MENSTRUAL DISORDERS IN TEENAGERS
Introduction
The reproductive organs of females are the ovaries, uterus, fallopian tubes, cervix, and vagina. These structures play a role in a woman’s menstrual cycle, which helps determine when she is fertile or ready for pregnancy.
Fertility starts during adolescence. This is usually signaled by the start of the menstrual cycle, which will recur for the next three or four decades. The menstrual cycle involves the female reproductive organs and certain hormones that are produced or regulated by the hypothalamus and the pituitary gland.
Menstrual cycles in adolescents usually last for 21-45 days. The first cycle is termed menarche. In general, cycles include an average of 2-7 days of menstrual bleeding (menses). Most women have menstrual cycles until they are around 45-55 years of age.
Some females may have irregularities with their menstrual cycle. These menstrual disorders are further categorized based on the changes in menses or the overall menstrual cycle.
Anovulatory Uterine Bleeding
Anovulatory uterine bleeding (AUB) refers to heavy and irregular uterine bleeding that is not caused by structural problems in the reproductive organs.
There are several causes of AUB. For adolescents, anovulatory cycles are the most frequently encountered cause. During the first 1-4 years after menarche, menstrual cycles may not be regular — teenagers may have irregular cycle durations, and egg cells may not be released in every cycle yet. This is because the hypothalamus and the pituitary are just starting to produce the hormones needed for menstruation.
AUB may also be related to pregnancy or caused by other medical conditions such as hypothalamic dysfunction, thyroid disorders, hematologic disorders, or infections.
Those with AUB may experience irregular or prolonged menstrual bleeding. Menses may be minimal (spotting) or heavy. At times, since there may be no egg cells released, the accompanying symptoms of uterine cramping, breast tenderness, and mood changes are absent.
A hematologic condition (e.g., coagulopathy) may be considered if the adolescent has very intense menstrual flow that leads to signs of anemia. If AUB is due to polycystic ovarian syndrome (PCOS), there may be persistent or recurrent acne, excess hair growth, or thickened and dark discoloration of the skin in the neck and other body folds.
Amenorrhea
Amenorrhea is simply the absence of menstrual bleeding. Most females start their menses during the first half of adolescence, usually at 12 years old. If they fail to have their first menses by 15 years of age or do not start menses by three years after breast development, they might have primary amenorrhea.
On the other hand, secondary amenorrhea occurs when menstrual cycles have stopped for around 3 months. This can be extended up to 6 months for females who have irregular cycle durations.
Primary amenorrhea may have various causes. Patients with Turner syndrome have delayed menses, as well as minimal to no breast development. Those who have breast development but do not undergo menses may have problems in reproductive anatomy or androgen insensitivity.
For secondary amenorrhea, the most frequent cause is pregnancy. PCOS, diabetes mellitus, traumatic brain injury, eating disorders, and stress are other possible causes.
Early Menstruation
Menses are considered too early if they arrive at 10 years of age or younger. This may be normal because of genetics, socioeconomic environment, and other environmental factors. However, early menstruation may also be a sign of underlying medical conditions, such as precocious puberty, Prader-Willi syndrome, Turner syndrome, or ovarian cysts.
Dysmenorrhea
Nearly half of the adolescents who have started their menstrual periods experience dysmenorrhea. This refers to painful abdominal cramping because of prostaglandins produced by the uterus during menses.
Other associated symptoms include back or thigh pains, nausea, vomiting, diarrhea, headache, fatigue, and feeling faint.
While most young women experience dysmenorrhea without further problems, some may have underlying endometriosis. If dysmenorrhea is severe or prolonged, it is crucial to see a gynecologist.
Endometriosis
Some teenagers may experience pain and discomfort related to their menses when they have underlying endometriosis. In this condition, the specialized cells that line the uterus grow in other locations of the body. The most common areas are the ovaries and fallopian tubes, but these can be found even outside the female reproductive tract. In some cases, endometrial tissue has been seen lining parts of the gastrointestinal tract, the central nervous system, and the pericardium (surrounding the heart).
