Menstrual Cycle as a Vital Sign in Adolescent Girls (Episode 576)

Full Transcript: Episode 576

Lisa Hendrickson-Jack:

This is the Fertility Friday Podcast, episode number 576.

In today’s episode, I am revisiting one of my favorite topics, which is the menstrual cycle as a vital sign. Why we should look at the menstrual cycle as a vital sign. And I think it’s also useful. When I first came out with the book, The Fifth Vital Sign, I think a lot of people hadn’t heard that concept before. So I know that that has been really the center of a lot of my work, I think, from the very start, because this has always been my understanding and this is how I always framed fertility awareness as part of the way that we are able to learn and understand that our cycle is part of us and it’s a reflection of health and all of that. So it’s always been a part of my own personal journey. It was part of my entrance into the world of fertility awareness. And so it was the natural title for my book, The Fifth Vital Sign, to really draw attention to that. And through the course of many interviews and all of the years of talking about it, a lot of people have asked me if I came up with this idea. And ironically, I didn’t come up with the idea. It was definitely presented to me at a young age, and so certainly that has shaped my understanding of it. And one of the examples of that is some of the research that I shared in The Fifth Vital Sign.

In the very first chapter of The Fifth Vital Sign, I share that both the American Academy of Pediatrics, AAP, and the American College of Obstetricians and Gynecologists, ACOG, report that menstruation should be monitored as a vital sign in adolescent girls. So in today’s episode, I’m going to take you through this committee opinion piece that was released in 2015 that really outlines that. One thing I’ll mention is that in this paper, they’re arguing that we should be looking at the menstrual cycle as a vital sign in adolescent girls. So they’re not necessarily saying that we should be looking at it this way in adult women specifically. But what’s interesting is that they’re highlighting some of the key reasons they feel that practitioners should be looking at teenage girls and they should be assessing and analyzing the menstrual cycle as a part of their typical workup. Because if they look at the menstrual cycle in this way, it could allow them to identify potential underlying issues or other problems.

So I’ll actually first start by going through some of their conclusions and recommendations, because of course when you have something that is a committee opinion, they are essentially having a meeting of minds and coming to some sort of consensus. They feel very strongly that this is something that should be done. This should be a standard part of medical practice. And ultimately, we will talk more about that because this came out 10 years ago — well, 10 years in December based on the date — and has clinical practice really changed that much? I would argue that it probably hasn’t changed as much as it needs to. But let’s go through some of their recommendations.

So this committee came together and they recommend that clinicians should educate girls and their caretakers — so not just the teenagers, but their parents also — about what to expect of a first menstrual period and the range of a normal cycle. So they’re saying we should be educating young girls and their parents about what a normal menstrual cycle looks like. Once girls begin menstruating, the clinician should ask at every preventative care or comprehensive visit for the patient’s first day of her last menstrual period and the pattern of menses. So, for me, it’s like, duh. But they’re saying that when you see a teenage girl for any reason, you should always ask about her period. You should ask when her last period was, and you should be asking about how those periods are taking place, how they’re unfolding.

We should be identifying abnormal menstrual patterns in adolescence because identifying them early could improve the early identification of potential health concerns in adulthood. So they’re linking issues with menstruation to potential health concerns in adulthood, of course, which is the key message when we’re looking at the menstrual cycle as a vital sign. They also say it’s important for clinicians to have an understanding of the menstrual patterns of adolescent girls specifically, because they need to have the ability to differentiate between normal and abnormal menstruation. So this is an essential skill, because if they don’t have it, they won’t be able to effectively evaluate their patients, their adolescent girl patients.

So that is the summary of the recommendations that came out of this document. One of the things that I’ll touch on in today’s episode is that when you look at research, I love looking at research. I think we’re blessed to live in a time where we can do this, we can really assess what’s going on, and we can turn to evidence-based sources for greater information, especially at a time when so many women suffer with menstrual health issues and they don’t feel that they’re fully being supported or listened to by their clinicians in many cases.

But the reality is that the research tells us that it takes an average of about 20 years before new research is implemented in standard medical practice. And you hear that stat and you think that can’t be right. Especially with all these people now talking about research, with all of the media that we have, with the internet. It can’t be right. It can’t be that it takes 20 years from when we have new research findings to when these ideas are implemented as standard practice in medical visits where the average patient goes into the medical office and this is the standard of care that they’re getting. But if you think about what I’m saying to you, that’s the reality of the situation because a lot of the research that we have been speaking about in this podcast over the past 11 years — that’s still not in routine practice. And the date of this paper is December 2015. So based on that scientific background around how long it takes research to become implemented in common practice, we’re still looking at 10 more years before this could be normalized.

So although there are more doctors, there are more clinicians that are looking at this and are asking these questions, think about your own personal life, your own experience. If you are a parent, if you have a young daughter, niece, if you have young adolescent girls in your life, think about if this is really happening yet. And it probably isn’t. Not to the degree that it should be. So I just wanted to point that out because I find it to be really powerful that this is coming out of ACOG — they’re saying this should be done at every appointment. But then my question is, if it’s not being done at every appointment, then what can we do to support these adolescent girls?

