Lawrence S. Neinstein, M.D., F.A.C.P.
Professor of Pediatrics and Medicine
USC Keck School of Medicine
Executive Director
University Park Health Center
Associate Dean of Student Affairs
   

 

 

Sexuality - Menses (B3)

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This section will focus on normal menstrual physiology and discuss the common abnormalities that occur in menstrual function in adolescents.

MENARCHE

Menarche is a landmark pubertal event for most females. Menarche is correlated to percent body fat with about 17% body fat required for menarche and 22% body fat reported to be required to maintain or restore menstruation. The average age of menarche dropped significantly from the 19 th century to the present time in Europe and North American. Some key points about menarche.

  • Average age of menarche in the United States is 12.7 years with a two standard deviation range of between 11 and 15. There is some more recent data in the United States that suggest puberty is even starting earlier than previously reported and this may also effect the age of menarche.
  • In two-thirds of adolescent menarche is a later pubertal event occurring at a SMR of 4, although it can occur in an earlier or later state of maturation.
  • Menarche occurs about 3.3 years after the start of the growth spurt, about 2 years after thelarche, and about 1.1 years after the peak height velocity.
  • Menstrual cycles become increasingly regular during the 5 to 7 years after menarche.
  • Menarche and ovulation are dependent on the development of a mature hypothalamic-pituitary-ovarian axis that includes both pulsatile release of LH secretion and also the midcycle surge of LH and FSH.

See normal axis below:


click for full-size image

DEFINITION OF MENSTRUAL CYCLE

A menstrual cycle is defined as that period of time from the beginning of one menstrual flow to the beginning of the next menstrual flow. The menstrual cycles includes:

Follicular Phase - approximately 14 days but highly variable and ending with ovulation.

  • After menstruation, low levels of estradiol and progesterone stimulate the hypothalamic release of GnRH with in turn increases the pituitary's release of FSH and LH.
  • FSH stimulates the maturation of ovarian follicles and LH stimulates theca cells of the ovary to produce androgens, which are then converted to estrogens in the granulosa cells of the ovary.
  • Estrogen stimulates proliferation of the endometrial lining (proliferative phase).

Ovulation

  • A preovulatory estradiol surge leads to a midcyde LH surge, which initiates ovulation.
  • A mature follicle releases an oocyte and becomes a functioning corpus luteum.
Luteal Phase
  • The luteal phase begins with ovulation and ends with the menstrual flow and usually lasts 14 ± 2 days.
  • Large amounts of progesterone are produced by the corpus luteum as well as estrogen.
  • Rising levels of estrogen and progesterone lead to falling levels of FSH and LIT
  • Progesterone stops the growth of the endometrium and stimulates differentiation of the endometrium into a secretory endometrium.
  • Without fertilization and human chorionic gonadotropin production, the corpus luteum involutes after about 10 - 12 days and sloughing of the endometrium. Local prostaglandin release leads to vasoconstriction and uterine contractions.

DYSMENORRHEA

Over 50% of adolescent females experience some menstrual dysfunction, including dysfunctional uterine bleeding, amenorrhea, dysmenorrhea, and premenstrual syndrome. Most are minor including mild dysmenorrhea and minor variations in cycles. Some can be severe and include severe debilitation dysmenorrhea and severe abnormal uterine bleeding.

Menarche can be a significant important pubertal event in a women's life. However, since there can be significant misinformation, the clinician can help to correct myths and misinformation. This area can be sensitive and clinicians should be sensitive to the teen's discomfort in this area.

Primary dysmenorrhea : Pain associated with the menstrual flow, with no evidence of organic pelvic disease.

Secondary dysmenorrhea : Pain associated with menses secondary to organic disease (e.g. endometriosis, ovarian cysts, adhesions, pelvic inflammatory disease).

