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Menstruation Disorders in Adolescents Workup

  • Author: Kirsten J Sasaki, MD; Chief Editor: Andrea L Zuckerman, MD  more...
 
Updated: Mar 09, 2015
 

Imaging Studies

Diagnostic imaging for primary amenorrhea, like the laboratory workup, depends on the findings from the history and physical examination.

Imaging studies for AUB generally begin with transvaginal ultrasonography. Imaging is not necessary in all patients, but it is recommended if abnormal findings (eg, an enlarged uterus) are noted on physical examination or if symptoms continue despite treatment in a patient with normal physical findings. Further evaluation may include hysterosonography or hysteroscopy[12] ; some patients may require laparoscopy, especially if a diagnosis of endometriosis is under consideration.

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Laboratory Studies

Primary amenorrhea

The laboratory workup for primary amenorrhea depends on the findings from the history and physical examination. If there is physical evidence of a blind-ending vaginal pouch, measurement of the testosterone level and karyotyping are indicated to differentiate between müllerian agenesis and complete androgen insensitivity syndrome.

If a uterus is present, basic laboratory evaluation includes a pregnancy test and levels of follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, thyroid-stimulating hormone (TSH), and prolactin. For interpretation of FSH and LH test results, the estradiol and progesterone levels must be low. In young women with no menses, it is sometimes necessary to draw weekly estradiol and progesterone levels until they indicate that the patient is in the early follicular phase, and then draw FSH and LH levels.

If the FSH is elevated, primary hypogonadism is likely, and karyotyping should be performed to determine whether there is evidence of Turner syndrome (45,X or 45,X/46,XX mosaic) or Swyer syndrome (46,XY). If the FSH is low or normal, the cause is likely hypothalamic, and further workup may include imaging of the head if no obvious cause (eg, stress- or exercise-induced hypothalamic dysfunction) is identified.

If the prolactin level is elevated, it is important to make sure that it was obtained in the fasting state without any recent nipple stimulation; if it was not, it may have to be repeated. If the prolactin level remains elevated and there is no recent medication use, including psychotropic medications to explain the elevation, magnetic resonance imaging (MRI) of the pituitary should be performed to evaluate for a pituitary microadenoma or adenoma.

With signs of hyperandrogenism, serum testosterone, dehydroepiandrosterone sulfate (DHEA-S), and 17-hydroxyprogesterone (17-OHP) levels should be checked to rule out an ovarian or adrenal tumor or congenital adrenal hyperplasia.

Abnormal uterine bleeding

Laboratory evaluation for abnormal uterine bleeding (AUB) should include a pregnancy test, a complete blood count (CBC), TSH levels, testing for gonorrhea and chlamydia, and screening for bleeding disorders when indicated.[12] In high-risk individuals, testing for HIV, syphilis, and hepatitis B and C should be considered as well.

For those with irregular bleeding patterns, measurement of hormone values (eg, estradiol, FSH, LH, and prolactin) may be indicated. Again, for proper interpretation of these values, they should be obtained in the early follicular phase; if menses are irregular, weekly estradiol and progesterone levels can be obtained until they are sufficiently low, at which point LH and FSH can be added. If there is concern about insulin resistance or metabolic abnormalities, one may consider performing a 2-hour glucose tolerance test, as well as fasting lipid levels.

If androgen excess is noted, or as part of an initial screen, one should consider evaluating free and total testosterone levels, DHEA-S, and 17-OHP. Screening for bleeding disorders includes CBC with platelets, coagulation studies, and, if there is concern about possible von Willebrand disease, von Willebrand-ristocetin cofactor activity, von Willebrand factor antigen, and factor VIII level.

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Contributor Information and Disclosures
Author

Kirsten J Sasaki, MD Associate, Advanced Gynecologic Surgery Institute

Disclosure: Nothing to disclose.

Coauthor(s)

Charles E Miller, MD, FACOG Clinical Associate Professor, Department of Obstetrics and Gynecology, University of Illinois at Chicago College of Medicine; Director, Minimally Invasive Gynecologic Surgery, Director, AAGL/SRS Fellowship in Minimally Invasive Gynecologic Surgery, Advocate Lutheran General Hospital

Charles E Miller, MD, FACOG is a member of the following medical societies: Endometriosis Association, International Academy of Pelvic Surgery, International Society for Gynecologic Endoscopy, Society of Reproductive Surgeons, Society of Robotic Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: AbbVie, Covidien, Ethicon, Gynesonics, Halt Medical, Hologic, Inc., Intuitive Surgical, Pacira Pharmaceuticals, Smith & Nephew Endoscopy, Stryker Endoscopy<br/>Serve(d) as a speaker or a member of a speakers bureau for: Ethicon, Intuitive Surgical, Smith & Nephew Endoscopy<br/>Royalties for: Thomas Medical/Catheter Research, Inc. (Miller Catheter).

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Andrea L Zuckerman, MD Associate Professor of Obstetrics/Gynecology, 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, Massachusetts Medical Society, North American Society for Pediatric and Adolescent Gynecology

Disclosure: Nothing to disclose.

