eMedicine Specialties > Pediatrics: Surgery > Gynecology
Menstruation Disorders
Updated: Jun 10, 2009
Introduction
Background
Menstruation disorders are a common problem during adolescence. These disorders may cause significant anxiety for patients and their families.1 Physical and psychological factors contribute to the problem. In order to treat menstruation disorders, becoming familiar with the normal menstrual cycle is important.
For a regular menstrual cycle, the median age of menarche is 12.77 years. The average interval between thelarche and menarche is about 2 years, and 90% of females menstruate by the time they have Tanner IV breast and pubic hair development. Most cycles occur between 21-35 days with 3-10 days of bleeding and 30-40 mL of blood loss. Anovulatory cycles and irregular menstrual patterns are common within 24 months of menarche.
Classification of menstrual disorders
Attempts are currently underway to establish a standardized international nomenclature for menstrual disorders. The existing broad classification is as follows:
- Amenorrhea and oligomenorrhea (lack of bleeding or too little bleeding)
- Dysmenorrhea (painful menstruation)
- Menorrhagia (excessive bleeding)
Amenorrhea
Amenorrhea may be primary (ie, never menstruated) or secondary (ie, menarche, but no periods for 3 consecutive months). Primary amenorrhea is the absence of menstruation by age 16 years in the presence of normal pubertal development or by age 14 years in the absence of normal pubertal development. Evaluating for breast and uterine development in patients with a menstruation disorder is important. Secondary amenorrhea is more common than primary amenorrhea. The most common etiology is dysfunction of the hypothalamic-pituitary-ovarian (HPO) axis.
Dysmenorrhea
Dysmenorrhea is a very common complaint and may be primary or secondary, although primary dysmenorrhea is more prevalent. Symptoms include crampy lower abdominal and pelvic pain that radiates to the thighs and back without associated pelvic pathology. Dysmenorrhea is caused by prostaglandins and leukotrienes during ovulatory cycles. Endometrial prostaglandin levels increase during the luteal and menstrual phases of the cycle, causing uterine contractions. Secondary dysmenorrhea is rare, and pain is associated with pelvic pathology (eg, bicornuate uterus, endometriosis, pelvic inflammatory disease, uterine fibroids). An underlying pelvic pathology (eg, endometriosis) or an uterine anomaly (eg, fibroids) may be present in about 10% of severe dysmenorrhea cases.2
Menorrhagia
Menstrual bleeding that lasts more than 8-10 days with blood loss of over 80 mL is considered excessive.
Pathophysiology
Hormonal changes in the normal menstrual cycle
In the ovulatory cycle, the hypothalamus secretes gonadotropin-releasing hormone (GnRH), which stimulates the pituitary to release follicle-stimulating hormone (FSH). This, in turn, causes an ovarian follicle to grow and mature. In mid cycle, a surge of luteinizing hormone (LH) occurs with an FSH surge, resulting in ovulation. The developing follicle produces estrogen, which stimulates the endometrium to proliferate. After the ovum is released, FSH and LH levels fall, corpus luteum develops at the site of the ruptured follicle, and progesterone is secreted from the ovary. Progesterone causes the proliferating endometrium to differentiate and stabilize. Fourteen days after ovulation, menstruation results from endometrial shedding secondary to the rapid decline in the levels of estrogen and progesterone from the involuting corpus luteum.
Hormonal changes during anovulatory cycles
Anovulatory cycles are common in the first 2 years after menarche because of the immaturity of the HPO axis. They can also occur in various pathological conditions.
In anovulatory cycles, the follicular growth occurs with the stimulation from FSH; however, due to lack of LH surge, ovulation fails to occur. Consequently, no corpus luteum is formed and no progesterone is secreted. The endometrium continues its proliferative phase excessively. When the follicle involutes, estrogen levels drop and estrogen withdrawal bleeding occurs. Most anovulatory cycles are regular with normal bleeding; however, the unstable proliferative endometrium can shed irregularly, resulting in prolonged heavy bleeding.
