Menstrual Disorders in Adolescent Girls

Female menstrual disorders are common during adolescence due to the slow maturation of the system situated in the brain called the hypothalamic-pituitary axis. The hypothalamic-pituitary axis is the mediator of the menstrual cycle. The failure of this system may lead to variations in the menstrual cycle. It can last up to two to five years after menarche (the first occurrence of menstruation). More than two-thirds of adolescent problems are related to menstruation in the forms of dysmenorrhea (painful period), amenorrhea or oligomenorrhea (absent or reduced periods), and menorrhagia (abnormal uterine bleeding).

Dysmenorrhea:

It is one of the common gynecological complaints during adolescence. About 60% of girls between the age of 12-17 years complain of dysmenorrhea. However, only 15% seek medical advice. The first few periods are pain-free due to the absence of ovulation. After that, dragging pelvic pain is common. This is due to pelvic vascular engorgement under the reflex of sex steroids. Dysmenorrhea may be primary or secondary.

Primary dysmenorrhea (spasmodic) develops early after uterus menarche, within the first two years. It is defined as painful menstrual cramps in the absence of clinically detected pelvic pathology. Possible diagnoses in the case of atypical severe pain are endocrine, myometrial disturbing action, prostaglandins, and vasopressin.

Secondary dysmenorrhea (congestive) may occur many years after menarche. The pain is usually more severe and precedes menstruation by several days. Colicky pain before a flow is relieved with menstruation. Common causes are endometriosis, pelvic inflammatory disease (PID), congenital genital tract malformation, cervical stenosis, cervical polyp, fibroid, intrauterine adhesion, and IUCD (intrauterine contraceptive device).

Diagnosis of Dysmenorrhea:

• A careful history is key to diagnosis.

• A pelvic examination is avoided in the young girl who is not active sexually. In such cases, genital per rectal examination can be done.

• A pelvic ultrasound will help to diagnose conditions such as structural uterine defects, fibroid, endometriosis, PID, and polyp.

• Rarely diagnostic laparoscopy is needed in case of severe atypical pain.

Amenorrhea:

Primary amenorrhea is when a girl does not start menstruation by the age of 16 years. Amenorrhea can be diagnosed with clinical history and examination. Also, we need to check thyroid tests, ultrasound, laparoscopy, and prolactin levels. Causes of primary amenorrhea are as follows:

1. CNS disorders like pituitary gland tumor, craniopharyngioma, stress, and antidepressant drugs.

2. Thyroid dysfunction.

3. Adrenal dysfunction like Cushing syndrome and congenital adrenal hyperplasia.

4. Ovarian dysfunction like premature ovarian failure and androgen-secreting tumor.

5. Outflow tract dysfunction like Scheuermann's syndrome, cervical or vaginal agenesis, imperforate hymen.

6. Pregnancy.

Menorrhagia:

Abnormal uterine bleeding is usually associated with anovulatory cycles. However, there are multiple reasons for anovulation.

• Anovulation due to inappropriate maturation of the HPA axis (hypothalamic–pituitary–adrenal axis), PCOS (polycystic ovarian syndrome), stress, obesity, and excessive exercise.

• It can also be due to blood dyscrasias like sickle cell anemia and ITP (idiopathic thrombocytic purpura), infections like endometritis and cervicitis, and systemic disorders like liver and kidney disease.

• Anatomical lesions like polyp, foreign body, sexual abuse, fibroid, and malignancy can result in anovulation.

• Pregnancy complications like post-abortion, ectopic pregnancy, hydatidiform mole (growth inside the uterus at the beginning of pregnancy), and retained products of conception can cause intermenstrual bleeding.

• Hypothalamic factors like eating disorders, stress, and low body fat can give rise to menorrhagia.

The diagnosis of menorrhagia depends on a thorough history, clinical examination, abdominal and vaginal examination, ultrasound, and diagnostic hysterolaparoscopy.

