Period Problems – PediaCast 253
Join Dr Mike Patrick and Dr Cynthia Holland-Hall in the PediaCast Studio as they discuss common menstrual problems. Topics include the science behind the normal cycle, early (precocious) puberty, delayed puberty, irregular periods, heavy & long-lasting periods, menstrual cramps & other symptoms, PMS (premenstrual syndrome), and tampons vs pads. Great listen for moms and dads… and teenage girls!
The Normal Menstrual Cycle
Early (Precocious) Puberty
Heavy & Long-Lasting Periods
PMS (Premenstrual Syndrome)
Menstrual Cramps & Other Symptoms
Tampons vs Pads
Announcer: This is PediaCast.
Announcer: Welcome to PediaCast, a pediatric podcast for parents. And now direct from the campus of Nationwide Children's, here is your host, Dr. Mike.
Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast. It's a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital in Columbus, Ohio.
It is Episode 253 for May 15th, 2013 and we're calling this one "Period Problems".
So I want to welcome everyone to the show. We have another nuts and bolts program for you this week. This time we're covering common menstrual issues, hence the name of the show "Period Problems".
Hey, you're probably wondering "What did he mean by that?" So we are talking about the menstrual cycle.
Now admittedly, if you only have babies, toddlers or young children at home, I have to admit I just don't have much for you this week. And I won't be offended if you bail on this particular episode and search through the archives for a topic of interest.
But before you go, I would ask this , if you know a family with a pre-teen or a teenage girl at home, tell them about this episode. Would you? Just let them know PediaCast Episode 253 covers everything that they would want to know about "periods;" and if you only have boys at home, same message.
So for those of you remaining, those with the pre-teen and the teenage daughters and the daughters themselves, moms and dads, I think this show will end up being a great listen for the young ladies in the home as well.
So you listen first. But if you think your daughters would benefit, and I really think they would, have them take a listen as well.
So what exactly is in the lineup? First, we're going to start with the science behind the normal menstrual cycle.
Now don't worry. We'll keep it understandable but to some degree we have to go into the science of what's normal because it's going to help us understand the problems better when we get to those.
Plus, and this is a little strange but I really think the menstrual cycle is a work of art. And for you, science types out there, I mean there's so many hormones and pathways all going on at the same time. It's really quite amazing.
Now having said that, I'll admit, I'm a little uncomfortable talking about periods even as a doctor, so I guess especially as a boy doctor. So I have invited a great studio guest to help me out.
Dr. Cynthia Holland-Hall is an adolescent medicine specialist here in Nationwide Children's, and she's going to help me cover the science behind the normal menstrual cycle. And then we'll delve into the possible problems, including early onset of puberty, also known as "precocious puberty". How early is too early and what exactly causes this to happen?
Delayed puberty, how late is too late? And again, what could be the cause?
Irregular periods, pretty common in the early teenaged years, why does this occur? Is it ever a concern, and if so, why, and how do you fix the problem? Also heavy and prolonged periods, are they merely an inconvenience or can they be harmful? Again, how much is too much, how long is too long and what can you do about them?
Then we'll dive into the ugly symptoms of menstruation including cramps, bloating, headaches, acne flares, mood swings, sleep problems, and the list goes on. Which of those symptoms could mean serious trouble, which one can you live with and the ones you could live with, what do you do when they become intolerable?
Plus we'll talk pads versus tampons. When can you start using tampons? What risks exist with using those? Should you just stick with pads and what about the eco-friendly washable cloth variety? Things like Lunapads, if you haven't heard of them, I'll introduce you. So that's all coming up.
First, I do want to remind you. If there's a topic that you would like us to talk about on PediaCast or if you have a question for me or want to point me in the direction of a news story, it's really to get in touch.
Just head over to pediacast.org and click on the Contact link. Also, I want to remind you the information presented in every episode of the program is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals.
All right, with all that in mind, we're going to take a quick break. And I'll be back to talk about "period problems," right after this.
[Short Break Music]
All right, we are back.
Dr. Cynthia Holland-Hall is an adolescent medicine specialist here at Nationwide Children's Hospital and an associate professor of Pediatrics at the Ohio State University College of Medicine.
She's a member of the North American Society for Pediatric and Adolescent Gynecology, the Society for Adolescent Medicine and the American Academy of Pediatrics. Dr Cynthia Holland-Hall's clinical interests include sexually transmitted infections, reproductive health and eating disorders.
She has co-authored two textbooks on adolescent medicine and she joins us now in the PediaCast studio to talk about "period problems". So I welcome to the show Dr. Cynthia Holland-Hall.
Dr. Cynthia Holland-Hall: Thank you. It's a pleasure to be here.
Dr. Mike Patrick: I really appreciate you stopping by. So let's talk first normal physiology of the menstrual cycle. And I know this is really a tall order in an audio program. It's complex and so we're asking you to do this without slides and pictures.
But I do think it's important for folks just to get an idea of the complexity.
So if you can just talk a little bit about what's going on with the menstrual cycle.
Dr. Cynthia Holland-Hall: Right. So it is very , very complex. I'm not going to go into the great complexities. I think you're the first person, Dr. Mike, who ever referred to the menstrual cycle as a work of art and I love that. It makes me just want to make you an honorary adolescent medicine physician right now.
So I'll try and keep it simple. You can tell me if you want a little more detail. But it all starts actually in the brain. The whole thing get set off in the brain in an organ called the hypothalamus that people may or may not have ever heard of.
