by Alison Contreras, PhD, FCP
In a new statement endorsed by the American Academy of Pediatrics last week, the American College of Obstetricians and Gynecologists (ACOG) recommended that young girls and adolescents start following signs of their fertility by charting their menstrual periods. The article notes, “By including this information with the other vital signs within the Review of Systems and History of Present Illness, clinicians emphasize the important role of menstrual patterns in reflecting overall health status.” The letter also sees charting as the necessary first step in treating menstrual abnormalities.
New ACOG Fertility Charting recommendations
In the article, ACOG specifically recommends that:
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Clinicians should educate girls and their caretakers (eg, parents or guardians) about what to expect of a first menstrual period and the range for normal cycle length of subsequent menses.
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Once girls begin menstruating, clinicians should ask at every preventive care or comprehensive visit for the patient’s first day of her last menstrual period and the pattern of menses.
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Identification of abnormal menstrual patterns in adolescence may improve early identification of potential health concerns for adulthood.
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It is important for clinicians to have an understanding of the menstrual patterns of adolescent girls, the ability to differentiate between normal and abnormal menstruation, and the skill to know how to evaluate the adolescent girl patient.
While tracking menstrual patterns is a great start to observing signs that indicate reproductive health, encouraging physicians to teach their patients to understand and track all of the observable signs that reflect these hormones, not just bleeding, would be a more useful recommendation.
Charting menses: A great first step
FACTS is encouraged by ACOG’s statement to young women to become more engaged in their knowledge and understanding of their health and fertility. Charting signs of fertility gives physicians access to more information than they would otherwise have about a patient. However, by limiting the recommendation to charting only the signs of menstruation (bleeding) physicians are missing an opportunity to record key details of a young woman’s cycle that provide more information about her hormonal health.
Charting menses is just one biomarker that a young woman has to help her physician determine if she ovulated that month.
Instead of only recommending that she look for evidence of ovulation after the fact, why not teach young girls to look for the signs of impending ovulation, as its happening?
What about charting cervical fluid?
Prior to ovulation, in response to rising estrogen produced in the ovaries, women can observe a cervical fluid discharge at the vulva. This fluid, secreted from the cervix, changes from sticky and tacky, to clear, stretchy, and slippery as ovulation approaches. Even young women can learn to observe these signs just as they would observe their menses. In fact, many women report that these secretions feel much like they are starting their menses, but they never observe blood.Observing and charting cervical fluid observations is no more complicated than observing menses. Even very young women can be taught to include this in their daily routine.
A record of cervical fluid observations can be a great tool for a young woman’s physician to identify if her cycle irregularities are due to hormonal reasons or if the bleeding she observes is due to organic reasons.
Improved charting recommendations
What if, instead, the recommendations looked like this?
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Clinicians should educate girls and their caretakers (eg, parents or guardians) about what to expect of a first menstrual period and the range for normal cycle length of subsequent menses. Anovulatory cycles will frequently be encountered in the first two years after menarche and do not require intervention or treatment unless they are of several months’ duration and are followed by menorrhagia.
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Clinicians should educate girls and their caretakers (eg. parents or guardians) about what to expect to observe with cervical fluid secretions including the changing pattern and timing, leading up to ovulation.
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Once girls begin menstruating, clinicians should ask at every preventive care or comprehensive visit for the patient’s first day of her last menstrual period and the pattern of menses, as well as what pattern of cervical fluid was observed that cycle.
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Identification of abnormal menstrual patterns and abnormal cervical fluid patterns in adolescence may improve early identification of potential health concerns for adulthood.
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It is important for clinicians to have an understanding of the menstrual patterns of adolescent girls, the ability to differentiate between normal and abnormal menstruation, and the skill to know how to evaluate the adolescent girl patient.
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It is important for clinicians to be educated in what normal and abnormal patterns of cervical fluid look like throughout an adolescence’s cycle, and the skill to know how to evaluate the adolescent girl patient.
One key barrier to getting young women to chart their cycles is the lack of knowledge among health professionals about the importance of these signs. Recommending young women chart their menses is a great first step towards understanding reproductive health, but a chart can go further towards diagnosing abnormalities if it includes signs of cervical fluid.
Many educational opportunities exist for physicians to learn more about charting in order to incorporate it into their practice. Check out our website here at FACTS for more resources, including our online presentations, to help educate physicians and promote greater health literacy through fertility awareness.
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Alison is the Director of Programs at FACTS and also educates women and couples about their fertility as a FertilityCare Practitioner in Washington, DC. She has educated women and couples with knowledge of their fertility since 2009 and is interested in research that helps physicians understand and improve their patient’s fertility.