Riddle me this: Irregular menses in adolescent girls

You're at your best in winning the trust of your young teenaged patients. Your innate sense of empathy makes you a born counselor and a source of caring, concern, and essential guidance!

Does your clinical IQ always keep pace with your emotional intelligence when it comes to menstruation issues? Do you know what could signal an abnormality versus typical irregularity?

Take the quiz to find out!

1. Irregular menstrual cycles characterized by longer intervals between menses during the first 3 years of menarche are a red flag that an underlying disorder is always best.

True

False

Answer: False

Although an underlying condition may be present, the most likely cause of irregular menstrual cycles in the first years of menarche is likely anovulation caused by immaturity of the hypothalmic-pituitary-ovarian (HPO) axis.

It typically takes from 6 months to 3 years of menarche to a mentstrual cycle to become regular, which for most girls and women at 3 years is 21-34 days long between cycles. During the first 3 years, the interval between cycles may be in the range of 21-45 days for 90% of girls but may be less than 20 days for some and more thana 45 days for others.

Further evaluation is warranted in girls with cycle length that is more than 90 days (3 months).

Sources

Jamieson MA. Disorders of Menstruation in Adolescent Girls. Pediatr Clin N Am 2015;62:943-961.

The American College of Obstetrics and Gynecologists. Committee on Adolescent Health Care. Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign. Committee Opinion No. 651. December 2015. Reaffirmed 2017. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Adolescent-Health-Care/co651.pdf?dmc=1&

2. Abnormal uterine bleeding characterized by irregular heavy menstrual bleeding may be caused by which of the following?

A) Polycystic ovary syndrome

B) Thyroid disease

C) Coagulopathy

D) All of the above

Answer: D - All of the above

Irregular heavy menstrual bleeding  (eg, bleeding that requires changing pad/tampon ever 1-2 hours, particularly in menses that lasts >7 days at a time) is commonly caused by anovulation. In the absence of ovulation or infrequent ovulation, further testing for underlying pathologies for irregular menstrual bleeding is warranted and include endocrinopathies (er, polycystic ovary syndrome [PCOS] and thyroid disease) caused by disturbances to the HPO axis.

Other conditions to consider include a coagulopathy such as von Willebrand's disease or platelet function disease or more rare serious problems such as hepatic failure or cancer.

Sources

Jamieson MA. Disorders of Menstruation in Adolescent Girls. Pediatr Clin N Am 2015;62:943-961.

The American College of Obstetrics and Gynecologists. Committee on Adolescent Health Care. Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign. Committee Opinion No. 651. December 2015. Reaffirmed 2017. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Adolescent-Health-Care/co651.pdf?dmc=1&

3. If an adolescent girl presents with a menstrual cycle that is absent or has stopped, what is the differential diagnosis primarily dependent on?

A)    The age and weight of the patient

B)    The activity level of the patient

C)    Whether the patient has primary or secondary amenorrhea

D)    Whether her physical history shows a pattern in her maternal lineage.

Answer: C - Whether the patient has primary or secondary amenorrhea.

The first thing to determine in diagnosing a patient who presents with a menstrual cycle that is absent or has stopped is to run tests to determine if the cause is due to primary amenorrhea (ie, lack of uterine bleeding by age 14 years and with no other secondary sexual characteristics, or lack of uterine bleeding by age 16 even with normal secondary sexual characteristics) or secondary amenorrhea (ie, absence of menstrual cycles for 90 days after having a regular perioud for at least 6 months).

Along with a detailed history and physical exam, laboratory tests to help in the differential diagnosis include the human chorionic gonadotopin urine test (to rule out pregnancy, which is the most common cause of secondary amenorrhea); a complete blood count (to assess anemia or systemic infection or inflammation); a thyroid function test (to check for hyperthyroidism or hypothyroidism); a prolactin level test (to rule out hyperprolactinemia); LH, FSH, and estradiol levels (to test the HPO axis); and tests to assess for nonclassical congenital adrenal hyperplasia (CAH) and PCOS (testosterone, sex hormone binding globulin, 17-hydroxyprogesterone levels). A pelvic ultrasound can be used to diagnose an absent uterus,  Turner's syndrome, or an abnormal vaginal outflow tract.

Source

Foster C, Al-Zubeidi H. Menstrual Irregularities. Pediatric Annals 2018;47:e23-e28.

4. Which of the following warrants referral to a specialist (eg, gynecology, pediatric gynecology or endocrine, genetics hematology, psychiatry)?

A) Inherited bleeding disorder

B) Delayed or arrested puberty

C) Primary physiologic dysmenorrhea beginning at 10 months after the onset of menarche

D) A and B only

E) All of the above

Answer: D - A and B only

Both an inherited bleeding disorder and delayed or arrested puberty may warrant further evaluation by a specialist. Other conditions also include an eating disorder or patients with complex situations that do not respond to traditional therapies.

Primary physiologic dysmenorrhea occurs months or a few years after the onset of menarche once the menstrual cycle becomes ovulatory. For girls with primary physiologic dysmenorrhea in whom ovulatory cycles have begun, reassurance that dysmenorrhea is typical may be all that is needed or treatment with nonsteroidal inflammatory drugs if the dysmenorrhea interferes with activities.

Note: Referral to a specialist is warranted when treatments fail to control menstrual pain. Also, outflow obstruction may be considered if dysmenorrhea is intractable or in girls who experience very painful menses at the onset of menarche.

Sources

Jamieson MA. Disorders of Menstruation in Adolescent Girls. Pediatr Clin N Am 2015;62:943-961.

5. Which of the following are among menstrual abnormalities that should alert pediatricians that evaluation is needed?

A) Menstrual cycles with an interval of 45-60 days during the first 2 years of menarche

B) Menses that have not started within 3 years of thelarche

C) Menses that have not started by age 14 and accompanied by hirsutism, or with an indication of excessive exercise or eating disorder

D) Menses that have nor started by age 15

E) All of the above except A

Answer: E - All of the above except A

It is not uncommon for the length of menstrual cycles to vary wthin the first 3 years of menarche and an interval between 45-60 days is not abnormal. As previously mentioned, an interval length of >90 days warrants further evaluation.

Onset of menarche typically begins with 2-3 years after breast budding (thelarche) at Tanner stage IV breast development. It rarely begins before Tanner stage III development. Girls in whom menarche does not occur within 3 years of thelarche, or by age 13, should be examined.

Lack of menarche by age 14 and accompanied by hirsutism may suggest exposure to excess androgens caused  by conditions such as PCOS or CAH. Lack of menarche by age 14 may be due to excessive exercise or an eating disorder as indicated by history of physical exam.

Lack of menarche by age 15 warrants an evaluation for pimrary amenorrhea.

Sources

The American College of Obstetrics and Gynecologists. Committee on Adolescent Health Care. Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign. Committee Opinion No. 651. December 2015. Reaffirmed 2017. https://www.acog.org/-/media/Committee-Opinions/Committee-on-Adolescent-Health-Care/co651.pdf?dmc=1&

Foster C, Al-Zubeidi H. Menstrual Irregularities. Pediatric Annals 2018;47:e23-e28.