Diagnostic Techniques To Rule Out Menstrual Disorders:

• Clinical Evaluation.

1. Current medications.

2. Menstrual flow and cycle length.

3. History of any gynecologic surgery or gynecologic disorders.

4. Sexual activity.

5. History of sexually transmitted diseases.

6. History of any contraceptive use.

7. Family history of fibroids.

8. History of a breast discharge.

9. Blood clotting disorders.

• Blood Tests: It is done to evaluate iron deficiency (anemia) or conditions like thyroid disorders or blood-clotting abnormalities.

• Pap Test: The cervical cells are collected and tested for infection, inflammation, or changes that can be cancerous or can lead to cancer.

• Ultrasound: High-frequency sound waves are used to create a detailed image of the pelvic organs.

• Magnetic Resonance Imaging (MRI): It is a diagnostic procedure that provides detailed images of the reproductive organs by using a combination of large magnets, radio frequencies, and a computer.

• Hysteroscopy: A hysteroscope inserted through the vagina to visualize the canal of the cervix and the interior of the uterus for examination.

• Biopsy (Endometrial): A needle is used to remove the tissue samples from the uterus lining during surgery to determine any cancer or other abnormal cells.

• Dilation and Curettage (D&C): A common gynecological surgery consists of widening the cervical canal with a dilator and scraping the uterine cavity with a curette (a spoon-shaped surgical tool) to remove tissue.

• Laparoscopy: It is a minor surgical procedure in which a thin tube with a lens and a light is inserted inside an incision in the abdominal wall to see into the pelvic and abdomen area.

• Transvaginal Ultrasound: It uses sound waves to produce images of the female reproductive organs, including the cervix, uterus, ovaries, fallopian tubes, and pelvic area.

• Cystoscopy: It is a thin tube with a camera and a light on its end. It is inserted into the urethra and bladder and transmits images to a screen for the doctor to see. The doctor will be able to see if there is any endometrial tissue inside the bladder. This is rarely needed in the diagnosis of a bleeding disorder.

Treatments of Menstrual Disorders:

Consulting about your menstrual disorder symptoms with your doctor can help decide what type of treatments can be best reduce or relieve your symptoms, including:

• Diuretics.

• Oral contraceptives.

• Dietary modifications.

• Vitamin or mineral supplements.

• Hormone supplements.

• Prostaglandin inhibitors.

• Tranquilizers.

• Antidepressants.

• Regular exercise.

• Surgery.

The treatment plan is based on the following factors:

• Age, overall health, and medical history.

• Current symptoms.

• The extent of the condition.

• Possible cause of the condition.

• Tolerance for specific medications, procedures, or therapies.

1) Endometrial Ablation: It involves using heat, electricity, laser, freezing, or other methods to destroy the uterus lining. These are recommended only for womenwho do not wish to get pregnant anymore. However, in the following treatment, a person must use contraception. Even though the endometrial ablation destroys the uterine lining, there is a slight chance of pregnancy, which could be dangerous to both the mother and the fetus. But overall, endometrial ablation procedures have a reasonable success rate at reducing heavy bleeding.

2) Endometrial Resection: In this surgical procedure, the surgeon will use an electrosurgical wire loop to remove the uterus lining.

3) Dilation and Curettage (D&C): In a D&C, the cervix is dilated, and special instruments are used to scrape away the uterine lining. A D&C can also be used to diagnose abnormal uterine bleeding. It is usually done under local anesthesia in the out-patients. However, this treatment is often only a temporary solution to heavy bleeding.

4) Myomectomy: Fibroids, which are the common cause of heavy bleeding, get resolved by removing the fibroids by a myomectomy procedure.

5) Hysterectomy: This is a commonly performed surgical procedure to end heavy bleeding. It is the only treatment that guarantees that bleeding will stop. It is a radical surgery that removes the uterus. A lengthy recovery period of about four to six weeks may be required for some women. Fatigue associated with this procedure can last much longer.