Number 651 (Replaces Committee Opinion 349, November 2006. Reaffirmed 2020)
Committee on Adolescent Health Care
The American Academy of Pediatrics endorses this document. This document reflects emerging concepts on patient safety and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
ABSTRACT: Despite variations worldwide and within the U.S. population, median age at menarche has remained relatively stable—between 12 years and 13 years—across well-nourished populations in developed countries. Environmental factors, including socioeconomic conditions, nutrition, and access to preventive health care, may influence the timing and progression of puberty. A number of medical conditions can cause abnormal uterine bleeding, characterized by unpredictable timing and variable amount of flow. 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. Identification of abnormal menstrual patterns in adolescence may improve early identification of potential health concerns for adulthood. 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. By including an evaluation of the menstrual cycle as an additional vital sign, clinicians reinforce its importance in assessing overall health status for patients and caretakers.
Conclusions and Recommendations
Based on the following information, the American College of Obstetricians and Gynecologists provides these conclusions and recommendations:
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.
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.
Identification of abnormal menstrual patterns in adolescence may improve early identification of potential health concerns for adulthood.
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.
Background
Young girls and their caretakers (eg, parents or guardians) frequently have difficulty assessing what constitutes normal menstrual cycles or patterns of bleeding. Patients and their caretakers may be unfamiliar with what is normal and patients may not inform their caretakers about menstrual irregularities or missed menses. In addition, a patient is often reluctant to discuss this topic with a caretaker, although the patient may confide in another trusted adult. Some adolescent girls may seek medical attention for cycle variations that actually fall within the normal range or may be unaware that their bleeding patterns are abnormal and may be attributable to significant underlying medical issues with the potential for long-term health consequences.
Clinicians also may be unsure about normal ranges for menstrual cycle length and the amount of menstrual bleeding during adolescence. Clinicians who are confident in their understanding of early menstrual bleeding patterns will be able to convey information to their patients more frequently and with less prompting; girls who have been educated about menarche and early menstrual patterns will experience less anxiety when they occur 1. By including an evaluation of the menstrual cycle as an additional vital sign, clinicians reinforce its importance in assessing overall health status for patients and caretakers. Just as abnormal blood pressure, heart rate, or respiratory rate may be key to diagnosing potentially serious health conditions, identification of abnormal menstrual patterns in adolescence may improve early identification of potential health concerns for adulthood.
Normal Menstrual Cycles
Menarche
Despite variations worldwide and within the U.S. population, median age at menarche has remained relatively stable—between 12 years and 13 years—across well-nourished populations in developed countries Box 1 2 3. The U.S. National Health and Nutrition Examination Surveys have found no significant change in the median age at menarche over the past 30 years, except among the non-Hispanic black population which has a 5.5-month earlier median age at menarche than it did 30 years ago 2. Studies have shown that a higher gain in body mass index during childhood is related to an earlier onset of puberty 4 5 that may result from attainment of a minimal requisite body mass index at a younger age. Environmental factors, including socioeconomic conditions, nutrition, and access to preventive health care, may influence the timing and progression of puberty 6.
Box 1.
Normal Menstrual Cycles in Adolescent Girls
| Menarche (median age): | 12.43 years |
| Mean cycle interval: | 32.2 days in first gynecologic year |
| Menstrual cycle interval: | Typically 21–45 days |
| Menstrual flow length: | 7 days or less |
| Menstrual product use: | Three to six pads or tampons per day |
Menarche typically occurs within 2–3 years after thelarche (breast budding), at Tanner stage IV breast development, and is rare before Tanner stage III development 7. By age 15 years, 98% of females will have had menarche 2. An evaluation for primary amenorrhea should be considered for any adolescent who has not reached menarche by age 15 years or has not done so within 3 years of thelarche. Lack of breast development by age 13 years also should be evaluated 8.
Cycle Length and Ovulation
Menstrual cycles are often irregular during adolescence, particularly the interval from the first cycle to the second cycle. Most females bleed for 2–7 days during their first menses 9 10. Immaturity of the hypothalamic–pituitary–ovarian axis during the early years after menarche often results in anovulation and cycles may be somewhat long; however, 90% of cycles will be within the range of 21–45 days 11, although short cycles of less than 20 days and long cycles of more than 45 days may occur. By the third year after menarche, 60–80% of menstrual cycles are 21–34 days long, as is typical of adults 10 11 12.
