Most women have an occasional anovulatory cycle, and it is fairly common for young girls to have cycles where they do not ovulate within the first year after menarche.
For adolescents, an anovulatory cycle can lead to heavy menstrual bleeding, which a young patient may mistake for a regular period. However, chronic anovulation with heavy bleeding can lead to iron deficiency, anemia and other issues that interfere with daily life. It may also be a sign of other conditions, such as polycystic ovarian syndrome (PCOS).
Polycystic Ovary shown on Voluson™ ultrasound.
It is important that gynecologists are able to identify when anovulatory cycles are normal and when they require further evaluation.
Identifying Anovulation in Teens and Young Girls
Although anovulation commonly causes irregular or absent periods, young girls may still experience fairly regular bleeding, with a menstrual cycle occurring every 21 to 45 days. At an early age, a patient may not realize they are not ovulating. They may have prolonged, heavy bleeding that soaks through a pad or tampon within one to two hours, or lasts seven days or more. This is often what will bring them to your office.
Immaturity in the hypothalamic-pituitary-ovarian axis in the first few years after menarche is often the cause of anovulation, according to the American College of Obstetricians and Gynecologists (ACOG). Lifestyle factors can also contribute to anovulatory cycles, including:
- Being overweight or underweight
- Extreme exercise habits, such as those of young athletes
- High stress levels
If the patient has been experiencing anovulatory symptoms for more than a year, she may need evaluation for causes other than immaturity. An individual in this situation is often estrogen deficient or has excess androgen; the latter may be a sign of PCOS. A pelvic ultrasound should be performed to look for signs of ovarian cysts to ensure appropriate early intervention.
Treating Anovulation in Adolescents
ACOG notes that most girls reach a normal cycle within three years of menarche as their bodies mature. However, heavy bleeding that leads to iron deficiency may require earlier action.
The first step in treatment is to wait for maturity and address lifestyle factors that may be contributing to anovulation. Referrals to a dietitian may be beneficial if the patient needs to gain or lose weight. Behavioral health referrals or relaxation tips may also help if the patient appears to be under significant stress that may be affecting their menstrual cycle.
If choosing to wait and see whether symptoms resolve on their own with age, be sure to monitor and address iron deficiency through diet or supplements.
Hormone therapy is another common treatment to regulate menstrual cycles. For girls who are still sexually immature, a low-dose transdermal estrogen therapy that preserves bone health may be the best approach. Combined oral contraceptives are an option for patients who are sexually mature. Oral contraceptives are also the first-line treatment for PCOS.
Anovulation does not often cause painful periods, but heavy bleeding can disrupt a teenager's daily life. Prolonged anovulatory cycles should trigger further evaluation to ensure that your young patients are receiving the care and support they need as they mature.