Menstruation: The sixth vital sign

Menstrual cycle changes can be as useful predicting potential health problems as an abnormal blood pressure, heart rate, or respiratory rate, according to a new study that advocates evaluating menses as a vital sign.

“It is important for clinicians to have an understanding of what is considered normal and abnormal menstruation in adolescents and know how to evaluate this patient population,” says Xiomara Santos, OB/GYN, a physician and assistant professor of obstetrics and gynecology at Texas Children’s Hospital who served on the committee reponsible for the recommenation. “Identification of abnormal menstrual patterns in adolescence may improve early identification of potential health concerns for adulthood.”

The new report was crafted by the American College of Obstetricians and Gynecologists’ (ACOG) Committee on Adolescent Care, and emphasizes the evaluation of adolescent menstrual patterns at each preventive care visit. It updates an earlier report with a similar message.

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“Clinicians should educate girls and their caretakers about what to expect of the first menses and the range for normal cycle length of subsequent menses. Once adolescent girls begin menstruating, clinicians should ask at every visit for the patient’s first day of her last menstrual period and the pattern of her menses,” she says. “By including this information with the other vital signs, clinicians emphasize the important role of menstrual patterns in reflecting overall health status.”

The median age of menarche is between 12 and 13 years of age, but can be impacted by environmental factors including socioeconomic status, nutrition, and access to healthcare, according to the report. Knowing what to expect can help with early identification of abnormal patterns that could signal other health problems.

Clinicians, too, must become well-versed in variations in menstrual patterns, the committee notes.

“It is important for clinicians to have an understanding of the menstrual patterns of adolescent girls, the ability to differentiate between normal and abnormal menstruation, and the skill to know how to evaluate the adolescent girl patient,” according to the guidance. “By including an evaluation of the menstrual cycle as an additional vital sign, clinicians reinforce its importance in assessing overall health status for patients and caretakers.”

One of the hurdles to assessing menstrual patterns and abnormalities is the hesitance of adolescent girls to discuss menstruation with their parents or caretakers. Sometimes, they may be more comfortable turning to another trusted adult, such as their pediatrician, for information of cycle patterns and menstrual flow.

Clinicians must be able to relay accurate information about normal ranges for menstrual cycle length and the amount of bleeding that is typical during adolescence, but this does not always happen, according to the report. The guidance outlines what is normal, and some of the conditions abnormal cycles may indicate.

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Despite concerns that puberty is beginning earlier, the report notes that the US National Health and Nutrition Examination Surveys have found no significant change in the median age at menarche over the past 30 years, except among the non-Hispanic black population (onset occurring about 5 months earlier over the 30-year period).

Puberty can be initiated well before the first menstrual period, which typically occurs 2 to 3 years after thelarche-or initial breast budding. Menarch can be expected around the time breast development reaches Tanner stage IV breast development but rarely before Tanner stage III. By the age of 15 years, 98% of girls have reached menarche, and the committee says evaluation for amenorrhea should be considered in any adolescent girls who have not reached menarche by age 15 years or within 3 years of thelarche. The committee also recommends evaluation if breast tissue has not developed by age 13 years.

Once the menstrual cycle has begun, it can be difficult for parents and caregivers-and especially for adolescents-to evaluate what is normal. Cycles are irregular throughout adolescence, according to the report, and bleeding typically lasts for 2 to 7 days during first menses with an abnormal interval prior to the next cycle.

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“Immaturity of the hypothalamic– pituitary–ovarian axis during the early years after menarche often results in anovulation and cycles may be somewhat long; however, 90% of cycles will be within the range of 21–45 days, although short cycles of less than 20 days and long cycles of more than 45 days may occur. By the third year after menarche, 60–80% of menstrual cycles are 21–34 days long, as is typical of adults,” according to the report.

When cycle intervals and lengths fall outside of these patterns, it can be cause for concern. Although some anovulation and resulting amenorrhea is common, it typically will not last more than 3 months, according to the committee, and these girls should be evaluated further. Additionally, adolescents who report heavy flow should be assessed. Menstrual bleeding can be difficult to evaluate, the committee acknowledges, but blood flow requiring menstrual product changes every 1 to 2 hours is considered excessive, especially when this patterns continues for more than 7 days.

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Ovulatory dysfunction can be a primary cause of abnormal bleeding during the first few years of menstruation and may not signal a health problem. In some cases, however, this dysfunction can be caused by endocrinopathies due to hypothalamic–pituitary–ovarian axis disturbances, including polycystic ovary syndrome, thyroid disease, mental stress, and eating disorders. Heavy menstrual bleeding is often associated with anovulation, but can also signal the presence of a clotting disorder-such as von Willebrand’s disease or platelet disorders-or other problems including hepatic failure or malignancies. When considering the presence of a health problem related to abnormal bleeding, the committee notes that it is important to first exclude pregnancy, sexual trauma, or sexually transmitted infections even if the adolescent denies sexual activity.

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American College of Obstetricians and Gynecologists recommends that children and caretakers first be exposed to education on puberty at the 7-year and 8-year preventive care visits. Assessment should consist of a full history and physical, including inspection of external genitalia.

“It is important to educate girls and their caretakers about the usual progression of puberty and development of the menstrual cycle,” the committee notes. “Adolescent girls should understand that menstruation is a normal part of development and should be instructed on the use of feminine products and on what is considered normal menstrual flow. It is preferred that caretakers and clinicians participate in this educational process.”

Once adolescents begin menstruating, physicians should include questions about the patient’s last menstrual period date and pattern at every preventive and comprehensive visit.

Having patients chart their menstrual patterns may be helpful, if the adolescent’s reporting skills are vague or possibly inaccurate. Physicians should also be sure to explain to adolescents the proper way to count cycle length-from the first day of the menstrual period to the first day of the next period. Charting is now made easy by a number of smartphone apps that can help girls relay accurate information to their physician, the committee says.

The following is a list of recommendations from ACOG on assessing and monitoring menstrual cycles as a vital sign:

• Clinicians should educate girls and their caretakers about what to expect of a first menstrual period and the range for normal cycle length of subsequent menses. 


• Once girls begin menstruating, clinicians should ask at every preventive care or  comprehensive visit for the patient’s first day of her last menstrual period and the pattern of menses. 


• Identification of abnormal menstrual patterns in adolescence may improve early identification of potential health concerns for adulthood. 


• It is important for clinicians to have an understanding of the menstrual patterns of adolescent girls, the ability to differentiate between normal and abnormal menstruation, and the skill to know how to evaluate the adolescent girl patient.