Etiology

Dysmenorrhea is predominantly secondary to the increase release of prostaglandins during menses. They can lead to uterine contractions as well as systemic symptoms including headaches, nausea, vomiting backache, diarrhea and dizziness. The key prostagladins involved include PGE 2 and PGF 2 a As anovulatory cycles are associated with lower prostaglandin levels there is usually no or very mild dysmenorrhea. Prostaglandins may also be locally elevated in cases of secondary dysmenorrhea.

Prevalence

About 45-70% of all postpubescent females have some degree of dysmenorrhea, with up to 15% of these females describing the pain as severe and being incapacitated for 1-3 days per month.

Clinical Manifestations

  • Usually begins 6-12 months after menarche
  • Local symptoms include spasmodic pain in lower abdomen with radiation to back and thighs.
  • Systemic symptoms include nausea or vomiting, fatigue, nervousness, diarrhea, backache and headache.
Differential Diagnosis
  • Gynecologic causes include endometriosis, pelvic inflammatory disease, benign uterine tumors, IUD, anatomic abnormalities such as congenital obstructive mullerian malformations, pelvic adhesions and ovarian cysts or masses.
  • Non-gynecologic causes include things such as inflammatory bowel disease, irritable bowel syndrome, mussculoskeletal pain from trauma or tumors, genitourinary abnormalities such as calculi or cystitus.
  • Genitourinary abnormalities: Cystitis, ureteral obstruction, calculi and psychogenic disorders.
Diagnosis

Diagnosis is usually based on a good history of the pain and a good menstrual history. Important history items also include sexual history, STIs, GI and GU symptoms and psychosocial history. A pelvic examination is not needed in a non-sexually active adolescent with a typical history unless the symptoms do not respond to medical therapy. Laboratory tests are not usually needed - however STI screening is important in sexually active teens. Future tests are needed if the pain does not respond to therapy or if a genital tract malformation is suspected. This may include diagnostic laproscopy in the adolescent who does not respond to a combination of antiprostaglandins and oral contraceptives.

Therapy

The two most effective treatments for primary dysmenorrhea are nonsteroidal anti-inflammatory drugs (NSAIDs) and oral contraceptives.

PREMENSTRUAL SYNDROME

The premenstrual syndrome (PMS) is used to describe an group of physical, cognitive, affective, and behavioral symptoms occurring cyclically during the luteal phase of the menstrual cycle and resolving quickly at or near the onset of menstruation. PMS may be a set of interrelated symptom complexes, each with its own pathophysiological mechanism. Up to 85% of menstruating women have some degree of symptoms before menses and 5-10% may have severe symptoms. In the mental health field this syndrome may overlap/be defines as premenstrual dysphoric disorder (PMDD). In PMDD, the focus is more on mood problems and are generally more severe.

Clinical Manifestations

Symptoms include:

  • Emotional symptoms including irritability, depression, fatigue, anger, insomnia, mood lability, anxiety, poor concentration, tearfulness.
  • Physical symptoms include: headaches, leg or breast swelling, increased appetitie, food cravings, weight gain, sense of abdominal bloating, fatigue and muscle or joint aches.
Diagnosis

The diagnosis depends on the history of cyclic symptoms, i.e. they must occur in luteal phase and resolve within a few days after the onset of menstruation. In addition, the symptoms must occur over several menstrual cycles and not be caused by other physical or mental health problems. The Diagnostic and Statistical Manual of Mental Health Disorders (DSM-4), 4 th edition has criteria for Premenstrual Dysphoric Disorder.

Diagnosis of Premenstrual dysphoric disorder (DSM-IV criteria)

Adapted from the American Psychatric Association. Diagnostic and Statistical Manual of Mental Health Disorders (DSM-4), 4th edition criteria:

  • In most menstrual cycles in past year at least five of the symptoms below were present with at least one being from the first four symptoms below, are present for most of the time one week before menses and begin to remit within a few days after the onset of the follicular phase (menses), and were absent in the week after menses.