Abnormal Uterine Bleeding
A number of medical conditions can cause abnormal uterine bleeding, characterized by unpredictable timing and variable amount of flow. Although a long interval between cycles is common in adolescence due to anovulation, it is statistically uncommon for girls and adolescents to remain amenorrheic for more than 3 months or 90 days (the 95th percentile for cycle length). Girls and adolescents with more than 3 months between periods should be evaluated. Although experts typically report that the mean blood loss per menstrual period is 30 mL per cycle and that chronic loss of more than 80 mL is associated with anemia, this has limited clinical use because most females are unable to measure their blood loss. Menstrual flow requiring changes of menstrual products every 1–2 hours is considered excessive, particularly when associated with flow that lasts more than 7 days at a time.
Abnormal uterine bleeding may be caused by ovulatory dysfunction, and bleeding patterns can range from amenorrhea to irregular heavy menstrual bleeding. Although ovulatory dysfunction is somewhat physiologic the first few years after menarche, it can be associated with endocrinopathies due to hypothalamic–pituitary–ovarian axis disturbances, such as polycystic ovary syndrome and thyroid disease, as well as mental stress and eating disorders 13 14. Heavy menstrual bleeding, commonly associated with anovulation, also has been associated with the diagnosis of a coagulopathy (including von Willebrand’s disease, platelet function disorders, and other bleeding disorders) or other serious problems (including hepatic failure) and, rarely, malignancy 15 16 17 18 19. See Box 2 for a list of potential causes of abnormal uterine bleeding in adolescents. The diagnosis of pregnancy, sexual trauma, and sexually transmitted infections should be excluded, even if the history suggests the patient has not been sexually active.
Box 2.
Causes of Abnormal Uterine Bleeding in Adolescent Girls
Pregnancy
Immaturity of the hypothalamic–pituitary–ovarian axis
Hyperandrogenic anovulation (eg, polycystic ovary syndrome, congenital adrenal hyperplasia, or androgenproducing tumors)*
Coagulopathy (eg, von Willebrand disease, platelet function disorders, other bleeding disorders, or hepatic failure)†
Hypothalamic dysfunction (eg, eating disorders [obesity, underweight, or significant fast weight loss] or stress-related hypothalamic dysfunction)
Hyperprolactinemia
Thyroid disease
Primary pituitary disease
Primary ovarian insufficiency‡
Iatrogenic (eg, secondary to radiation or chemotherapy)
Medications (eg, hormonal contraception or anticoagulation therapy)
(Video) The Menstrual Cycle as a Vital Sign in Navigating Rare DiseaseSexually transmitted infections (eg, cervicitis)
Malignancy (eg, estrogen-producing ovarian tumors, androgen-producing tumors, or rhabdomyosarcoma)
Uterine lesions
*See Polycystic ovary syndrome. ACOG Practice Bulletin No. 108. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:936–49 http://www.acog.org/-/media/Practice-Bulletins/Committee-on-Practice-Bulletins----Gynecology/pb108.pdf?dmc=1&ts=20150918T1543541376 and Management of adnexal masses. ACOG Practice Bulletin No. 83. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 110:201–14 http://www.acog.org/-/media/Practice-Bulletins/Committee-on-Practice-Bulletins----Gynecology/pb083.pdf?dmc=1&ts=20150918T1547432631.
†See Von Willebrand disease in women. Committee Opinion No. 580. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:1368–73 http://www.acog.org/-/media/Committee-Opinions/Committee-on-Adolescent-Health-Care/co580.pdf?dmc=1&ts=20150918T1548433882.
‡See Primary ovarian insufficiency in adolescents and young women. Committee Opinion No. 605. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:193–7http://www.acog.org/-/media/Committee-Opinions/Committee-on-Adolescent-Health-Care/co605.pdf?dmc=1&ts=20150918T1549212476.
Anticipatory Guidance
Clinicians should include pubertal development in their anticipatory guidance to children and caretakers beginning at the 7 year and 8 year visits 20. Clinicians should take an ongoing history and perform a complete annual examination, including the inspection of the external genitalia. It is important to educate girls and their caretakers about the usual progression of puberty and development of the menstrual cycle. Clinicians should convey that females will likely begin to menstruate approximately 2–3 years after breast development begins. Adolescent girls should understand that menstruation is a normal part of development and should be instructed on the use of feminine products and on what is considered normal menstrual flow. It is preferred that caretakers and clinicians participate in this educational process.
