Adolescence is a time of many changes. As girls grow into young women and become physically and sexually mature, they need additional care from health care providers. What is the typical age and progression of puberty, how do cycles regulate over time, are monthly menstrual periods are a sign of health?
Listen as Diane Merritt, MD discusses the importance of clinicians having an understanding of bleeding patterns in girls and adolescents, the ability to differentiate between normal and abnormal menstruation, and the skill to know how to evaluate young
patients' conditions appropriately.
Selected Podcast
Problematic Menstrual Periods in Adolescence
Featured Speaker:
Learn more about Diane Merritt, MD
Diane Merritt, MD
Diane Merritt, MD focuses her practice on pediatric and adolescent gynecology. She specializes in congenital anomalies of the reproductive organs, ovarian tumors in children and adolescents, contraceptive counseling, HPV in teens, genital injuries/repair, endometriosis and polycystic ovarian syndrome in adolescents. Dr. Merritt is consistently recognized in "The Best Doctors in America" list.Learn more about Diane Merritt, MD
Transcription:
Problematic Menstrual Periods in Adolescence
Melanie Cole (Host): Young patients and their parents are often unsure about what represents normal menstrual patterns. Clinicians may also be unsure about normal ranges for menstrual cycle length, amount, and duration of flow through adolescence. It's important to be able to educate young patients and their parents regarding what to expect of a first period and about the range for normal cycle length for subsequent menses. My guest today is Dr. Diane Merritt. She's a Washington University pediatric and adolescent gynecologist at St. Louis Children's Hospital. Welcome to the show, Dr. Merritt. What is a normal menstrual period? When should it start? What's the typical age for the progression of puberty?
Dr. Diane Merritt (Guest): Well, I'm so glad you asked that question. Normally, girls will start around age twelve but there is a range. Some girls may begin earlier or somewhat later depending either on their family genetics or their activity. A cycle length is usually once every month but in those first years it can be a bit shorter or longer, 21 days to 45 days. We would really like the flow to be less than seven days.
Melanie: Should young women start keeping track of their periods at that first sign?
Dr. Merritt: Well, that's a really good idea and, hopefully, before a girl ever begins her period she and her parents, usually the mother, have had an opportunity to discuss what to expect and to have a little chat about various hygiene products and keeping track is really a good idea. They can keep track just on a regular calendar but there are any number of smartphone applications that can be downloaded. This is where the girls are often more comfortable keeping track than their mothers and they can record each menstrual cycle. But, you have to remember that in that first year or two cycles are not regular, and its actually normal to have a long time span between each cycle and they may not come every month, so that's normal.
Melanie: What do they do if they notice that their flow is heavy or it lasts a little longer than maybe they've discussed or it comes too often or it's very, very light in terms of just a few little spots, do they count that as a period?
Dr. Merritt: Great question. It's really important that the range of normal be recorded and, hopefully, the girl is not going to be too reluctant to discuss this bleeding pattern with her parent and get some reassurance or with the pediatrician or primary care provider who is familiar with the normal pattern of early menstrual cycles. There are any number of concerns if the period becomes too delayed, too early, too long, and I'm happy to talk about that with you today.
Melanie: Then, let's discuss that and what should they generally use as a rule to follow?
Dr. Merritt: I have a simple rule which is one-ten-twenty. One, if a girl is bleeding more than a pad or tampon in an hour. Ten, certainly if the flow is longer than seven to ten days and twenty is if the cycles are occurring and we count from the first day of flow until the next first day of flow, if that interval is less than twenty days. If a girl is bleeding too heavy, too long or too close together that's a sign of a problem and she can become anemic.
Melanie: Young girls often complain about cramps and such. Are we allowed to, as parents, and should we discuss with our pediatrician or our adolescent gynecologist about whether they have pain or they're uncomfortable as this begins?