Frequency
International
Twelve percent of all gynecology referrals in the United Kingdom are for heavy menstrual bleeding.
Clinical
History
- Amenorrhea
- Detailed history of pubertal development
- Family history of menarche, pubertal development
- History of weight loss, stress, exercise (athletic activity)
- Detailed dietary history
- History of contraception, medications
- History suggestive of CNS disease (eg, headaches, visual changes)
- History of chronic illnesses (eg, Crohn disease)
- Dysmenorrhea
- Evaluation should include a detailed menstrual history and the relationship of the pain to the menstrual cycle.
- Ask about a family history of endometriosis.
- Ascertain the degree of incapacitation. If pain is mild and physical examination is normal, a pelvic examination is not indicated. If pain is severe and interferes with daily living, a pelvic examination is warranted. If a patient is sexually active, a pelvic examination is mandatory. Be suspicious of secondary dysmenorrhea if onset of dysmenorrhea occurs at menarche.
- Menorrhagia
- Date of menarche
- Menstrual calendar (invaluable)
- Sexual activity
- Use of hormones, such as oral contraceptive pills or depo-medroxyprogesterone acetate, and use of other medications such as warfarin, aspirin
- Chronic illnesses
- Bleeding disorders, including family and personal history
- CNS symptoms
- Acne, hirsutism
Physical
- Amenorrhea
- Height, weight, and growth charts
- Breast development, pubic hair
- Syndromic appearance (eg, short stature, webbed neck)
- Visual fields, thorough neurologic examination, optic fundi
- Evidence of hyperandrogenism (eg, acne, hirsutism, clitoromegaly)
- Evidence of thyroid disease
- Evidence of chronic illnesses
- Evidence of pregnancy
- Menorrhagia
- Growth percentiles
- Palpation of thyroid
- Breast examination for galactorrhea
- Evidence of bleeding elsewhere
- Pelvic examination, if sexually active
Causes
- Primary amenorrhea with absent breast development and present uterus
- Constitutional delay of puberty
- Hypothalamic dysfunction (eg, stress, anorexia, chronic illness, exercise)
- Pituitary failure
- Gonadal failure
- Gonadal dysgenesis (eg, Turner syndrome, Swyer syndrome)
- Gonadotrophin deficiency (eg, Kallmann syndrome)
- Primary amenorrhea with breast development and present uterus
- Hyperandrogenic amenorrhea
- Hypothalamic amenorrhea
- Hypothyroidism
- Hyperprolactinemia
- Outflow tract obstructions (eg, imperforate hymen, vaginal atresia)
- Primary amenorrhea with breast development and absent uterus
- Müllerian agenesis
- Androgen insensitivity
- Menorrhagia
- Anovulatory dysfunctional uterine bleeding (DUB)
- Immature HPO axis, adolescent DUB
- Hyperandrogenic chronic anovulation (eg, polycystic ovarian syndrome, adrenal hyperplasia)
- Pregnancy-related complications
- Sexually transmitted diseases
- Chronic illnesses
- Blood dyscrasia
- Trauma
- Drugs
- Endocrine disorders
- Neoplasms
Differential Diagnoses
Other Problems to Be Considered
Secondary amenorrhea and oligomenorrhea
Pregnancy
Hormonal contraception
Hypothalamic causes (eg, stress, exercise, eating disorder, chronic illness, drugs, tumor, obesity syndromes)
Pituitary causes (eg, hypopituitarism, tumor, infiltration, infarction)
Ovarian causes (eg, premature ovarian failure)
Androgen excess (eg, polycystic ovarian disease, adrenal hyperplasia, adrenal or ovarian tumor)
Other endocrine causes (eg, thyroid disease, Cushing disease)
Workup
Laboratory Studies
- Amenorrhea
- Workup depends on patient history and physical findings.
- No studies are necessary for constitutional growth delay.
