This is a very private topic and often girls are reluctant to even discuss it with their parents. Many people are often not sure what is normal and even many doctors give wrong advice on this topic. Young girls should be made to understand that menstruation is a normal part of development and should be instructed on use of feminine products and on what is considered normal menstrual flow. Ideally, both parents and health care providers can participate in this educational process. Teachers also have a crucial role to play in this process as well.

What is menarche?
Menarche is the medical term for the first menses or menstrual bleeding by a young girl.
Menarche is an important milestone in the physical development of females, therefore, young females and their parents must be educated about this topic and what to expect of a first period and about the range for normal cycle length of subsequent menses. Studies have shown that girls who have been educated about early menstrual patterns will experience less anxiety as development progresses.

The age of menarche varies, but in Anguilla the median age is between 12 and 13 years, although a few girls experience menarche as early as 10 years. Menarche typically occurs within 2-3 years after thelarche (medical term for breast budding). The vast majority of girls should see their first menses by age 16 but if there is a lack of breast development by age 13 one should start investigating girls between 14-15 if they have not experienced menarche.

What is the normal menstrual cycle for adolescents?
Many parents, adolescents and even doctors are often confused about what is the normal menstrual cycle for adolescents. Menstrual cycles are often irregular in the first few years after menarche for adolescents. Most girls bleed for 2-7 days during their first menses. Most normal menstrual cycles for adolescents range from 21 to 45 days. Longer cycles often occur in the first 3 years postmenarche; by the third year after menarche 60-80% of menstrual cycles are 21-34 days long as is typical of adults. Most adolescents by the time they reach age 20 have established a normal cycle length.

What is the normal menstrual flow for adolescents?
Most clinicians agree that the mean blood loss per menstrual period is 30ml per cycle and that chronic loss of more than 80ml is associated with anaemia. This has limited value because most females are unable to measure their blood loss. Attempts to measure blood loss on the basis of the number of pads or tampons used per cycle or the frequency of pad changes are often influenced by a number of variables for example, even the types and brands of pads and tampons may influence the results. Normally most adolescents will change a pad approximately three to six times a day. Menstrual flow requiring changes every 1-2 hours is considered excessive, particularly when associated with flow that lasts more than 7 days at a time.

Menstrual irregularities in adolescents
A number of medical conditions can cause irregular or missed menses in adolescents, and the one that I see most common in my practice is pregnancy.
It is very uncommon for girls and adolescents to not see their period for more than 3 months or 90 days once they have seen their first period. All girls and adolescents with irregular cycles, with more than 3 months between periods should be evaluated by a gynaecologist and should not be reassured that it is “normal” for this to occur. Causes of irregular periods or absent periods in adolescents include the following:
• Pregnancy
• Endocrine causes
• Stress related disorders
• Medications
• Exercise-induced amenorrhoea
• Eating disorders (both anorexia and bulimia)
• Tumours
The diagnosis of pregnancy must always be excluded even if the girl or adolescent denies any sexual activity.

Conclusion
Many young girls and adolescents as well as their parents are often unsure about what represents normal menstrual patterns. Many doctors as well are confused about the normal ranges for menstrual cycle length and amount and duration of menstrual flow for adolescents. All of our young girls in Anguilla must be educated about this very important topic from an early age. In some instances it might be necessary to educate parents as well about this important aspect of female development.

In summary, the median age of menarche (first period) is 12 years, and the menstrual cycle interval is typically 21 to 45 days with a menstrual flow length of 7 days or less. Parents needing further information should see their health care provider or health educator.

Ask Your Doctor is a health education column and is not a substitute for medical advice from your physician. Dr. Brett Hodge is an obstetrician/gynaecologist and family doctor who has over twenty years in clinical practice. Dr. Hodge has a medical practice in the Johnson Building in The Valley.

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