Core symptoms:

  • Markedly depressed mood, feelings of hopelessness or self deprecating thoughts
  • Marked anxiety, tension
  • Marked affective lability (i.e. feeling suddenly sad or tearful)
  • Persistent and marked anger or irritability or increased interpersonal conflicts

Other symptoms:

  • Decreased interest in usual activities such as friends and hobbies
  • Subjective sense of difficulty in concentrating
  • Lethargy, easy fatigability, or marked lack of energy
  • Marked changed in appetite, overeating or specific food cravings
  • Hypersomnia or insomnia
  • A subjective sense of being overwhelmed or out of control
  • Other physical symptoms (e.g. breast tenderness, bloating, weight gain, headache, joint/muscle pain)
  • The symptoms markedly interfere with work, school, usual activities, or relationships with others
  • Symptoms are not merely an exacerbation of another disorder such as Major Depressive Disorder, Panic Disorder, Dysthymic Disorder, or a Personality Disorder (although it may be superimposed on any of these disorders).
  • Criteria A, B, and C are confirmed by prospective daily ratings for at least two consecutive symptomatic menstrual cycles
Therapy

Many treatments have been advocated including: stress management, exercise, pyridoxine, Calcium, magnesium, vitamin E, primrose oil, oral contraceptives, natural progesterones, prostaglandin inhibitors, spironolactone, antidepressents including the SSRIs.

DYSFUNCTIONAL UTERINE BLEEDING

Dysfunctional uterine bleeding (DUB) is a common menstrual problem during adolescence and can be life threatening if severe. Dysfunctional uterine bleeding is abnormal uterine bleeding in the absence of structural pathology. Most cases in adolescents are secondary to anovulation, however, structural pathology must be excluded.

Normal menstrual cycles during adolescence are 21-40 days in length with 2-8 days of bleeding and 20-80 ml blood loss per cycle. Up to 80 percent of menstrual cycles are anovulatory in the first year after menarche. Cycles become ovulatory an average of 20 months after menarche.

Differential Diagnosis

While the majority of abnormal uterine bleeding in adolescents is secondary to anovulation, hospitalization or severe bleeding at menarche may suggest an underlying organic pathology. Other considerations in adolescents include pregnancy-related causes such as ectopic pregnancy or incomplete abortions, local pathology of the vagina, cervix or uterus such as foreign bodies or polyps or bleeding disorders such as Von Willebrands or those secondary to a chronic disease.

Anovulatory Bleeding

Most abnormal bleeding in adolescents is secondary to anovulatory cycles. The most common cause of this is gynecologic immaturity which is frequent in the first several years after menarche. This can lead to unopposed estrogen stimulation of the uterus resulting in heavy cycles. Other causes include hormonal contraceptives, thyroid dysfunction, polycystic ovarian syndrome, stress/excessive exercise and rarely late-onset congenital adrenal hyperplasia.

Evaluation

The assessment should include evaluating hemodynamic stability, site of the bleeding and the underlying cause. This should include a good menstrual history, sexual history, history of systemic diseases including possibility of thyroid dysfunction, history and family history of bleeding problems. The examination should focus on assessment of vital signs and orthostatic changes, sexual maturity ratings, signs of a bleeding disorder, and thyroid gland assessment. Also an evaluation for any obvious signs of a chronic disease. The pelvic examine is essential in a teen who is sexually active or if the history suggests local pathology.

Laboratory Tests

In mild anvoulatory DUB associated with a teen in early years after menarche, laboratory testing may not be needed. The most common tests needed are a sensitive pregnancy test to rule out an abnormal pregnancy, a hemoglobin level to assess the degree of anemia and platelet count if bleeding disorder is considered, STI screening in sexually active adolescent and TSH. If a bleeding disorder is consider a Prothrombin time and partial thromboplastin time are indicated but special tests may be needed if von Willebrand's disease is suspected. Other tests may be indicated if a particular chronic disease is suspected or if polycystic ovarian disease is suspected. In a virginal adolescent with a possible structural pathology, a pelvic ultrasound is essential.