Dr. Merritt: The initial menstrual cycles usually are an-ovulatory, and it often will take a few years for the girls to develop an ovulatory pattern and it's then that they start to experience cramping. So, those first periods may be quite light, quite short, relatively painless but some girls actually start out completely regular and if they're ovulating, they may have what we call “menstrual cramping” and there is absolutely every reason to manage that so that the girls can continue on attending school and participating in their activities. I really hate to think that a girl's menstrual period would keep her home from school.
Melanie: If you remember, back in the day girls couldn't do swimming in gym because they had their period but nowadays with tampons and such, but young girls don't always look to those as a source for absorbing flow. So, what do we tell our young girls about the products that are out there?
Dr. Merritt: I think this is a great discussion for moms to have with their daughters about the different options of hygiene products. I certainly find a great number of young competitive athletes who are able to choose to place tampons so that they can compete in their swim meets or track meets or other competitions using a tampon, and then they will frequently resort back to pads between events. I certainly also encourage young girls who choose to use tampons to please use the pad at night and not leave a foreign body in the vagina at bedtime.
Melanie: When do we take our young girls to see an adolescent gynecologist for the first time? Or, do we rely on our pediatrician for that care until they're having these regular periods or until their eighteen?
Dr. Merritt: I think many pediatricians are very comparable and it's part of pediatric training now to understand development and the role of the menstrual cycle being part of normal development. Certainly, the American Academy of Pediatrics and the American College of Ob/Gyn has encouraged primary care providers to think of menstrual cycles as a vital sign just as we look at blood pressure and pulse rates or a respiratory rate as a sign of what's normal and anything outside of the normal range may be attributable to a significant underlying health concern. Most pediatricians are really good at recognizing what's a normal period, a normal interval, and a normal amount of flow but sometimes I have patients who have been reassured that their irregular cycles or their heavy flow is just something they'll have to live with. At that point they're either referred to me, or mother will find out from her neighbor that there's a pediatric gynecologist in town who can help their daughter.
Melanie: What about those exams? Do young girls get a Pap smear?
Dr. Merritt: I'm so glad you asked that because I think that's one of the biggest concerns moms and daughters have about coming to a gynecologist. When you are a young girl, you absolutely don't need a Pap smear. In fact, we don't do internal exams on these young girls. We would never even put a speculum out on the table. Speculum exams and Pap smears begin at age 21. So, usually on the first visit, I may just talk to the girl and her mother or parent, whoever comes with her, about what to expect from their period and if they fall out of the normal range, for instance, if they're bleeding too long or too heavy, or there's a big interval of time between the cycles, or there are other markers like significant problems with hirsutism, which is excess body hair or acne, or if there are signs of a weight problem, perhaps an eating disorder, we really can intervene and make helpful suggestions just in initial talking. When it comes to the exam, I think it's a great and golden opportunity to teach young girls about their body so that they become comfortable with the vagina and how to care for it. Most moms are very excited to see their daughters understanding and learning how to take care of themselves. The lessons that we teach in our clinic about normal anatomy are very helpful and if a girl really is not wanting to undress, I have a diagram and we can just go over the diagram and explain everything and people can keep their clothes on.
Melanie: To wrap up, Dr. Merritt, what would you like other pediatricians to know about starting this process with their young patients and their parents and discussing maybe an abnormal menstrual period or amenorrhea or any of these things they might see in starting that discussion with their patients?
Dr. Merritt: Great question. I think menarche or the onset of periods is a really important milestone in physical development and there are a few things that the pediatrician really needs to look out for. Mainly, it's the girl who doesn't start her period but is showing every other sign of normal pubertal development, breast development and such. If three years go by after the breast tissue develops and they haven't started their period yet, it's time to touch base with us. Certainly, if a fifteen year old hasn't had her period, then it's really time to come in because I think in her heart, she's concerned. “Why am I'm not starting?” Signs of heavy flow, easy bruising, and a family history of bleeding need to be evaluated. So, on one hand, it's the girl that doesn't start and on the other hand it's the young girl who's bleeding too heavily.
Melanie: Tell us about your team. Why is St. Louis Children's Hospital so great to work with?
