I’ve written recently about teenagers having too-heavy periods and too-painful periods, and now I want to talk about too-irregular periods. These issues can overlap, but let’s focus on what it can mean when an adolescent doesn’t menstruate regularly — and on the question of how irregular is too irregular.
Dr. Andrea Bonny, an associate professor of pediatrics at The Ohio State University and chief of adolescent medicine at Nationwide Children’s Hospital, said that in the past, many doctors had thought that in the first two years after menstruation begins, “really, anything goes,” as far as frequency.
Now, she said, the thinking is that some irregularity is OK, but to go more than 90 days without a period for two consecutive periods is concerning — and should get worked up medically. After someone has been menstruating for two years, she said, intervals shorter than 21 days or longer than 45 days are considered abnormal, especially if they recur. And many adolescents with irregular cycles — like those with heavy periods, and like those with very painful periods — may be offered hormone treatments, either oral contraceptives or other hormone-based contraceptives.
The diagnosis hanging like a shadow over these conversations is polycystic ovary syndrome, or PCOS, the most common endocrine problem in reproductive age women, which has been the subject of recent work developing diagnosis and management guidelines in women. But it is a difficult — and sometimes controversial — diagnosis in adolescents, because the polycystic ovarian changes that give the syndrome its name, usually identified on ultrasound, can overlap with what ovaries normally look like in adolescents.
So in adolescents, making this diagnosis is not about doing ultrasounds, but about paying attention to menstrual cycles and also to other symptoms. The underlying cause is a high level of androgens, or what we usually think of as male sex hormones. Hyperandrogenism — more testosterone in the blood than is usual for adolescent girls — can also mean bad acne and hirsutism, body hair growing heavily and in patterns more associated with male puberty than with female puberty (for example, hair on the upper lip and chin, on the chest and abdomen, or on the back and arms). Girls with these symptoms should also be tested for other sources of androgens and for other hormonal issues like thyroid problems.
Raising awareness around PCOS is important because many adult women feel, looking back, that this diagnosis was not considered soon enough as a possible cause of fertility problems and other health issues they experienced; it is associated with metabolic alterations that can put women at risk for obesity, diabetes and heart disease. With adolescents, the priority should be treating the symptoms and helping girls understand the importance of the choices they can make around diet and exercise, which should be the real first line treatment.
[Read more: Information from the National PCOS Association]
“You don’t have to label to treat,” said Dr. Sharon Oberfield, a professor of pediatrics at Columbia University and chief of pediatric endocrinology, who was one of the authors of a recent update on the diagnosis and treatment of PCOS in adolescents. The formal diagnosis in adolescents, she said, which should not be made until at least two years after menarche, has to be based on high androgen levels and irregular menstrual periods. And many adolescents with irregular periods will not go on to develop PCOS.
Dr. Oberfield worries that making the diagnosis too early may give some younger girls the sense that the later problems are inevitable, and therefore bring up issues of anxiety and depression and body image problems, not to mention concerns about fertility. “We like to use the words, ‘at risk,’” she said. “The key issue of looking at these girls is sometimes with early screening you can do early intervention.” Some of the adolescents with these symptoms will go on to develop polycystic ovaries, but the priority when they are young should be to make sure there are no other underlying medical problem causing the excess androgens, and to help them understand what’s going on in their bodies.
Dr. Bonny said she explains to patients that men make a lot of testosterone, gesturing with her hand up near her head, and that most “women make a teeny tiny bit, but some make a bit more.” She explains that usually it’s the ovary producing it, and that the extra hormone tends to shut down their periods, and cause the acne and the hair growth.
Dr. Susan Coupey, an expert in adolescent medicine and gynecology at the Children’s Hospital at Montefiore in the Bronx, said that she explains, “there are two kinds of cells in the ovaries, the ones that make the eggs and the ones that make the hormones.” Too much testosterone in some girls, she said, “causes them often to have acne and have unwanted hair; it can also change their lipid metabolism.”
The hormone imbalance and its associated troubling symptoms are often treated with oral contraceptives. Since they contain estrogen, they stimulate the regular shedding of the endometrium — that is, the menstrual period. And that’s also important because it lowers the risk of endometrial cancer down the line.
In girls who can’t take hormonal contraceptives because of medical contraindications, or whose families don’t want them to, Provera, another form of female hormone that helps regulate menstruation, is sometimes used to induce what is called a “withdrawal bleed” if they go for more than three months without a period. Dr. Bonny said she tries to make sure that either a period or a withdrawal bleed happens at least four times a year.
Dr. Coupey said that with young girls and their families, though she explains that older women use these pills for birth control, for them, “I say, ‘You’ve got a hormone imbalance, taking this pill will put your ovaries to sleep.’”
For overweight patients, losing weight can help with the symptoms — but the hormonal issues can make this even harder than usual; the androgens and the insulin resistance tend to spur the body to gain weight, not lose it. Adolescents who have evidence of insulin resistance may be started on a medication called metformin, an oral treatment that helps control insulin resistance and blood sugar levels and sometimes makes weight management a little easier as well for kids with this problem.
Dr. Coupey said she suggests those prone to weight gain make a single change — usually cutting out sugary drinks — and then perhaps move on to a low-carbohydrate diet. And many of them eventually take both metformin and birth control pills. “Many of them do quite well,” she said.
If the metabolic issues are not addressed — with lifestyle changes, with medication, with close follow-up — these adolescents with persistent symptoms are at risk for Type 2 diabetes and cardiovascular problems as they grow, in addition to the reproductive and fertility problems that may arise, as well as mental health issues.
“You don’t have to diagnose PCOS in a young girl to tell her she’s at risk for it and still treat her,” Dr. Bonny said. “It’s the symptoms that are so troubling to these young women — follow her, make sure you provide some treatment for acne, hirsutism, abnormal periods.”