Pediatric Annals

CME 

What’s Normal? Accurately and Efficiently Assessing Menstrual Function

Darcie M. Takemoto, DO; Meera S. Beharry, MD, FAAP

Abstract

Many young women are unsure of what constitutes normal menses. By asking focused questions, pediatric providers can quickly and accurately assess menstrual function and dispel anxiety and myths. In this article, we review signs and symptoms of normal versus pathologic menstrual functioning and provide suggestions to improve menstrual history taking. [Pediatr Ann. 2015;44(9):e213–e217.]


Abstract

Many young women are unsure of what constitutes normal menses. By asking focused questions, pediatric providers can quickly and accurately assess menstrual function and dispel anxiety and myths. In this article, we review signs and symptoms of normal versus pathologic menstrual functioning and provide suggestions to improve menstrual history taking. [Pediatr Ann. 2015;44(9):e213–e217.]


Menarche is a sentinel event in a young woman’s life. Some young women see this as a positive event, whereas many others view it negatively.1,2 In her book Women’s Bodies, Women’s Wisdom, Dr. Christiane Northrup1 invites the reader to envision a culture in which menarche is viewed positively and celebrated; one in which subsequent menstrual cycles are a chance to become in tune with one’s creative energies, along with time for reflection and rest.3

The biologic and social significance of menses can only be ascertained through a detailed history. For many young women, their sources of information about reproductive health care are not reliable. Others may believe that pathologic symptoms are “normal” because other women in their family have them. Providers can help demystify menses and prevent future health problems through accurate assessment of menstrual function.4

Elements of History

The American Academy of Pediatrics has recommended using menstruation as an additional vital sign.4 The following elements of history help establish if patterns are normal or not: age at menarche; frequency of menses; duration of menses; quality of flow; and any associated symptoms. Asking about “the first day of the last menstrual period” is important not only for assessment of menstrual problems, but also for helping a young woman get in the habit of answering this question throughout her reproductive life. Other helpful questions are discussed below and are listed in Table 1.

Menstrual History Questions

Table 1.

Menstrual History Questions

Age

Menarche signals the end of puberty and the beginning of reproductive ability. It occurs between Sexual Maturity Rating 4 and 5 for both development of breasts and pubic hair and after the growth spurt (Figure 1).5 Menstrual bleeding that occurs without expected accompanying pubertal changes should prompt further evaluation for endocrine abnormalities, infection, trauma, or abuse.

Timing of puberty. Reprinted with permission from Emans and Laufer.5

Figure 1.

Timing of puberty. Reprinted with permission from Emans and Laufer.5

According to data from the third National Health and Nutrition Examination Survey (NHANES III), the age at which 50% of girls achieve menarche in the US is 12.06 years for non-Hispanic black girls, 12.25 for Mexican American girls, and 12.55 for non-Hispanic white girls.6 The age of menarche was 16 about 100 years ago. These changes are independent of changes in weight of the population.7 In developing countries, the average age of menarche is higher than that in the US.4 In addition, an increase in lifespan and a decrease in childbearing have resulted in women having more menstrual periods than before.

Girls who start menses before age 10 years or have menses that begin in less than 2 years after thelarche, or without evidence of other secondary sex characteristics, should be evaluated for precocious puberty/early menarche. Girls who have not begun menses more than 3 years after thelarche or by age 15 years should also be evaluated for anatomic, endocrine, or other metabolic causes of delayed menarche. This assessment can begin at the primary care physician’s office or by referral to adolescent medicine, gynecology, or endocrinology.4

Frequency

Menses that occur every 21 to 45 days are normal in the first year after menarche.4 As a young woman advances in gynecologic age, menses shorten to a length of 27 to 38 days by the 7th year after menarche.4 Bleeding outside of these ranges is likely due to anovulatory cycles, but may also be caused by thyroid dysfunction, poor control of chronic medical conditions, obesity, or disordered eating behavior.

In 2011, the International Federation of Gynecology and Obstetrics updated the classification of menstrual disorders for ease of communication and understanding.8 Terms such as polymenorrhea, oligomenorrhea, menorrhagia, menometrorrhagia, and dysfunctional uterine bleeding are now obsolete.8

All irregular bleeding is now referred to as abnormal uterine bleeding (AUB). The bleeding is further described as acute, chronic, or intermenstrual, and then subclassified according to etiology. The causes of AUB that are likely to affect adolescent girls are coagulopathy (C), ovulatory dysfunction (O), iatrogenic (I), or not yet classified (N). Adding the first letter of the term (eg, AUB-O for ovulatory dysfunction) completes the classification. The acronym COIN is used to group these causes together. “HMB” is the abbreviation used to refer to heavy menstrual bleeding.8

Many young women think that having a period once a month means that menses should start on the same day every month. When providing anticipatory guidance about menses and puberty, pediatric providers should explain the limits of normal. It may be helpful to provide menstrual calendars, like those available from the Center for Young Women’s Health,9 to help track symptoms and frequency of menses (Figure 2). There are also many apps available for smartphones and tablets to help track frequency of menses and associated symptoms. If a young woman chooses to use an app to track her periods, it is important to remind her that information about fertile time periods is not likely to be accurate given the variability in ovulation for women of young gynecologic age; therefore, the app should not be used as the only form of pregnancy prevention. Because many of the apps are based on a standard 28-day cycle, their menstruation predictions may be inaccurate, but they can still be useful for learning about the timing of menses.

