The majority of Caucasian girls start puberty around the age of 10 years and menarche around the age of 12and half years. The minorities in American start their sexual development and menarche much earlier. Human sexual development is divided into 5 stages also called Tanner stages. Stage 1 is pre pubertal and stage 5 is adult. The three stages 2, 3 and 4 are processes were most of the sexual and physical transformation takes place. Breast development acne body odor pubic hair armpit sweating testicular and penile growth takes place progressively in generally predictable way. Most girls will start their period in the middle of Tanner 4 in their sexual development. But they can start to ovulate as early as late Tanner three though boys can be fertile much earlier though they start wet dreams at Tanner three.
Though girls May start ovulation late Tanner 3 and mainly tanner 4, they may start menarche as they ovulate but many of them may not establish a regular menstrual cycle until the 2 rd year of commencing menarche. Some times it may take up to 3 or more years to establish regular menses as the hormonal control (the hypothalamic/pituitary ovarian axis) takes a while to establish rhythmic control of the menstrual cycle. In many females regular ovulation and uterine maturation may take a while to establish. It is also fine to skip a period occasional (2-4 times a year) due to various environmental reasons including stress, diet, weight change, strenuous physical activity, etc. Normal period is considered >8 times a year with average menstrual flow. It is considered abnormal when a women gets her period less than 8 times a year or skips her period three or more months in a row or if she is bleeding more than 10 days a month or have a heavy or spotty period. A regular menstrual bleeding is a bout 3-7 days with bleeding of 30-50 ml ( 6-10 small tampons) per cycle. An average moderately soaked pad or tampon can hold about a teaspoon of blood (5 ml). Heavily soaked tampon may hold about a table spoon (15 ml) of blood. Changing more than 12 small/moderate tampons (80 ml) and less than 2 tampon (10 ml) may be abnormal. Normal menstrual cycle is 21-35 days for an average of 28 days. This may be in response of the moon's electromagnetic forces that may be controlling the hormonal rhythmicity of the female reproductive cycle. Bleeding twice or more a month or bleeding less than 21 days or longer than 35 day after the last cycle is considered abnormal.
In female after 2 years of menarche, irregular period is considered 1) skipping menses 3 or more moths in a row (Amenorrhea), 2) < 8 menses a year 3) heavy bleeding >80 ml bleeding. 4) Little bleeding <2 days (<10ml). 5) Bleeding after 35 days of the last menstrual cycle.
Primary amenorrhea is considered in a female 15 years old or older who nerve started her period. In all conditions pregnancy need to be ruled out. As the commonest cause of amenorrhea is Pregnancy.
There are many causes of irregular period in a female including stress, overweigh/obesity, weight loss/abnormal weight, excessive exercise, illnesses, uterine and ovarian conditions, pituitary abnormalities including pituitary tumors, and genetic conditions such as Turners syndrome or hypogonadism, medications and hormone imbalances.
Hormonal imbalances such as uncontrolled/ undiagnosed/ hypothyroidism, excess cortisol, insulin resistance (metabolic syndrome), high prolactin level etcetera can cause irregular bleeding (period)
Polycystic ovarian syndrome is a mix of disorders consisting some of the following: 1) Amenorrhea or irregular period as mentioned above, 2) hyperandrogenia, (producing more male hormones called androgens such as testosterone, DHEAS and androstendione ), Hyperandrogenism ( skin manifestations such as acne, excess hair, thinning of hair or hair loss etc., with or with out cysts in the ovary. In PCOS (polycystic ovarian syndrome one does not have to have cysts in the ovaries to be diagnosed with PCOS. Many women with PCOS have no cysts in their ovaries and many normal women have cysts in their ovaries without PCOS. Women with PCOS have skin conditions (acne, facial hair and thinning of hair and hair loss) and metabolic conditions such as prediabetes or diabetes, fatty liver disease high lipids cardiovascular problems and infertility.
PCOS could be due to many causes, 1) adrenal causes, abnormal adrenal androgens with or without late onset adrenal hyperplasia. 2) insulin resistance (HAIR AN syndrome (hyperandrogenism insulin resistance ancanthosis nigricans syndrome)). increased insulin causes stimulation of male hormones in the ovaries by stimulating the ovarian theca cell to produce more male hormone. During insulin resistance (obesity) the body is resistant to insulin while the ovaries stay sensitive to insulin. Therefore PCOS is common in insulin resistance. The converse is also true. 3) The Hypothalamic/Pituitary /Ovarian axis abnormality. The pulse generator in the hypothalamus is faster in frequency. The pituitary ovarian axis rhythmicity is altered in PCOS. The rhythmicity is much faster in frequency than normal and ovaries do not have enough time to mature and ovulated. Since there is less ovulation, PCOS is a state of Anovulation. With out ovulation it is less possible to have a normal period. What ever the cause of PCOS, the final effect or out come is similar. PCOS affects the female reproductive, metabolic, hormonal, skin and social conditions. PCOS can cause weight gain and insulin resistance. The other way round is also true (vicious cycle)
Untreated or undiagnosed hypothyroidism, hyperprolactinemia and excess cortisol or adrenal androgens (like late onset adrenal hyperplasia) can also suppress pituitary hormone activity (altering the hormonal rhythmicity) leading to irregular period and/or amenorrhea.
