World Health Organization multicenter study on menstrual and ovulatory patterns in adolescent girls: II. Longitudinal study of menstrual patterns in the early postmenarcheal period, duration of bleeding episodes and menstrual cycles

doi:10.1016/S0197-0070(86)80015-8

Journal of Adolescent Health Care

Volume 7, Issue 4, July 1986, Pages 236-244

https://doi.org/10.1016/S0197-0070(86)80015-8 Get rights and content

During a two-year study, 670 girls (aged 11–15 years) submitted menstrual diaries that started at the onset of their first menstrual bleeding (Group I), and 802 girls (aged 11–15 years) who had already experienced menarche prior to the study (Group II) kept similar diaries. The two groups were recruited in three centers: Colombo (urban), Peradeniya (rural), both in Sri Lanka, and Hong Kong. The mean duration of bleeding episodes was 4.7 days (SD 1.8) in Group I and 4.9 days (SD 1.4) in Group II. The median length of the first cycle after menarche was 34 days, with 38.3% of the cycles being longer than 40 days. By the 5th cycle the median length was 31 days, similar to that of Group II. The establishment of cycle regularity was defined by three successive cycles within the range of 10 days with none of the three cycles shorter than 20 or longer than 40 days. This regularity was achieved by 19% of the Group I girls in the first three cycles and by 67% of these girls during the entire study period, compared to 89% in Group II.

