Abnormalities of Female Pubertal Development. Endotext [Internet]. Updated August 19, National Organization for Rare Disorders. Your Privacy Rights. To change or withdraw your consent choices for VerywellHealth. At any time, you can update your settings through the "EU Privacy" link at the bottom of any page.
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Related Articles. A Quick Rundown of the Symptoms of Hypogonadism. Is Premenopausal a Thing? The Function and Role of the Ovaries. What Is Anovolation? Primary amenorrhea is the complete absence of any menstruation by 15 years of age. Secondary amenorrhea is the cessation of menstruation for 3 months or more after it has started. In the first 2 to 3 years after the initial onset of menses, it is common for irregular cycles to occur, with adolescents often having several months of missed menses.
Many of these irregular cycles may be nonovulatory due to poor early regulation of the hormonal interactions between hypothalamic, pituitary, and gonadal hormones.
Tracking menstruation on a paper calendar or using a smartphone app can help determine if menstrual periods are becoming more regular for adolescents and for predicting when ovulation is most likely to occur. The information can be useful for both pregnancy planning and pregnancy prevention. The average age of menarche is This age has been decreasing over the past years and is most often attributed to improvements in child and adolescent nutrition.
Exogenous hormones in the diet also may contribute to this earlier initiation of menarche. The average age of menarche for White race females generally is slightly later compared to other races.
It is abnormal for menarche to occur before the appearance of secondary sexual development. Sexual abuse, genital trauma, tumors, or bleeding disorders should strongly be considered in the differential diagnosis of prepubertal females and experience vaginal bleeding.
Menarche generally is considered early if it occurs before 9 years of age and late if it occurs at or after 15 years of age. Menarche is considered delayed if there is more than a 5-year lapse between the onset of breast development SMR II breasts or breast buds and the first menses. Menarche occurs during a time of puberty that is associated with rapid growth velocity. Typically, adolescent females who experience menarche are not ovulatory with every cycle in the first year.
It is estimated that most will have ovulatory cycles within 5 years of menarche. Imperforate hymen is the most common congenital genital tract anomaly in females ranging from 1 in to 1 in 10, in prevalence. It can be noted at birth, as the estrogenized hymen in the newborn is often readily apparent. Other complex hormonal abnormalities such as androgen insensitivity syndrome can present with external female development and primary amenorrhea. Abnormal development of female gonads due to Turner syndrome also can lead to ovarian agenesis and absent menses.
Menarche is the result of complex interactions between the hypothalamic, pituitary, and ovarian hormones. It also can be affected by the thyroid, adrenal, and pancreatic hormones. Thyroid hormones are necessary for normal menses, and their deficiency or excess can inhibit menarche or lead to abnormalities in existing menstrual patterns.
Abnormally elevated adrenal androgens or insulin can affect normal ovarian estrogen production and decrease the normal pituitary production of luteinizing hormone. The hormone leptin appears to have a role in the maintenance of normal menstrual cycles as well. Stress and obesity appear to be predictors of early menarche. Normal menstruation is an indicator of fertility and reproductive ability.
Its absence should signal the provider to evaluate for pathology. Pulsatile hypothalamic production of gonadotropin-releasing hormone GnRH at puberty stimulates the pituitary production of follicle-stimulating hormone FSH and luteinizing hormone LH. This pulsatile secretion pattern appears to be necessary as continuous secretion of GnRH, or its synthetic analogs, inhibits pituitary production of FSH and LH and delays menarche. This can be used medically to delay puberty in children with precocious puberty.
FSH and LH, in turn, stimulate an increase in ovarian production of estrogens, primarily estradiol and androgens. Estradiol promotes maturation of ovarian follicles, with one follicle gaining dominance during each menstrual cycle. Increasing estrogen levels stimulate uterine endometrial proliferation and eventually cause a surge of LH production by the pituitary.
This LH surge causes ovulation or rupture of the dominant ovarian follicle. In patients with normal anatomy and delayed development, evaluating ovarian and pituitary hormones, including androgens, can assist in the diagnosis. Pituitary tumors, most often adenomas, may cause amenorrhea and can be associated with elevated prolactin levels and galactorrhea, as well as physical findings that may include breast discharge, headaches, and vision changes.
In primary amenorrhea, estradiol levels help measure ovarian function. If there is evidence of hirsutism or acne on an exam, testing of androgen levels, including free and total testosterone, DHEA-S, and hydroxyprogesterone, will help rule out androgen-secreting tumors and congenital adrenal hyperplasia as a cause. They also can help to confirm a diagnosis of polycystic ovary syndrome PCOS.
It should be pointed out that the absence of menarche can occur due to pregnancy, and ruling out pregnancy is essential in the evaluation. It involves dysregulation of the HPO axis and often causes amenorrhea. Complications of PCOS include obesity, diabetes mellitus type 2, and infertility. It is treatable but not curable. Menarche is one of the most significant milestones in a woman's life. The first cycles tend to be anovulatory and vary widely in length. They are usually painless and occur without warning.
Menarche occurs between the ages of 10 and 16 years in most girls in developed countries. Although the precise determinants of menarcheal age remain to be understood, genetic influences, socioeconomic conditions, general health and well-being, nutritional status, certain types of exercise, seasonality, and family size possibly play a role.
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