Dr. Merritt: Children's Hospital is really focused on the patient and there are any number of resources there starting with the guards that greet you as you walk in the front door, the people who work in the lab, the house officers and doctors who work there are truly dedicated to helping children be healthy and have a better life.
Melanie: Thank you so much for being with us today. It’s great information. A physician can refer a patient by calling children's direct physician access line at 1-800-678-HELP. 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital, you can go to www.stlouischildrens.org. That's www.stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.
Problematic Menstrual Periods in Adolescence
Melanie Cole (Host): Young patients and their parents are often unsure about what represents normal menstrual patterns. Clinicians may also be unsure about normal ranges for menstrual cycle length, amount, and duration of flow through adolescence. It's important to be able to educate young patients and their parents regarding what to expect of a first period and about the range for normal cycle length for subsequent menses. My guest today is Dr. Diane Merritt. She's a Washington University pediatric and adolescent gynecologist at St. Louis Children's Hospital. Welcome to the show, Dr. Merritt. What is a normal menstrual period? When should it start? What's the typical age for the progression of puberty?
Dr. Diane Merritt (Guest): Well, I'm so glad you asked that question. Normally, girls will start around age twelve but there is a range. Some girls may begin earlier or somewhat later depending either on their family genetics or their activity. A cycle length is usually once every month but in those first years it can be a bit shorter or longer, 21 days to 45 days. We would really like the flow to be less than seven days.
Melanie: Should young women start keeping track of their periods at that first sign?
Dr. Merritt: Well, that's a really good idea and, hopefully, before a girl ever begins her period she and her parents, usually the mother, have had an opportunity to discuss what to expect and to have a little chat about various hygiene products and keeping track is really a good idea. They can keep track just on a regular calendar but there are any number of smartphone applications that can be downloaded. This is where the girls are often more comfortable keeping track than their mothers and they can record each menstrual cycle. But, you have to remember that in that first year or two cycles are not regular, and its actually normal to have a long time span between each cycle and they may not come every month, so that's normal.
Melanie: What do they do if they notice that their flow is heavy or it lasts a little longer than maybe they've discussed or it comes too often or it's very, very light in terms of just a few little spots, do they count that as a period?
Dr. Merritt: Great question. It's really important that the range of normal be recorded and, hopefully, the girl is not going to be too reluctant to discuss this bleeding pattern with her parent and get some reassurance or with the pediatrician or primary care provider who is familiar with the normal pattern of early menstrual cycles. There are any number of concerns if the period becomes too delayed, too early, too long, and I'm happy to talk about that with you today.
Melanie: Then, let's discuss that and what should they generally use as a rule to follow?
Dr. Merritt: I have a simple rule which is one-ten-twenty. One, if a girl is bleeding more than a pad or tampon in an hour. Ten, certainly if the flow is longer than seven to ten days and twenty is if the cycles are occurring and we count from the first day of flow until the next first day of flow, if that interval is less than twenty days. If a girl is bleeding too heavy, too long or too close together that's a sign of a problem and she can become anemic.
Melanie: Young girls often complain about cramps and such. Are we allowed to, as parents, and should we discuss with our pediatrician or our adolescent gynecologist about whether they have pain or they're uncomfortable as this begins?
Dr. Merritt: The initial menstrual cycles usually are an-ovulatory, and it often will take a few years for the girls to develop an ovulatory pattern and it's then that they start to experience cramping. So, those first periods may be quite light, quite short, relatively painless but some girls actually start out completely regular and if they're ovulating, they may have what we call “menstrual cramping” and there is absolutely every reason to manage that so that the girls can continue on attending school and participating in their activities. I really hate to think that a girl's menstrual period would keep her home from school.
Melanie: If you remember, back in the day girls couldn't do swimming in gym because they had their period but nowadays with tampons and such, but young girls don't always look to those as a source for absorbing flow. So, what do we tell our young girls about the products that are out there?