The hypothalamus makes hormones , sort of chemical signals , and they tell another area of the brain, the pituitary gland, what to do. Now a lot more people are familiar with the pituitary gland. They've heard of that. They know it's associated with puberty and Candida kind of stuff. And it's very much associated with the periods as well.
So the hypothalamus makes hormones to tell the pituitary gland what to do. The pituitary gland makes more hormones that tell the ovaries what to do.
Now the ovaries have two big jobs–ovulation, the release of an egg every month; and hormone production. And the big hormones that , the ovaries produced many hormones, but two of the biggest are estrogen and progesterone that are kind of known as the, classically, the female hormones, if you will, although men have them, too.
And these hormones made in the ovaries affect the endometrium. Now the endometrium is that inside lining of the uterus that builds up and sheds and bleeds every month.
So we've got the hypothalamus, the pituitary gland, the ovaries, and the uterus, and sometimes we call these an axis hormonal communication system.
Here's where it gets really complicated. There's all kinds of feedback loops and different ways in which this axis is regulated. But that's what controls the menstrual periods.
Now ovulation is really the key to regular menstrual cycles.
And girls who are ovulating regularly, the hormones made by the ovaries tend to behave in a predictable fashion and the periods therefore are very predictable or fairly predictable as well. And the problem is, ovulation doesn't happen every month for many girls.
In fact it can take a good few years after the first period until ovulation occurs consistently. And when ovulation does not occur consistently, the hormones behave in a rather less predictable fashion and so some irregularity of the menstrual cycles is quite common.
Dr. Mike Patrick: I mean, what makes it all get started? Because obviously little girls aren't menstruating, what sort of the "switch" that turns this whole process on?
Dr. Cynthia Holland-Hall: That's kind of a million-dollar question. You know what starts puberty? Now I always try and make a distinction. Puberty is a much bigger processes.
You of course know than just menstruation. And what triggers puberty? We don't really know. It seems to be there are some critical elements there, a certain percent of body fat, a certain weight, a certain chronologic age. But we don't know exactly what sets all of and sets the whole process of.
Dr. Mike Patrick: Speaking of chronologic age, at what age do periods typically begin?
Dr. Cynthia Holland-Hall: So the kind of average age for the first period is about 12-1/2 years old. Of course, there's a tremendous amount of variability there. For Caucasian girls, it tends to be, may be a little bit older than that. For African-American girls, it's often a little bit on the younger side.
But 95% of girls start their period between the ages of 11 and 15 years old. By the time they're 15, about 98% of girls have had their first period.
Dr. Mike Patrick: Sure. A lot of parents are asking you predict when it's going to happen and I know when I was in private practice, we would say, two to three years after the onset of breast development. Is that still considered to be a true statement?
Dr. Cynthia Holland-Hall: Absolutely, in some ways, almost more useful than giving it a chronologic age. So exactly as you said, puberty is often the first sign of puberty that a parent sees or a person sees is some breast development.
And two to three years after , certainly within three years after the onset of breast development, yeah, we'd like to see that first period. In fact, if we don't see that, it might be a cause for some concern which we're going to get to later. I'm sure.
Dr. Mike Patrick: Sure. Now early is too early?
Dr. Cynthia Holland-Hall: So precocious puberty as you mentioned earlier so secondary sex characteristics, again, this looks more at overall sexual development than period per se. When is it too early to see those first signs of puberty?
So what we call the secondary sex characteristics–breast development, pubic hair development–for me, I think under the age of eight years old, to start to see those things probably should be evaluated by a pediatrician or a family Doc.
Having said that, many of those girls may be found that that's completely normal for them, particularly African-American girls who some data shows might demonstrate some breast development even as young as six years old, certainly as young as seven years old, and for Caucasians as well.
So it might well be within normal limits and not be a cause for alarm, but I feel that if you're starting to see those things, earlier than the age of eight, it makes sense to have your doctor check it out and make sure it's OK.
Dr. Mike Patrick: Yeah. And without going into too much detail, what are just a few of the things that could cause that to begin too early? So what would a doctor be looking for if they saw those secondary sexual characteristics before the age of eight?
Dr. Cynthia Holland-Hall: I think one of the key things that doctors are going to look at is, is this all of puberty happening early or just one isolated findings? So true precocious puberty is caused by an overall early maturation of that hypothalamic-pituitary-ovarian axis–that hormonal communication system that I talked about earlier.
And these girls have not only just breast development but they have body hair and periods, but they also have a growth spurts. Their bones mature faster. Everything is accelerated and starts at an early age. That's what we call central precocious puberty.
And usually we don't know what causes this. But in some cases, it can follow other brain disorders such as tumors, a history of brain irradiation, a significant brain injury or trauma. There are also genetic causes for this and the chronologic causes, hormonal causes, like thyroid disturbances.
But then there are other conditions that can be associated with just secretion of a particular sex hormones from another area of the body such as a tumor in the ovary or the adrenal gland that might just cause some isolated pieces of puberty to occur like just breast development, just pubic hair development.
These are all pretty rare conditions. Don't get me wrong.
But that's why a girl who starts to develop at a really age should be evaluated by a physician.
Dr. Mike Patrick: Yeah, sure. And then on the flip side of that, how late is too late?