Evaluation
Preventive health visits should begin during adolescence to start a dialogue and establish an environment where a patient can feel good about taking responsibility for her own reproductive health and feel confident that her concerns will be addressed in a confidential setting 20 21. Because menarche is such an important milestone in physical development, clinicians should educate adolescent girls and their caretakers about what to expect of a first menstrual period and the range for normal cycle length of subsequent menses. Once adolescent 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. 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.
Asking the patient to chart her menses may be beneficial, especially if her menstrual history is too vague or considered to be inaccurate. The importance of accurate charting should be emphasized and the patient should be educated about what would be considered an abnormal menstrual cycle. Clinicians should explain that cycle length is counted from the first day of a menstrual period to the first day of the next menses and may vary by cycle because this often leads to miscommunication between patients and clinicians. Use of technology can facilitate charting; there are a number of easy to use smart phones applications designed for this purpose.
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. Menstrual abnormalities that suggest the need for further evaluation are listed in Box 3.
Box 3.
Menstrual Abnormalities That May Require Evaluation
Menstrual periods that
have not started within 3 years of thelarche
have not started by 14 years of age with signs of hirsutism
have not started by 14 years of age with a history or examination suggestive of excessive exercise or eating disorder
have not started by 15 years of age
occur more frequently than every 21 days or less frequently than every 45 days
occur 90 days apart even for one cycle
last more than 7 days
require frequent pad or tampon changes (soaking more than one every 1–2 hours)
are heavy and are associated with a history of excessive bruising or bleeding or a family history of a bleeding disorder
Copyright December 2015 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved. ISSN 1074-861X Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Committee Opinion No. 651. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e143–6.
FAQs
How does menstrual cycle affect the vital signs? ›
The menstrual cycle—a complex process orchestrated by interactions between many of the body's tissues, cells, and hormones—reflects a person's overall health status and can be thought of as a “fifth vital sign,” along with blood pressure, body temperature, heart rate, and respiratory rate.
What is the menstrual cycle of an adolescent girl? ›While menstrual cycles tend to vary among adolescents, the length of a normal cycle ranges between approximately 20 to 45 days, with a mean cycle length of 32.2 days in the first and second gynecologic years.
Is menstrual health a vital sign? ›After blood pressure, heart rate, oxygenation, temperature, and pain, pediatricians should include an evaluation of menstrual cycles for adolescent females when assessing overall health, according to a recommendation from the American College of Obstetricians and Gynecologists (ACOG).
What is menstruation and menstrual cycle what happens in the body of female during menstrual cycle? ›Menstruation is a woman's monthly bleeding, often called your “period.” When you menstruate, your body discards the monthly buildup of the lining of your uterus (womb). Menstrual blood and tissue flow from your uterus through the small opening in your cervix and pass out of your body through your vagina.
Why hormones play a vital role in menstrual cycle? ›Luteinizing hormone and follicle-stimulating hormone, which are produced by the pituitary gland, promote ovulation and stimulate the ovaries to produce estrogen and progesterone. Estrogen and progesterone stimulate the uterus and breasts to prepare for possible fertilization.
What is the relationship between blood pressure and menstrual cycle? ›During the second half of the cycle (approx. days 14–28), the uterine lining is formed. At the end of this phase, if the egg is not fertilized, it will be excreted with the menstrual blood. Blood pressure and body temperature may be slightly elevated as compared to the first half of the cycle (on average 1-2 mm Hg).
What is the menstrual cycle explained to girls? ›The menstrual cycle is a natural process. It is a complex cycle controlled by female hormones that cause regular bleeding (periods). The menstrual cycle has four phases: menstruation, the follicular phase, ovulation and the luteal phase. Some women may experience menstrual problems (e.g. heavy bleeding).
Why is it common for adolescent girls to have irregular menstrual cycles? ›Young girls commonly experience DUB because their menstrual cycles have not yet settled into a pattern and ovulation isn't occurring. Older adolescents may not ovulate with stress or illness.
What are the three vital signs? ›- Body temperature.
- Pulse rate.
- Breathing rate (respiration)
- Blood pressure.