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Analyzing the atypical – Methods for studying the menstrual cycle in adolescents
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The female pubertal transition is characterized by a rapidly changing hormone milieu, which is heavily influenced by the first menstrual cycle – menarche. The first year following menarche is associated with menstrual cycles that are irregular and anovulatory. Peripuberty also marks the beginning of a female-biased risk for suicidality and depression, suggesting some influence by the menstrual cycle and ovarian hormone fluctuations. However, there are limited methods and guidelines for studying the menstrual cycle and related affective symptoms in this developmental window. Thus, this study’s objective was to identify the most accurate methods for detecting ovulation in irregular cycles (Part 1) and develop guidelines based on these methods for determining menstrual cycle phases. These methods were applied to investigate hormones and affective symptoms based on cycle phase and ovulation status in a sample of peripubertal females (Part 2).
Thirty-two peripubertal females (ages 11–14) provided daily urine samples of estrogen (E1G) and progesterone (PdG) metabolites and luteinizing hormone (LH), and ratings of affective symptoms for one menstrual cycle. Ten literature-derived methods for determining the presence of an LH-peak or PdG rise were compared, focusing on their feasibility for psychological research.
Methods by Sun et al. (2019) and Park et al. (2007) most accurately detected PdG rises and LH peaks in this sample, identifying 40.6% of cycles as ovulatory. As expected, ovulatory participants showed greater LH in the periovulatory phase (p = .001), greater PdG in the mid-luteal phase (p < .0001), and greater E1G in the periovulatory phase (p = .001) compared with anovulatory participants. Exemplary methods to compare psychological symptoms between both groups are provided.
Recommendations and guidelines for studying the menstrual cycle in irregular cycling adolescents are offered. Novel methods for ovulation detection identified phase-specific hormonal patterns in anovulatory and ovulatory adolescent cycles.
The female athlete triad
2023, The Youth Athlete: A Practitioner's Guide to Providing Comprehensive Sports Medicine Care
Female athlete triad (Triad) consists of spectrums of energy availability, menstrual function, and bone mineral density. Male athlete triad similarly is a syndrome that consists of decreased energy availability, functional hypogonadotropic hypogonadism, and low bone mineral density with or without bone stress injury In Triad, the energy deficit leads to functional hypothalamic amenorrhea through the reduced release of gonadotropin-releasing hormone and the resultant hypoestrogenic state caused by decreased levels of FSH and luteinizing hormone. The third component of the triad is decreased bone mineral density, which results from the energy deficit which may also include a hypoestrogenic state. Adolescent and young adult athletes should be screened for Triad at well child visits, preparticipation physicals or when they present with amenorrhea, bone stress injuries, or recurrent injuries. The Cumulative Risk Assessment tool can be used to determine an athlete's risk of having female athlete triad. Initial evaluation for female athlete triad should include a thorough history and physical exam. If an athlete has one or more components of Triad then further evaluation includes laboratory tests with additional workup if the athlete has amenorrhea. In athletes with one high-risk factor or two moderate-risk factors, bone mineral density should be examined with a dual-energy X-ray absorptiometry (DXA). Treatment should include a multidisciplinary approach with cooperation between the family, medical team, registered dietitian, athletic trainer, coach, and when needed, a mental health professional. Treatment should focus on correcting the energy deficit. Pharmacologic treatment can be considered for those not responding to nonpharmacologic treatment. Options include estrogen patches and cyclical progesterone in the amenorrheic athlete with low bone mass, and rarely, other pharmacological management in consultation with an osteoporosis expert. While there are no set guidelines, the Cumulative Risk Assessment score can be used to guide participation and return to play decisions.
Abnormal uterine bleeding in the adolescent
2023, Encyclopedia of Child and Adolescent Health, First Edition
Abnormal Uterine Bleeding (AUB) refers to menstrual bleeding abnormal in quantity, duration, or schedule in a nonpregnant female. In adolescent females, non-structural etiologies of AUB are far more common than structural causes. The evaluation of AUB in adolescents therefore focuses on these etiologies. Bleeding disorders such as von Willebrand's Disease, or ovulatory dysfunction due to an immature hypothalamic-pituitary-ovarian axis or other hormonal etiologies such as polycystic ovarian syndrome, are the most common causes in adolescent girls. Management of AUB depends not only on etiology, but also on the patient's hemodynamic status, degree of anemia, sexual history, presence of estrogen contraindications, and whether the patient is actively bleeding on presentation.
The FIGO Ovulatory Disorders Classification System
2022, Fertility and Sterility
Citation Excerpt :
Diagnosing the presence of an ovulatory disorder at the extremes of reproductive age can be challenging, depending on the perception of what is normal. For postmenarcheal girls aged under 18 years, infrequent menstrual bleeding or irregular menstrual cycles suggesting ovulatory dysfunction are common, with available evidence suggesting that the individual’s “normal” cycle length may not be established until the sixth year after menarche [30–32]. During this pubertal transition, ovulatory dysfunction impacts about 50% of adolescent girls in the first year after menarche with a cycle length that is typically in the range of 21–45 days [27, 28] but sometimes is as short as 20 days or may even exceed 60 days [32].
Ovulatory disorders are common causes of amenorrhea, abnormal uterine bleeding, and infertility, and are frequent manifestations of polycystic ovary syndrome (PCOS). There are many potential causes and contributors to ovulatory dysfunction that challenge clinicians, trainees, educators, and those who perform basic, translational, clinical, and epidemiological research. Similarly, therapeutic approaches to ovulatory dysfunction potentially involve a spectrum of lifestyle, psychological, medical, and procedural interventions. Collaborative research, effective education, and consistent clinical care remain challenged by the absence of a consensus comprehensive system for classification of these disorders. The existing and complex system, attributed to WHO, was developed more than three decades ago and did not consider more than 30 years of research into these disorders in addition to technical advances in imaging and endocrinology. This manuscript describes the development of a new classification of ovulatory disorders performed under the aegis of the International Federation of Gynecology and Obstetrics (FIGO) and conducted using a rigorously applied Delphi process. The stakeholder organizations and individuals who participated in this process comprised specialty journals, experts at large, national, specialty obstetrical and gynecological societies, and informed lay representatives. After two face-to-face meetings and five Delphi rounds, the result is a three-level multi-tiered system. The system is applied after a preliminary assessment identifies the presence of an ovulatory disorder. The primary level of the system is based on an anatomic model (Hypothalamus, Pituitary, Ovary) that is completed with a separate category for PCOS. This core component of the system is easily remembered using the acronym HyPO-P. Each anatomic category is stratified in the second layer of the system to provide granularity for investigators, clinicians, and trainees using the “GAIN-FIT-PIE” mnemonic (Genetic, Autoimmune, Iatrogenic, Neoplasm; Functional, Infectious and Inflammatory, Trauma and vascular; Physiological, Idiopathic, Endocrine). The tertiary level allows for specific diagnostic entities. It is anticipated that, if widely adopted, this system will facilitate education, clinical care, and the design and interpretation of research in a fashion that better informs progress in this field. Integral to the deployment of this system is a periodic process of reevaluation and appropriate revision, reflecting an improved understanding of this collection of disorders.
Los trastornos ovulatorios -el sistema de clasificación FIGO.
Los trastornos ovulatorios son causas comunes de amenorrea, sangrado uterino anormal e infertilidad, y son manifestaciones frecuentes del síndrome de ovario poliquístico (SOP).
Hay muchas causas potenciales y contribuyentes a la disfunción ovulatoria que desafían a los médicos, estudiantes, educadores y aquellos que realizan investigación básica, traslacional, clínica y epidemiológica.
De manera similar, los enfoques terapéuticos para la disfunción ovulatoria involucran potencialmente un espectro de intervenciones de estilo de vida, psicológicas, médicas y de procedimientos intervencionistas.
La investigación colaborativa, la educación eficaz y la atención clínica constante siguen siendo un desafío por la ausencia de un sistema integral de consenso para la clasificación de estos trastornos.
El complejo sistema existente, atribuido a la OMS, se desarrolló hace más de tres décadas y no consideró más de 30 años de investigación en estos trastornos además de los avances técnicos en imágenes y endocrinología.
Este manuscrito describe el desarrollo de una nueva clasificación de los trastornos de la ovulación realizada bajo la égida de la Federación Internacional de Ginecología y Obstetricia (FIGO) y se llevó a cabo utilizando un proceso Delphi rigurosamente aplicado.
Las organizaciones interesadas y las personas que participaron en este proceso incluyeron revistas especializadas, expertos en general, sociedades especializadas de obstétrica y ginecológica nacionales y representantes legales informados.
Tras dos encuentros presenciales y cinco rondas Delphi, el resultado es un sistema de tres capas en varios niveles. El sistema se aplica después de que una evaluación preliminar que identifica la presencia de un trastorno ovulatorio.
El nivel primario del sistema se basa en un modelo anatómico (hipotálamo, pituitaria, ovario) que se completa con una categoría separada para PCOS. Este componente central del sistema se recuerda fácilmente con el acrónimo HyPO-P. Cada categoría anatómica es
estratificada en la segunda capa del sistema para brindar granularidad a los investigadores, médicos y estudiantes que utilizan el "GAIN-FIT-PIE" mnemotécnicos (Genéticos, Autoinmunes, Iatrogénicos, Neoplásicos; Funcionales, Infecciosos e Inflamatorios, Traumatológicos y vasculares; Fisiológicos, Idiopáticos, Endocrinos).
El nivel terciario permite entidades diagnósticas específicas. Se anticipa que, si se adopta ampliamente, este sistema facilitará la educación, la atención clínica y el diseño e interpretación de la investigación de una manera que informe mejor el progreso en este campo.
Integral al despliegue de este sistema es un proceso periódico de reevaluación y revisión apropiada, reflejando una comprensión mejorada de este conjunto de trastornos.
The Launch of A Girl's First Period Study: Demystifying Reproductive Hormone Profiles in Adolescent Girls
2022, Journal of Pediatric and Adolescent Gynecology
Limited data exist on the reproductive hormone dynamics that govern the transition from menarche to the establishment of the mature ovulatory cycles of a fertile young woman. It is also unclear how environmental and lifestyle factors could modulate this transition in contemporary girls. Here, we introduce A Girl's First Period Study, an ambitious longitudinal study aimed at charting the early post-menarchal course of a cohort of healthy girls in the Triangle region of North Carolina.
The normal menstrual cycle
2022, Current Problems in Pediatric and Adolescent Health Care
The normal ovulatory menstrual cycle requires the presence of a mature hypothalamic-pituitary-ovarian axis and highly coordinated hormonal feedback loops. Consisting of three phases (follicular, ovulatory, and luteal), the normal menstrual cycle results in the formation of a mature follicle and release of an oocyte during each cycle, with menses occurring in the absence of fertilization. While adolescents may initially experience anovulatory cycles following menarche, the vast majority of cycles will be fairly regular, lasting 21 to 45 days in length with an average of three to seven days of bleeding. Absence of menarche by age 15, absence of menses for three consecutive months, and menses lasting eight days or longer with or without associated heavy bleeding are among the menstrual abnormalities that warrant further evaluation. Obtaining the menstrual history in adolescents with the knowledge of expected menstrual patterns allows the pediatric practitioner to provide appropriate counseling and education to adolescents and their families, and to identify menstrual abnormalities when they arise. Treating the menstrual cycle as a “vital sign” highlights the importance of normal menses as an indicator of an individual's overall health and enables timely identification of any concerning findings.

