Teen girls go through a lot. I see it in the office every day. A common question I get from parents and teens is how do I know if my daughter needs period management by a doctor?
It’s really important to understand what is normal with a period. I like to compare menstruation to a symphony orchestra — there are a lot of parts (think hormones, brain, ovaries, uterus!) and it takes time to get them all working together in harmony. It’s common to think that all girls should get their period once a month, but that’s not exactly true.
For the first five years after menarche (a girl’s first period), having irregular periods is typical. Teen girls should not expect to have their period come at the exact same time interval each month. Instead, think of it coming within a certain range of days, for example every 25 to 35 days.
I advise my patients to keep track of their periods to understand their cycles better. In the office, we give out a period tracker card to help them get started. I’ve also seen a number of downloadable apps that will help do this, too, but really any calendar will do. It’s important to remember period tracking starts with the first day of menstrual bleeding with one period until the start of bleeding with the next period. Often, I see girls who only count from when their period ends to the start of their next one, which isn’t accurate.
What is normal?
For the first five years after your first period:
- You should have a period every 21-45 days
- It should last seven days or less
- You should need to use less than seven saturated regular pads or tampons per day. If a girl uses overnight or super products, she should use less than four saturated products.
Minimum acceptable number of periods per year after first period:
- First year: Four periods
- Second year: Six periods
- Years three to five: Eight periods
- Years six through adulthood: 10 periods
Troubleshooting
Often girls come into our clinic with concerns of bad cramps, heavy menstrual bleeding or not having adequate number of periods per year (skipping or stopping).
Cramps
Cramps (known technically as dysmenorrhea) are the most common side-effect of menstruation in teen girls. Initially, your daughter may not experience or notice any cramps, but as the communication between her brain and ovaries matures and becomes more effective, she will likely begin having more frequent and more painful cramps.
It is very common within two to three years after her first period for her to have cramps with most periods as she more regularly releases an egg each month. When an egg is released, the lining of the uterus produces substances known as prostaglandins. Prostaglandins cause uterine muscle to contract, thus causing the cramps.
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Cramps are best treated with the use of over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Motrin, Advil) or naproxen (Aleve). NSAIDs stop the production of the prostaglandins and thus stop the cramps. In addition to the NSAIDS, heating pads, a warm bath or exercising can also provide additional relief.
Many teen girls will be able to stay at school, sports practice or work with severe cramps, but when a teen passes on going out with friends or any social activity, I find this is a symptom of severe cramps that need management. Of course, every girl is different and if you have any concerns about your daughter, don't hesitate to contact their primary care doctor.
Heavy menstrual bleeding
Excessive heavy menstrual bleeding (menorrhagia) is likely to occur either when your daughter first starts her periods or, just like cramps, two to three years after her first period as her brain and ovaries more effectively communicate and produce more hormones each month.
The first couple of periods after the first, your daughter’s duration of flow and products needed may be a bit more than the normal ranges listed above. She may bleed for eight to 10 days or need seven regular absorption products. Within the first four to six months, she should establish the normal bleeding duration and daily product use. After this time period, if she continues with longer than expected bleeding or saturates more than the expected number of products per day, she is at risk of developing low blood count. The same is true if over time your daughter’s periods become heavier and she is bleeding longer or saturates more than the expected normal number of products per day.
It is important that teen girls with heavy bleeding get enough iron, at least 18 mg a day. If you are concerned your daughter is not getting enough iron from her diet (iron-rich foods include red meat, seafood, beans, dark leafy greens, dried fruits and iron-fortified breads), she can take a daily multivitamin.
If your daughter’s bleeding becomes difficult for her to manage at school, she needs to bring a change of clothes to school or return to home to change because she bleeds through her products or she develops a low blood count, she needs menstrual management by a doctor.
Abnormal cycles
Once a girl starts her period, it is considered a vital sign like your pulse, respiratory rate and temperature. She should have an adequate number of periods per year — too many (polymenorrhea) or too few (oligomenorrhea) is her body telling her something is out of balance. These menstrual problems should be seen by a doctor. Your doctor will make certain there is not a hormone imbalance or physical cause of her abnormal cycles.
If your doctor doesn’t find a hormone imbalance, illness or pregnancy as the cause, then the most likely cause of abnormal cycles are diet, excessive weight gain/weight loss, exercise or stress.
Diet
Eating too much or too little, or not eating a good balance of foods, can impact a girl’s cycle. It’s important for girls, especially athletes, to make sure they are getting enough calories in their diets. Calories should come from protein and, believe it or not, fat and carbs.
Society has become fat and carb phobic. However, you can get carbs, protein and fat from fresh vegetables and fruit, which is important to incorporate into your diet. Dairy is also a good source. Meat and fish are good ways to fulfill your protein needs. If your daughter has a vegetarian or vegan diet, it’s best to work with a nutritionist to make sure she is getting all the nutrients she needs. MyPlate.gov is a good source for basic nutrition for all age groups.
Exercise
Exercise is very important for everyone, but girls need to be careful to not overdo it as it can disrupt or even stop periods. Balance is key. If you are in a sport or recently increased your exercise and your periods become irregular, you are likely burning more calories than you are taking in. This puts you at an increased risk of injuries, so you need to consult with your doctor.
Stress
Teenagers face a lot of stress between school, sports, jobs and social pressure (to name a few stressors!) and stress can disrupt periods. A few ways girls can manage stress is through exercise, mindfulness, getting enough sleep and better time management. If her stress is not responsive to healthy lifestyle changes, she may benefit from seeing a licensed therapist who can help her develop more effective coping skills.
Call the doctor…
It’s best to check in with your doctor if your daughter’s periods are interrupting with daily life (i.e. not able to participate in daily activities) and/or don’t fall within the normal parameters.
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Things to look out for:
- A period more often than every 21 days
- Not having a period for more than 90 days
- If she needs to change her pad or tampon hourly or she bleeds through more than seven regular pad or tampons in a 24-hour period
- If she has heavy or prolonged bleeding and dizziness with standing or new shortness of breath with exercising or climbing stairs.
Bottom line: If your daughter’s period prevents her from living and enjoying life to her fullest, she needs period management by a doctor.
As always, if you have any questions about your daughter’s periods or overall well-being, start with her primary care doctor. It’s what we are here for and we can help guide you through these exciting and often trying teen years .