Therapy

Therapy depends on the severity of the bleeding and the hemodynamic instability. It is unusual to require blood transfusions in adolescents with abnormal uterine bleeding. In most cases bleeding can be control with a combination of estrogens, progesterones or combination oral contraceptives.

AMENORRHEA

Definition

Many definitions have been used for amenorrhea but it is important to include chronological age, developmental age and clinical data to avoid mismanagement. However, it is important to remember that there is an average of 2 years between the start of breast development and menarche and that 95% of teens have attained menarche 1 year after attaining SMR-5. In addition, in developed countries 95-97% of females reach menarche by 16 years of age and 98% by 18 years of age. Definitions of primary and secondary amenorrhea include:

Primary amenorrhea: No episodes of spontaneous uterine bleeding by the age of 14-15 years with secondary sex characteristics absent or no episodes of spontaneous uterine bleeding by age 16-16.5 years regardless of normal secondary sex characteristics (chronological age). Developmentally, one can define primary amenorrhea if there are no episodes of spontaneous uterine bleeding, despite having attained SMR 5 for at least 1 year or despite the onset of breast development 4 years previously.

Seconary amenorrhea: No menses for 6 months or a length of time equal to three previous cycles after a previous episode of uterine bleeding.

Etiology

  • Primary amenorrhea without secondary sex characteristics (absent breast development) but with normal genitalia (uterus and vagina) includes genetic or enzymatic defects such as Turner syndrome, isolated pituitary gonadotorpin insufficiency or hypothalamic failure secondary to inadequate gonadotropin-releasing hormone (GnRH) release
  • Primary amenorrhea with normal breast development but absent uterus includes androgen insensitivity (testicular feminization) or congenital absence of the uterus.
  • Primary amenorrhea with no breast development and no uterus is extremely rare and includes several enzymatic defects and agonadism.
  • Primary and secondary amenorrhea with normal secondary sex characteristics (breast development) and normal genitalia (uterus and vagina) includes hypothalmic causes (including medications, drugs, stress, exercise, weight loss, hypothalamic lesions and PCOS), pituitary causes (tumors, empty sella), ovarian causes (Premature ovarian failure), and pregnancy.

Diagnosis

The evaluation includes (but always critical to rule out pregnancy)

  • History including history of systemic diseases, family history of ages of menarche or endocrine problems, pubertal growth and development, emotional status, medications, nutritional status, exercise history, sexual history, contraception and menstrual history
  • Physical Exam including sexual maturity rating, signs of systemic disease, androgen excess, thyroid dysfunction or genetic abnormalities, breast exam for galactorrhea and pelvic examination for vaginal agenesis, imperforate hymen or absent uterus.

Laboratory Evaluation

The evaluation for primary and secondary amenorrhea with normal secondary sexual characteristics and normal genitalia includes:

  • Pregnancy should always be considered and ruled out.
  • If evidence of androgen excess or galactorrhea is present, the adolescent should be evaluated or referred for evaluation of hirsutism or galatactorrhea.
  • If suspected, hypothyroidism and diabetes mellitus should be considered and ruled out.

If the above assessment is negative, one can administer a progesterone withdrawal test. A positive response of uterine bleeding to progesterone suggests circulating estradiol and a functioning hypothalmus, pituitary, ovaries and uterus. A prolactin level should be measured, as this is the most sensitive test for pituitary microadenomas. In addition, a TSH should be measured to rule out hypothyroidism. A negative response suggests either hypothalamic-pituitary dysfunction or ovarian failure. A high FSH level indicates ovarian failure, whereas a normal or low FSH suggests a hypothalamic-pituitary disturbance. Individuals with weight loss, anorexia nervosa, heavy substance abuse, or heavy exercise may or may not withdraw to progesterone

Treatment

The teacher/student should go to some of the listed references for further information on evaluation and treatment of primary amenorrhea with either absent uterus or absent secondary sexual characteristics