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^*: Collaborators in the study: H. Campbell, M.D., University of Wales, Cardiff; K. Edström, M.D., WHO Liaison Office with UN, New York; L. Engström, M.D., Centrallasarettet i Mölndal, Sweden; N. Kodagoda, M.D., University of Colombo, Sri Lanka; B. Lunenfeld, M.D., Chaim Sheba Medical Centre, Tel-Hashomer, Israel; M. Romer, BA, WHO, Geneva; P.C. Sizonenko, M.D., University of Geneva, Switzerland; G. Tang, M.D., Queen Mary Hospital, Hong Kong; A. Tserkovnyi, Ph.D., WHO, Geneva.

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Original ArticleWorld Health Organization multicenter study on menstrual and ovulatory patterns in adolescent girls: II. Longitudinal study of menstrual patterns in the early postmenarcheal period, duration of bleeding episodes and menstrual cycles

J Obstet Gynaecol

Variation of the human menstrual cycle through reproductive life

Int J Fertil

The incidence of anovular cycles in women

J Reprod Fertil

A statistical analysis of the menstrual patterns of 8000 Finnish girls and their mothers

Acta Obstet Gynecol Scand

Original Article
World Health Organization multicenter study on menstrual and ovulatory patterns in adolescent girls: II. Longitudinal study of menstrual patterns in the early postmenarcheal period, duration of bleeding episodes and menstrual cycles