Dr. Cynthia Holland-Hall: Most girls start having some breast development between about 10 and 11 years of age, so that's kind of the average. A kid who doesn't have anything at all by the age of 13–no signs of breast development, no signs of pubic hair or body hair development–that's getting to be a little unusual and that should be evaluated.
No period at all by the age of 15 concerns us. And again, as you mentioned before, no period within three years after the onset of breast development, so if a kid starts to develop breast when she's 10 and by 13 we're still not seeing a period, that girl should be evaluated.
I would not wait until she's 15 to say "OK, now it's time for me to get her evaluated for not having a period." So I really encourage parents to pay attention to those things, to make a mental note.
How old was your daughter the first time you noticed any breast development, for her to buy a training bra? I don't know if there's such a thing as a "training bride". I never really understood what we were training the breasts to do.
Anyway, how old was she when you noticed that? Make a mental note of it.
Dr. Mike Patrick: Do you find that you're reassured when you find that that's sort of a family pattern? So you know of mom and grandma, both sides, yeah, we started a little bit late. Obviously, you're not going to necessarily ignore it but you feel a little better about that.
Dr. Cynthia Holland-Hall: It's reassuring absolutely to know that this is kind of just in her genes.
Dr. Mike Patrick: Yup. And then as we talked about with precocious puberty, with delayed onset of puberty, what sort of problems or concerns are you worried about that could potentially caused that?
Dr. Cynthia Holland-Hall: Usually, like you were saying with family history especially, it is just what we call this "constitutional delay". Everything is just slowed down, what you might call a "late bloomer". And very often, it's nothing more serious than that.
But we do have to think about possible medical conditions that can be contributing to delayed puberty as well , malnutrition.
When I'm not a gynecology doctor, I'm eating disorder doctor so my antennae is always up for the presence of an eating disorder or malnutrition that can affect the pubertal process. Other kind of hormonal disorders, again, brain trauma or brain injury of some sort in the past, genetic disorders.
And occasionally, I'd say even in my line of work where I see a lot of these kids, every couple of years I diagnose a kid with an anatomical disorder of the genital tract that's stopping her from having periods.
Dr. Mike Patrick: Sure. What about within athletes? So you did talk about may be one of those triggers to start the whole process is an increase in their body mass. And sometimes you see some of these athletes who are very thin with , they're not really malnourished but they really don't a lot of fat percentage. Can that play a role in delayed onset?
Dr. Cynthia Holland-Hall: It can. And you know there was a time when we were hoping it would be as simple as that.
You need a certain percentage of body fat to undergo puberty, and like most things in medicine, it's not that simple. But there seemed to be a necessary element for a lot of young women to have a certain amount of body fat.
Dr. Mike Patrick: Sure. Now once periods begin, you did talk about , they have to ovulate once a month in order to keep that cycle going. When we talked about early on in the menstrual cycle years, in the earlier teenage years, that there often times are irregulars. Is that the primary reason for that?
Dr. Cynthia Holland-Hall: It is, what we call" anovulation"–lack of consistent ovulation is very common and then we don't see regular monthly periods. They might have a few months when everything looks like it's evening out then things get a little off again.
Dr. Mike Patrick: Sure. And then I would suspect anything that decreases your body fat or nutrition status. So if you had a period of an illness or maybe just during track season, that it may be irregular because of what's going on with your overall health.
Dr. Cynthia Holland-Hall: Yes, certainly the overall health. The reproductive system is very sensitive to the mental and physical health of the overall organ, so I might think.
Dr. Mike Patrick: Yeah, yeah, yeah. Now when are irregular periods a concern? Or are they ever a concern? So it has started but things are irregular.
Dr. Cynthia Holland-Hall: Yeah. So as you said, once periods start, they're not necessarily going to be regular right out of the gates. Some degree of irregularity is quite common especially during that first year or so, after the period begins.
And what we see most often is some significant variability in the cycle length. I don't want to define what I mean by that. When we talk about the menstrual cycle, what we're referring to is the number of days from the first day of one period until the first day of the next period.
And it's pretty rare for that to be boom. Twenty-eight days for every girl and you know right out of the gate again.
So some variability in the cycle length is common but I want to be really careful here because there is really commonly held belief that anything goes. And I would refer to it as , I would call it a myth really, that anything goes.
And even a lot of pediatricians really believe that, oh, within those first one or two years after the first period, I'm not going to worry about anything. No matter what her pattern of bleeding is, I'm not going to worry about it.
And I really spent a lot of my educational missions trying to dispel that myth. There are some really cool epidemiologic studies done, mostly in Scandinavian countries that looked at these big populations of girls who were in the process of puberty.
And what they did is , and I'm talking thousands of girls here , once they started having their periods they just track them. They had them write them down every single month or overtime, if it wasn't every month, what happens.
And what they found was that for 80% of these girls, even in that first year after they had their period, 80% of the cycles were between 21 and 45 days so between three weeks and six months, something in the order of monthly and included two to seven days of bleeding.
So really, to have a dramatic variability from that is something that could potentially be the sign, not always, but could potentially be the sign of a problem. So while some occasional variation is certainly acceptable. Consistent variation from that really should be checked out.
Dr. Mike Patrick: Sure. And then what would you do about that? So if you had someone , obviously you want to make sure that there's not a medical problem. But, let's say, there's not a medical issue that you're discovering. Is it something that you would want to make regular or is it OK that it is not regular?
