17 - Normal Menstrual Cycle

walk through what a healthy teen menstrual cycle looks like, why early cycles are often irregular, and how to recognize red flags that need care. We share practical ways to track flow, choose products, reduce pain, and support teens with sensitivity and clarity.

• menarche timing, influences, and normal ranges
• early anovulatory cycles and HPO axis maturation
• typical cycle intervals and expected variability
• defining normal flow, duration, and clot size
• dysmenorrhea care with NSAIDs and heat
• assessing heavy bleeding using product charts
• clear red flags for evaluation and amenorrhea criteria
• headaches, fainting, nausea, and quality of life
• cycle tracking options and privacy cautions
• product choices, period poverty, and advocacy
• focused adolescent history, nutrition, and activity
• culturally sensitive education and reassurance

What is PAG?
Pediatric and Adolescent Gynecology is a subspecialty of OBGYN (2 year fellowship) focusing on reproductive healthcare for children and young adults. It fills the overlap between general gynecologists and pediatricians. It is a multi-disciplinary field involving work with pediatric endocrinology, dermatology, hematology, surgery, ect. Go to NASPAG.org for more PAG educational resources.

Want to test your knowledge?
PAG WebEd cases are a great way to review our podcast content. 

Transcript

Welcome And Case Overview

SPEAKER_00 0:24

A 15-year-old underwent netarchy at age 13 and a half. Her periods have been coming at different times each month, and the number of days between them are variable. Her cycle lengths are 26 days, 36 days, 28 days, and 22 days. She is worried that she will always have irregular periods. Hi everyone. Welcome to Pag Over Pastries, a 20 to 30 minute review podcast regarding all things pediatric and adolescent gynecology. I'm Dr. Susan Kaufman, and I am a pediatric and adolescent gynecologist at Virtua Health in South Jersey. And with me today is Hello, I am Dr.

SPEAKER_01 1:06

Alia Fontaine, and I am a third-year resident in obstetrics and gynecology at Yale New Haven Hospital. It is a pleasure to be on this podcast. Thank you so much for having me in the opportunity.

SPEAKER_00 1:17

Well, thank you. I'm happy to have you join me. So today we will be talking about the normal menstrual cycle. Our reference is The Essentials of Pediatric and Adolescent Gynecology, which is a textbook that has been released by NASBAG. This is chapter eight, and it was written by Megan Harrison, Shelby Davis, and Andrew LuPau. So, Aliyah, what's your favorite pastry?

SPEAKER_01 1:43

I will have to say it is very seasonal, and currently it is an apple cider donut.

SPEAKER_00 1:49

Oh, that sounds great. All right, so why don't you get started?

Timing Of Menarche And Influences

SPEAKER_01 1:57

We know that the menstrual cycle is a marker of health. It's extremely important for us to discuss this today because treating the menstrual cycle is a vital sign. We must have timely identification of any abnormal menstrual patterns so we can best assist our patients in early identification of potential health issues. When we think about what is normal, first and foremost, the age range for normal menses, it does uh vary worldwide. Typically, that range is between ages 10 to 15, with a median age of 12 to 12 and a half. However, there are various factors that can influence the age of menarchy. For example, certain factors can be associated with earlier onset around the world. Some of those factors include nutritional status being more robust, higher BMI, higher socioeconomic status, but other factors that are also important and play a role would be physical health, activity level, emotional state, and ethnicity. And typically the onset of menses will occur about two to three years after the Larchy.

SPEAKER_00 3:07

And we need we should keep in mind that this is a tumultuous time for teenagers. Not only are they undergoing physical changes, but emotional changes. And, you know, it's our job to push for more and more education so young ladies know what's happening and why it's happening. But unfortunately, there's still a stigma that surrounds menses and menstrual products, um, not only in our country, but all around the world.

SPEAKER_01 3:37

We've talked about what is normal. Um, and uh the next question I have for you, Dr. Kaufman, would be: what is a normal menstrual cycle interval in that first year and in those first few years after menarchy?

