"I have an idea that the phrase "weaker sex" was coined by some woman to disarm some man she was preparing to overwhelm." ~ Ogden Nash
Menstrual Problems in Teens
What's a problem? What's normal? If you're not sure if your bleeding pattern is "normal", check in with your mom, your pediatrician, or one of us:
According to textbooks, your period should come once a month, and the menstrual fluid/blood you lose is on average, 6-9 tablespoons. The trouble is, your body can't read textbooks, and your periods may be different from those of your sisters and your friends.
Who is normal? Who could benefit from a consult (no exam, I promise), from a gynecologist with special training, experience and interest in adolescence?
We all know that menses can be disruptive, upsetting, embarrassing, uncomfortable, crampy, distracting, etc. but for some young women it can be medically dangerous. Very occasionally, I will be called from the E.R. about a young woman with her first or second period bleeding so heavily as to require blood transfusions.
On the opposite side, and more commonly, I am consulted by young woman who has experienced the onset of menses at 12 or 13 and then after a few months, may not get another period for a year. Or may only notice 2 or 3 periods/year, and may or may not mention it until her astute mom recognizes that she hasn't had to buy tampons in a long time. (True story.)
Just started your period? Irregular menses are to be expected. But there are patterns to watch out for that should signal you to check in with us. Characterizing one of these patterns may be difficult because of the range of variability in cycles during the first one to two years post-menarche and the difficulty in quantifying volume of flow. If it bothers you, speak with your mom or your pediatrician, they can guide you as to what is in the range of normal.
Various Common Period Problems
1.Infrequent Periods: menses that don't come regularly (few have a consistent 28-day cycle in the first 2 years, but "normal" is more 9 or more in a 12 month year.)
2. Heavy periods: a very heavy flow each month, requiring you to change your pad or tampon more than every 3 hours, or you bleed for longer than 1 week.
3. Painful periods: If motrin and a heating pad doesn't take care of it, you are one of the 10% of young women who have unusually painful periods who could benefit from extra help.
4. No Period, period. An absence of periods (called amenorrhea), means either your menses hasn't started by the time you are 16 or it did start and then stopped for more than 3 months.
5. Combination of the above. A few women have a combination of problems. Sometimes these things are normal; sometimes it means something is wrong. So if your periods aren't regular, or are too heavy or painful -- or if your period stops coming, please give us a call.
Infrequent Periods
Typically, after a woman has been menstruating by 2 years her cycle regulates and she will get her period every month or so. Therefore, most women get about 12 or 13 periods a year.
If menstruation DOESN'T happen every month - if a woman gets only 5 or 6 periods a year - this would be considered infrequent and should be mentioned to her physician.
However, if you've been menstruating awhile, there are several common reasons that can delay menstruation for a month, making it appear that you're "skipping" a period.
The most common reason to 'skip' a period is pregnancy. Other reasons include:
- weight loss
- restrictive eating: either calories, fat or both
- an excessive exercise (for example, running 40 miles per week)
- episode of extreme stress (family illness, divorce, social...)
- illness, for example thyroid disease, prolactin-producing tumors, malabsorption such as Crohn's disease and celiac disease (sensitivity to gluten.)
- summer - it isn't unusual to skip a period during the summer. The additional hours of daylight can affect your menstrual cycle.
- perimenopause = getting older, within the last 10 years before menopause, (around age 50), we start to "run out" of eggs, this can be seen earlier in women who smoke, have family history of early menopause, or certain illnesses.
Heavy Periods
Heavy periods are hard to define (as different people have their own tolerance for a bloody pad or tampon - some will change at first sign of spotting, on the other extreme, some will wait until reminded by soaking through panties...)
Generally when you need to change your pad or tampon often: hourly is too often, ("normal" is changing pad or tampon every 3 to 4 hours), and/or you notice blood clots, regularly soak through your clothing, or soak the sheets.
Why some women have heavy periods:
- The natural flow is just heavy
- Use of the birth control method called an IUD (the copper intra-uterine device)
- "Hormonal imbalance" (too little or no progesterone)
- PCOS: Polycystic Ovarian Syndrome: can lead to infrequent, but heavy, irregular menses.
- Fibroids or polyps (benign growths that sometimes occur in the uterus, usually not in teens.)
- Uterine abnormalities such as double uterus
- Thyroid disease (as noted above, can cause infrequent periods as well.)
- Endometriosis - a condition of heavy and painful periods, that tends to run in the family.
- Obesity: we make more estrogen in our fat cells by converting other hormones there. More fat cells generally means more estrogen, which means heavier lining every month, causing heavy shedding (menses.)
- Bleeding Disorder: 20% of young women who are anemic as a result of their monthly periods have an underlying correctable bleeding disorder as yet undiagnosed.
- Treament for these disorders ranges from observation to pharmacologicand/or surgical therapy. (We never have to resort to D&C or hysterectomy to control bleeding in young women, as may have been done in years past.) ]Potential sequelae of AUB include anemia and endometrial cancer. With appropriate management of the underlying problem, these sequelae may be prevented. Thus, it is crucial to establish the correct diagnosis before any therapy is administered.