- Obtain a karyotype if the patient is syndromic or has evidence of ovarian failure.
- Obtain serum FSH levels. Differentiating central from peripheral causes is important. High levels of FSH indicate ovarian failure or gonadal dysgenesis; low levels indicate hypothalamic or pituitary causes.
- Obtain a bone age in primary amenorrhea.
- Obtain a serum prolactin level.
- Obtain thyroid function tests.
- Obtain urine beta-human chorionic gonadotropin levels. This is mandatory for secondary amenorrhea.
- For secondary amenorrhea, consider testing serum LH, serum testosterone, dehydroepiandrosterone sulfate (DHEAS), 17-hydroxyprogesterone, and serum cortisol.
- Menorrhagia
- Test for gonorrhea and chlamydia if patient is sexually active.
- Obtain a urine pregnancy test.
- Obtain a CBC count with reticulocyte count.
- Obtain coagulation studies.
- Obtain a blood type and cross-match in very severe cases.
- Also consider testing for thyroid-stimulating hormone (TSH) level, FSH level, serum prolactin, and serum androgens if clinical evidence of hyperandrogenism is present.
Imaging Studies
- Amenorrhea
- Consider MRI of the head if CNS symptoms or hyperprolactinemia are present.
- Consider pelvic ultrasonography if absent uterus or structural anomalies are suspected.
- Dysmenorrhea: Ultrasonography and MRI may be helpful if secondary cause of dysmenorrhea is suspected.
- Menorrhagia: Consider pelvic ultrasonography if a mass or structural anomaly is suspected.
Treatment
Medical Care
- Amenorrhea
- Treatment depends on etiology. Direct therapy to the underlying cause.
- If the patient has a completely normal physical examination with secondary amenorrhea, consider administering medroxyprogesterone 10 mg daily for 5-10 days to see if withdrawal bleeding occurs. If this occurs, adequate levels of endogenous estrogen and normal anatomy are indicated.
- Dysmenorrhea
- Provide symptomatic relief with nonsteroidal anti-inflammatory drugs (eg, naproxen, ibuprofen) at the first sign of cramps.
- If nonsteroidal anti-inflammatory therapy fails, consider oral contraceptive pills for 3-6 months. If this fails as well, look for secondary causes of dysmenorrhea.
- Short-term use of selective estrogen receptor modulators (SERMs), such as tamoxifen, in selected refractory cases has produced good results.
- Menorrhagia
- Most cases of menorrhagia fall under the category of DUB. In situations in which a specific etiology is identified, treatment of the underlying cause is necessary.
- For patients with mild DUB, provide reassurance and observation. Instruct the patient to keep a menstrual calendar. Consider iron supplementation and antiprostaglandin medications during bleeding episodes.
- For patients with moderate DUB, prescribe combination oral contraceptive pills beginning with 4 monophasic 35-microgram pills a day and tapering down. Oral contraceptive pills are usually continued for 6 months. Medroxyprogesterone alone may also be used. Also administer oral iron and folic acid supplements.
- If DUB is severe, consider an undiagnosed underlying disorder, such as von Willebrand disease or factor VII deficiency. For patients with severe DUB, consider hospitalization and coagulation studies. Administer intravenous Premarin every 4 hours until the bleeding stops, up to 4 doses. Simultaneously administer a monophasic 35-microgram oral contraceptive pill every 6 hours for 24-48 hours and then twice daily to complete a 28-day course. If Premarin does not stop the bleeding after 4 doses, consider pelvic pathology. Examination under anesthesia and dilatation and curettage may be necessary.
