Menstruation Disorders in Adolescents Treatment & Management
- Author: Kirsten J Sasaki, MD; Chief Editor: Andrea L Zuckerman, MD more...
Management of Primary Amenorrhea
Treatment of amenorrhea depends upon the identified cause. The following is a brief description of treatment options.
In cases of müllerian agenesis, counseling is warranted to discuss the diagnosis with the patient and the family; this should include a discussion of future fertility options, including use of a gestational carrier, and sexual relationships. Treatment includes nonsurgical and surgical creation of a neovagina, as well as general gynecologic examinations to evaluate for vaginal stricture and stenosis.
For androgen insensitivity syndrome, complete gonadectomy may be performed after the patient has completed puberty to prevent gonadal neoplasia, for which the patient is at increased risk. In this case, use of a donor egg versus use of a gestational carrier may be discussed.
Anatomic defects, such as imperforate hymen or transverse vaginal septum, are treated with a surgical procedure to create a patent outflow tract. Usually, a successful, normal pregnancy and delivery can be anticipated.
For primary hypogonadism, if it is due to premature ovarian failure, treatment should include a discussion of hormone therapy, and additional assessment may be required, including testing for a premutation in the FMR1 gene. A donor egg can be utilized, with normal delivery expected.
In cases of functional hypothalamic amenorrhea, gaining weight and reducing exercise levels will likely result in resumption of menses.
Polycystic ovary syndrome (PCOS) is treated essentially as it would be in the context of abnormal uterine bleeding (AUB; see below).
Management of Abnormal Uterine Bleeding
Polycystic ovary syndrome
Treatment of PCOS depends on the patient’s goals, as follows:
For patients who wish to conceive, clomiphene citrate is the first-line treatment, followed by gonadotropins 
For those who are not attempting to conceive, a combined oral contraceptive pill (COCP) is usually the first line of treatment, provided that there are no contraindications; COCPs are therapeutic for multiple reasons, including regulating menstrual cycles, suppressing ovarian and adrenal androgen production and increasing circulating levels of sex hormone binding globulin, thus lowering the levels of free testosterone in the serum 
In addition to these treatment options, lifestyle modifications are recommended for overweight and obese PCOS patients so as to decrease their risk for cardiovascular disease, diabetes, and metabolic syndrome.[18, 41]
Metformin has also been demonstrated to decrease ovarian androgen production and insulin levels, and it may improve ovulation rates; however, it is not currently approved for treatment of PCOS-related menstrual dysfunction. It may be used to delay the development of diabetes in those with impaired glucose tolerance, but is not as effective as lifestyle modifications.
For patients with hirsutism, multiple treatment options are available. A multitiered approach is often necessary, combining cosmetic procedures with medications such as COCPs and antiandrogens (eg, spironolactone, flutamide and finasteride). When antiandrogen medications are being used, it is important to use contraceptives as well because the antiandrogens are teratogenic.
Heavy menstrual bleeding
First-line therapy for AUB – heavy menstrual bleeding (HMB) often includes nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, naproxen, and mefenamic acid. They have been demonstrated to decrease menstrual blood loss in comparison with placebo; they decrease prostaglandin levels, which are increased in women with AUB-HMB.
Additional treatment options include hormone therapy with COCPs, as well as the use of progestin-only medications, including pills, medroxyprogesterone acetate, and the etonogestrel implant (especially if there are contraindications to COCPs).
Another progestin-only option is the levonorgestrel-releasing intrauterine device (IUD),[44, 45] which has been demonstrated to decrease menstrual blood loss to a greater extent than NSAIDs, COCPs, or antifibrinolytic agents do. Although most of the studies on IUDs have been performed in women at least 18 years of age, this is an appropriate form of contraception in adolescents and thus may be an option for treatment of AUB-HMB.
A nonhormonal pharmacologic option that has been demonstrated to decrease HMB in adults is the use of antifibrinolytic drugs, such as tranexamic acid ; however, these agents are not currently approved for use in adolescents.
If a patient is diagnosed with von Willebrand disease, one should seek consultation with a hematologist in order to optimize the treatment regimen. Possible medical options include antifibrinolytic agents, COCPs, and progestin-only contraceptives. Additional nonhormonal treatment options include desmopressin acetate and recombinant factor VIII.
