What is the difference between puberty and menarche?
From as early as age eight in girls-and two years later, on average, in boys—the hypothalamus (part of the brain) signals hormonal change that stimulates the pituitary. In turn, the pituitary releases its own hormones called gonadotrophins that stimulate the gonads and adrenals. From these glands come a flood of sex hormones—androgens and testosterone in the male, estrogens and progesterone in the female–that regulate the growth and function of the sex organs. It is true that the gonadotrophins are the same for males and females, but the sex hormones they induce are different.
In the United States, the first sign of puberty occurs on average at age 11 in girls, with menstruation and fertility following about two years later. Boys lag behind by about two years. Puberty may not begin until age 16 in boys and continue in a desultory fashion past age 20. In contrast to puberty, adolescence is more of a social/cultural term referring to the interval between childhood and adulthood.
Menarche, on the other hand, is the beginning of the first menstrual period. Early puberty and menarche are caused by increases in weight and obesity as reflected by body mass index. It is also suggested that a decrease in age at menarche until the mid-1960s resulted from “positive” changes such as better nutrition, whereas decreases since that time are related to “negative” changes, such as overeating, fast foods, decreased physical activity, and possibly even chemical pollution.
What is significant for earlier pubertal development: Breast development before adrenarche (as manifested by pubic hair growth) as a pathway to puberty is associated with a greater proportion of body fat and greater waist circumference and waist/hip ratio. There is also a theorized or possible association with increased risk for breast cancer or cardiovascular risks later in life.
Delayed pubertal development with the absence of breast development by age 13 is strongly associated with impaired reproductive potential and should prompt an assessment to rule out ovarian failure with abnormal karyotype or other potentially irreversible problems. The absence of menstruation by age 15 is also uncommon and merits investigation.
What is the normal menstrual cycle duration in teenagers?
The menstrual cycles will vary significantly when a teenager first begins to menstruate. The normal cycles may range between 20 to 45 days with a mean cycle of 32 days. The old school of thought was that if the menstrual cycle was not regular that the teenager may not be ovulating and has estrogen dominance. Although there seems to be issues to the contrary in today’s literature, I still believe that many, if not most that are extremely irregular may not be ovulating or have inadequate ovulation. A simple method to evaluate is doing a progesterone blood test and/or a basal body temperature chart to determine whether ovulation is occurring.
What can be the consequences of abnormal menstrual cycles in teenagers?
Adolescents with cycles that are consistently outside of the range of 20-45 days and those that don’t ovulate, should be evaluated for pathologic conditions, such as polycystic ovarian syndrome (PCOS), eating disorders, thyroid disease, hyperprolactinemia, or even a conditions as ovarian insufficiency (premature ovarian failure). Health risks in adulthood such as osteopenia or osteoporosis in girls with eating disorders or possible cardiovascular disease and diabetes can all become manifested. Should an adolescent not be ovulating or have a poor ovulation (known as luteal phase defect) they can become more prone to endometriosis, fibroid tumors of the uterus, obesity, diabetes, infertility, and premenstrual syndrome (PMS) Most of these girls will have very heavy menstrual cycles and many have severe cramps. It’s interesting that in most of these adolescents with heavy menstrual cycles you will find that their mothers or grandmothers had similar problems, many of which were relatively infertile, had endometriosis, uterine fibroids, or premenstrual syndrome.
What can be the cause of heavy bleeding and how can it be diagnosed?
Any adolescent whose menses are heavy enough to soil the bedding or requiring protection more frequently that once an hour should be evaluated for causes of the bleeding. While adults with heavy bleeding may have conditions such as fibroids, endometrial polyps, hyperplasia, or even uterine or cervical malignancies, these conditions are rare in adolescents. There are reported coagulation conditions such as von Willebrand disease which occurs in as many as 1 percent of individuals. Some studies suggest that up to 20 percent may have some time of coagulation defect. Screening for these conditions should include compete blood count, a screen for von Willebrand disease, and total iron binding capacity and ferritin levels. Probably the more common cause is that of progesterone deficiency. The other occasional cause is that of PCOS where anovulation or oligo-ovulation can present with prolonged bleeding or with frequent bleeding.
These patients usually have irregular heavy cycles, hirsutism (hair growth on face or body), weight gain, insulin resistance (although some patients may not be overweight), and depression. The presence of insulin resistance can be determined with an HgbA1c blood test, insulin blood test, and/or five-hour glucose tolerance test. Those adolescents with anovulation or oligo-ovulation likely have an immature hypothalamic-pituitary-ovarian axis that can be genetic or acquired. The presence of anovulation or oligo-ovulation and luteal phase defects can be evaluated as mentioned above with progesterone blood testing, basal body temperature monitoring over a period of months. The basal temperature will rise about one degree when ovulation occurs. It requires a special mercury basal temperature thermometer.
What are the treatments of choice for heavy bleeding?
Obviously the coagulation conditions must be treated according to the condition diagnosed. PCOS patients are best served by diet control, exercise, cyclic progesterone if they are not ovulating, or ovulating infrequently and–should there be insulin resistant (occurs in over 89% of patients with PCOS)–they would need to be treated with metformin or a natural supplement without side effects, Berberine and grape seed extract (Sugar to Energy 1 at NBH).
Insulin resistance can be diagnosed, as mentioned above, with an insulin blood test, Hgb A1C and /or a five-hour glucose tolerance test. Those adolescents without PCOS that are anovulatory, oligo-ovulatory, or progesterone deficient should be treated with cyclic progesterone every 14-28 days or each cycle. There a very few, if any, significant side effects of using small doses of natural progesterone.
Using progesterone can regulate the prolonged cycles after a few months of use. It will also decrease the heavy flows, in most instances, and even reduce the menstrual cramps. Yet, to me, a very important reason for cycling with progesterone is to prevent the estrogen dominance which, if present over years, may lead to endometriosis, uterine fibroids, uterine or breast cancer, and weight gain.
This recommendation is clearly not in the mainstream treatments offered by gynecologists or endocrinologists. But, with over 33 years’ experience in treating patients with these conditions, it is clear to me that estrogen dominance, progesterone deficiency is the cause. This is substantiated by the fact that the standard of care to treat endometriosis and fibroids medically is to give the GNRH agonist, Lupron, for months to suppress the levels of estrogen, putting a patient into a temporary “post menopause state” which will shrink the fibroids and lesson the endometrial implants. During the three-to-six months of suppression, estrogen levels are essentially down to zero. This alone is enough evidence that we are obligated to treat teenagers who have estrogen dominance or progesterone deficiency with natural progesterone, not progestins such as Provera or birth control pills. These progestins have been shown to cause many more problems over time including an increased risk of breast cancer, weight gain, depression, decreased levels of testosterone from the ovaries causing libido issues, and many more. Traditional medicine will treat the symptoms and not the condition. It’s a lot easier to prescribe a birth control pill than go to all the trouble to diagnose the problem. I am convinced that we are obligated to evaluate these short-sighted diagnoses and treat adolescents that have these problems to prevent future morbidities and to significantly improve an adolescent’s quality of life.
Joseph R. NBH, MD FACOG
Medical Director
NBH Lifetime Health
Disclaimer: Much of the information in this blog is based on personal experience and on information gleaned from multiple reputable sources. While there is no single scholarly article to support the claims in this blog, the information is believed to be factually accurate.