- An international expert panel including obstetrician/gynecologists and hematologists has issued guidelines to assist physicians to better recognize bleeding disorders such as von Willebrand disease as a cause of menorrhagia and postpartum hemorrhage and to provide disease-specific therapy for the bleeding disorder.3 Historically, a lack of awareness of underlying bleeding disorders has led to underdiagnosis of these disorders in women with abnormal reproductive tract bleeding. The panel provided expert consensus recommendations on how to identify, confirm, and manage a bleeding disorder. If a bleeding disorder is suspected, consultation with a hematologist is suggested. An underlying bleeding disorder should be considered when a patient has any of the following:
- Menorrhagia since menarche
- Family history of bleeding disorders
- Personal history of one or more of the following: (1) notable bruising without known injury, (2) bleeding of oral cavity or GI tract without obvious lesion, or (3) epistaxis that persists more than 10 minutes (possibly necessitating packing or cautery)
- Recent literature (including information from the American College of Obstetricians and Gynecologists Committee on Gynecologic Practice) favors the use of levonorgestrel intrauterine devices (eg, Progestasert, Mirena coil) as safe and effective treatment for severe menorrhagia.4 The quality of life among patients receiving this treatment was comparable to those receiving surgical treatments.
Surgical Care
- Surgical options for the management of severe menorrhagia include thermal balloon endometrial ablation, transcervical resection of the endometrium (TCRE), and hysterectomy.5
Medication
Medications used in the management of menstrual disorders depend on the type of disorder and the etiology of the disorder.
Hormones
In patients with secondary amenorrhea who have a completely normal physical examination, medroxyprogesterone can be used to diagnose anovulation as the cause of amenorrhea (progesterone challenge test). Estrogens are effective in controlling acute, profuse bleeding. Estrogen also induces formation of progesterone receptors, making subsequent treatment with progestins more effective.
Medroxyprogesterone (Provera, Cycrin)
Short-acting synthetic progestin. Progestin therapy in adolescents produces regular cyclic withdrawal bleeding until maturity of positive feedback system is achieved. Progestins stop endometrial cell proliferation, allowing organized sloughing of cells after withdrawal. Typically does not stop acute bleeding episode but produces a normal bleeding episode following withdrawal.
Dosing
Adult
10 mg PO qd for 5-10 d
Pediatric
Adolescents: Administer as in adults
Interactions
Aminoglutethimide increases hepatic metabolism of medroxyprogesterone
Contraindications
Documented hypersensitivity; cerebral apoplexy, undiagnosed vaginal bleeding, thrombophlebitis, and liver dysfunction
Precautions
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in asthma, depression, renal or cardiac dysfunction, or thromboembolic disorders
Ethinyl estradiol and a progestin derivative (Ovral, Ortho-Novum, Ovcon, Genora)
Combination pills of estrogen and progesterone in varying doses are used in the management of DUB. 21-day or 28-day cycles are used. Reduces secretion of LH and FSH from pituitary by decreasing amount of GnRH
Dosing
Adult
Dysmenorrhea:
21-day cycle: 1 tab PO qd for 21 d, do not take tablets for 7 d then resume
28-day cycle: 1 tab PO qd; last 7 tabs in cycle are placebo to help maintain compliance
Menorrhagia, moderate: Initiate with 4 monophasic 35-mcg tab PO qid on day 1, then taper downward
Pediatric
Adolescents: Administer as in adults
Interactions
May reduce hypoprothrombinemic effects of anticoagulants; estrogen levels may be reduced with coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes; an increase in corticosteroid levels may occur when administered concurrently with ethinyl estradiol; use of ethinyl estradiol with hydantoins may cause spotting, breakthrough bleeding, and pregnancy; increase in fluid retention caused by estrogen intake may reduce seizure control
Contraindications
Documented hypersensitivity; thrombophlebitis, undiagnosed vaginal bleeding
Precautions
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Exercise caution in hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease
Conjugated equine estrogen (Premarin)
Induces the synthesis of DNA, RNA, and various proteins in target tissues. Reduces the secretion of LH and FSH from the pituitary by decreasing amount of GnRH.