Two problems associated with amenorrhea of increasing frequency in adolescents include amenorrhea associated with weight loss/eating disorders and amenorrhea associated with sports participation. Amenorrhea associated with eating disorders can result in bone mineral density (BMD) loss soon after amenorrhea develops. Treatment of this amenorrhea with estrogen is still undergoing evaluation for efficacy. The longer the duration of anorexia nervosa and/or weight loss, the less likely the BMD will return to normal. In addition, female adolescents who regularly participate in athletics may develop the female athlete triad including disordered eating, menstrual dysfunction (typically amenorrhea) and decreased bone mineral density. Treatment includes moderating exercise levels, increasing calcium intake to 1500 mg/day and estrogen replacement if estrogen levels are low.

POLYCYSTIC OVARIAN SYNDROME

This condition is a disorder of the hypothalamic-pituitary-ovarian system leading to temporary or persistent anovulation and usually androgen excess. Diagnosis can be important because the condition can be associated with increased metabolic and cardiovascular risks linked to insulin resistance and compounded by obesity. PCOS is one of the most common endocrine disorders, affecting approximately 5 - 10 % of premenopausal women. While the exact initiating cause of PCOS is not known, it may be related to abnormal hypothalamic-pituitary function, ovarian function, adrenal androgen metabolism or insulin resistance.

Clinical features and possible consequences include: anovulation, polycystic ovaries, hyperandrogenism, obesity, infertility, insulin resistance and hyperinsulinemia as well as impaired glucose tolerance, increased risk of endometrial cancer (secondary to unopposed estrogen stimulation) and elevated lipoprotein profiles,

Relative clinical manifestations includes:

Prevalence of Major Clinical Features of PCOS

 

Goldzieher and Axelrod (1963) 1

Balen et al. (1995) 2

Carmina and Lobo 3 (1996)

Number of patients

1079

1741

240

Amenorrhea

51%

19.2%

16%

Oligomenorrhea

NR

47%

64%

Polymenorrhea

NR

2.7%

4%

Normal menses

12%

29.7%

15%

Hirsutism

69%

66.2%

70%

Acne

NR

34.7%

11.2%

Obesity

41%

38.4%

43.7%

Acanthosis nigricans

¾

2.5%

2.1%

Therapy

Teacher/student is referred to one of the references included for detailed description of management.

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Questions

Question #1
Menarche correlates to what physiologic or developmental factors?

Answer #1
Menarche correlates to several physiologic and developmental factors:

  • Per cent body fat: Menarche tends to occur after about a 17% body fat and ovulation tends to require a higher percent body fat. Falling below these parameters can lead to anovulation and amenorrhea.
  • Age: In most countries there is an average age of menarche. This age has been falling in developed countries over the past one hundred years. However, there is a wide variation of age of menarche between individual and individual. Family history of menarche among mother and siblings can also correlate to age of menarche.
  • SMR: Two thirds of teens have their menarche at SMR of 4 and usually occurs about two years after thelarche and about 1.1 years after the peak height velocity.

Question #2
What are the three phases of the menstrual cycles?

Answer #2

  • Follicular phase: Characterized by FSH stimulation of follicles in the ovaries that produce estrogen stimulation of the endometrium and a proliferative endometrium.
  • Ovulation
  • Luteal phase: Occurs after ovulation and is characterized by a corpus luteum in the ovary producing both estrogen and progesterone leading to a secretory endometrium.

Question #3
What is the cause of primary dysmenorrhea?

Answer #3
Dysmenorrhea is caused by the secretion of local prostaglandins in the endometrium under the influence of progesterone. The local prostaglandins can cause myometrial contractility and vasoconstriction. These help control menstrual flow but can cause local and systemic symptoms of dysmenorrhea.


Question #4
What are the most common and effective forms of therapy for primary dysmenorrhea.

Answer #4
Both non-steroidals and oral contraceptive pills are highly effective for dysmenorrhea. The non-steroidal medications suppress the action of prostaglandins while oral contraceptives suppress ovulation and the production of prostaglandins.


