Menstrual concerns in adolescents: What pediatricians should know

Menstrual concerns in adolescents: What pediatricians should know

Menstrual concerns are common during adolescence, but irregular cycles, heavy bleeding, and period pain should not automatically be dismissed as expected features of puberty, according to Nichole Tyson, MD.

Tyson is chief of Pediatric Adolescent Gynecology at Stanford Children’s Hospital in Palo Alto, California. At the American Academy of Pediatrics (AAP) 2026 National Conference & Exhibition, she discussed how pediatricians can identify, evaluate, and initially manage common menstrual concerns in children and adolescents.

"About 40% of girls can report heavy periods. So, it's pretty darn common," Tyson said. She also highlighted dysmenorrhea, irregular cycles, primary amenorrhea, bleeding disorders, polycystic ovary syndrome—referred to by Tyson as PMOS—and endometriosis among conditions pediatricians may encounter.

What should pediatricians ask about menstrual bleeding?

History taking is particularly important when an adolescent presents with heavy or irregular menstrual bleeding, Tyson said.

A menstrual calendar can help establish the frequency and duration of bleeding. Tyson noted that the normal menstrual interval for a teenager is generally 21 to 45 days. A patient reporting periods "twice a month," for example, may actually be experiencing cycles approximately 21 days apart.

"You really only can elucidate and figure that out if you're keeping track," Tyson said. "And I think that's important that the teenager, the person having the periods, learns to track that."

Pediatricians should also ask how long bleeding lasts, how frequently the patient changes menstrual products, whether bleeding soaks through clothing or bedding, and whether symptoms interfere with school or other activities.

Fatigue and other symptoms suggestive of anemia should also be assessed. A history of excessive bleeding with dental procedures or wisdom tooth extraction may provide clues to an underlying bleeding disorder.

Tyson emphasized the potential value of identifying these disorders during adolescence.

"I think that's such a great asset to give a young person is to identify this bleeding disorder early in life to prevent blood transfusions and sort of catastrophic events later," she said.

Initial laboratory evaluation may include a complete blood count, ferritin, thyroid-stimulating hormone, follicle-stimulating hormone, and, when indicated, pregnancy testing and evaluation for androgen abnormalities. Tyson also discussed considering coagulation studies and a von Willebrand panel when evaluating heavy bleeding.

When should period pain raise concern?

Dysmenorrhea is common, but Tyson cautioned against normalizing significant menstrual pain.

"I think we all dismiss sort of period pain as sort of a coping, like yeah, yeah, grin and bear it," Tyson said. "But really, paying attention to these kinds of red flags is key."

Pain that is severe from the first menstrual period is not a typical pattern, she explained. Progressively worsening pain can also raise concern for endometriosis, particularly when accompanied by abnormal or heavy bleeding or a family history of endometriosis.

Tyson recommended initiating treatment while also validating the patient's symptoms. Initial approaches can include nonsteroidal anti-inflammatory drugs, heating pads, and hormonal therapy when appropriate.

Follow-up is an important part of that strategy.

"We don't just give them that and send them away," Tyson said. "So it's really important to bring them back in three to six months, see how they're using their medicine, see how the pain is resolving, and really, if it's not, then that's time to move on."

Patients who are not improving after 3 to 6 months of initial treatment may require further evaluation for conditions such as endometriosis.

When should pediatricians consider referral?

Tyson encouraged pediatricians to routinely ask adolescents about their periods, even when menstruation is not the reason for the visit.

"I think all pediatricians should be asking girls about their periods," Tyson said. "I think that's step one."

Menstrual tracking and basic laboratory testing can often begin in primary care. Pediatricians can also initiate treatment for dysmenorrhea and follow patients to determine whether symptoms improve.

Several patterns, however, may warrant additional workup or referral. Tyson highlighted absence of menarche by age 15, failure to menstruate within 3 years of the beginning of breast development, cycles occurring more frequently than every 21 days or less frequently than every 45 days, a gap of approximately 3 months between periods, or cycles that become irregular after previously being regular.

Anemia, suspected bleeding disorders, abnormal androgen testing, persistent dysmenorrhea, complex medical conditions, and failure to respond to initial treatment are other reasons to consider specialty care.

Referral can also be appropriate when patients or families want additional counseling about menstrual management or hormonal treatment.

"We don't really think there are any bad referrals or consults," Tyson said. "It's just ways to support each other and our patients most importantly."

Reference

Tyson N. Recognizing and Managing Common Gynecologic Disorders in Adolescents. Presented at: American Academy of Pediatrics 2026 National Conference & Exhibition; October 5, 2026; San Diego, CA.