Vital Signs (Body Temperature, Pulse Rate, Respiration Rate, Blood Pressure)
What are the two main functions of the menstrual cycle? ›
The first part of the cycle (follicular phase) prepares an egg to be released from the ovary and builds the lining of the uterus. The second part of the cycle (luteal phase) prepares the uterus and body to either accept a fertilized egg or to start the next cycle if pregnancy doesn't occur.
What happens during the menstrual cycle quizlet? ›Oestrogen causes the eggs in the ovaries to mature and the endometrium lining to thicken. Progesterone is produced to thicken the endometrium lining to prepare for implantation of a fertilised egg. Oestrogen and progesterone levels drop so the endometrium sheds and then begins the menstrual bleed.
Does estrogen play a vital role in regulating females menstrual cycle? ›Menstrual cycle
Estrogen plays a role in ovulation (when your ovaries release an egg) and thickens the lining of your uterus (endometrium) to prepare it for pregnancy.
The menstrual cycle is governed by an interaction between reproductive hormones (LH, FSH, oestradiol and progesterone) that result in growth of a follicle (follicles are fluid-filled sacs in the ovaries that contain eggs), ovulation (release of the egg from the ovary into the fallopian tubes), formation of the corpus ...
What are the vital roles of hormones? ›Hormones affect everything from blood sugar to blood pressure, growth and fertility, sex drive, metabolism, and even sleep. Their influence goes as far as changing the way we think and act day to day. There is no doubt that hormones are powerful.
How does menstrual cycle affect pulse rate? ›How does your period affect your heart rate? Your hormones fluctuate throughout your menstrual cycle. Generally, your heart rate increases slightly during ovulation and the week afterward (luteal phase). It decreases slightly during your period and the week afterward (follicular phase).
Does menstruation lower blood pressure? ›A heavy period can result in low blood pressure because you're losing more blood than normal. In a normal menstrual cycle, a woman loses an average of two to three tablespoons of blood over four to eight days.
What is the relationship between hormones and blood pressure? ›Changes in hormones during menopause can lead to weight gain and make blood pressure more sensitive to salt in the diet — which, in turn, can lead to higher blood pressure. Some types of hormone therapy (HT) for menopause also may lead to higher blood pressure.
What is a girl's first period called? ›Introduction. Menarche is defined as the first menstrual period in a female adolescent. Menarche typically occurs between the ages of 10 and 16, with the average age of onset being 12.4 years.
What would happen if a woman never got her period? ›reduce fertility. reduce your chances of falling pregnant. increase the risk of cardiovascular disease – such as high blood pressure. increase the risk of early onset osteoporosis – a long-term disease that makes your bones less dense and more fragile.
What if my daughter has her first period then nothing? ›
It's common, especially in the first 2 years after a girl starts getting her period, to skip periods or to have irregular periods. Illness, rapid weight change, or stress can also make things more unpredictable. That's because the part of the brain that regulates periods is influenced by events like these.
What are the 5 most important vital signs? ›- Body temperature. ...
- Pulse or heart rate. ...
- Respiratory rate. ...
- Blood pressure. ...
- Oxygen level/saturation (SpO2)
Vital signs reflect essential body functions, including your heartbeat, breathing rate, temperature, and blood pressure. Your health care provider may watch, measure, or monitor your vital signs to check your level of physical functioning.
Why is it important to monitor vital signs? ›Monitoring vital signs helps nurses identify when a patient has an elevated heart rate or blood pressure, which could indicate dehydration or shock; rapid breathing, which could indicate respiratory distress; or low blood pressure, which could indicate shock.
What is the best order for vital signs? ›The order of obtaining vital signs is based on the patient and their situation. Health care professionals often place the pulse oximeter probe on the patient while proceeding to obtain their pulse, respirations, blood pressure, and temperature.
What are the 6 types of vital signs? ›The six classic vital signs (blood pressure, pulse, temperature, respiration, height, and weight) are reviewed on an historical basis and on their current use in dentistry.
Why are vital signs called? ›Vital signs are an objective measurement of the essential physiological functions of a living organism. They have the name "vital" as their measurement and assessment is the critical first step for any clinical evaluation.
Why are vital signs so vital? ›Your vital signs measure your body's basic functions. Vitals display a snapshot of what's going on inside your body. They provide crucial information about your organs. Therefore, the importance of vital signs monitoring is that it allows medical professionals to assess your wellbeing.