And ultimately, one big step — because they did identify it themselves — is for the parents to be educated. So as the parent, as the caregiver, we need to become as educated as possible about the menstrual cycle. If you are a women’s health professional and you are not up to date with your knowledge around fertility awareness and the menstrual cycle, then that is a huge missed area of opportunity.

So, a little bit of background information that’s really helpful, especially when we’re looking at teenage girls. The average age of menarche, which is a girl’s first period, is still falling somewhere between 12 and 13 years, according to this research. And they provide some guidelines because they want the medical providers as well as the guardians and the parents and everyone to have an understanding of how it should look when it happens normally. So what they’re saying is that menarche typically occurs within about two to three years of what they call the Tanner stages of development. The Tanner stages of development is a medical outline for what is supposed to happen in puberty and how development is supposed to unfold. So when girls start to develop those lovely breast buds — I can remember when I had mine — they’re saying that in a normal situation, menarche, so your first period, should typically occur about two to three years after that. So if it’s going well beyond this time, she’s had the breast bud, she’s had some development, but we’re not seeing the period come, then that is an issue.

So the first step with using the menstrual cycle as a vital sign in any context is establishing what is actually normal, so that we know what normal is, and then that helps us to identify what is going on if it’s abnormal. Another stat from the paper is that by 15 years of age, 98% of females will have had their first period. So that’s really useful. Even on the podcast, I’ve interviewed a few women, and over the years I’ve had many conversations with women, clients, practitioners. And every now and then I speak to someone who said, “Yeah, I didn’t get my first period until I was 17.” Or, “I didn’t get my first period till I was 18.” Or, “I didn’t get my first period at all — I was put on the pill and I didn’t get my first period until I was 30.” None of those situations are normal.

And I remember having a conversation — I don’t remember if it was on this podcast or if I was interviewed on another podcast — but I said something like this, and the person I was speaking to kind of shared, “Well, you know, in some families it just happens later and it’s normal.” And it was kind of trying to normalize having a period at like 17 or 18, saying it was normal. And I pushed back on that because if it is normal, like if the person’s healthy and fine, then that’s its own thing. But even in this paper, they’re saying that if it’s going past age 16, 17, it warrants investigation. And that was more my point. It doesn’t mean we just automatically say that everything’s problematic. But what I can say is all the conversations that I’ve ever had with someone who tells me that they didn’t have their period until 16 or 17 or 18 — when you get into a conversation about their athletic activities, their diet, their eating, I’m hearing that they exercise a lot and they were really concerned about their weight. That’s just been my experience when I’m speaking to people in that situation.

And so what they’re saying in this paper, essentially, is know what’s normal. Know what falls into the normal parameters. And when it’s falling outside of normal, we need to be investigating. And so at very least, if you’re 16 or 17 and you haven’t had your first period, your doctor should be asking you questions — when have you had your menarche? — and then they should start asking questions about your activity level and exercise and all those things, just to identify if there are any flags that should be looked into.

So what they say in this paper, and I quote: “An evaluation for primary amenorrhea should be considered for any adolescent who has not reached menarche by age 15 or has not done so within three years of when they start developing breasts.” And again, this gives us a parameter, something to look for. They also say that lack of breast development by age 13 should also be evaluated. So they’re giving a variety of different factors that would indicate maybe suboptimal hormone development or hormone balance.

Another important aspect of this paper is that they define menstrual parameters for adolescent girls. And I think this is really useful as well, because a lot of the menstrual parameters that you have heard, if you’re a listener to my podcast, are for adult women of reproductive age. Once we are past menarche and those first three years of development, the menstrual cycle tends to shift into a certain pattern. But during those first two to three years after a girl’s first period, those parameters are a little bit different.

So a few things that they said about that. Menstrual cycles are often irregular during adolescence, particularly the interval from the first to the second cycle. So after the very first cycle, there’s the most irregularity, and then it starts to settle down. They also indicate that the immaturity of the hypothalamic-pituitary-ovarian axis during the early years after menarche often results in anovulation, and the cycles may be somewhat long. But what they say is that 90% of cycles will be within the range of 21 to 45 days.

So what they’re saying is that for adolescents during this time immediately following their menarche, we tend to see some cycle irregularity, some delayed ovulation, some longer cycles — but even so, most of the cycles are between 21 to 45 days. So we don’t automatically jump on anything that isn’t 28 days and call it irregular, because we know that this is a period of time when this is more common. But even so, you can see that there may be some cycles here and there that are over 45 days. By providing these parameters, they’re giving you guidelines. We need to know what’s normal for adolescent girls, especially in those years immediately following menarche, so that we don’t jump to conclusions and assume that there’s something wrong if her cycles are between that range of 21 to 45 days.

Another stat that is really useful that they share is that by the third year after menarche, 60 to 80% of menstrual cycles are 21 to 34 days long, as is typical of adults. So we’re specifically identifying this period during the one to three years immediately following menarche that is characterized by this fluctuation. But once they’re through that, the majority of girls after that first three years, their cycles start to settle down and fall into normal parameters.

