Vaginal Discharge and Other Changes
Another concern that will prompt an office visit or an urgent phone call is the appearance of vaginal discharge in the girl approaching puberty. As the levels of circulating estrogens begin to rise, the vaginal tissues respond by secreting a thick whitish tinged discharge. In some girls, this can be quite copious and confused with an infectious process. Reassurance that this is the result of the pubertal process is essential so as to avoid the use of unnecessary over-the-counter medications. It is important to mention that cyclic vaginal discharge is a normal part of the future menstrual cycle and will likely recur on a somewhat regular basis.
Variation in the normal process of puberty may also be evident in the appearance of the external genitalia. As the labial tissues become estrogenized and undergo physiologic hypertrophy, they often become asymmetric, and prominence of the labia minora can occur. Although this is not a functional issue, it can be of cosmetic and comfort concern for the adolescent. The clinician should reassure the patient that the progression of puberty may bring further anatomic changes, but any desire for surgical intervention on the part of the patient should be discouraged until well after the completion of puberty.
The age of menarche can vary greatly, with most girls achieving this milestone between ages 9 and 15 years, with average age being 12.5.4 Although the interval between the start of puberty and the first menstrual flow is typically about 2.5 years, there can be some variation. When menarche seems delayed, the parent and patient should be asked specifically as to the timing of breast development and the appearance of pubic hair, especially if there has not be a recent examination in which Tanner staging was documented. Primary amenorrhea, the absence of menses by age 15 years in the presence of normal growth and secondary sexual characteristics or the absence of secondary sexual characteristics by age 13 years, demands a thorough history and physical, with close attention to linear growth, Tanner staging, and any constitutional symptoms.
Once menarche occurs, menses can be quite irregular for a lengthy period of time or may be regular and predictable within a few short months. Tracking of menses is important so that one can identify the onset of ovulatory periods and possible fertility. Adolescents should be encouraged to take ownership of this process rather than allow a parent or guardian to do so. Several “apps” exist for mobile devices that make this task quite simple and allow quick recall of the information when required. Many of these applications have icons that are discrete when viewed on the device so as to prevent embarrassment and to encourage their use. Ovulatory menses are usually somewhat more painful and heavier in flow than their anovulatory predecessors, as well as more regular in occurrence. They may also tend to be associated with other symptoms that may have been absent at menarche such as headache, bloating, and premenstrual emotional lability.
Menses that fail to become regular within 2 to 3 years of menarche or are widely spaced (more than 3 to 4 months) can represent oligomenorrhea or secondary amenorrhea. Both of these entities require further evaluation, which can be initiated by the pediatrician in the office setting.
Secondary amenorrhea is commonly defined as the absence of menses for 3 or more months 2 years after menarche. A detailed history, including the documentation of menarche, cycle length, presence of dysmenorrhea, characteristics, duration of menstrual flow, and weight changes, should be all completed. Activities of daily living such as sleep, diet, and exercise should be noted, as well as any current stressors or medication use. Physical examination should focus on body mass index, size of the thyroid gland, presence of acanthosis nigracans, and signs of hyperandrogenism such as acne and hirsuitism. Oligomenorrhea or the presence of menstrual cycles lasting more than 35 days can also be caused by conditions that are responsible for secondary amenorrhea. Laboratory evaluation, which should be performed as a morning blood draw (Table 1) as well imaging, can aid in diagnosis after the history and physical examinations are completed as outlined above.
