Diagnosing and managing menstrual disorders in teen girls

Much like a person’s pulse rate, body temperature, respiration rate and blood pressure, menstruation can serve as a vital sign of a girl’s health and menstrual issues can indicate underlying health concerns. At the virtual 2021 American Academy of Pediatrics National Conference & Exhibition, Selma F. Witchel, MD, FAAP, professor of pediatrics at UPMC Children’s Hospital of Pittsburgh in Pennsylvania discussed the difference between normal and abnormal menses, the available toolbox, common irregular menses situations, and what to consider with menses in special populations.

The median age at menarche is 12.43 years. Normal menarche has a flow length of ≤7 days and typical product use is 3 to 6 pads or tampons a day. The cycle interval is irregular during the first gynecologic year; 21-45 days during the second gynecologic year; and 21-35 days from third gynecologic year until menopause. Signs of abnormal menses include menses lasting more than 7 days; initially regular menses becoming irregular; menses requiring pad/tampon changes every 1-2 hours and throughout the night; no menses by age 15 years with appropriate pubertal development; and no menses within 3 years of the onset of breast development.

Therapies available in the toolbox to use with menstrual disorders include combined oral contraceptives, the vaginal ring, depot medroxyprogesterone acetate, progestin-containing intrauterine devices, gonadotropin-releasing hormone (GnRH)-superagonists, and etronogestrel subnormal implants. Witchel noted that providers should be aware of whether treatments could impact bone mineral density during such a pivotal time, like combined oral contraceptives that have a mild negative impact or depot medroxyprogesterone acetate that has a significant adverse effect, or carry a risk of venous thromboembolism, such as combined oral contraceptives.

Witchel then discussed common irregular menstrual concerns including:

• Menses too early - A cause of early menstruation is precocious puberty, which can be either GnRH-dependent, which can be idiopathic, genetic, or tied to central nervous system, or GnRH-independent, which can be the result of Prader-Willi syndrome, Williams and Temple syndrome, autonomous ovarian cysts, etc. A GnRH agonist can be used in the former. Isolated vaginal bleeding with no other signs of puberty is a diagnosis of exclusion and can be the result of sexual abuse, infection, vaginal foreign body, ovarian cyst, hypothyroidism, or pinworm endometritis.
• Minimal breast development and delayed menses - Turner syndrome may be the cause in girls with short stature, cubitus valgus, shortened fourth metacarpals, short neck, high arched palate, neurosensory hearing loss, scoliosis, and Madelung deformity. It should be treated with growth hormone.
• Secondary amenorrhea - Stress, pregnancy, traumatic brain injury, eating disorders, and diabetes can all lead to secondary amenorrhea. Polycystic ovary syndrome (PCOS) is another cause and can be treated with lifestyle modification, combined oral contraceptives, and metformin when needed. Witchel stated that an accurate evaluation of PCOS can’t be done if the patient already using oral contraceptives. Furthermore, care should be taken when diagnosing PCOS in teenage girls. Other disorders should excluded before doing so and certain diagnostic criteria such as insulin resistance and hyperinsulinemia should only be used with adult women.
• Breast development and no menses - Causes can include androgen insensitivity, anatomical anomalies, or Mayer-Rokitansky-Kuster-Hauser syndrome, which may require surgical interventions.
• Heavy menstrual bleeding - Bleeding disorders, PCOS, infection, thyroid disease, and hemorrhagic ovarian cysts can all cause heavy menstrual bleeding. Bleeding disorders should be considered if there is a family history, menorrhagia since menarche, or a personal history of bleeding episodes. Treatment includes acute and maintenance therapies from the toolbox.

The session ended with Witchel discussing menstruation in adolescent girls with disabilities. She noted that menstrual management or suppression is often desired by this group. Providers should engage in shared decision-making when possible. Some physical disabilities may make some forms of menstrual hygiene more difficult or undesirable. Some medications may cause hyperprolactinemia and interactions may occur between some seizure medications and sex steroids. A hysterectomy is not considered appropriate management in this group. If it’s being considered as a last resort, Witchel recommended a consult with an ethics committee.

Reference

1. Witchel S. Evaluation and management of menstrual disorders in teens. American Academy of Pediatrics 2021 National Conference & Exhibition; virtual. Accessed October 8, 2021.