Adolescent Gynecology Corner: Understanding Menstrual Disorders

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Menstrual Problems in Teenagers — Heavy, Painful, Irregular & Absent

Menstrual problems in teenagers are common and often dismissed. This sheet gives what is normal, what to investigate, and how to treat heavy bleeding, painful periods and absent periods.

🎯 AT A GLANCE — MENSTRUAL PROBLEMS IN TEENAGERS

The menstrual history is a vital sign: ask at every visit about the last period and the pattern

Menarche is at 12 to 13 years on average, and 98% have started by 15

In teenagers about 90% of cycles are 21 to 45 days long, and a period lasts 2 to 7 days

Anovulation is common for the first 12 to 18 months and usually does not last more than 3 months

Heavy bleeding from the first periods suggests a bleeding disorder, most often von Willebrand disease

About 90% of painful periods are primary and begin 6 to 12 months after menarche; about 10% are secondary, most often endometriosis

Teach girls and parents what is normal early, from about 7 to 8 years

Irregular is often normal in the first two years; heavy, very painful, very late or absent is not. Exclude pregnancy first, then look for the cause.

🚨 EVALUATE OR REFER IF…

She soaks a pad or tampon every 1 to 2 hours, floods the sheets, or is faint, pale or has a fast pulse — check haemodynamic stability and consider admission

There is no menarche by 15 years, or within 3 years of breast budding, or no breast development by 13

There is monthly pain with no bleeding — suspect a blocked outflow, such as an imperforate hymen or a transverse septum

Periods stop for more than 3 months, or bleeding lasts over 7 days, or a cycle is under 21 or over 45 days

Pain started at menarche, worsens, or continues after 3 to 6 months of treatment; or pain with passing urine or stool during periods — think of endometriosis or an anomaly

Weight loss, over-exercise or an eating disorder, or signs of thyroid disease

Pregnancy, sexual abuse or a sexually transmitted infection is possible — ask confidentially, even if she says she is not sexually active

STEP 1 · RECOGNISE — normal or not?

🔍 NORMAL AND WHEN TO EVALUATE

Feature	Normal in a teenager	Evaluate if
Menarche	12 to 13 years; usually around breast stage IV	None by 15, or 3 years after breast budding, or no breasts by 13
Cycle length	21 to 45 days (60 to 80% are 21 to 34 days by 3 years after menarche)	Under 21 or over 45 days, or no period for over 3 months
Length of period	2 to 7 days	More than 7 days
Flow	Pads or tampons last several hours	Changed every 1 to 2 hours, clots over 2 cm, floods

🩺 HISTORY AND EXAMINATION

Date of the last period and the pattern; a diary or phone app helps

Pregnancy, sexual activity, sexual trauma and infection: ask her alone and confidentially, even if she denies sex

Stress, eating disorders, weight change, exercise; symptoms of thyroid disease, polycystic ovary syndrome, liver disease or a bleeding disorder

Family history of heavy bleeding, easy bruising, nosebleeds or late menarche

Check pulse and blood pressure (orthostatic if heavy bleeding), weight and height, pallor, bruising, acne, hirsutism, thyroid and breast stage

Inspect the external genitalia; a speculum or pelvic examination is usually not needed

STEP 2 · FIND THE PROBLEM AND TREAT IT — heavy, painful or absent periods

🧭 FROM THE PROBLEM TO THE PLAN

🩸 HEAVY OR IRREGULAR BLEEDING

Cause	Clues
Anovulation	The commonest cause early on, within 12 to 18 months of menarche
Bleeding disorder, most often von Willebrand disease	Heavy from the first period; easy bruising or nosebleeds; family history; about 1 in 4 who need admission or transfusion has a coagulopathy
Thyroid disease, PCOS, obesity	Irregular cycles; acne or hirsutism; weight; high oestrogen with anovulation
Pregnancy, miscarriage, infection, trauma	Always test, whatever she says
Stress, eating disorder	Weight loss, exercise, mood
Structural causes	Rare in teenagers

Tests: hCG, full blood count with platelets, ferritin and TSH. If anaemic or a bleeding disorder is suspected: PT, PTT, INR, fibrinogen, von Willebrand antigen and activity, and factor VIII. Take these before starting hormones, because hormones change the results. A pelvic scan is not routine; a transabdominal scan is enough if needed.

