FACTS Spotlight: National NFP Awareness Week


July 29, 2021

By Courtney Makris, DO

Editor’s Note: Earlier this week, FACTS published a review of research that exposes knowledge gaps in medical education regarding fertility and infertility. Rather than mere criticism, such research is vital to improve medical education to benefit patients and physicians, since studies suggest 25% of female physicians experience infertility,[i] a rate much higher than the U.S. general population.

The article summarized below is encouraging, with evidence that the American College of Obstetricians and Gynecologists (ACOG) supports an increase in fertility awareness education. It is a synopsis of ACOG’s Committee Opinion No. 651, “Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign.”ii ACOG’s statement aligns nicely with FACTS’ flagship presentation, The Female Cycle as the 5th Vital Sign. Follow the link for dates to our upcoming webinars addressing this and other fertility awareness topics.


It is important to educate young girls and their parents or primary caregivers about what constitutes a normal menstrual cycle and normal bleeding patterns, as abnormalities in the menstrual cycle could point to underlying medical issues with potential for long-term health consequences. The American College of Obstetricians and Gynecologists suggests that by considering the menstrual cycle as a vital sign that can be measured and evaluated, clinicians reinforce its importance in assessing overall health status.

“Just as abnormal blood pressure, heart rate, or respiratory rate may be key to the diagnosis of potentially serious health conditions, identification of abnormal menstrual patterns through adolescence may permit early identification of potential health concerns for adulthood.”[ii] – ACOG, 2015

Normal Menstrual Cycles

Prior to menarche, clinicians should educate girls and their caregivers about when to expect the first menstrual period as well as the range for normal cycle length and subsequent menses. In the United States, the median age of menarche is between 12 to 13 years of age.[iii] Menarche normally occurs within 2-3 years after breast budding, or thelarche, at Tanner Stage IV breast development.[iv] Factors that may affect age of menarche include body mass index (BMI), socioeconomic factors, nutrition, and access to preventive health care.[v] Evaluation for primary amenorrhea should be considered if menarche is not reached by age 15 or within 3 years of thelarche.[vi]. Once girls reach menarche, clinicians should inquire about the first day of the last menstrual period and their pattern of menses at every preventive care visit. It is important for clinicians to understand normal cycle length during adolescence and discuss this information with young girls and their caregivers. Because of the immaturity of the hypothalamic-pituitary-ovarian axis in adolescence, many cycles may be anovulatory and longer than in adulthood, but 90% of cycles will be between 21 and 45 days.[vii] By the third year after menarche, we can expect 60-80% to fall within the normal adult menstrual cycle range of 21-34 days.

Abnormal Uterine Bleeding

By teaching the normal menstrual cycle to young girls and their caregivers, we help patients to recognize menstrual irregularities and can reinforce the importance of using the menstrual cycle to identify potential health concerns. Clinicians should also discuss normal bleeding patterns with adolescents. Normal blood loss per menstrual period is 30 mL per cycle, or about 3-6 pads or tampons in a day.vii

Although physiologic ovulatory dysfunction is to be expected for the first three years following menarche, disturbance of the hypothalamic-pituitary-ovarian axis can also be caused by endocrinopathies such as polycystic ovarian syndrome (PCOS), thyroid disease, stress, and eating disorders. Heavy menstrual bleeding may be associated with coagulopathy, hepatic dysfunction, or malignancy.[viii]

Teaching Adolescents About Fertility Awareness

In the United States, 260 million dollars of federal funding is allocated to sex education. There are currently two main schools of thought regarding sex education: sexual risk reduction (SRR) and sexual risk avoidance (SRA). Sexual risk reduction provides comprehensive information regarding contraception, including effectiveness and failure rates, positive information regarding sexuality and sexual decision making, and is meant to empower teens to take responsibility of their health and wellbeing. Some criticisms of SRR include utilization of graphic materials and visuals and discussion of self-pleasure.

Sexual risk avoidance curriculums take an abstinence-based approach. Criticism of SRA is that there is little to no information given regarding contraception, and if information about contraception is discussed, failure rates may often be sensationalized. The solution to providing a truly comprehensive approach to sex education likely lies somewhere in the middle. At a minimum, young men and women should understand that pregnancy is the result of heterosexual intercourse and learn about the types of contraception available, the effectiveness rate of each method, and the different types of sexually transmitted infections (STI’s) along with potential consequences such as their impact on fertility.[ix]

Fertility awareness education teaches adolescents about the various signs of fertility and empowers them to take ownership of their health and fertility. It helps teens understand their biological capacity for reproduction, and by charting their biomarkers, adolescents can discover how their bodies are designed to work and develop a better sense of self. Through charting, teens learn the parameters of a healthy cycle including normal length, healthy bleeding patterns, dry days, wet days, ovulatory patterns, and healthy luteal phase patterns.