Unusually Painful Periods: "Dysmenorrhea"
There is a subset of young women who have unusually painful menses.They can start out painful after your first few periods (called "Primary Dysmenorrhea") or are immediately painful at menarche or can start years later (called "Secondary Dysmenorrhea".) It is important for your physician to make the distinction, because the treatments differ.
Primary Dysmenorrhea (PD): For some young women, their monthly cycle is associated with nausea, vomiting, diarrhea, cramps considered a "10 out of 10" on a pain scale. These young women lose school days, participation in sports and other social activities to stay home and get through these days. They started out fine, but within a few months on menarche the cramps, nausea and vomiting seemed much more dramatic than that of their friends.
PD is thought to be caused by excess prostaglandins found in some young women. Prostaglandins are hormone-like substances, found normally can cause dysrhythmic uterine contractions, hypercontractility, and increased uterine muscle tone leading to uterine ischemia.
They also can account for nausea, vomiting, and diarrhea via stimulation of the GI tract. The role of prostaglandins in the pathogenesis of primary dysmenorrhea is supported by the observation that nonsteroidal antiinflammatory drugs (NSAIDS) often help alleviate menstrual pain.
Painful periods generally do not occur until ovulatory cycles are established. Maturation of the axis leading to ovulation occurs at different rates in young women; 18 to 45 % of teens have ovulatory cycles two years postmenarche, 45 to 70 % by two to four years, and 80 % by four to five years.
Making the diagnosis of PD is generally based on talking to you, taking your history, we will rule out causes of secondary dysmenorrhea. If it isn't clear, we may order a pelvic ultrasound to delineate your anatomy, looking for an ovarian cyst, or uterine abnormality. Sometimes the diagnosis may overlap with gastrointestinal disease (IBS...)
Treating Primary Dysmenorrhea
The treatment of PD begins with antiprostaglandins (either ibuprofen or naprosyn in therapeutic doses.) If this fails and the patient is a candidate for combined estrogen-progesterone pill (OCPs), we will start the low-dose birth control pill. OCPs prevent menstrual pain by suppressing ovulation, which decreases uterine prostaglandin levels. An additional mechanism may result from the reduction of menstrual flow after several months of use. Randomized trials in adults and adolescents demonstrate moderate efficacy in pain relief.
Additional measures include heating pad, (now you can buy disposable heating paks from the drugstore that don't require electricity and can stick to your tummy and last for up to 8 hours), regular exercise and accupuncture.
Secondary Dysmenorrhea:can present at menarche or any time thereafter, and often include additional symptoms or clues that point to a problem other than pure excess prostaglandin production. These may include:
- Endometriosis
- Adenomyosis
- Ovarian cysts
- Pelvic adhesions
- Pelvic inflammatory disease
- Uterine polyps
- Congenital obstructive müllerian malformations
- Cervical stenosis
- Nongynecologic disorders
- Inflammatory bowel disease
- Irritable bowel syndrome
We can treat these adolescents to make their menses much more manageable. We use a stepwise approach, tailored to each young woman.
The Bottom Line: Please don't stay home and suffer. There are several medical options that can help you achieve a good quality of life if you have terrible periods.
Absence of periods: "Amenorrhea"
What's Normal? Some young women consult with our office because they haven't developed breasts or other signs of puberty by age 13-14, or started menstruating by age 15-16. Menstrual cycle disorders can cause a woman's periods to be absent or infrequent.
Although some women do not mind missing their menstrual period, these changes should always be discussed with a healthcare provider because they can signal underlying medical conditions and potentially have long-term health consequences. A woman who misses more than three menstrual periods (either consecutively or over the course of a year) should discuss this with their physician.
Amenorrhea = absence of menstrual periods, either:
- Primary (when menstrual periods have not started by age 16)
- Secondary(when menstrual periods are absent for more than three to six months in a woman who previously had periods)
- Oligomenorrhea:few or infrequent menstrual periods (fewer than 6-8 menses/year).
Secondary Loss of Menses: Red Flag if 3 months
Secondary amenorrhea = the absence of menses for more than three cycles or six months in women who previously had menses. In adolescents, it is uncommon for girls to remain without their menses for >90 days (the 95th % for cycle length).
Thus, adolescents without menses for 3 months warrant an evaluation. Once pregnancy is excluded, a step-wise endocrinologic evaluation can be considered. If labs are normal, a progesterone challenge or a trial of hormonal contraception may be necessary to reestablish menses.
Lack of menses in adolescents can be caused by:
- Pregnancy
- Dramatic weight loss. Amenorrhea is a frequent telltale sign of the eating disorder anorexia nervosa, an illness in which the patient --usually a young woman--starves herself in order to be thin.
- The "binge/purge" disorder, bulimia, in which the patient eats a lot of food (bingeing) and then makes herself throw up (purging).
- Excessive exercise, like running more than 40 miles per week, or elite training in ballet/gymnastics, etc.