Dr. Cynthia Holland-Hall: It's OK that it is not regular. So a lot of times I'll just provide reassurance. Some people come in, they say, "We can leave with this". We just want to make sure it's OK.
And so very often, the visit just ends up with some reassurance. Yeah, this is OK. I'm not worried. I don't see any other indication that there is a serious problem underlying this.
So we don't have to do anything about it.
Dr. Mike Patrick: Yup.
Dr. Cynthia Holland-Hall: Having said, if a girl is miserable by her periods, we certainly can intervene and try to make them better for her, even if it's not a sign of a serious medical problem even, if it's more of a quality of life issue.
Dr. Mike Patrick: Yeah, absolutely. And we'll get to some of those things.
Dr. Cynthia Holland-Hall: Sure.
Dr. Mike Patrick: Let's talk now about heavier periods.
Dr. Cynthia Holland-Hall: OK.
Dr. Mike Patrick: What causes some girls to have heavier and longer lasting periods than other girls?
Dr. Cynthia Holland-Hall: So again, the number one thing is that immaturity of that hormonal axis.
Whenever we're talking about menstrual irregularities whether it's too short, too long, too much, too little, although that is often all it is, that's what we call a diagnosis of exclusion, which is, Dr. Mike, is when we think that's probably "it" but we really still have to go through, at least in our heads all the different things that it could be and make sure it's not anything more serious before we come back to that.
So talking about heavy periods, I think we have to define what we're talking about a little bit first, so how much is too much, right?
So periods that are happening more frequently than every 21 days, lasting longer than seven days, consistently, and I conclude more than seven days of bleeding, and then the heaviness.
Trying to assess the heaviness can be hard because it's subjective and a girl only knows her own periods. So one of the things I asked is how often do you have to change your pad or your tampon? Not how often do you like to. How often do you have to? And because it's saturated, because it can't function anymore, right?
And so every one to two hours, if I have a girl for even half day or so if her period has to change every one to two hours, that concerns me why she's bleeding that fast. Kids who are going through more than six or eight products, six to eight pads or tampons per day, again, not because they just like to have a clean one but because they have to change that often. That could be a sign of a problem of bleeding too much.
Girls who pass blood clots. This is another big one. It's normal to pass some clots out of the vagina with a period but if they're bigger than an inch, bigger than about the size of a quarter, that's a little suspicious for why she's bleeding so heavily.
And then the development lastly, the development of anemia which is where a situation in which the body is not keeping up with the blood being lost. The body can't make up the red blood cells as fast as they're being lost.
So sometimes a pediatrician can even do a little quick check. A physician can do a quick check right there in the office for anemia. But I ask about symptoms of anemia. Do you get tired more quickly than usual? Not so much on overall fatigue, but if you're an athlete did you used to be able to play the whole half of your game without any problem. And now after the first quarter you're just exhausted and you want to sit down.
If you're a couch potato, you're heading up the stairs and you feel like you just run a mile, those could be signs of anemia.
Dr. Mike Patrick: Sure. Now with the heavy periods, one of the other topics that we had actually talked about, not too long ago in the show is Von Willebrand disease. So when we think about primarily the axis and hormones and that kind of variation but then there's other disorders like the bleeding disorder that could cause this as well.
Dr. Cynthia Holland-Hall: Absolutely. That's pretty high on my radar as well. So I think do we have hormonal problem here? Do we have a bleeding problem here? So when do I think about a bleeding disorder?
Well, certainly when I'm getting a lot of that history that I just mentioned , the clots and the heavy prolonged periods and frequent changes , but then I also ask about non-gynecologic bleeding as well.
Do you get bruises that you don't know where they came from? Do you cut your leg shaving and it takes 25 minutes for that little tiny nick to stop bleeding? I asked about surgical challenges. I asked about some common things like having their tonsils out or having a tooth pulled.
Was that pretty uneventful one that happened or did your surgeon? Or your oral surgeon mentioned, "Oh it just took me a little extra time to get the bleeding stopped." Those could be signs of a more global bleeding disorder.
Now a severe bleeding disorder is going to be picked up in early childhood but it's actually not at all unusual for a mild bleeding disorder like the most common forms of Von Willebrand disease, platelet function disorders, platelet storage pool deficiencies.
It's very common for the heavy periods to be the symptom that finally gets the diagnosis of this kind of off and rolling.
Dr. Mike Patrick: Yeah. I would think too that in each individual, so if you had heavier prolonged periods but that's their usual pattern versus someone who usually short or lasting or smaller period and now suddenly they have a larger one that's out of the ordinary for them that would be a whole different concern.
Dr. Cynthia Holland-Hall: Absolutely. Most of the kids , now not every patient reads the textbook as you know.
But for the most part, yeah, if I have a kid, my periods were regular. They were manageable for three, four years. Now they've gotten really heavy all of a sudden. Yeah, I'm thinking a lot more about a hormonal cause in her.
The kids with bleeding disorders, it tends to be right out of the gate. They're 12 years old and their periods are always heavy, long 14 days, or just may be not even that long but going through product after product and the parents say, "I¡¦m in the grocery store constantly buying more pads."
Dr. Mike Patrick: Right. Right. So I think we're getting at here, too, is that some of this is lifestyle, in terms of whether you need to do something about it. So if the heavy prolonged periods are interfering with your life or they're causing anemia or another health issue, then you're going to want to do something about them. So what options are available there?
