Finding Root Causes of Menstrual Cycle Abnormalities in Adolescents: A Review
By: Jessica Kraft
Director’s Note: In today’s blog, former FACTS elective student Jessica Kraft summarized the review article titled, “Proactive Management of Menstrual Cycle Abnormalities in Young Women” [1] published in The Journal of Perinatal & Neonatal Nursing. In this review of menstrual cycle abnormalities in adolescents, the author, Mary Lee Baron, discusses factors that may be at play, including polycystic ovary syndrome (PCOS) and eating disorders. The author hopes by shifting to a more holistic view of the patient, medical professionals can identify the root cause of adolescent cycle irregularities for better health in adolescence and throughout a woman’s life. To learn more about FACTS’ efforts to advance women’s health across the lifespan, including updates on amenorrhea in adolescents, don’t miss our conference in Austin, TX on April 19-20, 2024. Registration is NOW OPEN!
Introduction
A gap exists in women’s health education between learning about the menstrual period and preparing for pregnancy where we can teach young women to identify patterns within their reproductive cycle. Such education encourages them to take an active role in their health and may lead to earlier detection of menstrual cycle abnormalities. Various systemic conditions impact the menstrual cycle, including obesity, thyroid disease, insulin resistance, inadequate nutrition, and stress.
“We can teach young women to identify patterns within their reproductive cycle… [which] encourages them to take an active role in their health and may lead to earlier detection of menstrual cycle abnormalities.”
When medical professionals first evaluate a young patient with an anovulatory pattern, the goal is to determine the cause of the abnormal findings. By charting her biomarkers with a fertility awareness-based method (FABM), a patient can provide a daily diary of observations that reflect her hormonal changes. Traditionally, the first line treatment for irregular menstrual cycles has been oral contraceptive pills (OCPs). However, prescribing OCPs does not help determine the root cause and may lead to an increase in the bleeding irregularity, since adolescents often forget to take the medication.
PCOS
An evaluation for PCOS should be considered in young patients with anovulation. PCOS is a common endocrine condition that affects 5 to 10 percent of women in the United States and can lead to infertility if untreated. Patients with PCOS are also at increased risk of developing type 2 diabetes, cardiovascular disease, and endometrial cancer later in life. Women with PCOS often have inconsistent cervical mucus and basal body temperature patterns. Long cycle lengths and even completely dry cycles are also commonly seen in PCOS.
Teaching young women to chart their cycles has many benefits. Patterns consistent with conditions such as PCOS may be identified sooner, leading to earlier diagnosis and treatment. Through continued charting, the patient can see how the treatment improves her cycle irregularities, which may motivate her to adhere to the treatment plan.
“Through continued charting, the patient can see how the treatment improves her cycle irregularities, which may motivate her to adhere to the treatment plan.”
Simple lifestyle changes can drastically improve menstrual cycles and overall health in women with PCOS, and this can be stressed to adolescents and young women. Metformin treats the underlying insulin resistance associated with PCOS while allowing the menstrual cycle to normalize and ovulation to occur. Metformin reverses hyperinsulinemia while reducing LH, sex hormone-binding globulin, and ovarian androgens, all of which play an important role in ovulation. Although oral contraceptives will “regulate” the menstrual cycle, they do not improve the increased insulin resistance seen in PCOS patients or prevent its potential long-term consequences. In fact, some studies show OCPs may worsen insulin resistance and increase the risk of developing cardiovascular disease in these patients.
Beyond these potential long-term somatic consequences, a psychosocial aspect also plays a role in patients with PCOS. Increased androgens and obesity may contribute to mood disorders and depression. Body image must be considered when treating adolescents and young women. Hirsutism, acne, and obesity can cause psychological distress. Although short-term treatment of these symptoms is important, the patient must understand that managing the underlying condition will improve her overall health as well as her ability to conceive later in life.
Uncontrolled PCOS has been linked to recurrent spontaneous abortions. In pregnancy, these patients are at an increased risk of gestational diabetes and preeclampsia. Metformin enhances the formation of the follicle and improves the quality of the oocyte. When given during pregnancy, metformin decreases the risk of spontaneous abortion and the development of gestational diabetes.
Eating Disorders
Eating disorders such as anorexia and bulimia are another common cause of menstrual cycle irregularities and secondary amenorrhea. In anorexia, inadequate nutrition and body weight can cause hypothalamic hypothyroidism and cessation of ovulation. Eating disorders are common in female athletes and in women who are physically active and whose disordered eating does not meet their caloric needs. The female athlete triad can have long-term consequences and is now defined by the presence of menstrual dysfunction, poor energy availability, and decreased bone mineral density. [2] Due to poor nutritional intake, these women may also complain of fatigue, injuries, irritability, and the inability to perform athletically. Being aware of risk factors for anorexia and bulimia and asking about perceived body image, dietary and exercise habits can aid in early diagnosis and treatment.
Conclusion
When adolescents and young women chart their menstrual cycles, abnormalities are more easily noticed, and a prompt diagnosis of underlying causes can be made. Medical professionals who approach patients holistically can have a significant impact on their future health and fertility by diagnosing the root cause of menstrual abnormalities rather than simply “regulating” their cycles with OCPs. Moreover, every effort should be made to educate young women about the benefits of good nutrition and maintaining a healthy body weight. In some women, such lifestyle habits may not only cause the return of normal ovulation and menstruation but will also contribute to healthier pregnancies later in life.
“Medical professionals who approach patients holistically can have a significant impact on their future health and fertility by diagnosing the root cause of menstrual abnormalities rather than simply “regulating” their cycles with OCPs.”
References
[1] Barron, Mary Lee MSN, APRN, BC. Proactive Management of Menstrual Cycle Abnormalities in Young Women. The Journal of Perinatal & Neonatal Nursing 18(2):p 81-92, April 2004.
[2] Maya J, Misra M. The female athlete triad: review of current literature. Curr Opin Endocrinol Diabetes Obes. 2022;29(1):44-51. doi:10.1097/MED.0000000000000690.
ABOUT THE AUTHOR
Jessica Kraft
Jessica Kraft is a fourth-year medical student at Philadelphia College of Osteopathic Medicine in Georgia. She completed her undergraduate education at Mercer University in Macon, Georgia. She plans to do her residency in obstetrics and gynecology and is interested in maintaining women’s health in every stage of life. She enrolled in the FACTS elective to learn more about natural family planning methods to counsel patients on all options, so they can make the best decisions regarding their health and fertility.
