Menstrual Problems: An Update for Pediatricians

Educational Objectives

The goal of this program is to improve the diagnosis and management of menstrual disorders in pediatric patients. After hearing and assimilating this program, the clinician will be better able to:

1. Diagnose secondary amenorrhea.
2. Choose optimal therapy to reduce testosterone levels.
3. Differentiate among various types of female genital mutilation.

Summary

Menstruation: normal menarche occurs between 9 and 15 yr of age; normal cycle length is between 3 and 7 days, but some women have cycles of <3 days; cycle interval should be 21 to 45 days; flow is difficult to quantify, so hemoglobin and hematocrit are used to determine menorrhagia

Puberty: delayed puberty is the absence of breast development in girls by 13 yr of age and absence of testicular growth to ≥4 mL volume of 2.5 cm in boys; precocious puberty is generally <8 yr of age for girls and <9 yr of age for boys; mean age at menarche is generally ≈12.4 yr but varies with ethnicity and race

Common menstrual disorders in adolescents: amenorrhea — is primary or secondary; primary involves no menstrual cycle by the end of the 15th year; patients with no menstruation at the end of the 15th year may have Mayer-Rokitansky-Kuster-Hauser syndrome (missing vagina); the external pelvic examination is important; primary amenorrhea may be because of hypothalamic-pituitary-adrenal axis suppression caused by emotional or physiologic stress, chronic disease, weight fluctuations, hypothalamic-pituitary-ovarian axis immaturity, thyroid or adrenal disease, and androgen-secreting tumors; secondary amenorrhea or oligomenorrhea is <8 periods/yr or no periods for ≥3 mo; the primary diagnosis for this condition is polycystic ovary syndrome (PCOS); ≈10% of girls have PCOS; weight changes, stress, thyroid and adrenal problems, or Addison disease are contributors to secondary amenorrhea

Dysmenorrhea: is also primary and secondary; primary is physiologic and related to prostaglandin release; secondary dysmenorrhea is pathologic and most commonly caused by endometriosis; ≈10% of women of reproductive age have endometriosis; most pelvic inflammatory disease and cervicitis is caused by nongonococcal and nonchlamydial pathogens, thus are difficult to be diagnosed during screening; chronic pelvic pain can also cause secondary dysmenorrhea and is usually because of trauma; obstructive mullerian malformations may also cause secondary dysmenorrhea

Heavy menstrual bleeding: has a very wide differential diagnosis; it is described as one sanitary pad or tampon every hour soaked through for several hours, use of multiple pads at the same time, bleeding for >1 wk, blood clots the size of a quarter or larger, or daily activities limited by bleeding; symptoms include tiredness, fatigue, and shortness of breath, prompting clinicians to investigate iron deficiency anemia; von Willebrand disease is the most common reason for heavy bleeding, particularly at menarche onset; pregnancy is also a concern; other less common causes include vaginal laceration and other injuries; also consider thyroid as a cause for heavy bleeding

Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD): PMS includes physical pain or psychological symptoms before menses and resolve with menses; elevated progesterone, reduced estrogen (luteal phase) and associated decreased or rapidly cycling serotonin levels in the brain cause PMS; if PMS symptoms reaches pathologic levels, suicidal thoughts may emerge; patients remain isolated (from family), unable to focus on studies, demotivated, remain in bed, and exhibit depression symptoms; the condition is known as PMDD; reassure the patients that they are normal; it is because of menstrual cycle issues; alterations in levels of hormones and chemicals may exacerbate an underlying mood disorder; it is similar to major depression but never lasts for 2 wk; management options include estrogen and progestin pills and/or selective serotonin reuptake inhibitors (eg, fluoxetine); the speaker prefers starting one treatment at a time, starting with hormone pills

Menstrual vs gender dysphoria: clinicians should be careful as some patients have distress because of menstrual periods; it is more often because of the gender they are identified with rather than period symptoms; menstrual suppression in these patients may alleviate distress

Polycystic ovary syndrome: diagnosis is complicated and is debated; most clinicians use the Rotterdam criteria in adolescents; the diagnosis is for ≥2 out of 3 possible symptoms; one of these symptoms is hyperandrogenism; evaluate free testosterone levels; the active testosterone causes coarse hair growth and cystic acne; total testosterone may or may not be elevated; hyperandrogenism is a clinical or laboratory diagnosis; irregular menses at >2 yr after menarche may suggest PCOS; polycystic ovary morphology is uncommon in adolescents; it is more common in older teens or young adults

Treatment of PCOS: includes lifestyle modifications, low glycemic index diet, and exercise for 30 to 60 min/day; however, it is difficult to treat PCOS with lifestyle modifications alone; lifestyle changes should focus less on losing weight and more on altering the way the body metabolizes sugar; other options include combined hormonal contraceptives (ethinyl estradiol and progestin), metformin, and anti-androgens (low-dose spironolactone); spironolactone blocks the testosterone receptors but does not lower free testosterone levels; combined hormonal pills suppress free testosterone levels; estrogen increase the production of sex hormone binding globulin in the liver that binds to free testosterone and removes it from the system; drospirenone is another treatment option; it is a progestin-only form for patients unable to take estrogen; drospirenone is a class IV progestin with antiandrogenic properties; drospirenone statistically increases risk for blood clot formation, but the clinical risk is low and the American College of Obstetrics and Gynecology states use of drospirenone is acceptable; drospirenone 4 mg pills suppress free testosterone; laser treatment or hair removal therapy are effective to manage hair growth; clinicians should inform patients about long-term consequences of PCOS (eg, central adiposity, metabolic syndrome, infertility); 2 out of 3 criteria are required out of clinical or biochemical hyperandrogenism, oligomenorrhea, and polycystic ovaries under Rotterdam criteria for diagnosis; speaker rarely considers pelvic ultrasonography unless patients experience pain, which could suggest large cysts or torsion