Dr. Cynthia Holland-Hall: I have some great news about irregular periods, in general. There is a fantastic medication out there for the treatment of irregular menses.
It's effective. It's safe. Even in pre-teens, it's safe.
There are inexpensive generics available of this medication. There's one problem with this medication, which is, that it is more commonly known as the birth control pill and that makes some people uncomfortable.
Dr. Mike Patrick: Yeah.
Dr. Cynthia Holland-Hall: So I spent a lot of time counseling my patients that we need to be able to think about the use of these medications. I prescribe them every day to girls. Sometimes, pre-teen girls or girls of any age who don't need birth control.
They made the great choice. They don't need birth control. They're not sexually active. But there are a lot of medical indications for these pills as well. Irregular periods, heavy periods, cramps, acne, prevention of ovarian cysts. They're not just for pregnancy prevention. They can be very effective in managing period problems.
Dr. Mike Patrick: Really you're giving them hormone, the estrogen-progesterone or some combination thereof. So if their body's not making in a regular fashion, you're providing that same hormone to them so that then they can be more regular because they're getting the constant or the right dose at the right time.
Dr. Cynthia Holland-Hall: Absolutely. And the way I explained it to my patients is, we're taking over your ovaries job for a little while here. We're going to put your ovaries to sleep. We're not doing anything permanent to your ovaries. I would never give you a medication that would do anything to your ovaries that wasn't absolutely a life-saving medication for you.
So we're putting your ovaries to sleep, temporarily. We're taking over their job and we're going to do it in a more predictable fashion. Your ovaries are doing it right now. While that happens the girl is going to continue to mature. She's going to continue to age and that hormonal communication system will continue to regulate.
We're not stopping that process from happening. So it might be that we use these pills for six months or a year and then we can reconsider. Hey, we want to see what your body is doing on its own.
Frankly at that point I have a lot of girls like "I don't want to know what my body is doing on its own. I like knowing when I'm getting my period and knowing that's going to be manageable."
Dr. Mike Patrick: Sure. Now when you're talking about using birth control pills for that purpose, is there a role for the other forms of birth control like the injectable like Depo Provera, for instance, in that same situation or really pills the better way to go?
Dr. Cynthia Holland-Hall: It depends on what your goals are and if you're willing to take a little bit of a chance. I like pills because I can take them away if they don't agree with your body. I can take them away. We're going to stop them. It will be gone in a few days.
We have different pills out there. We can manipulate and do some fine tuning with them. And really the pills, which contain the combination of estrogen and progesterone, which is the case for the vast majority of the birth control pills out there, that's the medication that's going to give you a regular predictable monthly period.
Now we certainly can use other options that take out the estrogen and just use progesterone and that's like the Depo Provera shot.
There's progesterone oral medications. Sometimes we need to do that for medical reasons. We can't use estrogen for various reasons. Usually, it's OK to use but it's the pills that are going to give the regular monthly period.
These other things sometimes we can use to try and stop the periods but sometimes they can have some association with irregular bleeding. And again, you give a shot. The Depo Provera shot is a three-month injection.
It may not last. It's given every three months. You give that. You can't take it away. You wait it out till it's out of the system.
Dr. Mike Patrick: And I think it's important to point out at this point, obviously, these things would also act as birth control. And it's important that these girls really understand that this is not going to protect them against sexually transmitted diseases.
Dr. Cynthia Holland-Hall: Absolutely. Absolutely. Condoms remain important for anyone who chooses to be sexually active.
Dr. Mike Patrick: What signs and symptoms then are common around the menstrual cycle? I mean the list is long but I think some girls would be reassured to know "Hey, it's not just me."
What things do you see that are common?
Dr. Cynthia Holland-Hall: Far and away, the most common problems that we see are cramps and PMS. So I think those are the two biggest complaints. So we use the medical term dysmenorrhea to sort of encompass not only the pelvic cramping but all the rotten things that sometimes girls experience in association with their periods whether its nausea, back pain, leg pain, headaches. You made reference to some of this right up at the beginning of the show.
So I see a lot of kids with cramps and a lot of kids with PMS which , it's an interesting diagnosis. One that we really don't understand nearly as well as we wished we did. But just kind of moody getting a short temper, a short fuse, more irritability, kind of ups and downs especially those few days, maybe a week before the period, may be one or two days into the period.
That can be a tough time for girls.
Dr. Mike Patrick: And the boys who are living with the girls.
Dr. Cynthia Holland-Hall: And the boys and women and mothers.
Dr. Mike Patrick: Yes.
Dr. Cynthia Holland-Hall: I hear a lot about mothers like who was that girl last week. She's gone now and I'm happy about that.
Dr. Mike Patrick: When do those symptoms usually begin with relation to the cycle?
Dr. Cynthia Holland-Hall: That's a great question. Sometimes people get re-assured because their daughter may be starts her period. They seem pretty uneventful, not too crampy, not too moody now and she goes for a year. Then after a year or two the cycles become more regular but we also start to see more cramping, maybe more PMS, particularly with the cramping.
What's going on there? It comes back to the ovulation. Some of these particular processes–PMS, menstrual cramps , are more associated with ovulatory cycles. So as the ovulatory cycles become more common a couple of years after the first period, so do some of these symptoms.
Dr. Mike Patrick: Is it usually right around the time that you're actually having the period when you have to start a few days before that?