- Restrictive fat intake
- Polycystic Ovarian Syndrome
- Certain medications that work through the CNS
- On some very low dose of birth control pills, there may be little or no menstrual flow
Bleeding or "spotting" between periods The only type of normal bleeding or "spotting" (light bleeding) between periods is spotting that happens for some women when they ovulate (which is about fourteen days before the start of the next period). If you have any other type of bleeding or spotting between cycles, you should check in with us.
Evaluation of Bleeding
The differential diagnosis of genital tract bleeding in adolescents is similar to that in adult women However, the most common causes vary according to age.
Rule out Pregnancy: In adolescents in particular, disorders of pregnancy, particularly ectopic pregnancy, and the possibility of pelvic infection should be considered early in the evaluation. It is essential to rule our pregnancy in the adolescent, regardless of the stated sexual history. This is especially important in those adolescents who present with unexplained vaginal bleeding..)
Once pregnancy has been excluded, by taking your history, we determine whether the bleeding is cyclic (regular) or acyclic (irregular) in nature. As an example, DUB ("dysfunctional uterine bleeding) is the most common cause of excessive menstrual flow in adolescents with irregular bleeding, whereas bleeding disorders and structural anomalies (eg, polyps, fibroids) are more common in those with cyclic bleeding.
Ovulatory bleeding: As a general rule, bleeding that is preceded by premenstrual symptoms (breast tenderness, water weight gain, mood swings, or abnormal cramping) is ovulatory. In contrast, heavy bleeding that occurs irregularly is usually anovulatory. However, many patients are between these extremes, and determination of the ovulatory status may be difficult.
In this case,the endometrium lacks the stabilizing effect of progesterone. In such cycles, the endometrium becomes excessively thickened. It breaks down and sloughs when estrogen is withdrawn (estrogen-withdrawal bleeding) or when it becomes unstable (estrogen-breakthrough bleeding).
Adolescents with regular menses have cyclic estrogen secretion that permits orderly growth and shedding of the endometrium (on account of hormone withdrawal), even in the absence of ovulation. In addition, the secretion of progesterone associated with the occasional ovulatory cycle in these adolescents helps to stabilize endometrial growth and permits more complete shedding.
Polycystic ovary syndrome (PCOS) is a common cause of abnormal bleeding in the adolescent with chronic anovulation. The diagnosis of PCOS is based upon clinical and biochemical criteria. It is considered in adolescents with obesity, menstrual irregularity, insulin resistance, and/or signs of hyperandrogenism (generally hirsutism and acne). If PCOS is a consideration, other causes of hyperandrogenism and other causes of irregular menses must be ruled out. Please see our web entry on PCOS for more info.
Other causes
Other hormonal causes of irregular bleeding in adolescents include hypothyroidism, and hyperprolactinemia . The causes of hyperprolactinemia are include discussed separately, but pituitary tumors and certain medications (eg, metoclopramide and methyldopa).
Psychological or exercise-induced stress and eating disorders with large weight loss may cause acute anovulation in adolescents. However, these disorders are typically associated with a hypoestrogenic state and amenorrhea.
Finally, breakthrough bleeding related to infections of the vulva, vagina, or cervix may give an adolescent the false impression that her menses are "irregular”.
Bleeding disorders
Menorrhagia that occurs at regular intervals or at the onset of menses is often related to a bleeding diathesis and less commonly to systemic illness or structural lesions. Inherited bleeding disorders are considered in the differential of all patients presenting with menorrhagia .
In retrospective studies, the prevalence of bleeding disorders among adolescents hospitalized for menorrhagia ranges from 5 to 28 %. In one series of 59 adolescents who were hospitalized with acute menorrhagia, and in whom genital tract pathology had been excluded, an underlying coagulopathy was present in approximately one-fifth overall, one-third of those requiring a transfusion, and one-half presenting at menarche.
Coagulation disorders among adolescents with menorrhagia include von Willebrand disease, Glanzmann thrombasthenia, idiopathic thrombocytopenic purpura, platelet dysfunction, and low platelets secondary to malignancy or treatment for malignancy (ie, chemotherapy or hematopoietic stem cell transplantation)
Bleeding disorders in adolescents also may be related to the use of medications such as anticoagulant or platelet inhibitors, or excess aspirin, ibuprofen use.
Excessive bleeding prompts an evaluation of hematologic status.
The laboratory evaluation generally includes:
- Blood tests to r/o anemia, low platelets, abnormal clotting and iron deficiency.
- If the patient's first menses is very heavy or she requires a blood transfusion we will rule out a possible mild, late-presenting bleeding disorder, such as von Willebrand's disease.
It is important that the von Willebrand panel be obtained when the patient is not taking hormones because any additional estrogen may falsely elevate VWF into the normal range.
Therefore we will obtain the panel should be obtained at the time of presentation or after exogenous estrogen (like the birth control pill) has been discontinued for seven days.
We will also obtain blood group typing since blood group O is associated with lower levels of VWF, and consult with a hematologist if the levels are low.
"The state of the world today demands that women become less modest and dream/plan/act/risk on a larger scale.” ~ Charlotte Bunch
[some content borrowed/edited from uptodate.com: Nirupama K De Silva, MD, Robert K Zurawin, MD, Jan 2010, and beinggirl.com, 7/10]