And this is something where if you are working with adolescent girls, if you’re working with a female population and you don’t know this information and you just think all cycles are 28 days and you don’t know that there are these additional parameters for adolescent girls, then you may be incorrectly assessing the situation. You may be calling things problems when it’s just a stage of development. We can’t use the menstrual cycle as a vital sign unless we know what is normal — and not just normal in general, but normal for that specific phase.

They also state that it’s statistically uncommon for girls and adolescents to remain amenorrheic for more than three months or 90 days. So if you’re seeing that in your patient population, you should be looking at it. Girls and adolescents with more than three months between periods should be evaluated. They define what’s normal for blood loss and define what is heavy bleeding. They say menstrual flow requiring changes of menstrual products every one to two hours is considered excessive, particularly when associated with a flow that lasts more than seven days at a time. So just establishing general guidelines and encouraging clinicians to be specifically asking about menstruation, because they want to make sure that they’re identifying any potential issues early on.

Heavy menstrual bleeding is commonly associated with anovulation. It’s been associated with diagnoses of bleeding disorders, platelet function disorders, other bleeding disorders, and other serious problems. So they’re making that connection between abnormal menstrual cycle events and underlying health conditions.

Just to kind of wrap it up — they also talk a little bit about the period before a girl’s first period. So when you’re working with young girls in those ages, let’s say 9, 10, 11, leading up to that average age of menarche, they’re saying that they should be providing information to the girls and to the family about what to expect, about what’s normal, to anticipate this and to reinforce that this is a normal part of development. Because all of this would be beneficial. It’s beneficial to educate the parents. It’s beneficial for the clinician to be educated. It’s beneficial to educate the child herself so she knows what to expect. And all of this would lead to better outcomes because the more people that know what the normal parameters are and what to watch for, the more we can identify if there are any issues.

Now, the one thing that does come to mind is that although this all sounds wonderful, we also know how our allopathic medical model responds to every period issue. So while it’s important for these issues to be identified, and particularly identified early, if the solution is just to put every girl on birth control, then that’s hardly the answer. I mean, if you have a lot of doctors identifying potential issues in young teenage girls, the way that they’re trained in medical school is just to put them on the pill, right? Unless there are other issues going on. Ultimately, for hypothalamic amenorrhea — if you have the girl who’s exercising a lot and not eating enough — you would hope that the first line of defense would be to educate the parents about proper diet, nutrition, things like that. But as we know, just ask five women in your life or think of your own experiences. What happened when you went to the doctor and you said you had irregular cycles or heavy bleeding or irregular periods, whatever the case was — PMS, acne — you were told to go on the pill.

So I think that it’s a start to identify the menstrual cycle as a vital sign and to recognize that we need to be paying attention to the parameters of menstruation and to use that information to ensure that women and girls are getting the correct diagnoses as soon as possible. But ultimately, we have to be demanding better in terms of the treatment. Because giving someone a birth control pill that suppresses their ovulation doesn’t solve the problem. It doesn’t help to improve their health. And when they decide to come off the pill, they’re still likely to have that same issue there, because the pill didn’t actually fix it or correct it. The pill is used for symptom management, but it ultimately doesn’t solve the actual problem.

So that would be my thought when I — because this is such wonderful information. It’s wonderful and refreshing to read this coming out of the medical establishment about how we should be using the menstrual cycle as a vital sign and how we should be knowledgeable about the normal parameters so we can identify when they’re going outside of the parameters. But then my question is, how are you going to treat it? Because if you’re just going to put everyone on the pill, then I have an issue with that. When we’re identifying underlying issues, there are theoretically often more natural approaches that we can take to rectify some of those hormonal imbalances.

But I think the first line of defense — if you are a woman, if you are a mother, if you have young women in your life, if you are a women’s health professional who is working with female patients who also have daughters and other young women in their life — the first thing to do is to make sure that we educate ourselves. If we educate ourselves and we have a good idea of what some of these normal parameters are, then that sets us up for success. We can identify things early. And regardless of how the medical system might be responding, it empowers us to have more confidence to seek out the care that we need.

If you have a practitioner, you know what the normal parameters are, you know that your cycles are falling outside of that and you have some concerns, and your practitioner’s like, “Yeah, it’s fine. Just go on the pill.” — you know that you have other options. You can talk to a different type of practitioner. You can look for a functional medicine practitioner who might be more likely to actually address some of those issues from the root cause. It doesn’t have to be that you just have this one option and all paths lead to the pill. It gives us the ability to do better.

And I think when I see pieces like this that are looking at the menstrual cycle in this way, it is certainly refreshing. It is certainly exciting and encouraging because it does mean that things are changing. The tides are turning. And I do believe that things will get better for women. But I don’t think it happens passively. I think that we have to continue to demand better. We have to ask for different options in our doctor’s offices. And ultimately, the more unhappy that we are and make that known with the establishment, the more likely there is to be change. If we’re not talking about it, if we’re not demanding better, if we’re not trying to find ways to improve the situation for women, then nothing’s going to change. But I am certainly optimistic. I do see that there is a lot of forward motion in this area.