Menstrual Disorders

Published on 06/06/2015 by admin

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Last modified 06/06/2015

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83 Menstrual Disorders

Kamillah Wood, Sara B. Kinsman

Menstrual irregularity is one of the most common concerns that pediatricians address with their adolescent female patients. Being prepared to provide anticipatory guidance regarding the normal menstrual cycle will help ensure that adolescent females do not experience complications associated with dysfunctional uterine bleeding such as changes in lifestyle, anemia, hospitalization, and transfusions. When adolescent females and their caretakers are taught the risks of excessive menstrual flow, they may be more likely to call a pediatrician before an adolescent has developed a significant anemia. Teaching patients to keep a calendar of their menstrual cycles can help adolescent females to actively care for their own health and begin to communicate effectively with their providers about a number of related health topics, including dysmenorrhea, nutritional needs, and reproductive health needs.

Dysfunctional uterine bleeding (DUB) is menstrual bleeding that is not consistent with the expected timing or flow for average menstrual cycle. The normal menstrual cycle occurs every 28 days with a normal range from 21 to 35 days. Menstrual bleeding typically lasts 4 days with a normal range of 2 to 7 days. Typical blood loss is expected to be 30 mL of blood per cycle with the upper limit of normal being 80 mL per cycle. The average age for menarche in the United States is currently 12.3 years. Although anovulation is common in the first 12 to 24 months after menarche affecting approximately 50% of cycles, excessively frequent menses or high volumes of menstrual flow need to be managed carefully to avoid significant blood loss. Specifically, pediatricians can teach adolescent females and their caretakers that excess blood loss may result from when menstrual flow soaks more than six full pads or tampons per day, lasts for greater than 7 days, and occurs more frequently than every 21 days.

Eitology and Pathogenesis

The most common cause of DUB in young women is anovulation. A normal menstrual cycle starts on the first day of menstruation and begins with the follicular phase. During this phase, a developing ovarian follicle synthesizes estrogen, which promotes endometrial growth and proliferation. As estrogen levels continue to increase, estrogen provides positive feedback centrally to the pituitary gland, causing a surge in luteinizing hormone (LH) excretion. This results in release of the ovum from the follicle. The follicle forms the corpus luteum and the beginning of the luteal phase. Estrogen levels decrease, and the corpus luteum begins to produce progesterone. The progesterone promotes stabilization of the endometrial mucosa as well as glandular changes within the endometrial wall to provide an environment for implantation of a fertilized ovum. Without implantation, the corpus luteum cannot maintain production of progesterone, leading to sloughing of the endometrial lining or menstruation approximately 14 days after ovulation.

Anovulatory cycles result when the increase in estrogen during the follicular stage does not result in a surge of LH and therefore ovulation cannot occur. Because the endometrium is mainly exposed to estrogen without progesterone, it can become highly thickened, resulting in heavy, prolonged, or unsynchronized sloughing of the lining (Figure 83-1).

Figure 83-1 Neuroendocrine regulation of menstrual cycle.

Clinical Presentation

The pediatrician should take a detailed history, including questions regarding the degree and pattern of vaginal bleeding. Asking these questions of the adolescent with the caretaker present can be helpful. Sometimes a dialogue between the adolescent and her caretaker may facilitate a fuller understanding of her bleeding pattern. Questions should include the age of menarche, the duration and amount of bleeding associated with the first few menses, the duration of menstruation subsequently, frequency, the color of menstruation, the presence of clots in the menstrual discharge, the number of pads or tampons used daily, and any need to change pads or tampons during the night. The presence of dysmenorrhea will also be helpful. Despite careful history taking, most adolescent and adult females cannot accurately account for the total amount of blood loss; however, aspects of this history will still inform the pediatrician’s laboratory evaluation.

In a confidential setting, the pediatricians should ask the adolescent directly about her sexual history, including consensual and nonconsensual sexual intercourse, history of sexually transmitted diseases, use of hormonal contraceptive methods or intrauterine devices (IUDs), and history of pregnancies or abortions. Questions of physical or sexual abuse are important, although adolescent females may need to be reminded that pediatricians are mandated reporters and will need to ensure the adolescent’s safety by reporting history of abuse to other helping adults.

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