If menstrual cycles are affecting a young woman’s ability to study or work, it’s time to get help for those period problems.
Generally speaking, it’s easy to dismiss adolescent girls’ period complaints as “growing pains” or an inevitable part of the pubertal transition. It is almost expected that menstrual periods during this time of great change should be irregular, painful and/or heavy. Of course, there is great variability from girl to girl with a wide range of what is considered medically normal. So how is a parent to know when period complaints are truly problematic enough to warrant seeking medical treatment? A few levels of period problems exist that both teenage girls and parents should note.
The average age of the first period for girls in the United States is somewhere between 12 and 13, but there is a wide range of normal. Generally speaking, breast development before age 8, lack of breast development by 13 or no menstrual period by 16 could be abnormal and should be brought to the attention of a child’s medical provider. Seeking care for early breast development, delay in breast development or late first menstrual period is important. Catching these rare conditions early prevents any other concerns from sprouting.
Establishing regular, monthly periods requires proper hormonal signaling from the brain to the ovaries and then the uterus. It is a complicated process that sometimes takes a little time to regulate, so it is not unusual for periods to be irregular for the first one to two years after the first period. However, even in the first couple of years, it is not normal to have periods three months or more apart. This could signal that the infrequent menstrual cycle pattern may persist long term and create more period problems. Frequent menstrual periods, periods less than three weeks apart, can also be problematic, especially if the bleeding is heavy.
Many teenagers have heavy periods, so where should the line be drawn? A normal cycle includes seven total days of bleeding and up to 80 milliliters of total blood loss. We use other measures as warning signs for heavy bleeding. Bleeding that soaks through a regular or larger size pad or tampon in an hour for two hours in a row is evidence of further period problems. Passing blood clots the size of a quarter or larger can indicate rapid bleeding that accumulates in the uterus before it passes all at once. Menstrual bleeding that leads to anemia, iron deficiency, hospitalization or transfusion should prompt a more in-depth evaluation.
A bleeding disorder is a condition of the blood that causes delayed or inadequate blood clot formation, resulting in prolonged bleeding. While bleeding disorders are not common in the general population, they can be more common among adolescent women with particularly heavy menstrual bleeding. Prolonged menstrual bleeding more than seven days, passage of blood clots and rapid pad changes prove reason enough to test for a bleeding disorder. However, other bleeding symptoms such as nosebleeds, gum bleeding and easy bruising or a family history of bleeding disorders should increase suspicion.
Von Willebrand’s disease, a disease that affects the initiation of a blood clot and how platelets stick together, is the most common bleeding disorder. Young women with heavy menses may have other disorders such as platelet dysfunction and low levels of clotting factors. Not every teenager with heavy or prolonged bleeding will warrant testing for a bleeding disorder or other period problems. However, it is important to identify the ones who need testing and the ones who have a true bleeding disorder. Early diagnosis can improve the treatment of heavy periods but also prepare these young women for future situations that will require preventive treatment such as surgery and pregnancy.
Menstrual periods during adolescence can be painful with cramps that start a few days before the cycle and continue through the early part of the cycle. Typically, menstrual cramps respond well to heating pads and exercise, as well as over-the-counter, non-steroidal anti-inflammatory such as ibuprofen. Pain is considered abnormally severe if the painful period is associated with episodes of vomiting or is completely unimproved with a non-steroidal anti-inflammatory. If menstrual pain persists between menstrual cycles and causes more period problems, it could be an indicator of other more rare, benign conditions of the abdominal or pelvic organs such as an ovarian cyst or endometriosis. If someone is missing school frequently due to period pain, it is probably a good time for an evaluation.
When to seek help
While it is not unusual for young women to have one or more problems related to their periods, it is important to identify when a medical evaluation can help. If a young woman has irregular, heavy or painful periods that meet the criteria for evaluation, she can undergo evaluation and treatment with a pediatric-adolescent gynecologist or adolescent medicine specialist. If bleeding is heavy or prolonged, with or without other bleeding symptoms or family history, she can be referred to the Women’s Bleeding Disorder Clinic.
Knowing specifically when period problems become truly problematic can help patients and parents decide when to seek care. However, anytime menstrual cycles affect a young woman’s ability to study, work or participate, it is time to make an appointment to talk.
This post was written by Celeste Ojeda Hemingway, MD, MHPE, and Allison Wheeler, MD, MSCI. Dr. Hemingway was raised in San Antonio, Texas, before coming to Vanderbilt to complete her undergraduate degree in Chemistry and Molecular Biology. She completed her medical training and residency in Obstetrics and Gynecology at Vanderbilt and serves as the residency program director. Dr. Hemingway is an Assistant Professor of Obstetrics and Gynecology with a Focused Practice Designation in Pediatric and Adolescent Gynecology. Dr. Wheeler was raised in Lexington, Massachusetts, before coming to Vanderbilt to complete her Pediatric Hematology/Oncology and Transfusion Medicine fellowships at Vanderbilt Medical Center. She completed her medical training at the University of Massachusetts and residency in Pediatrics at Baystate Hospital in Springfield, Massachusetts. She is now an Assistant Professor of Pediatrics and Pathology with a special interest in coagulation abnormalities and bleeding disorders, including women with bleeding disorders.
If you need help
The Vanderbilt’s Women’s Bleeding Disorder Clinic, a specialty clinic recognized by the Foundation for Women and Girls with Bleeding Disorders, is a collaborative practice for young women with bleeding disorders and menstrual problems. The clinic provides comprehensive diagnostic and treatment services for women affected by these conditions. We collaborate with the patient and her family to address menstrual concerns and provide a comprehensive plan to treat any non-menstrual bleeding. Click here to learn more.
Vanderbilt’s Pediatric and Adolescent Gynecology Practice offers evidence-based gynecologic care for children and teenagers up to age 19. Young patients are evaluated and treated by full-scope, board-certified obstetrician-gynecologists who have special interest and expertise in pediatric and adolescent patients. Our youngest pediatric patients receive family-centered care in a positive atmosphere. Click here to learn more.