Menstrual calendars. Reprinted with permission from the Center for Young Women’s Health.9

Figure 2.

Menstrual calendars. Reprinted with permission from the Center for Young Women’s Health.9

Duration

Normal menstrual flow lasts 3 to 7 days.4 Menses that last more than 10 days are diagnostic for HMB/AUB. Evaluation for etiology should begin. Details of how to proceed with evaluation and referral are provided in the article “Evaluation and Management of Adolescents with Abnormal Uterine Bleeding” in this issue.

Flow that lasts fewer than 3 days may be a sign of trauma, infection, pregnancy, or anovulatory cycles. Anovulatory cycles may occur for about half of the cycles in the first gynecologic year.4 Evaluation for pregnancy is warranted in any case of abnormal bleeding. Too little bleeding may indicate pregnancy or implantation bleeding, and heavy or prolonged flow may indicate miscarriage.

Quality

Normal menstrual flow is 30 to 80 mL per cycle. Unless a young woman is using a menstrual cup, it is difficult to quantify menstrual bleeding in terms of milliliters. A more useful guide is 10 to 15 menstrual pads per cycle or 3 to 6 pads or tampons per day. Blood flow above these parameters is considered HMB and should be evaluated further.

When asking about use of menstrual products, it is important to specify the amount of blood covering the menstrual pad or tampon. Some young women will report high frequencies of pad change, but when asked how soaked the pads are it is clear that they are minimally soiled. The authors have found it useful to ask “Are the pads soaked front to back and side to side?” We sometimes draw a pad or tampon on the exam table paper and ask the young woman to color in the amount of blood that is usually on a pad or tampon. This decreases ambiguity about amount of blood loss.

Additional symptoms suggestive of HMB are menstrual accidents or bleeding onto clothing, use of multiple menstrual products to prevent menstrual accidents, passage of blood clots that are larger than the size of a quarter, and/or school avoidance during menses.

Heavy menstrual flow should prompt evaluation for bleeding disorders. Evaluation should begin with a history of other signs and symptoms of bleeding diathesis, especially von Willebrand deficiency in the patient and other family members. Other relevant historical elements include a family history of HMB, thyroid dysfunction, endometriosis, fibroids, and gynecologic (breast, uterine, ovarian, and cervical) cancers.

Associated Symptoms

Dysmenorrhea has been reported in up to 90% of adolescent women and is the most common presenting gynecologic complaint.10 Symptoms such as severe menstrual cramping, nausea, vomiting, diarrhea, headaches, backaches, muscle aches, flushing, insomnia, depression, and anxiety are common and often described as premenstrual syndrome (PMS).5,10 The symptoms generally begin with the onset of menses or 1 to 2 days preceding menses. Premenstrual dysphoric disorder (PMDD) is the clinical term used to describe significant mood symptoms of anxiety and/or depression that accompany menses or begin a few days before menses.

Some young women with epilepsy or migraines may experience exacerbation or resolution of their symptoms with menses. Some young women with developmental delay may experience worsening of behaviors during that time, which may be a manifestation of PMS or PMDD.

Many families view these as an inevitable part of menstrual life and are reluctant to use medications, especially hormonal contraception, to treat dysmenorrhea. The authors have found that reminding parents and patients that their male counterparts are not experiencing these symptoms helps to motivate them to control symptoms. If menses are regular, well timed, and consistent, then use of nonsteroidal anti-inflammatory drugs can eliminate cramping and other pain symptoms. For PMDD, use of selective serotonin reuptake inhibitors continuously or during the luteal phase from the time of ovulation until 1 to 2 days after the onset of menses can relieve symptoms. For either condition, use of hormonal contraception, particularly combined estrogen-progesterone products, can eliminate symptoms.11 Details of menstrual suppression are delineated in the article “Monthly Periods—Are They Necessary?” in this issue.

Anticipatory Guidance

Many young women may not understand that menarche signals the beginning of their reproductive life and that they can get pregnant if they engage in sexual activity. Prepubertal, pubertal, and postmenarchal visits are excellent opportunities to discuss this with patients and families. It can also be an opportunity to dispel myths and rumors about how reproductive organs function and how menstrual hygiene products work. Discussion of proper hand hygiene when using and disposing of menstrual hygiene products should be included at this time. Use of douches and other cleansing or deodorizing products should be discouraged. A discussion of the signs and symptoms of physiologic versus pathologic discharge may also be helpful.

