Mimi McEvoy, MA, RN, PNP, Jane Chang, MD, and Susan M. Coupey, MD ABSTRACT Menstrual disorders such as amenorrhea, exces- sive uterine bleeding, dysmenorrhea, and premen- strual syndrome are common reasons for visits to healthcare providers by adolescent girls. Although menstrual irregularity can be normal during the first few years after menarche, other menstrual signs and symptoms may indicate a pathological condition that requires prompt attention and refer- ral. This article discusses four common menstrual disorders seen in adolescent girls and focuses on specific nursing interventions aimed at eliciting an accurate menstrual history, providing confidentiali- ty and communicating therapeutically, administer- ing culturally sensitive care, and promoting inde- pendence and self-care. Key Words: Adolescents; Amenorrhea; Dysfunc- tional uterine bleeding; Dysmenorrhea; Females; Menstrual disorders; Nursing care. Nursing Interventions urses working with adolescent girls know that preoccupation with appearance and body function is a normal accompaniment to the physical changes of pu- Nberty. This preoccupation is often heightened by the fact that as many as 75% of adolescent girls experience some kind of problem associated with menstruation (Ziv, Boulet, & Slap, 1999). Therefore, it is no surprise that for adolescent girls, menstrual disorders, such as delayed or irregular cycles, excessive flow, and painful menses, are January/February 2004 MCN 41 common reasons for visiting healthcare providers (Tuttle, Then FSH begins to rise again in response to the low estro- 1991; Ziv et al., 1999). Although menstrual irregularity gen and progesterone levels, and the next cycle begins. can be normal during the first few years after menarche, In anovulatory cycles, the LH surge at midcycle does there are many different congenital, endocrine, hematolog- not occur, thus the follicle does not release the ovum and ic, and psychosocial conditions that can present as men- no corpus luteum forms. The endometrial lining of the strual disorders during adolescence. uterus remains in the proliferative phase because no prog- This article describes the four most common menstrual esterone is secreted. Eventually, the unruptured follicle in- disorders seen in adolescent patients: amenorrhea, excessive volutes, estrogen levels decrease, and menstrual bleeding uterine bleeding, dysmenorrhea, and premenstrual syn- occurs. Sometimes during an anovulatory cycle, the follicle drome (PMS). Also addressed are specific nursing interven- does not involute, continues to increase in size, and forms tions designed to address the accurate assessment of men- a follicular cyst. The estrogen secreted by the cyst contin- strual problems, communication challenges, cultural differ- ues to stimulate the endometrium to proliferate and grow. ences in attitudes toward menstruation, and empowering An endometrium that has not been exposed to proges- adolescents to seek reproductive healthcare. terone is unstable, so the patient may experience irregular spotting and/or bleeding and sometimes may bleed heavily. Normal Menstrual Cycle In the United States, the average age at menarche is 12.16 To identify and treat menstrual disorders, it is helpful to years for African-American girls and 12.88 for Caucasian briefly review the menstrual cycle. There are three phases girls (Herman-Giddens, Slora, Wasserman, et al., 1997). to the ovulatory menstrual cycle: the follicular phase, ovu- The average interval between the beginning of breast devel- lation, and the luteal phase. During the follicular phase, opment and menarche is two years. Most girls menstruate there is pulsatile release of gonadotropin-releasing hormone by the time they reach Tanner stage 4 breast and pubic hair development. The menstrual cycle is defined as the number of days between the first day of bleeding of the last menses to the first day of bleeding of the next menses. In the World Health Organization (WHO) study on men- strual and ovulatory patterns in adolescent girls, the mean Up to 75% of adolescent girls menstrual cycle length was 50.7 days in the first cycle after menarche and bleeding lasted for an average of 4.7 days. experience some kind of The mean cycle length decreased steadily until it was 30 days by the 24th cycle and lasted for an average of 4.9 problem associated with days (World Health Organization [WHO], 1986). menstruation. Four Most Common Menstrual Disorders in Adolescents Amenorrhea and Oligomenorrhea For any menstrual disorder, use of appropriate terminology will help to accurately describe and communicate the prob- from the hypothalamus, which then stimulates the pituitary lem to the healthcare team. Primary amenorrhea is the ab- to secrete follicle-stimulating hormone (FSH) and