If a patient is taking a short-acting hormone, it is important to counsel her about proper administration of the medication. It is also important to provide counseling about what she may expect in terms of bleeding patterns, especially during the first few months of use. If a patient was recently started on contraceptives, unscheduled bleeding is common in the first 3 months, and in many cases, all that is needed is reassurance.
If irregular bleeding persists and the adolescent is taking a low-dose COCP (eg, < 20 µg ethinyl estradiol), the intermenstrual bleeding (IMB) may resolve if the estrogen dose is increased. Depending on when the bleeding occurs during the cycle, she may benefit from increasing either the progestin level or the estrogen support in her formulation.
For patients who are taking progestin-only formulations, bothersome unscheduled bleeding can often be treated by administering NSAIDS or by providing brief estrogen supplementation with COCPs, provided that no contraindications exist.
Management of Dysmenorrhea
First-line therapy for primary dysmenorrhea consists of NSAIDs, which inhibit prostaglandin synthesis and lead to less vigorous uterine contractions. Improvement may occur if regularly scheduled doses are started 1-2 days before anticipated menses. If improvement is not seen after three menstrual cycles, a trial of oral contraceptive pills for three menstrual cycles may be offered.
Secondary dysmenorrhea is less likely to respond to NSAIDs than primary dysmenorrhea is.
NSAIDs are a common first-line treatment for endometriosis, though there is no current evidence that these agents reduce endometriosis-related pain. Oral contraceptives, progestins, androgens, and gonadotropin-releasing hormone (GnRH) agonists are the mainstays of medical therapy.
COCPs decrease pain as compared with placebo, and in patients who experience pain during withdrawal bleeding, pain reduction has been demonstrated with continuous oral contraceptives. Progestins, administered orally and subcutaneously, provide pain relief and offer benefit equivalent to that of GnRH agonists, with fewer side effects.
GnRH agonists do provide effective relief of endometriosis-related pain, but they have significant side effects, including osteopenia, vaginal dryness and hot flashes. If these agents are used for longer than 6 months, add-back therapy should be initiated.
Pelvic inflammatory disease
Treatment of pelvic inflammatory disease (PID) consists of antibiotics (given orally or intravenously, depending on the patient’s clinical presentation and findings) and, potentially, drainage of an abscess or surgical intervention. In view of the known sequelae of untreated PID, it is recommended that all sexual active women presenting with lower abdominal or pelvic pain with no other identifiable etiology, or cervical motion, uterine or adnexal tenderness be empirically treated for PID.
ACOG Committee Opinion No. 349, November 2006: Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Obstet Gynecol. 2006 Nov. 108(5):1323-8. [Medline].
Munro MG, Critchley HO, Broder MS, Fraser IS. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011 Apr. 113(1):3-13. [Medline].
Chumlea WC, Schubert CM, Roche AF, Kulin HE, Lee PA, Himes JH, et al. Age at menarche and racial comparisons in US girls. Pediatrics. 2003 Jan. 111(1):110-3. [Medline].
World Health Organization multicenter study on menstrual and ovulatory patterns in adolescent girls. II. Longitudinal study of menstrual patterns in the early postmenarcheal period, duration of bleeding episodes and menstrual cycles. World Health Organization Task Force on Adolescent Reproductive Health. J Adolesc Health Care. 1986 Jul. 7(4):236-44. [Medline].
Vihko R, Apter D. Endocrine characteristics of adolescent menstrual cycles: impact of early menarche. J Steroid Biochem. 1984 Jan. 20(1):231-6. [Medline].
Fraser IS, McCarron G, Markham R. A preliminary study of factors influencing perception of menstrual blood loss volume. Am J Obstet Gynecol. 1984 Aug 1. 149(7):788-93. [Medline].
Reindollar RH, Byrd JR, McDonough PG. Delayed sexual development: a study of 252 patients. Am J Obstet Gynecol. 1981 Jun 15. 140(4):371-80. [Medline].
Slap GB. Menstrual disorders in adolescence. Best Pract Res Clin Obstet Gynaecol. 2003 Feb. 17(1):75-92. [Medline].
Mashchak CA, Kletzky OA, Davajan V, Mishell DR Jr. Clinical and laboratory evaluation of patients with primary amenorrhea. Obstet Gynecol. 1981 Jun. 57(6):715-21. [Medline].
Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012 Jul. 120(1):197-206. [Medline].
Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol. 2013 Jul. 122(1):176-85. [Medline].