Early Cycle Patterns And Physiology

SPEAKER_00 3:50

Some young ladies will regulate immediately, and others can take six months. The textbooks say that people should be fairly regulated within two years, but actually it can take two to five years for periods to regulate. So generally, initially, we'll see cycles of 21 to 42, 45 days. Periods may last less than seven days, but in my experience, the younger a young lady starts her periods, the more bleeding that she has. Average pad or tampon use is about three to six per day, but again, it depends on whether they're using a superabsorbent menstrual product. There's a positive feedback loop that goes from the ovary to the pituitary. And as the ovary starts to make more estrogen, it stimulates LH production, and that stimulates ovulation and progesterone production, and that's what helps to regulate periods. In the first couple of years, 50 to 80 percent of periods will be anovulatory, and that's why they'll be irregular. Now there are other reasons for irregularity like hormonal issues and so on, but the primary reason is just anovulation due to an immature hypothalamic pituitary axis. The textbook says that the younger someone is when they experience menarchy, the quicker their cycles become ovulatory, implying regularity. But in my experience, I see just the opposite. When I see nine and ten-year-olds starting their periods, I think they are more irregular, they bleed longer and heavier and stay irregular for a longer period of time.

SPEAKER_01 5:41

I was very curious about that. I have not seen too many Haitians yet in my early training with this concern. So thank you for sharing the clinical expertise.

Blood Loss, Symptoms, And Pain Care

SPEAKER_00 5:52

You're welcome. And there's some evidence to suggest that the age of menarchy is moving down. You had mentioned 12 years and four months. Other places, sources have mentioned 11 years and nine months. So, what about blood loss? Everybody thinks they're bleeding too much and too heavily. So, how do we interpret that?

SPEAKER_01 6:12

So, definitely I would like to talk about the blood loss and also the symptoms. Uh, so blood loss, we talk about you should not have more than three to six pads or tampons a day. Your period typically shouldn't last longer than a week. Um, and we recognize that yes, it's okay to have clots, but those clots should typically be very small, maybe the size of a quarter or less. And, you know, like you mentioned before, there can be some variation in duration of the cycle. So it can be 21 to 45 days in those first two to five years before the period becomes a little bit more normal. And you can quickly say, Yes, my menstrual cycle comes every 28 days, like clockwork. Symptoms that are very common for someone to experience alongside their mencies can include dysmenorrhea, defined as this episode of pain with the menstrual cycle. Um, it can lead to, unfortunately for some patients, impacting their quality of life where they can't go to school or go to work because the pain is so severe. But typically, there are supportive measures when patients have this type of dysmenorrhea or um pain associated with their menstrual cycle that can be regulated with some non steroidals as long as they do not have any contraindications and then supportive measures like hot packs, form compresses, and repositioning. Other things can include feeling bloated, some people have hormonal uh imbalances, and then they have the manifestation of that and mood changes as well.

unknown 7:39

Yeah.

Measuring Flow And Product Variability

SPEAKER_00 7:40

Um, I just want to make another comment about the quantity of bleeding. The textbook says 40 milliliters, but if you break that down into, you know, five pads a day, five milliliters on each pad, 40 milliliters seems like a very small amount. And so we have to take a really good history when somebody comes in because they're having heavy periods. You have to know exactly what products they're using. There are now ultra super tampons, and of course, there's the overnight pads, and a lot of young ladies are wearing period underwear, all of which make it difficult to quantify. There are some charts you can use with your patients that show pictures of pads and tampons, and you can show them a chart and say, tell me what your pad or tampon looks like.

SPEAKER_01 8:32

Do you use any type of charts at your in your practice, Dr. Cox?

SPEAKER_00 8:35

Yes, I do. I do. So and and the other thing besides using charts, sometimes I make my own, sometimes I get them off the internet, is sometimes I just take a piece of paper and draw a pad and ask the and give the young lady a crayon and say, color this in for me. Show me what your average pad looks like. If she's having trouble really picking something off the chart, I ask her to draw it for me. And that really helps me to understand. Aside from starting periods and having irregular periods, and we talked about the reasons for that. Sometimes people don't start their periods when we expect them to, or we they continue to be irregular. So, what are some indications that we should evaluate somebody and not just tell them, oh, this is normal, just wait it out?