What is the normal heart rate? ›A normal resting heart rate should be between 60 to 100 beats per minute, but it can vary from minute to minute. Your age and general health can also affect your pulse rate, so it's important to remember that a 'normal' pulse can vary from person to person.
How does the uterus change during the menstrual cycle? ›The levels of estrogen gradually rise, signalling the start of the follicular, or proliferation, phase of the menstrual cycle. The discharge of blood slows and then stops in response to rising hormone levels and the lining of the uterus thickens, or proliferates.
Can menstruation affect blood oxygen levels? ›
I have revealed that low oxygen levels (hypoxia) occur in the lining of the womb (endometrium) during menstruation and this drives repair after the lining has been shed. Women with HMB have a defective hypoxic response during menstruation.
Does menstrual cycle affect pulse? ›Throughout the month, your body undergoes many hormonal changes that affect factors such as your resting heart rate and body temperature. On average, your heart rate increases two beats per minute during your fertile days right before your monthly period.
Can periods cause low BP? ›Summary. Some women do experience fainting spells during their periods. In many cases, hormonal changes in the body during your period may be part of the reason. These can lead to lower blood pressure, less blood volume, lower blood sugar, anemia, and a more sensitive vagal response.
Why does heart rate increase when bleeding? ›The initial compensatory responses to reduced circulating blood volume due to hemorrhage is an increased heart rate and systemic vascular resistance in order to maintain perfusion to vital organs (Gutierrez et al. 2004).
What causes periods of high heart rate? ›SVT triggers
SVT is usually triggered by extra heartbeats (ectopic beats), which occur in all of us but may also be triggered by: some medications, including asthma medications, herbal supplements and cold remedies. drinking large amounts of caffeine or alcohol. stress or emotional upset.
The smaller female heart, pumping less blood with each beat, needs to beat at a faster rate to match the larger male heart's output. Further women have a different intrinsic rhythmicity to the pacemaker of their hearts, which causes them to beat faster [3].
What increases blood flow during period? ›Foods like turmeric, ginger, cinnamon, jaggery, coconut, pineapple, papaya, and beetroot can help in inducing bleeding and increasing your flow. You should include extra fibre and iron in your daily meals and consume as many fruits and vegetables as possible.
What affects period blood flow? ›Body weight changes, exercise, and stress can all alter menstrual flow, causing light periods. Periods that are lighter than usual are not normally a cause for concern. People often find that their menstrual flow varies from month to month, and some months are simply lighter than others.
Does menstruation affect blood volume? ›It's widely accepted that the average person loses between 30 and 40 milliliters, or two to three tablespoons, of blood during menstruation. But some research suggests that this figure may actually be closer to 60 milliliters, or about 4 tablespoons.
Does temperature rise during menstruation? ›During the menstrual cycle, body temperature rises and falls slightly due to the change in hormone levels. The shift in temperature is slight, yet significant. It requires a basal body thermometer to detect – that's a thermometer that shows two decimal places.
Why do I get short of breath before my period? ›
Feel like you're out of breath faster than usual? Chalk it up to hormones. Where you are in your menstrual cycle can affect your breathing patterns, according to a study published in the American Journal of Respiratory and Critical Care Medicine.
Why can I feel my heartbeat in my stomach during my period? ›Why Do I Feel a Pulse in Stomach? While feeling a pulse in your stomach can be alarming, it's usually nothing to worry about. You're most likely just feeling your pulse in your abdominal aorta, which carries blood from your heart to the rest of your body.
What helps low blood pressure during period? ›Make sure to drink at least 1.5-2 litres of water every day, and even more during your period, if you suffer from symptoms of low blood pressure. This can help to dilute your blood and improve circulation. First published April 2019, updated February 2022.
Can dehydration affect your period flow? ›If we don't have enough water, the quality and volume of our blood is impacted and things are just not going to flow as they should. Drinking enough water and having a good hydration status should be the first place to start when understanding your period and cycle.
How do you control low blood pressure during your period? ›- taking over-the-counter pain relievers, such as NSAIDs, for pain.
- using a heating pad or hot water bottle for cramps.
- diet and lifestyle changes, such as reducing your caffeine and alcohol intake and eating healthy foods.
- making sure you get enough sleep.