Strickland JL, Wall JW. Abnormal uterine bleeding in adolescents. Obstet Gynecol Clin North Am. 2003 Jun. 30(2):321-35. [Medline].
Fauser BC, Tarlatzis BC, Rebar RW, Legro RS, Balen AH, Lobo R, et al. Consensus on women's health aspects of polycystic ovary syndrome (PCOS): the Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group. Fertil Steril. 2012 Jan. 97(1):28-38.e25. [Medline].
Dunaif A. Insulin action in the polycystic ovary syndrome. Endocrinol Metab Clin North Am. 1999 Jun. 28(2):341-59. [Medline].
Carmina E, Oberfield SE, Lobo RA. The diagnosis of polycystic ovary syndrome in adolescents. Am J Obstet Gynecol. 2010 Sep. 203(3):201.e1-5. [Medline].
ACOG Practice Bulletin No. 108: Polycystic ovary syndrome. Obstet Gynecol. 2009 Oct. 114(4):936-49. [Medline].
Coviello AD, Legro RS, Dunaif A. Adolescent girls with polycystic ovary syndrome have an increased risk of the metabolic syndrome associated with increasing androgen levels independent of obesity and insulin resistance. J Clin Endocrinol Metab. 2006 Feb. 91(2):492-7. [Medline].
Farhi DC, Nosanchuk J, Silverberg SG. Endometrial adenocarcinoma in women under 25 years of age. Obstet Gynecol. 1986 Dec. 68(6):741-5. [Medline].
Higham JM, O'Brien PM, Shaw RW. Assessment of menstrual blood loss using a pictorial chart. Br J Obstet Gynaecol. 1990 Aug. 97(8):734-9. [Medline].
Claessens EA, Cowell CA. Acute adolescent menorrhagia. Am J Obstet Gynecol. 1981 Feb 1. 139(3):277-80. [Medline].
Minjarez DA, Bradshaw KD. Abnormal uterine bleeding in adolescents. Obstet Gynecol Clin North Am. 2000 Mar. 27(1):63-78. [Medline].
Kadir RA, Economides DL, Sabin CA, Owens D, Lee CA. Frequency of inherited bleeding disorders in women with menorrhagia. Lancet. 1998 Feb 14. 351(9101):485-9. [Medline].
Ragni MV, Bontempo FA, Hassett AC. von Willebrand disease and bleeding in women. Haemophilia. 1999 Sep. 5(5):313-7. [Medline].
Werner EJ, Broxson EH, Tucker EL, Giroux DS, Shults J, Abshire TC. Prevalence of von Willebrand disease in children: a multiethnic study. J Pediatr. 1993 Dec. 123(6):893-8. [Medline].
Shankar M, Lee CA, Sabin CA, Economides DL, Kadir RA. von Willebrand disease in women with menorrhagia: a systematic review. BJOG. 2004 Jul. 111(7):734-40. [Medline].
Edlund M, Blombäck M, von Schoultz B, Andersson O. On the value of menorrhagia as a predictor for coagulation disorders. Am J Hematol. 1996 Dec. 53(4):234-8. [Medline].
National Heart, Lung, and Blood Institute. NIH Publication No. 08-5832. The diagnosis, evaluation, and management of von Willebrand disease. National Heart, Lung, and Blood Institute. 2007. Available at http://www.nhlbi.nih.gov/guidelines/vwd/vwd.pdf.
Kouides PA, Conard J, Peyvandi F, Lukes A, Kadir R. Hemostasis and menstruation: appropriate investigation for underlying disorders of hemostasis in women with excessive menstrual bleeding. Fertil Steril. 2005 Nov. 84(5):1345-51. [Medline].
Committee Opinion No.580: von Willebrand disease in women. Obstet Gynecol. 2013 Dec. 122(6):1368-73. [Medline].
Jacobson L, Weström L. Objectivized diagnosis of acute pelvic inflammatory disease. Diagnostic and prognostic value of routine laparoscopy. Am J Obstet Gynecol. 1969 Dec 1. 105(7):1088-98. [Medline].
Speroff L, Darney PD. A Clinical Guide for Contraception. Philadelphia: Lippincott Williams & Wilkins; 2005.
Gallo MF, Nanda K, Grimes DA, Lopez LM, Schulz KF. 20 µg versus >20 µg estrogen combined oral contraceptives for contraception. Cochrane Database Syst Rev. 2013 Aug 1. 8:CD003989. [Medline].