Testing: the speaker prefers to perform laboratory panels before initiating hormonal therapy so that the therapy does not alter test results; hormonal therapy can be initiated after taking the samples without waiting for the results; assess for estrogen contraindications; the Centers for Disease Control and Prevention-Medical Eligibility Criteria for Contraceptive Use is available on the website and as an app that includes a chart showing the medical eligibility criteria for estrogen and its contraindications; counsel regarding the medical role of hormonal medication before a confidential interview; parents should know about the medications prescribed to their children; identify the patient’s goal before initiating treatment; consider oral medroxyprogesterone (eg, Amen, Curretab, Provera) challenge in patients with absent periods for >3 mo; the challenge includes 10 mg/day administered for 10 days and wait; patients should have a withdrawal bleed in ≤2 wk that empties the uterus and cleans the endometrium; the patients are then prescribed a combined pill; initiating a combined pill in patients with absent periods for >3 mo may result in prolonged and heavy bleeding; initiate a combined pill on day 5 of the period after medroxyprogesterone challenge; progestin only therapy is an option for individuals who do not want periods; estrogen is not a choice in such cases as it builds endometrium; progestin stabilizes the endometrium and keeps it thin

Genitourinary (GU) examination: GU examination is challenging in any individual, but is particularly difficult in adolescents with sexual violence or who had experienced sexual abuse

Female Tanner Staging: most pediatricians are performing male GU examinations; they examine the testes and counsel the patients; male GU examination is relatively easy as the male GU organs are externally placed and are accessible; embarrassment and reluctance to perform female GU examination reinforces the idea in girls that they should be embarrassed; it is important to conduct a proper female GU examination

Vulvar anatomy: the different areas of the vulva are sometimes not clearly demarcated; the reasons for performing GU examination is to determine any abnormalities; Lichen sclerosus is common and underdiagnosed; it accounts for 7% to 15% of diagnoses in prepubertal children; these patients take 1 to 2 yr for diagnosis as they are treated with fluconazole for yeast infection, bacterial vaginosis, or sexually transmitted infections; patients with Lichen sclerosus have pain, irritation, itching, dysuria, vaginal bleeding (because of fissures), and pain with defecation; skin may have a “cigarette paper” appearance and symmetric hyperpigmentation; atrophy occurs if it is not treated; refer the patients to a dermatologist or gynecologist

Female genital mutilation: have various stages; unawareness about the normal female genital anatomy may increase the chances of missing abnormal condition; type I involves removal of the clitoral hood or clitoris (often); type II involves removal of clitoris (removal of labium minora and leaving majora open); type III involves removal of the clitoral hood, clitoris, and all the inner lips; often the outer lips are sewn shut; type III is easiest to recognize; it is often associated with infection; it is illegal in the United States; it is also illegal to take the child out of the United States to other countries (home countries), having surgery, and coming back into the United States; document the GU examination is such cases as it allows law enforcement agencies to conduct further investigation

Trauma informed examination: many patients are reluctant to undergo GU examination; consent from the child is required for GU examination; if the child does not consent, inform them about reason to conduct the examination; engage parents during the GU examination to assure the children; ensure them that it would not hurt and will not take long; prefer using anatomical terms during the examination; resist retraumatizing these individuals; ask for permission and inform its necessity; offer draping to protect modesty; use appropriate language, eg, use “point the knees to the opposite walls” instead of “spread the legs”; continue communicating with the patient during the examination; language and communication are important; maintain normal pacing as rushing may miss something and slowing down may agonize the patient; examine in a position preferred by the patient (lithotomy position, lateral decubitus position); start with the smallest speculum and size up; always use lubrication, not water; offer self-insertion of the speculum

Readings

Chamli A, Souissi A. Lichen sclerosus. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 31, 2023; Hassannezhad K, Asadzadeh F, Iranpour S, et al. The comparison of sexual function in types I and II of female genital mutilation. BMC Womens Health. 2024;24(1):31. Published 2024 Jan 8. doi:10.1186/s12905-023-02860-9; Hofmeister S, Bodden S. Premenstrual Syndrome and Premenstrual Dysphoric Disorder. Am Fam Physician. 2016;94(3):236-240; Kota AS, Ejaz S. Precocious puberty. In: StatPearls. Treasure Island (FL): StatPearls Publishing; July 4, 2023; Nakano R, Hashiba N, Washio M, et al. Diagnostic evaluation of progesterone. Challenge test in amenorrheic patients. ActaObstetGynecol Scand. 1979;58(1):59-64. doi:10.3109/00016347909154916; Panjawatanan P, Riahi S, Chaidarun SS. FRI398 a case of secondary amenorrhea: is it only PCOS to blame?. J Endocr Soc. 2023;7(Suppl 1):bvad114.1591. Published 2023 Oct 5. doi:10.1210/jendso/bvad114.1591; Spritzer PM, Lisboa KO, Mattiello S, et al. Spironolactone as a single agent for long-term therapy of hirsute patients. ClinEndocrinol (Oxf). 2000;52(5):587-594. doi:10.1046/j.1365-2265.2000.00982.x.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Titchen was recorded at the 45th Annual Las Vegas Seminars: Pediatric Update, held December 13-15, 2024, in Las Vegas, NV, and presented by the American Academy of Pediatrics, California Chapter 4. For information on future CME activities from this presenter, please visit https://aap-ca.org/events. Audio Digest thanks Dr. Titchen and the American Academy of Pediatrics, California Chapter 4 for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

Lecture ID:

PD712101

Qualifies for:

ABP MOC

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.