Question of the Week

For January 5, 2016

Your answer is correct.

Obtain an abdominal ultrasound Ask the patient to keep a menstrual cycle diary Test levels of thyroid-stimulating hormone, follicle-stimulating hormone, luteinizing hormone, prolactin, and testosterone Measure hematocrit, platelet count, and von Willebrand factor Perform a bimanual examination

Key Learning Point View Case Presentation

In the first postmenarchal year, the most common cause of irregular menstrual bleeding is anovulatory cycles.

Detailed Feedback

In the first postmenarchal year, the most common cause of irregular menstrual bleeding in an otherwise healthy adolescent girl is anovulatory cycles, because the hypothalamic–pituitary–ovarian axis feedback loops are not yet mature. Most menstrual cycles range from 21 to 45 days, last 7 days or fewer, and require three to six sanitary pads or tampons per 24-hour interval.

Irregular menses can be associated with a variety of medical conditions, including pregnancy, endocrinopathies, hormone-producing tumors, uterine and ovarian disorders, infection, trauma, bleeding disorders, medications, excessive exercise, and eating disorders. Therefore, patients who demonstrate the following menstrual cycle abnormalities should undergo further workup:

  • The development of markedly irregular periods after establishment of regular monthly periods
  • Amenorrhea lasting >90 days
  • Periods lasting >7 days
  • Heavy periods requiring frequent pad or tampon changes (soaking through more than one pad or tampon every 1 to 2 hours)

Further workup — including a bimanual examination, laboratory evaluation, and imaging — is unnecessary in a healthy adolescent girl who reports irregular bleeding but has a normal physical examination and none of the above-described menstrual abnormalities.

Last reviewed Jun 2018. Last modified Feb 2015.

Citations

American Academy of Pediatrics Committee on Adolescence. Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Pediatrics 2006 Nov; 118:2245.   > View Abstract

Gray SH. Menstrual disorders. Pediatr Rev 2013 Jan 3; 34:6.   > View Abstract

19 Comments

  1. Dayo January 5, 2016 at 11:48 am - Reply  >

    Consider perimenopause or the climacteric as well.

    • Bukar Bakki January 5, 2016 at 2:11 pm - Reply  >

      The issue of requesting a PT is very appropriate despite the reported virginity.

    • Glenn E. Fleming January 7, 2016 at 11:19 am - Reply  >

      She’s 13 years old. Why would that be high on your differential diagnosis for a 13 yo who just started menstruating and has otherwise normal physical exam findings?

    • Chris Barclay January 7, 2016 at 2:20 pm - Reply  >

      This would be an extreme example of over-medicalisation. Leave her alone. Don’t confuse physiology with pathology.

  2. carolyn goldstein January 5, 2016 at 11:54 am - Reply  >

    the first thing i would do is get a pregnancy test. i have seen positives in similar patients.

  3. Dr A White MD January 5, 2016 at 11:56 am - Reply  >

    Any woman even a l child in early menarche should have a pregnancy test if they have a history such as this.Simple, cheap and avoids a red face in the future. Even if this young woman denies sexual activity one knows that this information can be incorrect. It avoids invasive physical examination which I agree is not suitable at this time..

    • Dr. Alameri January 10, 2016 at 8:12 pm - Reply  >

      I agree

  4. Josh GJJosh Grossman, Colonel MC MD FACP January 5, 2016 at 1:10 pm - Reply  >

    Outstanding for both U.S.M.L.E. III prep. and for A.B.I.M. prep. Thank you!

  5. DR. TAREQ BURGAN January 5, 2016 at 2:35 pm - Reply  >

    COMMON THINGS ARE COMMON !
    THE MOST COMMON CAUSE OF IRREGULAR PERIODS DURING THE FIRST 2 YEARS AFTER MENARCH IS UNOVULATORY PERIODS ..
    NO NEED TO DO MORE THAN WATCHING , TO THOSE WHO SUGGESTED TO RULE OUT PREGNACY , I SHOULD REMIND YOU THAT THE CASE IN QUESTION PRESENTED WITH 6 MONTHS OF AMEORRHEA REGARDLESS OF THE SPOTTING ,SHE WOULD HAVE HAD UTERINE ENLARGEMENT COMPATIBLE WITH 6 MONTHS PREGNANCY .

    • RHH January 8, 2016 at 8:32 pm - Reply  >

      The question said nothing about her abdominal exam. Nor do we know if she might have an early pregnancy after months of anovulation. So a urine pregnancy test is a good idea. If you don’t do it, eventually one of these cases will embarrass you.

  6. Dr Kannan Kerala India January 5, 2016 at 11:09 pm - Reply  >

    In my public health practice involving adolescent girls in India Mensturation is a new biological episode involving social and cultural customs. The other major confounder is stress and shock in adolescent girls. The dairy keeping to some extent relieves the stress and produces a psychological confidence.

  7. DJC January 6, 2016 at 2:13 am - Reply  >

    Thank you Dr. Burgan for that response. If a doctor is instructive about what it means exactly to be sexually active (remember Bill Clinton?) by talking with the teen (with her parent stepping outside the door for a moment) then there is no need to distrust her honest answer. There is nothing worse for a patient-doctor trust than a doctor not believing you when you tell the truth, except, of course, having to have a blood test for no reason and having to pay the bill for it- for no reason. Most teenage girls I have met *do* consider a blood test to be invasive and painful and causes dread. They feel pain far more than many tough old men doctors.

  8. Beatrice Cooper January 7, 2016 at 8:02 pm - Reply  >

    I’m not sure keeping a menstrual diary is necessary
    Come back if not regular in a year or so makes more sense
    I think it is an abuse to do a blood test without the child’s consent, and what’s wrong with those very accurate urine tests – if indicated?

  9. Dr. Subhi Bajis MD January 7, 2016 at 9:14 pm - Reply  >

    This is a normal physiological process at this age. Just watching and follow up her.

  10. Andrzej Pawlak, MD January 8, 2016 at 10:55 am - Reply  >

    She needs help in taking care of herself (keeping a menstrual diary in that context) and encoragement for asking further questions when arise

  11. Marcio Koenigkan MD January 10, 2016 at 11:48 am - Reply  >

    A conduta é tão simples que deixou alguns inseguros

  12. kamala January 11, 2016 at 1:43 am - Reply  >

    Thank you,V.rarely a teenager in her early menstrual age gets perfect menstrual cycles.So wait and see for a few more cycles /months or an ultrasound of abdomen which is noninvasive may clear up doubts: in my opinion.

  13. John January 15, 2016 at 6:13 pm - Reply  >

    First and foremost, do no harm: respect the child; appreciate the natural history of sexual development; and, to be safe follow up to observe physiological changes indicating a concerning condition – like childhood pregnancy.

  14. V. Farington WHNP February 4, 2016 at 12:29 pm - Reply  >

    What an opportunity to allow her some positive self-concept! “Yes you’re perfectly normal with irregularity now and in the future, it can happen for many reasons. Charting your bleeding can help predict the next one but gets more accurate as you get older. And we always do a routine pregnancy test for all ladies who have period-related problems. It may seem silly but it’s routine, cheap, physically noninvasive, and it’s urine! Here’s the cup, there’s the bathroom.”

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