Highlights
- In young women, the median age of menarche is 12.43 years, the mean cycle interval is 32.2 days in the first gynecologic year, menstrual cycle duration is typically 21 to 45 days, menstrual flow length is less than 7 days, and menstrual product use is 3 to 6 pads daily.
- 10% of women menstruate at 11.1 years, 90% by 13.8 years, and 98% by 15.0 years.
- Menarche typically occurs 2 to 3 years after thelarche at Tanner stage IV breast development and correlates with age of onset of puberty and breast development.
- During the early years of menarche, cycles may be long because of anovulation but 90% of cycles will be within the range of 21 to 45 days.
- When age at menarche is younger than 12 years, as we are now witnessing in India, 50% of cycles are ovulatory.
- When age at menarche is older, it may take 8 to 10 years for the adolescent to become fully ovulatory.
- By the third year after menarche, 60% to 80% of menstrual cycles are 21 to 45 days in duration as is typical of adults.
- Normal cycle length is established around the sixth gynecologic year at a chronological age of approximately 19 years.
- Primary amenorrhea has been defined as no menarche by 16 years.
- Secondary amenorrhea is defined as absence of menses for 6 months but since the 95th percentile for cycle length is 90 days, the guidelines advise evaluation after 90 days of amenorrhea.
- Irregular menses may be caused by pregnancy, endocrine disorders, PCOS, hyperprolactinemia, adrenal and ovarian tumors, drug effects, stress, significant weight loss, or substantial change in eating or sleep habits.
- Mean blood loss per menstrual period is 30 ml.
- Chronic blood loss of more than 80 ml is associated with anemia.
- Most adolescent women report changing pads 3 to 6 times daily; flow requiring a change of pad every 1 to 2 hours is considered excessive.
- Acute menorrhagia is most commonly associated with anovulation.
- The most common hematologic problem causing acute menorrhagia is von Willebrand’s disease; other conditions such as hepatic failure and malignancy are less common. In the general population, the prevalence of von Willebrand’s disease is 1%, but as many as 1 in 6 girls presenting to the emergency department with acute menorrhagia may have von Willebrand’s disease.
- Menstrual conditions that may require evaluation include the following:
- No menses within 3 years of thelarche.
- No menses by 13 years with no pubertal development.
- No menses by age 14 years with hirsutism.
- No menses by 14 years with excessive exercise or weight loss.
- No menses by 14 years with suggestion of genital tract obstruction.
- No menses by 15 years.
- Change from regular to irregular menses.
- Menses more frequently than every 21 days or less frequently than every 45 days.
- Menses 90 or more days apart.
- Menses lasting more than 7 days.
- Pad changes more than once very 1 to 2 hours.
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