Evaluating Menstrual Regularity in Adolescence

Column Author: Emily Paprocki, DO | Pediatric Endocrinologist, Assistant Professor of Pediatrics  

Column Editor: Amita Amonker, MD, FAAP| Pediatrics | Pediatric Hospitalist | Division Billing Liaison, Division of Pediatric Hospital Medicine | Physician Advisor, Care Management and Utilization Review | Assistant Professor of Pediatrics, University of Missouri-Kansas City School of Medicine | Clinical Assistant Professor of Pediatrics, University of Kansas School of Medicine

According to the American College of Obstetricians and Gynecologists,¹ a number of medical conditions can cause abnormal menstrual cycles, characterized by unpredictable timing and a variable amount of flow. Although long intervals between cycles are common in adolescence for the first two years after menarche, it is uncommon for girls and adolescents to remain amenorrheic for more than three months or 90 days (the 95th percentile for cycle length). Girls and adolescents with more than three months between periods or those that remain otherwise irregular two years after menarche (see Table 1), should be evaluated for underlying causes.

Common etiologies of abnormal menstrual cycles include polycystic ovary syndrome (PCOS), obesity/insulin resistance, thyroid dysfunction, eating disorders, hyperprolactinemia (including medication induced), and systemic illness. Rare causes include androgen-producing tumors, adrenal enzyme defects such as congenital adrenal hyperplasia, autoimmune disease affecting pituitary gland or ovaries, and Cushing’s syndrome.²

PCOS is a common cause of abnormal menstrual cycles and affects 6%-15% of women of reproductive age.³ PCOS develops in genetically predisposed females where the severity of clinical expression is compounded by environmental, nutritional and lifestyle factors. PCOS includes ovulatory dysregulation and hormonal imbalance, which favors increased androgen production. PCOS is diagnosed in adolescents with menstrual irregularity (see Table 1) coupled with biochemical (elevated total or free testosterone) or clinical (hirsutism or severe acne) hyperandrogenism.^2,3 Short- and long-term consequences of menstrual dysfunction and hormonal imbalance may include hirsutism and severe acne, depression and anxiety, insulin resistance, weight gain and diabetes, non-alcoholic fatty liver disease, heart disease, endometrial cancer, and infertility.

An evaluation for abnormal menstrual cycles includes:

• Medical history: Look for change in weight, eating, or exercise patterns, medications, pregnancy risk, and symptoms of polyuria/polydipsia, changes in vision, and headaches.
• Family history: Look for irregular menstrual patterns, thyroid conditions, PCOS and diabetes.
• Physical exam: Look for male pattern hair growth (upper lip, chin, chest, lower abdomen and upper back), prominent acne, signs of autoimmune disease (vitiligo), signs of insulin resistance (acanthosis nigricans), and violaceous stretch marks.
• Initial laboratory evaluation: May include pregnancy test, TSH, total and free testosterone, prolactin, LH, FSH, DHEAS, 17-hydroxyprogesterone, and HbA1c.
• Diagnosis: Consider a diagnosis of PCOS if there is menstrual irregularity coupled with biochemical or clinical hyperandrogenism (hirsutism or severe acne).
  • Total testosterone > 40 ng/dL or elevated free testosterone based on lab reference range
  • Hirsutism (modified Ferriman-Gallwey Score 4-6 suggests hirsutism)
  • Menstrual irregularity (Table 1)
• Treatment:
  • If any of the above hormonal labs are out of range, consider a referral to pediatric endocrinology for that specific concern.
  • If evaluation is concerning for PCOS, consider referral to the Multi-Specialty Adolescent PCOS Program (MAPP) clinic within endocrinology clinic prior to starting any treatment.
  • If evaluation is normal except for irregular menstrual cycles, consider treatment with combined oral contraceptive pills, combined hormonal patches, vaginal rings, progestin-only pills, depot medroxyprogesterone acetate, the levonorgestrel-releasing intrauterine device, and the etonogestrel implant. Treatment approach should be individualized based on patient preferences and goals, average treatment effectiveness, and contraindications or risk factors for adverse events. Consider referral to adolescent medicine or pediatric gynecology clinic at Children’s Mercy Kansas City for further assistance with regulating menstrual cycles if desired.

Table 1: Menstrual Regularity

References:

1. ACOG Committee Opinion No. 651: menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Obstet Gynecol. 2015;126:e143-e146.
2. Witchel SF, Oberfield S, Rosenfield RL, et al. The diagnosis of polycystic ovary syndrome during adolescence. Horm Res Paediatr. 2015;83:376-389.
3. Teede HJ, Misso ML, Costello MF, et al. Recommendations from the international evidence-based guideline for the assessment and management of polycystic ovary syndrome. Fertil Steril. 2018;110(3):364-379.