ADOLESCENT MENSTRUAL DISORDERS: Update

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Menarche, or the onset of menses, is a hallmark of female pubertal development. It represents successful progression through the early stages of sexual maturation and is a rite of passage for some young women. By late adolescence, 75% of girls experience some problem associated with menstruation. Delayed, irregular, painful, and heavy menstrual bleeding are leading reasons for physician office visits by adolescents,35 and dysmenorrhea is the leading reason for school absenteeism among girls.20 This article discusses normal menstrual function during adolescence, then reviews the clinical presentation, evaluation, and management of adolescent dysmenorrhea, dysfunctional uterine bleeding (DUB), amenorrhea, and polycystic ovary syndrome (PCOS).

Section snippets

NORMAL MENSTRUAL CYCLE

The mean age of menarche in the United States is 12.7 years. According to 1985 data from Tanner and Davies,31 3% of girls reach menarche before age 11 years and 3% after 14.5 years. A 1997 study of 17,000 girls in the United States indicates that 3% of white girls and 6% of African-American girls have some breast development by age 6 to 7 years.16 These data suggest that the age definitions of precocious puberty and primary amenorrhea should be lowered and that different definitions are needed

Clinical Characteristics

Dysmenorrhea, or painful menses, is classified according to its underlying cause. Primary dysmenorrhea is associated with normal ovulation and normal anatomy. Secondary dysmenorrhea is associated with pelvic pathology. The distinctive clinical characteristics of primary and secondary amenorrhea guide subsequent evaluation and management (Table 1).

Primary dysmenorrhea increases in prevalence from 39% of postmenarcheal girls at age 12 years to 72% at age 17 years.32 This trend reflects the

Clinical Characteristics

DUB is abnormal endometrial sloughing in the absence of structural pathology. Anovulation, with exposure of the endometrium to unopposed estrogen, is the most common cause of irregular or prolonged vaginal bleeding during adolescence.3 The thickening endometrium in the anovulatory setting lacks the stabilizing effect of progesterone that occurs during the proliferative phase of a mature, ovulatory cycle. As a result, the endometrium begins to break down. A much less common cause of DUB during

Clinical Characteristics

Amenorrhea, similar to dysmenorrhea, is categorized as primary or secondary. The categories refer to the timing of onset when applied to amenorrhea, whereas they refer to cause when applied to dysmenorrhea. Primary amenorrhea is defined as the absence of menarche. Secondary amenorrhea is defined as the absence of menstrual periods at some point after menarche.

Complexity and controversy arise on the fine-tuning of these definitions. For example, the chronologic age by which menarche should occur

Clinical Characteristics

The clinical manifestations of PCOS are highly variable and may include oligomenorrhea, amenorrhea, DUB, hirsutism, acne, obesity, insulin resistance, and acanthosis nigricans. PCOS accounts for 30% to 40% of secondary amenorrhea and 90% of oligomenorrhea in adult women and is the leading cause of hirsutism in adolescents.8 It was first described in 1935 as amenorrhea, hirsutism, and obesity and was called Stein-Leventhal syndrome30 The acronym HAIR-AN syndrome was proposed by Barbieri and Ryan2

SUMMARY

Menarche is an important event during adolescence. For most girls, it marks successful progression through puberty and the onset of reproductive capability. Confidential and sensitive discussion of growth and development, body image, menstrual function, and sexual behavior is an important component of the annual health examination. Menstrual problems are common during adolescence and frequently require evaluation and intervention. Although most problems are explained by maturation of the

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    Address reprint requests to Laurie A. P. Mitan, MD, Division of Adolescent Medicine, PAV 2129, Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229–3039

    *

    Department of Pediatrics, Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio

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