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At the 40th National Conference of the National Association of Pediatric Nurse Practitioners, in New Orleans, experts presenting a session on menstrual management said that amenorrhea and heavy menstrual bleeding (HMB) can both indicate a variety of medical issues in the pediatric patient population.
Nurse practitioners should be taking menses into consideration when assessing female adolescent and teenage patients.
In fact, assessing a patient’s menstrual cycle can be an important vital sign, much like blood pressure and weight.
At the 40th National Conference of the National Association of Pediatric Nurse Practitioners, in New Orleans, experts presenting a session on menstrual management also said that amenorrhea and heavy menstrual bleeding (HMB) can both indicate a variety of medical issues in the pediatric patient population.
Neither condition is considered the norm, they said.
“You need to pause and reflect when your patient says, ‘I haven’t had a period in 4 months,’“ said co-presenter Joan Mezera, MA, RN, CLC, CPNPâ€PC, PMHS.
Gathering information on a patient should include the age of a mother’s first menses, age of thelarche, medication history, sexual history, and use of antipsychotic medications or illicit drug use, as well as academic history, family conflict, peer interactions, and social stressors, she said.
A genital examination should also be included in the examination to determine secondary sexual characteristics and identify signs of a condition that may be causing amenorrhea or HMB.
A review of a girl’s systems can also yield clues to her menstrual state, according to Mezera.
Clinicians should consider changes in mood, vision, or weight; exercise patterns; galactorrhea;headaches; sleep concerns; sexual activity; unwanted hair growth; and vaginal discharge, and initiate a 24-hour diet recall, if needed.
Maintaining a heavy weight or weight gain, for example, is one cause of HMB, said co-presenter Meara Henley, DNP, MSN, RN, CPNPâ€PC.
“If you have extra adipose tissue, you have more bleeding,” she said.
Contrarily, loss of too much weight can lead to amenorrhea.
In gathering information on a young patient, Henley and Mezera both noted that not all girls are truthful about their sexual activity.
For that reason, Henley recommended speaking to patients privately, and without parents, which could make them more likely to be truthful.
Still, both experts said that testing for certain conditions can be more reliable than information provided by a patient.
“I do a pregnancy test on every single patient, even if they tell me they’re not sexually active,” Mezera said.
Likewise, Henley said that she has all her patients with HMB tested for chlamydia and gonorrhea.
“We know that teens sometimes don’t like to tell you what’s going on,” Henley said.
If a condition is not identified with initial examination and initial testing, further tests may be ordered, such as an ultrasound.
“There are so many scenarios and so many considerations,” Mezera said.
The causes of menstrual abnormalities include endocrine conditions, female athlete triad, polycystic ovarian syndrome (PCOS), and tumors, as well as acquired conditions, such as eating disorders, exercise-induced issues, medications, and stress-related hypothalamic dysfunction.
Treatment plans will depend on the cause and severity of amenorrhea or HMB. Treating patients with oral contraceptives is common for some menstrual-related conditions, such as PCOS.
“Oral contraception can help regulate menses but does not address PCOS,” Mezera said. “Diet and exercise are better treatments and can address elevated [body mass index], which afflicts 75% of patients with PCOS.”
Parent apprehension should be considered when addressing oral contraceptives, Henley said.
“I get a much better response by calling it a hormonal treatment, rather than birth control,” she said.
Education about different types of contraceptives, including an intrauterine device, should be shared with patients and parents, as many families do not know about these options or may have preconceived notions that are false, Henley said.
“There [are] absolutely no studies that show birth control leads to increased promiscuity,” she said.
RELATED CONFERENCE COVERAGE
Mezera J, Henley M. Managing "Monthlies": What the NP needs to know about menstrual management. Session presented at: 40th National Association of Pediatric Nurse Practitioners national conference; March 7, 2019; New Orleans, LA. https://www.napnap.org/sites/default/files/userfiles/Conferences/2019Speakerhandouts/103%20-%20Henley%20Mezera.pdf. Accessed March 7, 2019.