Diagnosing and treating the adolescent with irregular menstruation

One of the most valuable best practice tips that Catherine M. Gordon, MD, MS, FAAP, a professor of pediatrics, Baylor College of Medicine, Houston Texas offered during her session, “Irregular periods: what to do next?” was the discussion of making an early diagnosis of polycystic ovary syndrome (PCOS), the hormonal problems that cause an inconsistency in menstruation for teenagers. “Think about menstruation as a vital sign in adolescents,” she noted. “Variations in the normal pattern may have implications for overall health.”

While the normal menstrual cycle usually occurs when both breast and pubic hair development is Tanner stage 4 (12.5 years of age for most adolescents), it make take more than 2 years for that adolescent to become ovulatory. Furthermore, Gordon explained, abnormal uterine bleeding (AUB) can be detected by a number of screening markers:
• Menorrhagia: prolonged/heavy uterine bleeding
• Intermenstrual bleeding (metrorrhagia): uterine bleeding that occurs at irregular intervals
• Menometrorrhagia: prolonged uterine bleeding occurring at irregular intervals
• Oligomenorrhea: uterine bleeding that occurs at prolonged intervals of 41 days – 3 months
• Polymenorrhea: uterine bleeding occurring at regular intervals of < 21 days.

There are a number of things that can cause AUB, including a lack of a single follicle becoming dominant (so no rise in progesterone), and the endometrium becoming excessively thickened and unstable. An important note: “The more prolonged an adolescent’s anovulation, the greater the risk of AUB,” says Gordon.

So how to diagnosis correctly? Determining if an adolescent’s menstruation is cyclic or acyclic is a good place to start. Normal cyclic intervals with heavy bleeding can point to a uterine issue, such as use of an IUD, or infection, foreign body, polyp, endometriosis, etc. Acyclicity, or a cycle of 45 days, usually have anovulatory AUB due to lack of negative feedback, and is associated with psychosocial problems, eating disorders, athletic competition, PCOS, ovarian insufficiency, endocrinopathies, and malignancy. To correctly diagnose, Gordon reminds practitioners to take a complete family, endocrine, menstrual, and sexual history, a history of systemic illness (anemia, bleeding disorders, frequent nose bleeds, etc), and note use of all medications. “A menstrual calendar is an invaluable tool, can be completed by the patient, offers information, and can be tracked with phone apps,” noted Gordon.

For the diagnostic workup, Gordon recommends the following:
• Pregnancy test: urine (if +, follow w/ quantitative serum pregnancy test)
• CBC and ferritin: anemia, thrombocytopenia, and iron deficiency
• STI screening
• Thyroid function tests for all patients with moderate to severe menorrhagia • Coagulation screen: prothrombin time, vWF profile, blood group typing, etc.
• FSH, LH and testosterone: total and free
• Pelvic ultrasonography
• Endometrial biopsy generally NOT indicated in adolescents

Additionally, in treating these patients, both estrogen (to heal the endometrial bleeding) and progestins (to induce endometrial stability) are recommended. There are, however, “many modes of therapy,” Gordon says, “with the most common being monophasic oral contraceptive pills.”

Finally Gordon summarized her session with the following:
• One of many neuroendocrine abnormalities can lead to aberrant patterns
• Variations in the normal pattern may have implications for overall health in adolescents o May signify an underlying medical problem o Concerning implications for bone health
• Educate clinicians, patients and their parents: (21- 45 days is the normal cycle length).

And remember to report abnormal patterns to a primary care doctor.

Reference
Gordon CM. Irregular periods: what to do next. 2022 AAP National Conference & Exhibition. October 9, 2022. Anaheim, California.