Red Flags That Need Evaluation

SPEAKER_01 9:24

There are actually quite a few, and I'm very excited to go through these and to talk about them currently. So uh one of the first ones is uh a patient who presents and they don't they have not seen their period within three years of breast blood development. Um, there's patients who um have not had a venstrual cycle and they don't have breast development and they've reached the age of 13. There are patients who do not have menarchy and they do have breast development and they now have reached the age of 15. Patients who are now having a longer duration of irregular menses, um, three years post the initiation of their menstrual cycle, regular menses that are very irregular, whether that's in quantity or quality or the cycle length duration, mencies that are occurring more frequently than 21 days or less frequently than 45 days. As you can recall, this window between 21 to 45 days is our normal period. And if we think about a cycle duration that's also going beyond every three months before a patient is seeing their menstrual cycle. I also previously was discussing how a period typically shouldn't last beyond seven days. So when a patient is presenting with continued bleeding beyond seven days, that is not normal. Um, and then and we would like to have further evaluation. And the most another most common thing I've seen from the side of being a resident who is seeking consults for pediatric patients that present to the emergency department really are patients that are bleeding through the products that they're using or having to change their sanitary items more frequently than every two hours. And that is not normal and they should attain additional workup. The other important aspects of patients who definitely should seek support and workup, additional evaluation would include patients who are having pain with their activities, like I mentioned before, dysmenorrhea, such that if they can't go to school, they can't go to work, the supportive measures are not making a dent. You know, they've tried medicational options as well, and their menstrual cycle is intolerable, dare I say. And then if a patient is presenting to the practice and um or presenting for uh for evaluation, and you can tell that there's some underlying and or associated severe mental health concerns, whether that's gender dysphoria, depression, or suicidal ideation that is associated with their menstrual cycle, definitely there should be additional workup and studies.

Headaches, Fainting, And Quality Of Life

SPEAKER_00 12:09

Right, right. And these mental health effects from the period are not uncommon and should be taken very seriously. And besides cramps and heavy bleeding, girls can have headaches. There's something called catamenial headaches where they occur exclusively with the period, starting just before when the estrogen level starts dropping in the luteal phase and they get a headache. Some people may pass out from their periods, especially with very severe cramps. Some young ladies have significant nausea and vomiting, and this can lead to dehydration and dizziness. Some young ladies will get heart palpitations and other symptoms. So these are, you know, all serious symptoms that need to be dealt with because not only do they impact somebody from a medical health standpoint, but they impact young women in their quality of life. Like you said, we can't just tell girls, oh, just go to bed, stay in bed for a week, get up when your period's over, like they used to do 30 years ago. That doesn't work anymore.

SPEAKER_01 13:18

No. And I think it just reiterates what we talked about earlier: menstrual periods and understanding normal and abnormal is vital. It is a vital sign.

SPEAKER_00 13:30

So when somebody comes in and we're gonna and they want to talk about their periods and we're, you know, taking their history and taking their menstrual history, what are some things we want to suggest that they do in terms of their periods?

SPEAKER_01 13:45

There are many options, uh, right? Like depending on what the patient desires, they can use a paper calendar, they can use an electronic calendar. There are so many apps these days that are created to help support um logging and tracking ovulation, initiation of mencies, completion of mencies, and it can really be partnered even with the patient's fertility goals and family planning needs. And most importantly, it can be very helpful ways to really understand what their menstrual cycle looks like. And um, like Dr. Kaufman mentioned, what the volume that is that they're experiencing from their menstrual cycle.

SPEAKER_00 14:21

But we also have to keep in mind that not everything we put on the cloud is confidential. So it's it's always good to caution somebody to be careful what they might be writing in their menstrual calendar.

SPEAKER_01 14:34

In your practice, what do you typically see as a different types of period products that adolescents are using? Because there's so many options out there.

Tracking Cycles And Privacy

SPEAKER_00 14:42

There are so many. And every once in a while I take a stroll down the menstrual product aisle in the store, so I can keep fresh about what's there. All kinds of tampons that, you know, go from slim and athletic to ultra-absorbent. We have the same thing with pads. There are pull-ups for young women who are having very heavy periods. We have menstrual cups, both reusable and disposable. And we have period panties, which is something that came out maybe 10 years ago. And there are multiple companies that manufacture them now, and they are really a boom to taking care of yourself during your period, especially if you are in a situation where you have what's called period poverty or menstrual product poverty. The pants are expensive, but when you buy one pair, that's a whole different situation than buying a full box of pads or a full box of tampons. And it's uh good to have a handout or have a conversation with our patients about all these products.

SPEAKER_01 15:50

It's really important to start considering what exactly is my patient using and how saturated is it? How often are they changing it?

SPEAKER_00 15:59

There's been a big push to give access to period products and make them free. In many states, period products are taxed, but it's a medical item. A lot of schools don't provide them. You know, it's a good project for someone who may be in a school where they're not providing them free for the students.

SPEAKER_01 16:20

That sounds like an area for advocacy.

SPEAKER_00 16:23

Definitely. All right. So now we have this 15-year-old who's coming in concerned about her periods, and we're gonna take a history. So, what kind of questions do we want to ask her?