Dr. Cynthia Holland-Hall: Especially PMS almost by definition tends to start sometime during the week before. The menstrual cramps it's variable. Some girls start cramping a couple of days before the bleeding begins. Some girls just start when the bleeding begins and it's all about developing some , getting in tune with your body.
Really starting to learn the signs and so we can in some cases start treatment as quickly as possible when we know it's common.
Dr. Mike Patrick: Sure. And then breast soreness and heaviness, I want to mention that one specifically, too, because sometimes girls are like "Hey, although this is my period, what's going up on top?"
Dr. Cynthia Holland-Hall: Yeah. The same hormones that affect the periods can affect the breast tissue, estrogen in particular so some breast tenderness, achiness, fullness. Some girls even say I have my period bra and my regular bra [Laughter] because they see an appreciable difference in breast size.
Dr. Mike Patrick: And the headaches and the acne flares, some migraine patterns can be affected by the menstrual cycle, too.
Dr. Cynthia Holland-Hall: Yeah, absolutely. Hormones don't just hang out in our uterus and ovaries and breast tissue. They go all through the body and they can affect mood, headaches ,all kinds of symptoms.
Dr. Mike Patrick: Are there any particular symptoms that would be a concern?
Dr. Cynthia Holland-Hall: We can talk about treatment in a moment I'm sure. But when our typical treatments don't work, that's really when I get the most concern. The vast majority of the patients I see have what's called primary dysmenorrhea so menstrual cramps that don't have a serious underlying cause, just a little bad luck. You're one of the women who get lousy menstrual cramps.
Dr. Mike Patrick: Yup. Yup.
Dr. Cynthia Holland-Hall: Usually when it is that primary menstrual cramping without being a sign of an underlying problem, they usually get better. Our treatments usually work. When they don't that's when I start to think about may be other problems.
Dr. Mike Patrick: Sure. And then also if it out of character for what their regular pattern would be, so if you have a girl who does have some menstrual cramps but now they have really more severe abdominal pain than is typical for them, you probably want to seek help because there could be something else going on.
Dr. Cynthia Holland-Hall: Absolutely. And especially if a girl has chosen to become sexually active then we think a lot about pregnancy, pregnancy complications, infections, that can sort of acutely more suddenly change the pattern of bleeding or the pain associated with the menstrual period.
Dr. Mike Patrick: Sure. What about ovarian cysts? What exactly are those and do they play a role in pain in these types of symptoms?
Dr. Cynthia Holland-Hall: So again, a cyst is something that starts off as a perfectly normal functional process. And it's a part of ovulation. When that egg is kind of selected by the ovary to be 'the egg' that's going to pop out that month with ovulation, there is a little cystic structure, little follicle that forms around it.
And sometimes in the process of a little bit of a dysfunctional, a little bit of a messed up, ovulation, a little ovulation mistake or after ovulation that cyst can hang around for a little while and it can get bigger.
And in some cases, it can become painful.
Usually they go away on their own and we don't worry too much about them. It's very rare that they need to be surgically treated, or anything like that. They usually go away after the next cycle. But that would be much more likely the cause , a more isolated episode of more severe pain.
Cysts don't really cause monthly severe pain that then goes away in between the periods. That's how they work.
Dr. Mike Patrick: Sure. And then I suspect just like with the prolonged and heavier bleeding some of it then is, how are these symptoms affecting your day-to-day living? And so, if it's something that you're dealing with then great, but on the other hand, if this is really something that you're missing school, you're missing work, your relationships with the family are under stress because of the mood swings, let's say.
I mean there are all ways that these symptoms could interfere with your life.
What options are available to help deal with them?
Dr. Cynthia Holland-Hall: Yeah. I have to throw my little statistics in here. You know, 15% of girls say they missed school on a monthly basis, on a regular basis because of their periods. And I feel really strongly as a holistic adolescent medicine doctor, this really unacceptable to me.
It's tough because sometimes they heard. They've just got this message from their family or society and "Hey, man, that's what it's like to be a woman. It stinks sometimes. You know but I had heavy periods. I had cramps. Your grandma did. Your aunt did. Your sister did."
And that makes them think it's normal and there's nothing we can do about it. There's absolutely stuff we can do about it.
So yeah, even if there's not a serious problem, medical problem, if I have a girl who's missing school, she's missing sports, she's missing out on her social life, I absolutely encourage some intervention.
So what are some of the things that we can do for , let's start with cramps. What are some of the treatments that we have available for them?
And the first thing is pretty simple. You probably have it in your medicine chest already which is ibuprofen, or its neighbor drug, naproxen. So these are both over-the-counter medications. They can be really effective for treating menstrual cramps.
They tend to work better than Tylenol. I'll get back into a little bit of science here just because I think it's interesting. So Tylenol is a very nice pain reliever. And if it works for your cramps, that's just fine. Go ahead and take your Tylenol.
But ibuprofen and naproxen, in addition to being pain relievers, they actually work to reduce the amount of the substance called prostaglandin. That's not important to remember but it's made in the lining of the uterus and it actually causes the cramping to occur.
And so ibuprofen and naproxen actually reduce the amount of that substance that's made. So they really work at, not only as pain relievers but at the cause of the problem as well, and that's why they tend to be among our most effective medications.
So again, the over-the-counter versions are just fine. I encourage people to start with the recommended doses that are written on the bottle but then to keep in mind that in a healthy person without any other medical problems, it's usually acceptable , I encourage people to check with their doctor before they do this. , but for most patients, it's acceptable to use, for example, three ibuprofen tablets which would 600 milligrams, two naproxen tablets instead of the one that's written on the box.
