Menstruation Disorders in Adolescents Clinical Presentation
- Author: Kirsten J Sasaki, MD; Chief Editor: Andrea L Zuckerman, MD more...
Although primary amenorrhea is not diagnosed until a female with normal secondary sexual characteristics has reached the age of 16, it is recommended to start an evaluation if she has failed to menstruate by the age of 15 or within 5 years of breast development. Another indication of delayed puberty, and cause for workup, is lack of breast development by the age of 13 years.
The evaluation should start with a thorough history to assess for any history of vaginal bleeding, development of other secondary sexual characteristics, or evidence of excess androgens, such as hirsutism or increased muscle mass. A review of systems should include any changes in weight, stress or activity level, headaches, visual disturbances, or milk production.
The past medical history should include questions about childhood health or chronic illness, as well as use of any medications, including metoclopramide and antipsychotic agents. The family history should include any history of delayed puberty or premature ovarian failure.
Abnormal uterine bleeding
Evaluation of abnormal uterine bleeding (AUB) should commence with a thorough history that includes, including age of menarche, menstrual bleeding patterns (eg, number of cycles over the past 12 months), duration and severity of menstrual flow, and pelvic pain associated with the cycle.
Some adolescents may find the creation of a menstrual calendar or diary helpful for identifying menstrual patterns. Because every woman changes her pad or tampon differently, it may be difficult at times to establish the presence of heavy menstrual flow; in such cases, it may be helpful to ask about use of overflow pads or multiple pads or about disruption of daily activity as a result of menstrual flow.
A history of current or previous sexual activity should be elicited, as well as a history of any previous sexually transmitted infections (STIs) and any current vaginal discharge or dysuria. These questions should be posed in a nonthreatening, nonaccusatory manner. Relating the identification of the menstrual disorder to a possible infection may place the adolescent at ease.
All chronic medical conditions and all medications or herbal supplements should be identified. Specific inquiries should be made about the use of anticoagulants, antipsychotics, nonsteroidal anti-inflammatory drugs (NSAIDs), and hormonal contraceptives, which can all cause irregular menses. All previous surgical procedures should be noted, and any complications (eg, postoperative bleeding) should be detailed.
Another important component of the history includes a thorough family history for bleeding disorders, especially von Willebrand disease. If a patient is taking any short-acting exogenous hormones, especially if she is doing so for contraception, it is important to ensure that these agents are being taken appropriately and consistently.
Dysmenorrhea can occur with regular bleeding patterns or can be associated with abnormal uterine bleeding. Primary dysmenorrhea presents with painful menses and occasionally is accompanied by nausea, vomiting, diarrhea, fatigue, and headache. In secondary dysmenorrhea, the pain often precedes the onset of menses.
Endometriosis may be asymptomatic but can also cause cyclic and acyclic pelvic pain, painful menses, dysuria, dyschezia and infertility. It may be present in as many as 70% of adolescents who present with dysmenorrhea. Pelvic inflammatory disease (PID) can present with painful, irregular uterine bleeding or vaginal discharge.
Physical examination for primary amenorrhea begins with measurement of height, weight, body mass index (BMI), and vital signs. One should also evaluate for staging of thelarche and adrenarche, as well as for signs of hyperandrogenism, including hirsutism, acne, and clitoromegaly.
Thelarche marks the beginning of breast development and includes five Tanner stages, as follows :
Stage 1 - No palpable breast tissue
Stage 2 - Development of breast buds with elevation of the papilla
Stage 3 - Enlargement of the breast without separation of the areola
Stage 4 - Formation of a secondary mound, as the areola and papilla project above the breast
Stage 5 - Recession of the areola to the contour of the breast
Adrenarche indicates the activation of the adrenal cortex to produce androgens; it is associated with pubarche, or the development of pubic hair.
The examination should also include evaluation of physical features consistent with Turner syndrome, such as short stature, webbed neck, shield chest, and widely spaced nipples. If feasible, a genital examination should be performed to evaluate for presence of an imperforate hymen, absent or blind-ending vagina, or transverse vaginal septum, as well as the presence of a cervix, uterus and ovaries. If this is not possible, imaging can be performed to evaluate for the presence of müllerian structures.
Abnormal uterine bleeding
Physical examination for AUB should include height, weight, BMI, and vital signs. As with the examination for amenorrheic patients, one should inspect for signs of hyperandrogenism and also for indications of insulin resistance, which may suggest polycystic ovary syndrome (PCOS). If there is suspicion of a possible bleeding disorder, physical evaluation should include inspection for petechiae, skin pallor, ecchymoses, and swollen joints.
If there is concerned about possible PID, a speculum examination should be performed to inspect for discharge, and endocervical samples should be collected for detection of gonorrhea or chlamydia. Urine samples can also be tested with nucleic acid amplification if a vaginal examination is not feasible. A bimanual examination assessing for cervical motion tenderness, uterine and adnexal tenderness is also important when there is concern about possible STI.
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