There is no clear cause of endometriosis, but experts note that genetics, environmental factors, and the backflow of menses may contribute to developing this condition.
Endometriosis may or may not present with any symptoms, such as spotting, dysmenorrhea, pain during sexual intercourse, and infertility. Interestingly, in most cases, when the documented pain is severe, the displaced endometrial tissue is smaller than those with mild to moderate pain.
Premenstrual syndrome
Premenstrual syndrome (PMS) refers to physical, emotional, and psychological symptoms that women may feel during the last phase of the menstrual cycle before menses starts. Nearly half of all women of reproductive age experience some form of PMS.
The cause of PMS is not completely known, but research shows a connection between symptoms and several changes in estrogen levels that occur at the last phase of the menstrual cycle before menstruation starts. These trigger the brain to release different neurotransmitters that may involve classic mood swings and fatigue in PMS.
Signs and symptoms of PMS include abdominal or back pain, headache, nausea, constipation, weight gain, decreased or increased appetite, tender breasts, irritability, sadness, anger, and fatigue. These symptoms can be severe enough to halt typical daily activities and decrease an affected person’s productivity.
Managing Menstrual Disorders
Important tools in diagnosing and managing menstrual disorders are taking note of the medical history and physically examining the patient. A pelvic examination and/or a pelvic ultrasound may also be done to rule out any structural problems. Some patients may need to undergo laparoscopy, MRI, or tissue biopsy.
A urine pregnancy test is an essential part of the diagnosis. Even if the patient claims that they are not pregnant, this may still be requested by the healthcare provider because bleeding during pregnancy may become life-threatening.
Causes of AUB may vary, so managing AUB will ultimately depend on the underlying condition. Several laboratory tests may be requested for each patient with AUB. This can include a complete blood count, coagulation panel, thyroid function tests, STD laboratory tests, serum testosterone, and other hormone levels.
Healthcare providers will assess patients and, on a case-to-case basis, determine if the patient needs further observation or medical or surgical treatment. Again, this is also based on the underlying condition that caused the menstrual disorder.
Pain relievers (like NSAIDs) may be given to decrease pain and some of the bleeding. Oral contraceptives, gonadotropin-releasing hormone (GnRH) analogs, selective serotonin receptor inhibitors (SSRIs), and other hormonal treatments may be started, depending on the condition, symptoms, and side effects.
Other additional treatments may involve changes in the diet, starting (or increasing the intensity of) exercise, cognitive and behavioral therapies, massages, and increased sleeping periods.
Because menstrual disorders may affect a young adult’s fertility or ability to have children, medical advice and counseling should be done to ensure the family is aware of these consequences or complications.
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Sources:
- National Health Service (2023). Periods and fertility in the menstrual cycle. Taken from: https://www.nhs.uk/conditions/periods/fertility-in-the-menstrual-cycle/
- De Silva, N.K. (2022). Abnormal uterine bleeding in adolescents: Evaluation and approach to diagnosis. UpToDate. Taken from: https://www.uptodate.com/contents/abnormal-uterine-bleeding-in-adolescents-evaluation-and-approach-to-diagnosis
- Hester, M. (2021). Diagnosing and managing menstrual disorders in teen girls. Contemporary Pediatrics. Taken from: https://www.contemporarypediatrics.com/view/diagnosing-and-managing-menstrual-disorders-in-teen-girls
- American Academy of Pediatrics (2020). Menstrual Disorders in Teens. Caring for Your Teenager. Taken from: https://www.healthychildren.org/English/health-issues/conditions/genitourinary-tract/Pages/Menstrual-Disorders.aspx
- Lobo, R.A., Gershenson, D.M., Lentz, G.M., & Valea, F.A. (2016). Comprehensive Gynecology 7th ed. Elsevier.
- Tsamantioti ES, Mahdy H. Endometriosis. [Updated 2022 Sep 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK567777/
- Lacroix AE, Gondal H, Shumway KR, et al. Physiology, Menarche. [Updated 2022 Mar 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470216/
- Gudipally PR, Sharma GK. Premenstrual Syndrome. [Updated 2022 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560698/
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