If your doctor says, "It's OK," it can be very effective to use these higher doses. And the other thing we do is, I tell girls, "Look, you just came in to see me because you're telling me your periods are miserable every single month."
"So next month, let's not wait and see if it's going to be miserable. Let's just assume it's going to be miserable. Start your medication as soon as you know your period's coming and take it on a schedule basis."
"Take your ibuprofen three times a day. Take your naproxen twice a day."
"Try and keep that pain under control right from the beginning rather than waiting until it gets bad and then try and bring it back under control which is harder."
Dr. Mike Patrick: Yup.
Dr. Cynthia Holland-Hall: So those are the over-the-counter things. Some people again are good old friend the birth control pill can be extremely effective when those things don't work. So keep that in mind.
A lot of people are more comfortable with non-pharmacologic treatments and there are a lot of them outdoor that might , for many of these types of treatments there are some small studies that indicate they could be useful.
We all wish there were more bigger studies. But some things that are possibly useful and very unlikely to cause any kind of harm. Include get some exercise, heat packs, heating pads. They make those ones that you can stick right on the abdomen over the uterus. That can be helpful.
Things like self-hypnosis and biofeedback can be useful for menstrual cramps, omega fatty acids, vitamin B, magnesium–so lots of possible things that might help, unlikely to be harmful.
Dr. Mike Patrick: Sure. When a girl has issues with her period, a lot of times they're seeing a pediatrician. And some pediatricians are more comfortable dealing with these issues than others. How should a teen girl decide who to talk to about this?
And I guess that flows into when should she see a gynecologist? Does she need to see a gynecologist? When should she see an adolescent medicine specialist? Who should she be talking to about? Obviously her parents.
Dr. Cynthia Holland-Hall: Of course.
Dr. Mike Patrick: From medical professional standpoint, where should she go?
Dr. Cynthia Holland-Hall: Yeah. So it's great to start with her pediatrician or family doctor if they are comfortable and if she is comfortable. You even admit it as great a Doc as you are and as familiar you are with such a variety of pediatric problems, it can get a little funny to talk about periods sometimes.
The girls can get really nervous. So I always preface those visits with "I know. You just met me five minutes ago and here I'm asking you these crazy personal questions about your life, right?"
But it's great to start with the pediatrician and see if they are comfortable because many pediatricians are very comfortable treating these things. If they're not, it can get a little tough. So if you're here in Central Ohio, we'll put in a little plug for my adolescent medicine division here.
We have lots of female doctors who treat menstrual problems. And anywhere if you're somewhere where there's a big children's hospital chances are, there will be adolescent medicine providers there.
We are very comfortable with treating menstrual disorders and menstrual problems. Gynecologists of course are available to us as well. Some of them just like pediatricians, some are comfortable treating menstrual problems; some are not with a gynecologist. Some of them are comfortable treating young people. Some of them are less comfortable or take a less developmental approach to communicating with patients and taking time.
Pediatricians what I like about adolescent medicine Docs, we're pediatricians, most of us are. And we're really comfortable talking to kids and language that they understand and sizing up where they are developmentally and facilitating that communication. So those are some of the options.
Dr. Mike Patrick: I always asked that question when a teenage girl would come in for a well check up when I did private practice. And when does she need to see a gynecologist? When does she need to see a gynecologist over and over again?
And especially in a town where there may not be an adolescent medicine specialist, when do you recommend that girl see a gynecologist?
Dr. Cynthia Holland-Hall: For problems or for routines?
Dr. Mike Patrick: The routine. Yup.
Dr. Cynthia Holland-Hall: What I really recommend is I'm always trying to help my pediatric colleagues get a little more comfortable doing some of this really basic stuff. For example, looking at the vagina, knowing, just outside, just externally and knowing what they're looking at and being comfortable with that.
Performing basic STD testing in patients who are sexually active, addressing basic period problems, and if your pediatrician does all that stuff and is comfortable with all that stuff, there's really no need to see a gynecologist unless there's a problem or until you turn 21, which is the age that's recommended for Pap smears now, to begin cervical cancer screening at age 21.
Dr. Mike Patrick: Great. And the adolescent clinic here at Nationwide Children's Hospital I do want to mention that folks, if you are interested in getting connected with the adolescent medicine folks, we do have that link in the Show Notes that I've been talking about, the Connect Now link.
And for this particular episode, it will say "Connect Now with an Adolescent Specialist" and when you click on that link, it will take you to a form that is specific for PediaCast listeners. And you can basically make a referral for yourself that way.
And someone from adolescent medicine will get back in touch with you about making an appointment. So it's just a really easy way to connect if folks head over to PediaCast Episode 253 at pediacast.org in the Show Notes.
They'll be able to find that link.
And like a lot of the clinics here at Nationwide Children, it is a multi-disciplinary clinic so you guys, it's not just adolescent medicine physician, you guys also have social workers, nutrition, dietary support and supportive psychologist, psychiatrist–the whole gamut.
Dr. Cynthia Holland-Hall: Yeah, we're very certainly plugged in to the hospital behavioral house system as a whole and then for some specific problems, like eating disorders and things like that. We have psychologist and dietitians. We have general social workers who helped with all of our patients.
