Include Menstrual Cycle as a Vital Sign for Teens, ACOG Says

Ricki Lewis, PhD

November 25, 2015

Including evaluation of the menstrual cycle as a vital sign can alert healthcare providers to disorders that cause abnormal uterine bleeding in adulthood, according to a committee opinion from the American College of Obstetricians and Gynecologists, published online and in the December issue of Obstetrics & Gynecology.

"Just as abnormal blood pressure, heart rate, or respiratory rate may be key to diagnosing potentially serious health conditions, identification of abnormal menstrual patterns in adolescence may improve early identification of potential health concerns for adulthood," the opinion states.

Median age at menarche is typically between the 12th and 13th year (median, 12.43 years) in nations with adequate nutrition. Irregular cycles are common in early adolescence, with a longer time between the first and second cycles than happens later. Within 3 years, 60% to 80% of menstrual cycles are between 21 and 34 days long, as is the average among adults.

When cycles do not even out, it may be a sign of problems, but adolescents may lack information on menstruation, be uneasy asking for it, and not have the experience to recognize an atypical pattern of menses. Therefore, clinicians need to ask about menstruation patterns and educate patients and their parents or caregivers about what is the normal range of duration of menses and amount of bleeding, the committee notes.

Among patients whose cycles do not fall within the normal range, the committee recommends physicians first rule out pregnancy, sexually transmitted infections, and sexual trauma, and then extend clinical evaluation to exclude the following causes of abnormal uterine bleeding: coagulopathy, thyroid disease, immaturity of the hypothalamic–pituitary–ovarian axis, hyperprolactinemia, hyperandrogenic anovulation (including polycystic ovary syndrome, congenital adrenal hyperplasia, and androgen-producing tumors), hypothalamic dysfunction (including eating disorders and response to stress), primary pituitary disease, primary ovarian insufficiency, response to a medication, iatrogenic causes such as radiation or chemotherapy, and malignancy (rhabdomyosarcoma, androgen-producing tumors, and estrogen-producing ovarian tumors).

The opinion lists menstrual cycle characteristics that require evaluation:

  • Onset: Reaching age 15 years without menarche. The first period begins by age 15 years for 98% of patients, which is within 3 years of thelarche. The age of concern is 14 years for girls with hirsutism or who have a history or presence of an eating disorder or of excessive exercise.

  • Frequency of menses: Menses that takes place more frequently than every 21 days or less frequently than every 45 days, or a gap of 90 days between periods, even for one cycle. Mean cycle interval is 32.2 days for the first year.

  • Duration: Menses lasts more than 7 days.

  • Excessive bleeding: Soaking more than one pad or tampon every 1 to 2 hours, history of easy and excessive bruising or bleeding, or a family history of a bleeding disorder.

The committee recommends that discussions of menstruation begin at the 7- or 8-year visit. Once menstruation has started, clinicians should ask a girl/adolescent patient at every visit the first day of the last menstrual period and her pattern of menstruating. Patients should be encouraged to chart their cycles, perhaps using smart phone apps.

Obstet Gynecol. 2015;126:1328. Full text

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