The initial evaluation into irregular period is to take detailed history and complete physical evaluation. Over 80% of the answers come from taking a detailed history and performing complete physical exam. The next step is to perform complete laboratory and imaging work up. Labs for Amenorrhea profile including pregnancy, adrenal androgens, thyroid profile, CAH profile, metabolic profile, prolactin, ovarian hormone insulin karyotype or genetic testing (if indicated) etc. should be performed (complete bill of health).
And once the diagnosis of PCO is established treatment should be initiated including life style change, weight loss, healthy balanced diet and structured regular physical activity. Medical therapy should be initiated as soon as other causes are eliminated (thyroid, adrenal, prolactin etc.). Hormonal causes so as thyroid abnormalities, excess adrenal androgens such as late onset CAH and abnormal prolactin level need to be treated promptly.
PCOS need to be treated with low androgenic birth control pills, metformin and if there is skin manifestation spironolactone, fenastride, vaniqua etc. can be considered.
Going back to your daughter: Your daughter is 14 years old. When did she start her period?. Does she have dark skin on her neck?. Is there a family history of PCOS in females or men who lost hair early (Balding)?.
Lets consider she started her period over 2 years ago and she truly has PCOS. PCOS is a group of disorders. It is not one disease. It is difficult to pinpoint to a single cause, because there is no single cause in PCOS. It is a syndrome (collection of disorders) not a single disorder. It can be due to insulin resistance, adrenal abnormalities, hypothalamic/pituitary/ovarian axis disorder (change in rhythmicity of the pulse generator in the hypothalamus). Any of the above and or combination of the above causes or something else . No one knows for sure. But it has to be evaluated and treated well, because it has long term consequences. Your doctor should also rule out thyroid abnormalities, adrenal anomalies including late onset CAH, prolactin and pregnancy (unlikely) and karyotype or genetic testing if indicated. Let him/her perform a complete evaluation. The history, physical exam and laboratory work up should determine if she has PCOS. PCOS is mostly a diagnosis of exclusion of other hormonal causes. Free and total testosterone are usually high and a protein called SHBG is low in PCOS. Metabolic abnormalities are also common in PCOS.
There is no doubt that PCOS cause excessive weight gain. And it is also true that excessive weight gain may cause PCOS. No one knows which one comes first, weight gain or PCOS. But two of them are locked up in a vicious cycle. Once the diagnosis of PCOS is established, treatment should be commenced swiftly. Life style change should be addressed in detail. weight management is very important. Even as small as 5% weight loss will make a big difference. healthy balanced diet with lots of fresh vegetables is essential. Daily structured physical activity is also very necessary. It will be very helpful to see a good nutritionist for good nutritional guidance. Weight loses is very important aspect of the treatment of PCOS. A desired modest weight loss of 5-10% will lead to a major improving in the PCOS. If weight loss is difficult through diet and structured daily exercise, appetite suppressing agents can be tried, if your doctor would be willing to help you. Some of the medications to be considered besides of course metformin, would be Topamax 100-200mg twice a day, contrave (naltrexone/welbuterin), orlestat, Adderall, qysmia, Belvic phentermine, victoza, saxenda etcetera as indicated or on an individual bases.
It is also very important to realize that she needs to be on low androgenic birth control pills for the PCOS. Since she is not ovulating regularly, she needs those female hormones replaced and the uterus need to be able to shed regularly to protect the uterus from future uterine problems. Metformin is most of the time added in the treatment of PCOS. It can be used liberally to help her with the metabolic conditions (insulin resistance) of PCOS and help the ovaries function better. Other medications such as spironolactone, vaniqua etc. can be considered if indicated and if she has skin conditions such as hirsutism or thinning of hair (hair loss).
You need to work with your daughter, nutritionist and your physician closely. Involve her in structured sports activity and make sure you have a good handle in a healthy balanced diet with lost fresh vegetable. If needed get a referral to see a specialist in PCOS.
and nutritional management. I recommend scheduling your daughter to see a gynecologist who specializes in adolescent gynecology. I also recommend a book available on Amazon, "The PCOS Diet."
I hope this information is helpful to you and your daughter.
Milinda Morris, MD, FACOG, NCMP, DACBN