Question #5
What is the difference in timing between dysmenorrhea and premenstrual syndrome?

Answer #5
Dysmenorrhea tends to start just at the time or just before the time of menses. PMS starts after ovulation, peaks and is resolving by the onset of menses.


Question #6
List the top of causes of abnormal uterine bleeding in adolescents?

Answer #6
90% or more are secondary to anovulatory cycles usually resulting from an immature hypothalamic-pituitary-ovarian access. Anovulation can also result from stress, medications, drug use, eating disorders and excessive exercise. Other causes include thyroid dysfunction, pregnancy related complications, local vaginal or uterine pathology, or bleeding disorders.


Question #7
What is the definition of secondary amenorrhea?

Answer #7
No menses for 6 months or a length of time equal to three previous cycles after a previous episode of uterine bleeding.


Question #8
What are the most frequent manifestations of polycystic ovarian syndrome?

Answer #8
The most common manifestations include obesity, menstrual irregularities, androgen excess and infertility. However, other complaints and concerns include acanthosis nigricans, insulin resistance, lipid abnormalities and glucose intolerance.

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Cases

CASE #1

You are evaluating a 14 year old female who complains of significant pain near her menses.

Question
What would be important history items to ask?

Answer

    • Menstrual history - Her menarche was at age 11. Her periods were irregular for about six months and now they occur about every 25-35 days.
    • Character of the pain - The pain occurs at the time of her menses each month and lasts about 1-2 days. The pain is lower abdominal and sometimes in the back.
    • Sexual history - She has a boyfriend but they have never had intercourse. She has no history of sexual intercourse. She has no history of any STIs.
    • Medications used for the pain - She tried a multivitimin her mother gave her but it did not help.

Question
Do you need to do a pelvic examination in this adolescent?

Answer
Because the teen is not sexually active and the symptoms are highly consistent with primary dysmenorrhea a pelvic examination is not indicated and therapy can be tried first.


Question
You advise the teen to try some non-prescription non-steroidal medication and she lets you know that her pain is 90% better with the medication. You do not hear from her for about two years. She returns at that time and she again complains of painful periods not responding as well to the medication you previously advised. What would be important history items to ask at this point?

Answer

    • Menstrual history - She gives you a similar history as her first visit and her menses have continued to be regular.
    • Character of the pain - The pain still occurs at the time of her menses each month and lasts about 1-2 days. The character of the pain has not changed.
    • Sexual history - She has a new boyfriend but this time she gives a history of starting a sexual relationship about three months ago. This has been a consensual relationship. She has no vaginal discharge. Her boyfriend has used a condom at every sexual encounter.
    • Medications used for the pain - She has tried over-the-counter ibuprofen and while it worked for about a year, it has been less effective recently

Question
Do you need to do a pelvic examination in this adolescent?

Answer
Because the teen is sexually active and the symptoms have changed and are no longer responding to the original ibuprofen, a pelvic examination is indicated. The examination is normal, there is no vaginal discharge, there is no cervical motion tenderness or uterine/adnexal tenderness. A wet mount is unremarkable and a gonorrhea and chlamydia test are negative.


Question
What interventions are indicated at this point?

Answer

  • Discussion of contraception - As combined oral contraceptives could alleviate primary dysmenorrhea, this might be a very good option of this adolescent.
  • Treatment of her dysmenorrhea - As the diagnosis is still likely dysmenorrhea, either changing to another non-steroidal medication or adding an oral contraceptive are two reasonable choices.
  • Exploring whether she wants involvement of her parents in her contraceptive choices - As has entered into some life choices of a sexual relationship and contraception, it would be important to explore whether her parents are involved, whether she wants their involvement and if not, what are her concerns a bout their involvement.
  • Protection against STIs - If she chooses oral contraceptives, she needs to be fully aware that these will not protect against STIs and her boyfriend will continue to need to use condoms to decrease the risk of STIs.
  • Continued follow-up - She will need follow-up to see if the changes in her medications decrease her pain. She will also need another pelvic examination in one year or sooner for STI screening depending on her sexual history and number of partners.