Summary

In the United States, normal menstrual cycles begin at age 12.5 years, and have an average length of 32 days in the first year and shorten thereafter. Normal menstrual flow lasts less than 7 days and requires use of no more than 6 pads a day to prevent menstrual accidents.

Menarche marks an opportunity to educate and empower young women about their reproductive health as well as general health. Through taking a menstrual and gynecologic history, providers can identify issues that may require referral for management.

References

  1. Sommer M, Sutherland C, Chandra-Mouli V. Putting menarche and girls into the global population health agenda. Reprod Health. 2015;12(1):24. doi:10.1186/s12978-015-0009-8 [CrossRef]
  2. Sommer M, Sahin M. Overcoming the taboo: advancing the global agenda for menstrual hygiene management for schoolgirls. Am J Public Health. 2013;103(9):1556–1559. doi:10.2105/AJPH.2013.301374 [CrossRef]
  3. Nothrup C. Women’s Bodies, Women’s Wisdom: Creating Physical and Emotional Health and Healing. New York, NY: Bantam; 2010:99–163.
  4. Diaz A, Laufer MR, Breech LLAmerican Academy of Pediatrics Committee on AdolescenceAmerican College of Obstetricians and Gynecologists Committee on Adolescent Health Care. Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Pediatrics. 2006;118(5):2245–2250. doi:10.1542/peds.2006-2481 [CrossRef]
  5. Emans SJ, Laufer MR. Emans, Laufer, Goldstein’s Pediatric & Adolescent Gynecology. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
  6. Chumlea WE, Schubert CM, Roche AF, et al. Age at menarche and racial comparisons in US girls. Pediatrics. 2003;111:110–113. doi:10.1542/peds.111.1.110 [CrossRef]
  7. Anderson SE, Dallal GE, Must A. Relative weight and race influence average age at menarche: results from two nationally representative surveys of US girls studied 25 years apart. Pediatrics. 2003;111(4 Pt 1):844–850. doi:10.1542/peds.111.4.844 [CrossRef]
  8. Munro MG, Critchley HO, Broder MS, et al. FIGO Working Group on Menstrual Disorders. FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age. Int J Gynaecol Obstet. 2011;113:3–13. doi:10.1016/j.ijgo.2010.11.011 [CrossRef]
  9. Center for Young Women’s Health, Boston Children’s Hospital. Menstrual periods. http://youngwomenshealth.org/2010/04/21/menstrual-periods/. Accessed August 11, 2015.
  10. Harel Z. Dysmenorrhea in adolescents. Ann N Y Acad Sci. 2008;1135:185–195. doi:10.1196/annals.1429.007 [CrossRef]
  11. Rapkin A, Mikacich J. Premenstrual dysphoric disorder and severe premenstrual syndrome in adolescents: diagnosis and pharmacological treatment. Pediatr Drugs. 2013;15:191–202. doi:10.1007/s40272-013-0018-4 [CrossRef]

Menstrual History Questions

Questions for All Girls Follow-Up Questions/Comments
When was the first day of your last menstrual period?
How old were you when you had your first period?
How often do you get your period? If stuck, ask “do periods come once a month everymonth?” If “irregular,” clarify. If “sometimes twice a month,” clarify intermenstrual interval.
When you have your period, how long does it last? See text regarding assessment of exceptionally long or short intervals.
Do you get cramps? If yes, when do they start? or When do you get them (before period, first couple of days, throughout period)? Do you take anything to help with the pain? (Options can include herbal supplements, overdose or underdose of over-the-counter analgesics, or other substances.)
Any other changes around the time of your period? Probe for symptoms of dysmenorrhea and mood changes. If yes, do you take or do anything to control these symptoms?
How many pads or tampons do you use on a typical day? How many pads or tampons do you use on a heavy day? or How often do you change your tampons or pads? Are they completely soaked (side to side and front to back) when you change them? Do you have menstrual accidents (bleeding on to your clothing)? If yes, how often do they occur? Do you pass blood clots? If so, how large are they? (Coin sizes help make them understandable. Anything larger than a quarter is concerning.) Consider asking/assessing for signs and symptoms of bleeding disorder if patient’s responses indicate heavy menstrual bleeding.
Do you ever miss school/work because of your period? If yes, probe for associated symptoms.
Do you have vaginal discharge? If yes, probe for a description. Many young women think that physiologic discharge is pathologic. This creates an opportunity to provide anticipatory guidance about the signs and symptoms of abnormal discharge.
Authors

Darcie M. Takemoto, DO, is a Pediatric Resident, Texas A & M Health Science Center, Department of Pediatrics, McLane Children’s Scott & White. Meera S. Beharry, MD, FAAP, is an Assistant Professor of Pediatrics, Texas A & M Health Science Center, Adolescent Medicine Section Chief, Department of Pediatrics, McLane Children’s Scott & White.

Address correspondence to Meera S. Beharry, MD, FAAP, MS-CK-100, McLane Children’s Specialty Clinic, 2401 S. 31st Street, Temple, TX 76502; email: mbeharry@sw.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00904481-20150910-08

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