common cause of pain unresponsive to the therapy described above (8).
Primary amenorrhea is uncommon. Only about 3% of North American women have not menstruated by age 17 years, and even among this group a significant number have constitutional delay determined by history and physical. If further evaluation is needed, an excellent review of the topic is given by Emans and Gold-stein (6). With a reported 25% of Canadian adolescents sexually active by age 14 years (9), pregnancy testing should be done in all women who present with amenorrhea.
History and physical examination, and sometimes the pregnancy test, will direct the need for further laboratory work. The next step is to test thyroid-stimulating hormone (TSH), prolactin, luteinizing hormone (LH), follicle-stimulating hormone (FSH) and dehydroepiandrosterone sulphate (DHEAS) levels. If the levels are normal, a challenge with medroxy progesterone acetate 10 mg daily for five days is indicated. The patient should have withdrawal bleeding two to seven days after this trial. Any bleeding is considered positive. With normal TSH and prolactin levels, this test confirms a normal hypothalamic-pituitary-ovarian axis and an intact reproductive tract (10). It is appropriate in the otherwise nutritionally and emotional healthy teen to give reassurance and observe over three to five months the onset of spontaneous menstruation. Some prefer at this point to cycle the patient with progesterone or combination oral contraceptives for a few months. Remember to counsel sexually active teens about contraception and STD prevention.
In those who fail to have withdrawal bleeding or who have abnormal laboratory tests, evaluation by an endocrinologist or gynecologist with an interest in paediatric and adolescent gynecology is indicated.
Dysfunctional uterine bleeding refers to prolonged excessive menstrual bleeding in the absence of structural pelvic pathology, usually associated with irregular periods. A complete history should include details about sexual activity, genital trauma, medications taken and systemic illnesses. Classens and Cowell (10) found that 20% of patients presenting with significant menorrhea have a coagulation disorder. Therefore, evidence of generalized bleeding or bruising should be sought on personal and family history as well as on the physical examination. Because of the need to rule out abnormalities of pelvic anatomy, a pelvic examination should be done. If this is not possible, evaluation via a rectal examination and ultrasound will help define structural problems or masses. By far, the most common cause of heavy menstrual bleeding (see above for normal bleeding guidelines) is anovulation. This is associated with a lack of the normal negative feedback mechanism. The estrogen-rich progesterone-poor cycle does not have an LH surge, and there is lack of maturing of the endometrial vessels. All of these, when present, help to limit bleeding. In their absence, there is irregular and often incomplete shedding of the uterine lining, resulting in excessive, painless bleeding.
Laboratory evaluation should include a pregnancy test, a complete blood count and smear, reticulocyte count, red cell indexes, prothrombin, partial thromboplastin time and bleeding time. If the bleeding time is abnormal, further evaluation for von Willebrands should be done. Depending on the history and physical examination, a thyroid profile as well as virilization tests (LH, FSH, PROLACTIN, DHEA-S and free testosterone) may need to be assessed. The treatment of dysfunctional uterine bleeding is dependent on the severity of the bleeding. Table 5 gives one approach to management.
Menstrual disorders in adolescent are very common. By helping patients understand the normal processes of puberty and menstruation, adolescent patients start to see physicians as a source for health education and care. The vast majority of menstrual concerns during adolescence can be diagnosed and treated without the need for invasive or extensive testing.