💊 TREATING HEAVY BLEEDING

Situation	Treatment	Notes
Stable, mild or moderate	NSAID first line; tranexamic acid 1 to 1.3 g three times a day on heavy days, up to 5 days	Add iron; check ferritin; medical treatment is first-line and surgery only if it fails
Acute heavy bleeding	High-dose combined pill taper; a high-dose progestin taper if oestrogen is contraindicated	One pill a day is usually not enough to stop acute bleeding
Maintenance	Combined pill, oral or injectable progestin, or levonorgestrel IUS	Many reach amenorrhoea within 6 months with DMPA or the IUS
Unstable or not responding	Admit; IV oestrogen or antifibrinolytic; a Foley balloon, clot evacuation or examination under anaesthesia if needed	Rarely needed; transfusion is often unnecessary
Bleeding disorder	Refer to haematology; counsel about safe medicines and future surgery	Avoid aspirin and NSAIDs if a platelet function disorder is likely (from memory)

😣 PAINFUL PERIODS

Type	Clues	Management
Primary (about 90%)	Starts 6 to 12 months after menarche, with ovulatory cycles; no pelvic disease	NSAID: naproxen 5 mg/kg (maximum 500 mg) twice a day, or mefenamic acid 500 mg three times a day, with food, starting 1 to 2 days before the period and continuing for 2 to 3 days
If not enough	Heavy bleeding as well, or contraception wanted	Combined pill, continuous or extended; or a progestogen, implant or levonorgestrel IUD; review at 3 months
Secondary (about 10%)	Pain from menarche, worse towards the end of bleeding, pain with urine or stool in the period, family history of endometriosis, or no response after 3 to 6 months	Transabdominal pelvic ultrasound; refer to gynaecology; endometriosis is the commonest cause, then obstructive anomalies, adenomyosis, infection and cysts

Non-drug help: heat, exercise and rest may complement medicines or replace them if she cannot take them. (from memory) A vaginal examination is rarely needed in a teenager.

🚫 NO PERIODS

Group	Cause	What to do
Normal breasts, outflow blocked	Imperforate hymen or transverse vaginal septum: monthly pain, a bulging hymen or mass; Müllerian agenesis (MRKH): no vagina or uterus; androgen insensitivity: 46XY	Examine, ultrasound or MRI, karyotype; surgery is curative for hymen or septum
Poor breast growth, high FSH, low oestradiol	Ovarian insufficiency: Turner syndrome (short stature, webbed neck, shield chest), Swyer syndrome, autoimmune or iatrogenic	Karyotype; low-dose oestrogen from about 12, then a progestogen; a combined pill is not for puberty induction; remove intra-abdominal gonads in 46XY
Low or normal FSH	Functional hypothalamic amenorrhoea from weight loss, exercise or stress; hyperprolactinaemia; constitutional delay; thyroid disease; PCOS	Nutrition, weight and stress care; dopamine agonist for prolactin; lifestyle for PCOS

First tests: exclude pregnancy; FSH, oestradiol, TSH, prolactin; transabdominal pelvic ultrasound; karyotype if the uterus is absent or ovarian insufficiency is suspected.

STEP 3 · COUNSEL AND FOLLOW UP — what she needs to hear

🗣️ WHAT TO TELL HER AND HER PARENT

Irregular periods are common in the first two years; heavy, very painful or missed periods deserve a check

Keep a period diary or use an app, and note flow, pain and missed school

Eat iron-rich food and take iron if advised, because anaemia is common in Indian girls (from memory)

Pain medicine works best if she takes it early, with food, at the start of her period

She can talk to you privately about sex, abuse and worries; keep it confidential

Tell her when to come back or go to hospital: soaking a pad every hour, feeling faint, or severe pain

Follow up to check the response, her iron and her quality of life

⚠️ COMMON PITFALLS

Saying “irregular is normal” for a girl with heavy bleeding or none for over 3 months

Missing a bleeding disorder in a girl with heavy bleeding from menarche

Starting hormones before the bleeding disorder tests

Skipping the pregnancy test because “she is not sexually active”

Not looking at the hymen in a girl with monthly pain and no periods

Using a combined pill to induce puberty

Giving the NSAID late or at too low a dose

Missing an eating disorder or over-exercise

No iron, no follow-up

Memory Aid

PERIOD

Six steps for a teenager with a period problem.

P

Pregnancy first — also infection and abuse, asked in private

E

Evaluate against the normal — 21 to 45 days, up to 7 days

R

Red flags — hourly pads, no menarche by 15, cyclic pain with no bleeding

I

Iron and the bleeding screen — ferritin, von Willebrand tests before hormones

O

Offer the right treatment — NSAID, tranexamic acid, hormones; treat the cause

D

Diary and follow-up — review at 3 months, check iron

Remember: a girl’s period is a vital sign; do not dismiss it, and do not forget to ask in private.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: a Contemporary OB/GYN summary of ACOG Committee Opinion 785 on heavy menstrual bleeding in adolescents; the Contemporary Pediatrics article “Menstruation as the sixth vital sign”; Exxcellence pearls on abnormal uterine bleeding in adolescents (tranexamic acid 1,300 mg); the Royal Children’s Hospital Melbourne dysmenorrhoea guideline (NSAIDs, hormones, atypical features); and an Obstetrics & Gynaecology Magazine review of primary amenorrhoea (2019, now several years old). Tranexamic acid dosing differs between sources (1 g and 1.3 g). Items marked “from memory” (platelet disorders and NSAIDs, non-drug measures, anaemia in India) were not checked. These sources are from the United States and Australia; drugs and services differ in India: follow local protocols.