Laboratory Studies for Diagnosis of Polycystic Ovary Syndrome
Polycystic ovary syndrome. Although there are many causes of menstrual irregularities, the most common entities in most pediatric practices are likely to be polycystic ovary syndrome (PCOS), a variation of the female athlete triad, and hypomenorrhea or oligomenorrhea secondary to hormonal forms of contraception. Acne, hirsuitism, and laboratory results that demonstrate excess androgens are consistent with the diagnosis of PCOS. A multisystem disease, PCOS can result in decreased fertility, impaired glucose metabolism, obesity, and cardiovascular disease. Once identified, treatment modalities include a combination of oral contraceptives pills (OCPs) and the use of medications that help correct abnormal glucose tolerance if warranted. Lifestyle changes that promote weight loss are an essential component of treatment in girls who are overweight. OCPs correct the menstrual abnormalities and stop the progression of hirsuitism as well as improving acne. Hirsuitism that remains cosmetically unacceptable may respond to antiandrogenic medications such as spironolactone or require permanent removal. Endocrinologic consultation may be necessary for patients that do not meet diagnostic criteria for PCOS (Table 2), have signs of insulin resistance, or who are unresponsive to initial therapy.
Rotterdam Criteria for Diagnosis of Polycystic Ovary Syndrome
Female athlete triad. The female athlete triad is commonly described as disordered eating, menstrual irregularities, and low bone mass. The menstrual disruption in this triad is usually secondary amenorrhea or oligomenorrhea; however, some girls will present with primary amenorrhea after age 16 years. Although frequently associated with runners, this syndrome can occur across many different types of athletes and across many ethnic and socioecomonic groups.5 A detailed history with careful questioning about eating habits, exercise, and sports participation performed in a sensitive and confidential setting may reveal etiology of the menstrual abnormality. Although OCPs will help correct the bone mass and menstrual component, nutritional and psychological counseling are needed to improve the overall health and well-being of the athlete. Many patients may show two of the symptoms described in the triad but are at risk for developing the complete entity if not treated and counseled appropriately. Compliance with the prescribed regimen must be closely monitored to insure complete and long-term nutritional restoration and to maximize bone density.
Oligomenorrhea. Although regulation of menses is considered by most girls to be a positive side effect of hormonal contraception, patients often do not recall being told that menses may be different while using these methods, despite the best efforts of their health care provider to explain this and other possible side effects. Light or absent menses as well as breakthrough bleeding may prompt an urgent visit as the girl may be convinced something “is wrong” or that she may be pregnant. A pregnancy test for sexually active teens done in the office may be reassuring as many adolescents are not confident in their ability to properly perform the at-home version. Once a negative result has been documented, the patient can be reassured that oligomenorrhea is a common and often desired effect and is not harmful in any way. Careful questioning about compliance and daily timing of the taking the pills may reveal the cause of breakthrough bleeding, as pills should be taken as close to the same time every day as possible. Other forms of hormonal birth control such as injectables and intrauterine devices can also cause disruption of menses so providers should take care to explain this to all adolescents using or planning to use such methods.
Dysmenorrhea. Dysmenorrhea during adolescence may be either physiologic or represent underlying pathology. The teenage patient that seeks relief of painful menses should be screened for endometriosis, a condition once thought to be uncommon in younger women. Endometriosis is the presence of ectopic endometrial tissue, most frequently located in the pelvis or abdomen.6 This functional tissue can cause chronic abdominal pain (noncyclic) as well as marked dysmenorrhea (cyclic), pelvic pain, and bowel or bladder symptoms. Left untreated, endometriosis can have a significant impact on fertility. Although the dysmenorrhea from this condition and physiologic menstrual pain can both be treated with OCPs, the establishment of a firm diagnosis is essential to prevent long-term sequelae. Any patient that does not respond to OCP therapy, has a family history of the disease, or has other noncyclic complaints should be referred to a gynecologist skilled in the care of adolescents. Girls that appear to have primary dysmenorrhea should respond well to OCPs or nonsteroidal anti-inflammatory drugs (NSAIDs) alone or in combination. The dosing and timing of NSAIDs should be thoroughly explained to the patient as medication started after the escalation of pain or in too low of a dosage will not offer maximum relief. OCPs will not only moderate the discomfort but will also likely provide more predictable, lighter, and shorter menses as well as protection against unwanted pregnancy. Adolescents should always be reminded that a condom is necessary each and every time they have intercourse, regardless of who the partner is and what other type of birth control is used.