Case #2

A 13 year old teen comes in complaining of a three week history of heavy menstrual bleeding.

Question
What would be important history questions to ask?

Answer

  • Menstrual history - Her menarche was at age 12. Her periods have been irregular since that time. She occasionally has heavy periods but this has been the heaviest and longest. She has had to use about 8 super absorbent tampons each day for the past several days. However, the bleeding seems to be almost stopping at this point.
  • Bleeding history - She denies any bleeding history. She had an appendectomy as child without any problems and several teeth pulled without any problems.
  • Medical history from both mother and teen - There is no history of any chronic diseases and her review of systems is negative. There is also no history to suggest a thyroid problem and there is no family history of thyroid diseases.

You mention to mother that you want to spend some time taking a history from the teen and you will meet back up in about 15 minutes at which time you take a sexual history. After reassuring the teen confidentiality of information, she discusses that she does not have a boyfriend and that she has never had a sexual relationship. She is ok also discussing that information with her mother.


Question
What would be important to check for on physical examination?

Answer

  • Vital Signs - Her pulse is 80 and Blood pressure is 110/70 with no orthostatic changes.
  • Thyroid/neck exam - There is no thyromegaly or adenopathy
  • Signs of chronic disease - Cardiac, lung, abdominal exam are all unremarkable. Her skin shows no petechiae or ecchymotic areas.
  • Pelvic examination - You decide to defer the pelvic examination given that the adolescent is not sexually active and she has no current active bleeding and no history of any vaginal trauma.

Question
What laboratory tests would be indicated at this point?

Answer

  • CBC - This would be useful to see the adolescents underlying hemoglobin status as well as indication if she is iron deficient (based on MCV). Her hemoglobin is 12.5 with normal indices.
  • Pregnancy test - Probably not mandatory in this teen and would depend on how confident you are about her medical history and the presence of continued bleeding. With continued bleeding a pregnancy test might be warranted.
  • Other tests at this point are probably not indicated.

Question

What would be your interventions at this point?

Review your findings and diagnosis with the teen and her mother and or father. This would include the normal history and physical examination and your diagnosis of dysfunctional uterine bleeding.

  • Based on her normal CBC and indices, her normal examination and the fact that she is not currently bleeding, observation is indicated rather than medication.
  • Menstrual calendar: Having her keep a menstrual calendar could be helpful with further episodes.

The teen continues to have irregular menses for 3-4 more years but never any episodes of heavy prolonged bleeding. She comes to you because her menses are still higher irregular. She is also concerned about her weight and a rash she has had for the past year on her neck.

What additional history would be important at this time?

Answer

  • Menstrual history - Her menses occur about every 3 months now but they are now longer heavy. There is no history of dysmenorrhea. Her mothers periods are regular.
  • Medical history - There is still no other history to suggest any chronic disease. Her review of systems is negative except for her weight and rash. She has no constipation or dry skin.
  • Nutritional history - She denies that she has changed her diet or exercise patterns.
  • Sexual history - She has a boyfriend but they have not had sexual intercourse. She is still virginal by history.

Her physical examination demonstrates an obese adolescent whose weight is at the 90 th percentile for age while her height is at the 25 th percentile. Her blood pressure is 120/80. She has no enlargement of her thyroid and her cardiac, lung and abdominal exam are normal. There is no evidence of hirsutism. She has the following rash:

Rash
click for full-size image


Question
What is the rash above?

Answer
Given her obesity, this rash characterized by hyperpigmentation and thickened areas in intertriginous areas such as the axilla, groin and neck suggest acanthosis nigricans.


Question
What is the likely diagnosis of her condition?

Answer
Given her menstrual irregularities that started with menarche, her obesity, and acanthosis nigracans it is quite possible that she has polycystic ovarian syndrome.