Dosing
Adult
Severe DUB: 25 mg IV q4h until bleeding stops, up to 4 doses; concurrently administer 35-mcg oral combination contraceptive pill PO q6h for 24-48 h, then bid to complete a 28-day cycle
Pediatric
Not established
Interactions
May reduce hypoprothrombinemic effect of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce estrogen levels; pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogen-induced inactivation of hepatic P450 enzyme; loss of seizure control has been noted when administered concurrently with hydantoins
Contraindications
Documented hypersensitivity; known or suspected pregnancy; breast cancer, undiagnosed abnormal genital bleeding, active thrombophlebitis or thromboembolic disorders; history of thrombophlebitis, thrombosis or thromboembolic disorders associated with previous estrogen use (except when used in treatment of breast or prostatic malignancy)
Precautions
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Certain patients may develop undesirable manifestations of excessive estrogenic stimulation, such as, abnormal or excessive uterine bleeding or mastodynia; estrogens may cause some degree of fluid retention (exercise caution); prolonged unopposed estrogen therapy may increase risk of endometrial hyperplasia
Nonsteroidal anti-inflammatory drugs (NSAIDs)
These agents block formation of prostacyclin, an antagonist of thromboxane, which is a substance that accelerates platelet aggregation and initiates coagulation.
Naproxen (Aleve, Anaprox, Naprosyn)
For relief of mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which results in a decrease of prostaglandin synthesis.
Dosing
Adult
500 mg PO once, after 6 h initiate 250 mg PO q6-8h; not to exceed 1.25 g/d
Pediatric
Adolescents: Administer as in adults
Interactions
Coadministration with aspirin increases risk of inducing serious NSAID-related side effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; may increase PT when taking anticoagulants (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Contraindications
Documented hypersensitivity; peptic ulcer disease; recent GI bleeding or perforation; renal insufficiency
Precautions
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Category D in third trimester of pregnancy; acute renal insufficiency, interstitial nephritis, hyperkalemia, hyponatremia, and renal papillary necrosis may occur; patients with preexisting renal disease or compromised renal perfusion risk acute renal failure; leukopenia occurs rarely, is transient, and usually returns to normal during therapy; persistent leukopenia, granulocytopenia, or thrombocytopenia warrants further evaluation and may require discontinuation of drug
Mineral supplementation
These agents are used to provide adequate iron for hemoglobin synthesis and to replenish body stores.
Iron sulfate (Feosol, Feratab, Fer-Iron, Slow-FE)
A nutritionally essential inorganic substance.
Dosing
Adult
325 mg PO qd
Pediatric
Adolescents: Administer as in adults
Interactions
Absorption is enhanced by ascorbic acid; interferes with tetracycline absorption; food and antacids impair absorption
Contraindications
Documented hypersensitivity
Precautions
Pregnancy
A - Fetal risk not revealed in controlled studies in humans
Precautions
GI upset; iron toxicity is observed with ingestion of large amount and can be fatal especially in children; parenteral (IV) administration may cause several reactions, including headaches, malaise, fever, generalized lymphadenopathy, arthralgia, and urticaria; can cause severe anaphylaxis; others include phlebitis at infusion site
Follow-up
Complications
- Excessive or prolonged bleeding can result in anemia.
- Excessive stimulation of the endometrium by estrogens with chronic anovulation increases the risk of endometrial cancer. Treating patients intermittently with combination oral contraceptives or progestins is important.
- Endometrial ablation procedures may cause uterine perforation.
Patient Education
- Educate patients about proper maintenance of a menstrual calendar. This is an invaluable tool in the evaluation of menstrual disorders.
- For excellent patient education resources, visit eMedicine's Women's Health Center and Pregnancy and Reproduction Center. Also, see eMedicine's patient education articles Amenorrhea, Vaginal Bleeding, Female Sexual Problems, Birth Control Overview, and Birth Control FAQs.
Miscellaneous
Medicolegal Pitfalls
- Always rule out pregnancy in a female with abnormal bleeding who is sexually active.
- Remember that a coexisting infectious disease may be present.