Programs to Teach Fertility Awareness to Teens

Various programs have been developed to teach fertility awareness to teens, including Teen STAR and Teen FEMM. Teen STAR is geared toward helping adolescents discover their inherent value, understand the changes that happen during puberty and adolescence, and develop a positive sense of self and a healthy view of sexual behavior. In studies of sexual behavior in adolescents, 6.5% of women in a Teen STAR program initiated sexual activity compared to 15.4% of women in the control group. Similarly, 20% of teen women in a Teen STAR program discontinued sexual activity, compared with 9% in the control group.[x] A randomized controlled trial in a Chilean high school showed teen pregnancy rates at 3.3% for those enrolled in Teen STAR, compared with 18.9% for those in the control group.[xi]

Teen FEMM differs from Teen STAR in that it does not take a sexual avoidance approach. Teen FEMM provides teens with information to understand what is normal and healthy at every stage of life, and how to develop healthy habits. Teen FEMM focuses on recognizing signs of health, understanding hormones, brain development and emotions, sexual health, and how daily decisions impact health. Both programs provide valuable opportunities for teenagers to learn to track their cycle as a vital sign of health.


[i] Stentz NC, Griffith KA, Perkins E, Jones RD, Jagsi R. Fertility and childbearing among American female physicians. J Womens Health (Larchmt). 2016;25:1059–1065.

[ii] Committee Opinion No. 651 “Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign.” Obstetrics & Gynecology. 2015;126(6). doi:10.1097/aog.0000000000001215.

[iii] Finer LB, Philbin JM. Trends in ages at key reproductive transitions in the United States, 1951–2010. Womens Health Issues 2014;24:e271–9.

[iv] Biro FM, Huang B, Crawford PB, Lucky AW, Striegel-Moore R, Barton BA, et al. Pubertal correlates in black and white girls. J Pediatr 2006;148:234–40.

[v] Apter D, Hermanson E. Update on female pubertal development. Curr Opin Obstet Gynecol 2002;14:475–81.

[vi] Reindollar RH, Byrd JR, McDonough PG. Delayed sexual development: a study of 252 patients. Am J Obstet Gynecol 1981;140:371–80.

[vii] World Health Organization multicenter study on menstrual and ovulatory patterns in adolescent girls. II. Longitudinal study of menstrual patterns in the early postmenarcheal period, duration of bleeding episodes and menstrual cycles. World Health Organization Task Force on Adolescent Reproductive Health. J Adolesc Health Care 1986;7:236–44.

[viii] Diagnosis of abnormal uterine bleeding in reproductive-aged women. Practice Bulletin No. 128. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012; s120:197–206.

[ix] FACTS lecture: Fertility Awareness – Solutions for Teaching Adolescents with Dr. Allison Dreher, MA and Dr. Marguerite Duane.

[x] Vigil P, Riquelme R, Rivadeneira R, Klaus H. Effect of Teen STAR, an Abstinence-only Sexual Education Program on Adolescent Sexual Behavior, Rev Med Chil, 2005; 133(10):1173-1182.

[xi] Cabezon C. Vigil P, et al Adolescent pregnancy prevention: an abstinence-centered randomized controlled intervention in a Chilean public high school J Pediatr Adolesc Gynecol 18: 212, 2005.

About the Author

Courtney Makris, DO

Courtney Makris, DO is a resident in obstetrics and gynecology in Grand Rapids, Michigan. She earned her medical degree at LECOM-Bradenton and wrote this article while on the FACTS fertility awareness elective. After completing both parts of the elective, she chose to also join the FACTS ambassador program.


The FACTS CME Course is HERE!

The FACTS 4-part CME Course – Fertility Awareness Based Methods (FABMs) for Family Planning and Restorative Reproductive Women’s Healthcare prepares you as a medical professional to present more comprehensive options for family planning and women’s health monitoring and management of a range of reproductive health concerns. Through online lectures, live case study discussions, and readings, this course will explore the broad applications of modern Fertility Awareness-Based Methods (FABMs) and their role in pregnancy prevention, infertility, and women’s health.

The course is divided into four parts; you may elect to do any or all of them and they may be completed in any order. Each part is worth up to 14 AAFP-approved CME credits.

• Part A, An Introduction to Modern FABMs for Family Planning
• Part B, Special Topics in FABMs for Helping Couples Achieve or Avoid Pregnancy
• Part C, FABMs for Restorative Reproductive Medicine and at Various Stages of Life
• Part D, Medical Applications of FABMs

Click here to download the full lesson schedule for the course. 

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