And everybody loves teenagers and everybody's very comfortable taking care of teenagers from the person at the registration desk to the nurse who puts you in a room and takes care of you to the physicians and everyone else.
Dr. Mike Patrick: Great, great place. So one more item that I had mentioned. Pads versus tampons. This is another one that a lot of girls want to know.
Dr. Cynthia Holland-Hall: Yeah.
Dr. Mike Patrick: Can you use tampons right out of the gate? Should you start with pads? What's your feeling on those things?
Dr. Cynthia Holland-Hall: So most people start with pads just because they're a little less intimidating to get started with. So from a medical standpoint though, there's really no medical reason that a girl of any age can't use a tampon.
Now some of them might be more psychologically , most of them I think are more psychologically comfortable and physically comfortable, too, using a pad. But there's no particular age or medical situation in which, OK, now it is acceptable for you to use tampons.
As they get older, some girls just develop more curiosity and say, "What's with these tampons? I think I'm going to like to give them a try. They sound like they might be useful to me."
Dr. Mike Patrick: Sure. Because with tampons you do hear some people , some people hear warnings , what are the concerns with tampons?
Dr. Cynthia Holland-Hall: So, of course, when you and I were young, younger [Laughter].
Dr. Mike Patrick: Careful.
Dr. Cynthia Holland-Hall: Than we are now. I know, I know.
Dr. Mike Patrick: [Laughter]
Dr. Cynthia Holland-Hall: There was a big scare about toxic shock syndrome.
And this is a very severe infectious disease that , and I want to say the 70s, maybe early 80s , was associated with certain types of tampon use and particularly the very kind of super plus heavy-duty tampons that were left in place for a long time.
So toxic shock, it hasn't gone away. It still exists. It will always exist as a syndrome. But the association with tampons is not one that is seen extremely, commonly. So I think using some basic kind of commonsense approach toward using tampons, use the lightest one that you need.
If you don't need a super plus, don't use a super plus. Change them on a regular basis. Don't leave your tampon in more than four hours. And with kind of commonsense approach to tampon use, you shouldn't waste any time overnight. Don't lose any sleep worrying about toxic shock syndrome.
Dr. Mike Patrick: Sure. And then I also want to mention the eco-friendly washable called Lunapads. It's just one brand of them but there's other ones out there.
The women at our house swear by these things. They really, really enjoy using them. And I don't get any kickbacks or anything.
I just wanted to share a great product. Don't put a link their site in the Show Notes. They are absorbable and washable eco-friendly things.
Speaking of links in the Show Notes, there will be a link to the Adolescent Medicine Division here at Nationwide Children's Hospital. For the parents out there, we have a couple of links for you from the Nationwide Children's Hospital Health Library on precocious puberty and delayed puberty.
And then for the teenagers out there, we have some links from KidsHealth. All about menstruation, irregular periods, coping with common period problems and then one called tampons, pads and other period supplies.
So that and then the Lunapads link and then, of course, the Connect Now With An Adolescent Medicine Specialist link–that's all going to be over at pediacast.org in the Show Notes for Episode 253.
So Dr. Holland-Hall, we really appreciate you stopping by and sharing your knowledge with us.
Dr. Cynthia Holland-Hall: It's been my pleasure. Thank you for having me.
Dr. Mike Patrick: All right. We're going to take one more quick break and I will be back to wrap up the show, right after this.
[Short Break Music]
All right, we are back. My final word this week is kind of lame. I'll just admit that upfront. But I think it is important. So it's lame but important.
Because sometimes we sweep period problems under the mat, we don't like to talk about them. So I'm hoping that this episode will get families talking.
And as I mentioned in the intro, this is a good time to introduce PediaCast to your daughters. It's a great introduction to some of the problems that they may face. We have a little Science, lots of practical advice, so I really think that this is one of those shows you got to share with your girls.
Also, if you know anyone who doesn't listen to PediaCast but you know they have pre-teen or teenage daughters at home, be sure to tell them about Episode 253 over at pediacast.org, guess that's this show.
Just email in the link and let them know about the program. If you're aware of a single dad with daughters, yeah, this show is definitely for him. And of course, let your doctor know, even if your girls don't have problems, you can bet that your pediatrician or your family doctor is dealing with plenty of families at home or at in the office, the families who are dealing with period problems in their homes.
And I think this episode will be a fantastic resource for them to share with their patients as well so make sure you let your doctors know about this program. So I really just what I'm saying is I need your help spreading the word, so share this episode.
I'd like to see it gets lots of mileage and that's my final word. I want to thank all of you for taking time out of your day to make PediaCast a part of it.
Also, once again, thanks to Dr. Cynthia Holland-Hall, adolescent medicine specialist here at Nationwide Children's Hospital for stopping by the studio.
iTunes reviews are helpful as our links, mentions, shares, retweets and repins and all those social media sites. PediaCast is on Facebook, Twitter, Google Plus and Pinterest. Be sure to tell your family, friends, neighbors, and co-workers about the show.
And your child's doctor, remember posters are available under the Resources tab at pediacast.org. Once again, the Contact link is available at pediacast.org. You can get in touch with me if you have a particular question or a comment or a suggestion for a topic or a news story. Just head there, click on the Contact link and let me know.
All right. That does wrap things up for this week. And until next time, this is Dr. Mike saying, stay safe, stay healthy and stay involved with your kids.
So long everybody!
Announcer: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.
e you next time on PediaCast.