- In severe cases of menorrhagia, rule out a coagulation disorder
References
Cosgrove L, Riddle B. Constructions of femininity and experiences of menstrual distress. Women Health. 2003;38(3):37-58. [Medline].
Harel Z. Dysmenorrhea in adolescents and young adults: etiology and management. J Pediatr Adolesc Gynecol. Dec 2006;19(6):363-71. [Medline].
James AH, Kouides PA, Abdul-Kadir R, Edlund M, Federici AB, Halimeh S, et al. Von Willebrand disease and other bleeding disorders in women: Consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol. May 28 2009;[Medline].
American College of Obstetricians and Gynecologists Committee on Gynecologic Practice. ACOG committee opinion. No. 337: Noncontraceptive uses of the levonorgestrel intrauterine system. Obstet Gynecol. Jun 2006;107(6):1479-82. [Medline].
[Best Evidence] Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev. 2006;(2):CD003855. [Medline].
Braverman PK, Sondheimer SJ. Menstrual disorders. Pediatr Rev. Jan 1997;18(1):17-25; quiz 26. [Medline].
Emans JS, Laufer M, Goldstein DP. Delayed puberty and menstrual irregularities. In: Pediatric and Adolescent Gynecology. 4th ed. 1998:163-261.
Gordon CM. Menstrual disorders in adolescents. Excess androgens and the polycystic ovary syndrome. Pediatr Clin North Am. Jun 1999;46(3):519-43. [Medline].
Harlow SD, Campbell OM. Epidemiology of menstrual disorders in developing countries: a systematic review. BJOG. Jan 2004;111(1):6-16. [Medline].
Iglesias EA, Coupey SM. Menstrual cycle abnormalities: diagnosis and management. Adolesc Med. Jun 1999;10(2):255-73. [Medline].
Mitan LA, Slap GB. Adolescent menstrual disorders. Update. Med Clin North Am. Jul 2000;84(4):851-68. [Medline].
Slap GB. Menstrual disorders in adolescence. Best Pract Res Clin Obstet Gynaecol. Feb 2003;17(1):75-92. [Medline].
Keywords
menstruation disorders, irregularities of menstruation, menstrual disorders, amenorrhea, oligomenorrhea, dysmenorrhea, secondary dysmenorrhea, painful menstruation, menorrhagia, anovulatory cycles, irregular menstrual patterns, thelarche, menarche, dysfunctional uterine bleeding, DUB, menstruation disorders, hypothalamic-pituitary-ovarian axis, HPO axis, endometriosis, pelvic inflammatory disease, uterine fibroids, Crohn disease, constitutional delay of puberty, hypothalamic dysfunction, pituitary failure, gonadal failure, Turner Syndrome, Swyer syndrome, gonadotrophin deficiency, Kallmann syndrome, hyperandrogenic amenorrhea, hypothalamic amenorrhea, hypothyroidism, hyperprolactinemia, outflow tract obstructions, imperforate hymen, vaginal atresia, Müllerian agenesis, androgen insensitivity
Contributor Information and Disclosures
Author
Latha Chandran, MD, MPH, Associate Professor of Pediatrics, Associate Dean for Academic Affairs, Director, Division of General Pediatrics, State University of New York at Stony Brook School of Medicine
Latha Chandran, MD, MPH is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.
Medical Editor
Elizabeth Alderman, MD, Director of Fellowship Training Program, Director, Adolescent Ambulatory Service, Clinical Professor, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Montefiore Medical Center
Elizabeth Alderman, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine
Disclosure: Nothing to disclose.
Pharmacy Editor
Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner
Managing Editor
Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.
CME Editor
Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.
Chief Editor
Andrea L Zuckerman, MD, Assistant Professor of Obstetrics/Gynecology and Pediatrics, Tufts University School of Medicine; Division Director, Pediatric and Adolescent Gynecology, Tufts Medical Center
Andrea L Zuckerman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine
Disclosure: Nothing to disclose.
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