Period Products And Access

SPEAKER_01 16:37

I definitely need to understand, obviously, her background, her history, her medications, her allergies, her family history, like all of that is something hopefully we've already talked about, whether in a screening questionnaire or during the visit as well. But um I want to make sure I'm understanding, as you mentioned before, her pubertal stages. Like when did she experience tharchy in relation to the initiation of her menarchy? I want to know what her menstrual duration it looks like, how frequently she's having men sees, not just for the times that she's given us, but maybe a little bit longer frame if she can provide that. I'm very curious to know about the amount of flow and I love it. I can see myself taking a white sheet of paper, drawing out a pad, and asking her to color it in for me here. And then, you know, I want to make sure that I'm not missing out on what her hygiene and access looks like, regardless of the volume that she's identified to me that she's having per menstrual cycle. I'm curious to know if she's experiencing any associated symptoms with her menses. As Dr. Kaufman mentioned, some patients can have really bad headaches, nausea vomiting. We know that dysmenorrhea can also occur with menstrual cycle. Of course, uh, for all adolescent patients who have endorsed that they are sexually active, I would like to take more history from them about sexual activity.

Taking A Focused Adolescent History

SPEAKER_00 17:54

Right, absolutely. And something else, I always ask about their physical activity level. You know, are they involved in sports, dance, gymnastics, cheer, music? Because the the amount of physical activity um or lack of physical activity can impact their periods. I also take a nutrition history that will also impact periods, both the initiation, both menarchy, and then the regularity of the periods and who they live with, because that can impact mental health, and then that can impact their periods.

SPEAKER_01 18:30

What does your nutritional status uh history portion look like? Can I hear a little bit more about that?

SPEAKER_00 18:35

Okay. I ask them do they eat breakfast and what do they eat? What's a common breakfast for them? Do they eat lunch and are they eating a school lunch? Are they packing their lunch? And specifically, what are they eating in school? Because they might say, Yeah, I eat a school lunch, but they're eating chips or fries. Or they might say, I'm packing something, but they're bringing just a piece of fruit and nothing more. So their their nutritional history is going to impact their periods and how fast they regulate. The other thing that I do is if I have a 9, 10, 11, 12-year-old who comes in with menstrual concerns, the first thing I do is I ask them, what is a period? And do you know what a period is? Do you know why you get a period? Do you know where the blood is coming from? And I would say 85 to 90% of the time I just get blank stares. Either they haven't had classes in school about this, or there hasn't been enough time at home for adequate conversation. And so I ask them, would you like me to explain this to you? And I'll bring up a picture of a uterus, tubes, ovaries, vagina, and I'll talk about how this process works. Because you can never have enough education. And I think my patients appreciate it. And if they don't want to hear it, they tell me and we move on.

Nutrition, Activity, And Education

SPEAKER_01 20:01

And you are able to fill in the gaps and help them because they'll go and tell their friends or their siblings and whoever they feel comfortable with. And this helps expand the dialogue and also say that this is normal. That is normal to have this, you know, and let's make sure you're aware what will be abnormal. So these conversations behind the scenes and feeling more comfortable in their bodies will make it and you know more powerful. For them, whether at home or at school or the next time they have a visit.

Resources, Survey, And Contact Info

Cultural Sensitivity And Communication

SPEAKER_00 20:27

Right. And you make a very important point. Sometimes we dwell on the abnormal. It's so important to emphasize what's normal. And I would just add that we have to be sensitive in how we ask our questions because we are dealing with very young ladies who are not used to talking about all of these very private things. We're dealing with different cultures that may have different approaches to explaining this and may not even talk about it. We may have moms that are just like, I can't talk to my daughter about this. That's going to be your job or the school's job. So just being sensitive in how we address the subject and ask our questions. Okay, so back to our case. So the patient has cycle-to-cycle variability, as is typically seen in adolescence. Within three years of menarchy, the period cycles typically become more consistent. So that's what we can advise our patient and follow her along through this time span. Just don't send her away and say, come back to me in three years if you're still having very variable cycles. But you know, see her on a regular basis to assess how she's doing. For more information, please visit Tagover Pastries page on our NASBAG website. And this will include a transcript of all the podcasts and links to references. Thank you so much for listening to our podcast today. We also invite you to visit the NASBAG website to fill out a brief survey that will help us know who our listeners are and how we can continue to grow our podcasts. If you have any questions for today's speaker or feedback for us, please feel free to email us at Pag Capital P A G over Pastries at gmail.com. And Aliyah, it's been a pleasure recording with you today. Thank you so, so much. You've made this so much fun and educational.

SPEAKER_01 22:38

It's been a pleasure for me as well. Thank you for talking about