Question
Any other important historical items or tests to run at this point?

Answer
It would be important to assess her family risk factors for diabetes and cardiovascular disease, this would include smoking.

She has a mother a 45 year old mother with a history of type II diabetes. There is no history of cardiac disease in her parents. She does not smoke.

It would also be a good idea to screen her for diabetes with a fasting blood sugar and a lipid panel. Assuming these are normal, the most important intervention at this point would be nutritional interventions for weight reduction and increased exercise. For her menstrual irregularities, oral contraceptives could be considered. These would be particularly helpful if she had either a need for contraception or evidence of hirsutism.

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Web Sites

http://www.youngwomenshealth.org/menstrual.html
Boston Childrens hospital site on guide to puberty and menses

http://www.aafp.org/afp/990800ap/489.html
AAFP article on primary dysmenorrhea

http://www.pcosupport.org/
PCOS Association: This website includes facts and figures on PCOS, as well as on-line support.

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References

American Academy of Pediatrics. Committee on Sports Medicine and Fitness. Medical concerns in the female athlete. Pediatrics. 2000;106:610.

American College of Obstetrics and Gynecology. ACOG Practice Bulletin: Premenstrual syndrome; April 2000; 15.

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4 th Edition, DSM-IV-Text Revision. R.R. Washington , D.C. : American Psychiatric Association, 2000.

Carmina E. Lobo RA. Polycystic ovary syndrome (PCOS): arguably the most common endocrinopathy is associated with significant morbidity in women. J Clin Endocrinol Metab 1999;84:1897.

Cowan BD, Morrison JC. Management of abnormal genital bleeding in girls and women. N Engl J Med, 1991;324:1710.

Ellis MH, Beyth Y. Abnormal vaginal bleeding in adolescence as the presenting symptom of a bleeding diathesis. J Pediatr Adolesc Gynecol, 1999;12:127.

Emans SJ. Delayed puberty and menstrual irregularities. In: Emans SJ, Laufer MR, Goldstein DP, eds. Pediatric and Adolescent Gynecology, 4th ed. Philadelphia : Lippincott-Raven, 1998;163.

Gidwani GP. Amenorrhea in the athlete. Adolescent Medicine. 1999;10:275.

Gordon CM. Menstrual disorders in adolescents: excess androgens and the polycystic ovary syndrome. Pediatr Clin N Am 1999;46:519-543.

Halbreich U. Premenstrual syndromes: closing the 20th century chapters. Curr Opin Obstetr Gynecol 1999;11:265.

Hobart JA, Smucker DR . The female athlete triad. Am Fam Physician. 2000;61:3357.

Iglesias EA, Coupey SM. Menstrual cycle abnormalities: diagnosis and management. Female Reproductive Health; Adolescent Medicine: State of the Art Reviews 1999;10:255-273.

Kahn JA, Gordon CM. Polycystic ovary syndrome. Adolescent Medicine. 1999;10:321.

Lobo RA. Carmina E. The importance of diagnosing the polycystic ovary syndrome. Ann Int Med 2000;132:989.

Minjarez DA, Bradshaw KD. Abnormal uterine bleeding in adolescents. Obstet Gynecol Clin North Am, 2000;27:63.

Mitan LAP, Slap GB. Adolescent menstrual disorders: Update. Med Clin North Am, 2000;84:851.

Neinstein LS. Adolescent Health Care, A Practical Guide, 4 th Edition, 2002,

Chapter 49: Normal Menstrual Physiology - Catherine Gordon and Lawrence Neinstein

Chapter 50: Dysmenorrhea and Premenstrual Syndrome - Paula Braverman and Lawrence Neinstein

Chapter 51: Dysfunctional Uterine Bleeding - Laurie Mitan and Gail Slap

Chapter 52: Amenorrhea - Catherine Gordon and Lawrence Neinstein

Chapter 58: Hirsutism and Virilization - Catherine Gordon and Lawrence Neinstein

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