From the Guidelines
It is considered abnormal for females to fail to start menstruation by age 16, a condition known as primary amenorrhea, and medical evaluation is recommended at this point. According to the guidelines from the international late effects of childhood cancer guideline harmonization group, in collaboration with the PanCareSurFup consortium, published in the Journal of Clinical Oncology in 2016 1, referral to pediatric endocrinology or gynecology is recommended for any survivor who has primary amenorrhea by 16 years of age. This recommendation is based on expert opinion and highlights the importance of timely evaluation for girls who have not started menstruating by this age.
Some key points to consider in the evaluation of primary amenorrhea include:
- No signs of puberty by 13 years of age, which also warrants referral to pediatric endocrinology or gynecology 1
- Failure of pubertal progression, which is another indicator for referral 1
- The presence of other signs of puberty, such as breast development, which can help guide the timing of medical evaluation
The evaluation of primary amenorrhea typically involves a physical examination, hormone level testing, and possibly imaging studies to determine the underlying cause of the delayed menstruation. Early intervention is crucial as some causes may require treatment to prevent long-term health consequences such as bone density loss or fertility issues.
From the Research
Definition of Abnormal Menstruation
Abnormal menstruation in adolescent girls can cause psychological and physical strain, and it is essential to understand what is normal and what is concerning 2.
Age of Menarche
The absence of menarche by age 15 is statistically uncommon and should be evaluated 3.
- The absence of pubertal development by age 14 is associated with a high probability of conditions with impaired reproductive potential.
- Girls with normal ovarian function begin puberty on average at 10.5 years old, although there is variation according to ethnicity and degree of excess weight gain 4.
Evaluation and Treatment
Care providers who understand what is normal and what is concerning can educate and often reassure the young woman and her family, and initiate investigations and/or treatment in an expedient fashion to limit psychosocial and/or physical morbidity 2.
- When a diagnosis of hypogonadism is established, treatment with estrogens may be initiated between age 11 and 12 years, with dose increases approximately every 6 months until adult levels are reached 4.
- In some situations, treatment may be delayed to allow time for diagnosis or permit more time for linear growth, or address unique risks found in girls treated for various cancers or blood disorders 4.
Special Considerations
Girls with Prader-Willi syndrome often present with delayed onset of puberty despite frequent premature adrenarche, and an estrogen replacement protocol may be started at the chronological age or bone age of 12-13 years, taking into consideration the uterus size 5.
- A number of conditions with the potential for significant sequelae in adulthood can present as abnormal menses in adolescence, and thus merit early diagnosis and management 3.