small sence of menses within 2 years of achieving Tanner stage 4 amounts of luteinizing hormone (LH), which stimulate breast development or with delayed puberty, defined as no ovarian follicular growth. The growing follicle secretes es- breast development by the 12th birthday. If menarche has trogen, which induces proliferation of the endometrial lin- not occurred in either of these circumstances, an investiga- ing of the uterus. A dominant follicle is present approxi- tion should begin, regardless of the girl’s chronologic age mately 7 days before ovulation. As estrogen levels peak, the (Iglesias & Coupey, 1999). Breast development begins at a pituitary gland releases a large LH surge and a smaller FSH mean age of approximately 9 years for African-American surge at midcycle, and ovulation occurs. girls and 10 years for Caucasian girls in the United States; The luteal phase is characterized by the presence of the 99% of African-American girls and 96.5% of Caucasian corpus luteum, which is formed by the luteinization of the girls will have at least Tanner stage 2 breast development follicular cells. The corpus luteum produces estrogen and by age 12 years (Herman-Giddens et al., 1997). Secondary progesterone. Progesterone counteracts the effects of estro- amenorrhea is a more common complaint and is defined gen on the endometrium, inhibiting proliferation and pro- as an absence of menses for 6 months or more in a girl ducing the glandular changes that make the lining receptive who had been menstruating regularly. Oligomenorrhea is to implantation by the fertilized ovum. Without fertilization, defined as irregular, infrequent menses for a period of 1 the corpus luteum cannot survive and regresses, which re- year or longer. sults in a decrease in both estrogen and progesterone. The There are many different causes of amenorrhea. There decrease in hormones triggers synchronous sloughing of the are anatomic causes, such as imperforate hymen or agene- endometrial lining approximately 14 days after ovulation. sis of the vagina and uterus, which always present as pri- 42 VOLUME 29 | NUMBER 1 January/February 2004 Selected causes of itary-ovarian axis. The female reproductive system usually Figure 1. oligomenorrhea and amenorrhea requires approximately 2 years to mature before adoles- cent girls will have consistently regular ovulatory cycles. Pregnancy These anovulatory cycles are most often fairly regular; Chronic illness however, they can be either shorter or longer than the standard 28-day cycle of the mature ovulating woman. Substance abuse Apter, Viinikka, & Vihko (1978) studied the hormonal Anorexia nervosa patterns of the adolescent menstrual cycle and found that Excessive exercise the majority of cycles within 2 years of menarche were anovulatory, as determined by peak progesterone levels of Depression Ͻ1.0 ng/mL, whereas subjects who were at 5 years since Psychological stress their menarche ovulated in more than 80% of their cycles, Hypothyroidism achieving peak progesterone levels of 8–10 ng/ml. There- fore, “gynecologic age,” which is the amount of time in Polycystic ovary syndrome months or years since menarche, is more pertinent to the consideration of the different causes of anovulation than Causes of excessive chronologic age. Figure 2. uterine bleeding However, for many adolescents, anovulation results from a pathological condition. Polycystic ovary syndrome Dysfunctional uterine bleeding (PCOS), also referred to as functional ovarian hyperandro- Complications of pregnancy genism or hyperandrogenic chronic anovulation, is a com- mon condition seen in adolescent girls and is estimated to Sexually transmitted infection occur in up to 10% of women (Knochenhauer, Key, Kah- Bleeding disorders, such as von Willebrand sar-Miller, et al., 1998). The clinical manifestations are disease or factor deficiencies variable, but the most common signs and symptoms in- clude irregular periods or intervals of amenorrhea, hir- Endocrine disorders, such as polycystic ovary sutism, acne, and obesity. Classical polycystic ovaries are syndrome or thyroid disease not a common feature of this condition in the adolescent Vaginal trauma or foreign body age group. The evaluation of a girl with amenorrhea includes a de- Uterine, vaginal, or ovarian neoplasms tailed history, including history of growth and pubertal de- Drugs, such as hormones or warfarin velopment, sexual history, and psychosocial history, with specific questions regarding athletic training, depression, weight loss or gain, or stress. Physical examination must include Tanner staging of both breasts and pubic hair and mary amenorrhea, but most other conditions can present a genital examination. Laboratory evaluation is guided by as either primary or secondary amenorrhea.