Casey PM, Long ME, Marnach ML, Bury JE. Bleeding related to etonogestrel subdermal implant in a US population. Contraception. 2011 May. 83(5):426-30. [Medline].
Janssen EB, Rijkers AC, Hoppenbrouwers K, Meuleman C, D'Hooghe TM. Prevalence of endometriosis diagnosed by laparoscopy in adolescents with dysmenorrhea or chronic pelvic pain: a systematic review. Hum Reprod Update. 2013 Sep-Oct. 19(5):570-82. [Medline].
Committee opinion: no. 562: müllerian agenesis: diagnosis, management, and treatment. Obstet Gynecol. 2013 May. 121(5):1134-7. [Medline].
Krasna IH, Lee ML, Smilow P, Sciorra L, Eierman L. Risk of malignancy in bilateral streak gonads: the role of the Y chromosome. J Pediatr Surg. 1992 Nov. 27(11):1376-80. [Medline].
Committee opinion no. 605: primary ovarian insufficiency in adolescents and young women. Obstet Gynecol. 2014 Jul. 124(1):193-7. [Medline].
Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002 Feb 7. 346(6):393-403. [Medline]. [Full Text].
Lethaby A, Duckitt K, Farquhar C. Non-steroidal anti-inflammatory drugs for heavy menstrual bleeding. Cochrane Database Syst Rev. 2013 Jan 31. 1:CD000400. [Medline].
U S. Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR Recomm Rep. 2010 Jun 18. 59:1-86. [Medline].
Kaunitz AM, Bissonnette F, Monteiro I, Lukkari-Lax E, DeSanctis Y, Jensen J. Levonorgestrel-releasing intrauterine system for heavy menstrual bleeding improves hemoglobin and ferritin levels. Contraception. 2012 Nov. 86(5):452-7. [Medline].
Gupta J, Kai J, Middleton L, Pattison H, Gray R, Daniels J. Levonorgestrel intrauterine system versus medical therapy for menorrhagia. N Engl J Med. 2013 Jan 10. 368(2):128-37. [Medline].
Matteson KA, Rahn DD, Wheeler TL 2nd, Casiano E, Siddiqui NY, Harvie HS, et al. Nonsurgical management of heavy menstrual bleeding: a systematic review. Obstet Gynecol. 2013 Mar. 121(3):632-43. [Medline].
Committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol. 2012 Oct. 120(4):983-8. [Medline].
Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000. CD000249. [Medline].
Hatcher R, Trussell J, Nelson A, et al. Contraceptive Technology. New York: Ardent Media; 2007.
Abdel-Aleem H, d'Arcangues C, Vogelsong KM, Gaffield ML, Gülmezoglu AM. Treatment of vaginal bleeding irregularities induced by progestin only contraceptives. Cochrane Database Syst Rev. 2013 Oct 21. 10:CD003449. [Medline].
Harel Z. Dysmenorrhea in adolescents and young adults: etiology and management. J Pediatr Adolesc Gynecol. 2006 Dec. 19(6):363-71. [Medline].
Allen C, Hopewell S, Prentice A, Gregory D. Nonsteroidal anti-inflammatory drugs for pain in women with endometriosis. Cochrane Database Syst Rev. 2009 Apr 15. CD004753. [Medline].
Vercellini P, Frontino G, De Giorgi O, Pietropaolo G, Pasin R, Crosignani PG. Continuous use of an oral contraceptive for endometriosis-associated recurrent dysmenorrhea that does not respond to a cyclic pill regimen. Fertil Steril. 2003 Sep. 80(3):560-3. [Medline].
Schlaff WD, Carson SA, Luciano A, Ross D, Bergqvist A. Subcutaneous injection of depot medroxyprogesterone acetate compared with leuprolide acetate in the treatment of endometriosis-associated pain. Fertil Steril. 2006 Feb. 85(2):314-25. [Medline].
Surrey ES. Gonadotropin-releasing hormone agonist and add-back therapy: what do the data show?. Curr Opin Obstet Gynecol. 2010 Aug. 22(4):283-8. [Medline].
U.S. Selected Practice Recommendations for Contraceptive Use, 2013: adapted from the World Health Organization selected practice recommendations for contraceptive use, 2nd edition. MMWR Recomm Rep. 2013 Jun 21. 62:1-60. [Medline].