Adolescence

Adolescence, the normal life phase from menarche (first period) until age 20, is a time of growth and change—physically, emotionally and socially. It is the transition from girlhood into adult womanhood.

1. The job of adolescence is to grow, build strong bones, mature breasts, develop regular cycles by about a year after menarche, and ovulatory (egg-releasing) cycles most of time by the end of adolescence; it is also time to begin learning our strengths and weaknesses as individuals.

2. It is normal to have far apart and unpredictable flow in the first year after menarche, to have the majority of cycles that are anovulatory or ovulate with a short luteal phase (less than 10 days of progesterone production). It is also normal initially to have breast areola (darker skin about the nipple) that is only an inch across. It is normal to gain only a few more inches in height and also to fill out into a more womanly shape.

3. Adolescent women need the Three A’s: acceptance by their peers (and by themselves), achievement in school or sports or hobbies that make them feel proud, and affection from parents, a friend or two or another trusted adult. They also need 8-10 hours of sleep, regular exercise, time to laugh and play as well as to study. Finally they need a positive future to dream about.

4. Various things can go wrong in adolescence—cramps, heavy flow, irregular or skipped cycles, the development of acne and far-apart flow (also called Polycystic Ovary Syndrome or Anovulatory Androgen Excess). Cramps mean pelvic pain before and during the first day or two of the flow; they are caused by prostaglandin production in the muscle wall of the uterus and in the endometrium (uterus lining). Cramps are effectively treated by high-dose over-the-counter ibuprofen. Heavy flow reduces by half with one (200 mg) ibuprofen every meal. Anovulatory Androgen Excess can often be prevented In summary—adolescence is an amazing time of life that we only appreciate when we’ve grown out of it. All of what makes us unique is developed during this time of challenge and promise.

Heavy flow means losing more menstrual blood than is normal. A normal menstrual period requires us to change two soaked normal-sized sanitary products (vaginal pads, tampons) two to four days a cycle or to empty a menstrual cup of a teaspoon (5 millilitres, ml) of blood twice a day for two to four days in a period. Normal cycles last from three to six days; heavy flow usually, but not always, lasts longer than seven days. Women often describe heavy flow as "flooding," or "clotting" and requiring that they change sanitary products every couple of hours during the day.

The official definition of heavy flow is loss of 80 ml or more blood in one menstrual period since that amount of blood loss causes iron-loss anemia in 80 of 100 women. Since 5 ml is a teaspoon and a soaked usual-sized tampon/pad holds about that much, heavy flow means losing 16 teaspoons or soaking 16 normal-sized pads/tampons (or emptying a full 30-ml menstrual cup almost three times) in one whole period.

Heavy flow is usually caused by too much estrogen (that makes the lining of the uterus grow very thick and fragile) and too little progesterone (whose job is to control endometrial growth and make it stronger). Heavy flow is most common in the teen years and in perimenopause when it is experienced by at least 25 of every 100 women. The good news is that simply taking one tablet of ibuprofen (over the counter, non-steroidal anti-inflammatory) (200 mg is the usual-sized tablet) with each meal will decrease heavy flow by a quarter to a half. Tell every woman you know! Read more about heavy menstrual flow here.

"Cramps" is the common name for painful periods or what doctors call dysmenorrhea. Cramps typically start just before and are most severe during the first days of menstrual flow. Younger women and those who have never been pregnant or delivered a baby are more likely to have and to have worse cramps. Interestingly, cramps also seem to increase in perimenopause (the transition to menopause). The pain of cramps is due to increased release by the lining and muscle walls of the uterus of a fatty hormone called a prostaglandin. More prostaglandins are made when the opening of the uterus is very tight (and therefore pressure inside it builds to high levels) and also when estrogen levels are higher. It is likely (but not yet adequately studied) that higher progesterone levels counterbalance estrogen's effects and decrease cramps. Painful periods can be effectively treated with ibuprofen, an over-the-counter pain pill that is from the "anti-prostaglandin family". Ibuprofen (400 mg or two 200-mg tablets) must be taken at the first hint of cramps and a further 200 mg tablet taken as soon as the pain begins to return (even if that is only an hour later). If you wait, ibuprofen won't help because ibuprofen works to prevent the formation of the prostaglandins that the cause the pain.

Contraception means preventing pregnancy. There are many ways women can prevent pregnancy—they range from refusing to have sex (being celibate), to using a physical barrier (such as a condom for a man or woman, diaphragm or cervical cap) plus a spermicide, to an operation that "ties" the fallopian tubes preventing fertilization of the egg and causing permanent sterility. (Note—researchers have now learned that risks for ovarian cancer arise in the tubes therefore any woman choosing tubal sterilization should request tubal removal.) Most contraception is reversible but tubal removal or ligation and vasectomy are not.

There are two basic kinds of contraception: those that rely on high hormone levels to disrupt reproductive hormonal cycles and those that don't. Hormonal contraception is traditionally in the form of "The Pill" but today combined hormonal contraception (CHC, combined estrogen and a progestin) usually for 21 of 28 days, can be a pill, a patch or a vaginal ring. The CHC hormone levels, although called "low dose" must be high enough to interfere with normal menstrual cycle hormones, ovulation and preparation of the lining of the uterus for implantation. The common CHC dose of 20 microgram ethinyl estradiol is approximately four times higher than natural menstrual cycle estradiol levels. CHC must be taken reliably to be effective, disturbs cyclic hormones, carries a risk of blood clotting and may cause adolescent bone loss. The progestin-only pill is also a possibility—it is taken daily, is an androgenic (male-hormone-like) progestin and often gives irregular bleeding. Hormones are sometimes part of intrauterine devices (IUD) as in the levonorgestrel (an androgenic progestin) IUD used to decrease heavy bleeding in perimenopause. Depo-MPA (sometimes called Depo-Provera) is 3-monthly high dose injection of a non-androgenic progestin—its advantages are its effectiveness, 3-months duration and its disadvantages are weight gain and depression.

Non-hormonal reversible contraception uses a diaphragm or a condom as a physical barrier and always requires simultaneous insertion of vaginal spermicide. These methods cause no hormonal disruption, can be quite effective contraception, prevent sexually transmitted diseases but are of little value if not consistently and conscientiously used. Copper IUDs are also a long-acting, effective, non-hormonal contraception that can now be chosen by nulliparous or young women. They are highly effective and have few serious adverse effects.