Additional Contributors

Elizabeth Alderman, MD Director, Pediatric Residency Program, Director of Fellowship Training Program, Adolescent Medicine, Professor of Clinical Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Children's Hospital at Montefiore

Elizabeth Alderman, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, North American Society for Pediatric and Adolescent Gynecology, Society for Adolescent Health and Medicine

Disclosure: Nothing to disclose.

Acknowledgements

Latha Chandran, MBBS, MD, MPH Professor of Pediatrics, Vice Dean for Undergraduate Medical Education, Stony Brook University School of Medicine, New York

Latha Chandran, MBBS, MD, MPH is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

References
  1. 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].

  2. 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].

  3. 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].

  4. Marshall WA, Tanner JM. Variations in pattern of pubertal changes in girls. Arch Dis Child. 1969 Jun. 44(235):291-303. [Medline]. [Full Text].

  5. 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].

  6. Rosenfield RL. Clinical review: Adolescent anovulation: maturational mechanisms and implications. J Clin Endocrinol Metab. 2013 Sep. 98(9):3572-83. [Medline]. [Full Text].

  7. Vihko R, Apter D. Endocrine characteristics of adolescent menstrual cycles: impact of early menarche. J Steroid Biochem. 1984 Jan. 20(1):231-6. [Medline].

  8. 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].

  9. 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].

  10. Slap GB. Menstrual disorders in adolescence. Best Pract Res Clin Obstet Gynaecol. 2003 Feb. 17(1):75-92. [Medline].

  11. 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].

  12. Practice bulletin no. 128: diagnosis of abnormal uterine bleeding in reproductive-aged women. Obstet Gynecol. 2012 Jul. 120(1):197-206. [Medline].

  13. Practice bulletin no. 136: management of abnormal uterine bleeding associated with ovulatory dysfunction. Obstet Gynecol. 2013 Jul. 122(1):176-85. [Medline].

  14. Strickland JL, Wall JW. Abnormal uterine bleeding in adolescents. Obstet Gynecol Clin North Am. 2003 Jun. 30(2):321-35. [Medline].

  15. 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].

  16. Dunaif A. Insulin action in the polycystic ovary syndrome. Endocrinol Metab Clin North Am. 1999 Jun. 28(2):341-59. [Medline].

  17. 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].

  18. ACOG Practice Bulletin No. 108: Polycystic ovary syndrome. Obstet Gynecol. 2009 Oct. 114(4):936-49. [Medline].

  19. 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].

  20. Farhi DC, Nosanchuk J, Silverberg SG. Endometrial adenocarcinoma in women under 25 years of age. Obstet Gynecol. 1986 Dec. 68(6):741-5. [Medline].

  21. 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].

  22. Claessens EA, Cowell CA. Acute adolescent menorrhagia. Am J Obstet Gynecol. 1981 Feb 1. 139(3):277-80. [Medline].

  23. Minjarez DA, Bradshaw KD. Abnormal uterine bleeding in adolescents. Obstet Gynecol Clin North Am. 2000 Mar. 27(1):63-78. [Medline].

  24. 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].

  25. Ragni MV, Bontempo FA, Hassett AC. von Willebrand disease and bleeding in women. Haemophilia. 1999 Sep. 5(5):313-7. [Medline].

  26. 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].

  27. 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].

  28. 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].

  29. 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.

  30. 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].

  31. Committee Opinion No.580: von Willebrand disease in women. Obstet Gynecol. 2013 Dec. 122(6):1368-73. [Medline].

  32. 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].

  33. Speroff L, Darney PD. A Clinical Guide for Contraception. Philadelphia: Lippincott Williams & Wilkins; 2005.

  34. 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].

  35. 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].

  36. Hubacher D, Chen PL, Park S. Side effects from the copper IUD: do they decrease over time?. Contraception. 2009 May. 79(5):356-62. [Medline]. [Full Text].

  37. 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].

  38. Committee opinion: no. 562: müllerian agenesis: diagnosis, management, and treatment. Obstet Gynecol. 2013 May. 121(5):1134-7. [Medline].

  39. 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].

  40. Committee opinion no. 605: primary ovarian insufficiency in adolescents and young women. Obstet Gynecol. 2014 Jul. 124(1):193-7. [Medline].

  41. 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].

  42. 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].

  43. U S. Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR Recomm Rep. 2010 Jun 18. 59:1-86. [Medline].

  44. 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].

  45. 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].

  46. 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].

  47. Committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol. 2012 Oct. 120(4):983-8. [Medline].

  48. Lethaby A, Farquhar C, Cooke I. Antifibrinolytics for heavy menstrual bleeding. Cochrane Database Syst Rev. 2000. CD000249. [Medline].

  49. Hatcher R, Trussell J, Nelson A, et al. Contraceptive Technology. New York: Ardent Media; 2007.

  50. 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].

  51. Harel Z. Dysmenorrhea in adolescents and young adults: etiology and management. J Pediatr Adolesc Gynecol. 2006 Dec. 19(6):363-71. [Medline].

  52. 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].

  53. 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].

  54. 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].

  55. 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].

  56. 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].

 
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