Dr. Merritt: I think this is a great discussion for moms to have with their daughters about the different options of hygiene products. I certainly find a great number of young competitive athletes who are able to choose to place tampons so that they can compete in their swim meets or track meets or other competitions using a tampon, and then they will frequently resort back to pads between events. I certainly also encourage young girls who choose to use tampons to please use the pad at night and not leave a foreign body in the vagina at bedtime.
Melanie: When do we take our young girls to see an adolescent gynecologist for the first time? Or, do we rely on our pediatrician for that care until they're having these regular periods or until their eighteen?
Dr. Merritt: I think many pediatricians are very comparable and it's part of pediatric training now to understand development and the role of the menstrual cycle being part of normal development. Certainly, the American Academy of Pediatrics and the American College of Ob/Gyn has encouraged primary care providers to think of menstrual cycles as a vital sign just as we look at blood pressure and pulse rates or a respiratory rate as a sign of what's normal and anything outside of the normal range may be attributable to a significant underlying health concern. Most pediatricians are really good at recognizing what's a normal period, a normal interval, and a normal amount of flow but sometimes I have patients who have been reassured that their irregular cycles or their heavy flow is just something they'll have to live with. At that point they're either referred to me, or mother will find out from her neighbor that there's a pediatric gynecologist in town who can help their daughter.
Melanie: What about those exams? Do young girls get a Pap smear?
Dr. Merritt: I'm so glad you asked that because I think that's one of the biggest concerns moms and daughters have about coming to a gynecologist. When you are a young girl, you absolutely don't need a Pap smear. In fact, we don't do internal exams on these young girls. We would never even put a speculum out on the table. Speculum exams and Pap smears begin at age 21. So, usually on the first visit, I may just talk to the girl and her mother or parent, whoever comes with her, about what to expect from their period and if they fall out of the normal range, for instance, if they're bleeding too long or too heavy, or there's a big interval of time between the cycles, or there are other markers like significant problems with hirsutism, which is excess body hair or acne, or if there are signs of a weight problem, perhaps an eating disorder, we really can intervene and make helpful suggestions just in initial talking. When it comes to the exam, I think it's a great and golden opportunity to teach young girls about their body so that they become comfortable with the vagina and how to care for it. Most moms are very excited to see their daughters understanding and learning how to take care of themselves. The lessons that we teach in our clinic about normal anatomy are very helpful and if a girl really is not wanting to undress, I have a diagram and we can just go over the diagram and explain everything and people can keep their clothes on.
Melanie: To wrap up, Dr. Merritt, what would you like other pediatricians to know about starting this process with their young patients and their parents and discussing maybe an abnormal menstrual period or amenorrhea or any of these things they might see in starting that discussion with their patients?
Dr. Merritt: Great question. I think menarche or the onset of periods is a really important milestone in physical development and there are a few things that the pediatrician really needs to look out for. Mainly, it's the girl who doesn't start her period but is showing every other sign of normal pubertal development, breast development and such. If three years go by after the breast tissue develops and they haven't started their period yet, it's time to touch base with us. Certainly, if a fifteen year old hasn't had her period, then it's really time to come in because I think in her heart, she's concerned. “Why am I'm not starting?” Signs of heavy flow, easy bruising, and a family history of bleeding need to be evaluated. So, on one hand, it's the girl that doesn't start and on the other hand it's the young girl who's bleeding too heavily.
Melanie: Tell us about your team. Why is St. Louis Children's Hospital so great to work with?
Dr. Merritt: Children's Hospital is really focused on the patient and there are any number of resources there starting with the guards that greet you as you walk in the front door, the people who work in the lab, the house officers and doctors who work there are truly dedicated to helping children be healthy and have a better life.
Melanie: Thank you so much for being with us today. It’s great information. A physician can refer a patient by calling children's direct physician access line at 1-800-678-HELP. 1-800-678-4357. You're listening to Radio Rounds with St. Louis Children's Hospital. For more information on resources available at St. Louis Children's Hospital, you can go to www.stlouischildrens.org. That's www.stlouischildrens.org. This is Melanie Cole. Thanks so much for listening.