Menarche

The menstrual cycle is divided into two main phases which can be described on the basis of the simultaneous changes taking place in the ovaries and the endometrial layer of the uterus – the follicular (ovaries) or proliferative (uterine endometrium) and the luteal (ovaries) or secretory (uterine endometrium). The two phases (follicular/proliferative) and (luteal/secretory) are separated by the event of ovulation, in which the egg cell is released from the developing follicle in the ovary into the female reproductive tract. The normal sequence of events of the menstrual cycle are as follows:

• Phase 1: Follicular or proliferative phase: After the end of the previous menstrual period that typically lasts up to a week, the first phase of the new menstrual cycle begins. The pituitary gland secretes two hormones, follicle-stimulating hormone (FSH) and luteinising hormone (LH), which are raised to a steady level in this first phase to bring about the development and growth of oocyte, or egg, follicles in the ovaries (follicular phase). Follicles in the ovaries contain within them the egg that will be released on ovulation with the rupture of the fully mature follicle. As follicles continue to grow they produce estrogen, the hormone responsible for the proliferation and growth of uterine tissue (proliferative phase) in preparation for a possible pregnancy.
• Ovulation: Approximately 14 days into the menstrual cycle the follicles growing in the ovary become fully mature and the estrogen they produce reaches a peak. A rise in estrogen levels in the ovaries signals to the pituitary gland, via a positive feedback loop, to produce more LH and FSH. When the LH levels surge to a peak, the mature follicle ruptures and the egg is released from within it into the reproductive tract.
• Phase 2: Luteal or secretory phase: After ovulation, the level of estrogen falls as the follicles that produced it are no more. Low level of estrogen results in the end of uterine tissue proliferation. Even though the uterine tissue does not grow and thicken much further, the glands in it are active and prime the uterus to host a potential pregnancy (secretory phase). This drop in estrogen levels also signals to the pituitary gland to not release more FSH or LH. The remaining cellular debris of the ruptured follicle reorganises itself into a structure called corpus luteum (luteal phase) and produces high progesterone levels and some estrogen. Progesterone is the hormone required to sustain a pregnancy if conceived. In the absence of pregnancy or fertilisation, the corpus luteum regresses and the small amount of estrogen it produces diminishes, resulting in the breakdown of the endometrium lining which is let out as menstrual bleeding.

The first appearance of menstrual symptoms can be distressing to young children, especially so if they are unaware of them. Taking special care, the matter should be broached with them with the utmost sensitivity. Although different girls may experience menarche differently, the following common signs and symptoms are usually present:

• Vaginal bleeding: Appearance of blood or spotting in the underpants is the first and most obvious sign of the onset of menstrual periods. However, the appearance of vaginal bleeding in children younger than 9 years, or in the absence of other secondary sexual characteristics like growing breasts or pubic and armpit hair, could be due to other causes like trauma and should be checked out by a doctor. 
• Abdominal cramps or period pains are common with menstrual periods irrespective of the female’s age. Although a little pain is considered normal, intense pain that hampers the patient’s daily life is called dysmenorrhea and ideally needs evaluation by a gynaecologist. 
• Other symptoms of premenstrual syndrome (PMS)

Some females experience a set of forewarning symptoms leading up to the start of their menstrual period, commonly known as premenstrual syndrome (PMS). Symptoms and signs begin a few days before the period and can last until the menstrual period ends. Signs and symptoms of PMS include, but may not be limited to:

• Acne or pimples, especially on the face, may appear around this time due to the change in hormone levels. These pimples usually regress after the menses end. 
• Abdominal bloating during this time is normal. The body tends to retain extra water at this time due to hormone level changes.
• Sore breasts around this time of the month can be experienced by some females. Wearing a supportive bra is recommended to manage the soreness. If the discomfort is unmanageable, an over-the-counter analgesic like paracetamol or ibuprofen can be taken.
• Back pain, especially of the lower back, is common and may or may not be associated with abdominal cramping. A hot water bottle can provide some comfort. An over-the-counter analgesic or NSAID can be taken for unbearable pain.
• Constipation or diarrhea: Alterations in bowel movements during menstrual periods are commonly reported by females and usually resolve once the menses end.
• Fatigue or feeling more tired than usual is also normal at this time. Although menstrual periods do not usually interfere with everyday life and activities, if one feels the need, getting some rest may be a good idea.
• Irritability, mood swings or feeling extra emotional is possible during menses because of the changing levels of hormones.
• Increased hunger or food cravings may be experienced as menstruation increases the body’s metabolic rate and energy demands. Therefore, even if one does not undertake any physical exertion, it is normal to feel hungrier than usual.
• White or clear vaginal fluid is usually present a few days before the onset of menstrual bleeding.

Young girls are often concerned about what is considered normal and what is not when it comes to menstruation. Although variations are common, the following are some of the parameters considered normal, deviation from which may require help from a gynaecologist:

• Age of menarche: Between 9 to 15 years. The average age is around 12.5 years. 
• Length of a menstrual cycle: Regular cycles that occur every 21 to 40 days are normal. The average length of menstrual cycles is 28 days. Ovulation occurs approximately in the middle at around 14 days.
• Duration of menstrual bleeding: Two to 8 days of bleeding is normal. Bleeding for more than 10 days should be investigated by a doctor.
• Quantity of bleeding: Different people have different types of menstrual flow. Usually, the second day of the menstrual period has the heaviest flow, decreasing subsequently after it. Needing to change tampons or pads after less than two hours or passing clots the size of a coin or larger is considered heavy bleeding and should be evaluated by a gynaecologist.

Once a girl begins menstruation, she will have the option to choose from a selection of menstrual hygiene products to use. Following are some that are commonly available:

• Sanitary napkins, sanitary pads or simply pads are the most commonly used menstrual hygiene product in India. The product comes wrapped in packaging and needs to be opened and applied with the adhesive side facing the underwear. The sanitary napkin soaks up the blood and one can go about their day undetected. Sanitary napkins come in various sizes and bigger ones may be needed on days with heavier menstrual flow or at nighttime. Pads should be changed regularly every 4 to 8 hours to avoid getting an infection.
• Tampons: Not used as commonly in India, tampons are another option to consider. They need some getting used to and are placed in the vaginal canal by gently pushing it in. Threads stick out at the bottom of the tampon for easy removal. Tampons should be changed every 4 to 8 hours to prevent infections.
• Menstrual cups: An eco-friendly alternative to the former two, it is a small cup-shaped device made of silicone or rubber. With clean hands, it is folded in half and inserted, similar to a tampon, into one's vaginal canal and then rotated to open and spring the menstrual cup into place. It is easier to insert after wetting it and depending on the flow can be worn for up to 12 hours. However, it should be used after determining the right size and fit after consulting a gynaecologist.

Sometimes the delay or absence of menarche and abnormal uterine bleeding (too much or too little, too soon or too late) can be a signifier of an underlying condition that needs medical attention. The following should warrant consultation with a gynaecologist:

• Primary amenorrhea or the absence of menstrual periods by 15 years of age: Amenorrhoea means the absence of menstrual periods without pregnancy. Amenorrhea can occur due to various problems affecting the hypothalamus, pituitary, ovaries and overall health, weight and BMI (body mass index) of the child. If menarche is not reached by 15 years, a gynaecologist should be consulted. Causes of primary amenorrhea can include:
  • Constitutional delay: This means that menarche and puberty are naturally delayed in the individual and will occur slightly later than others. 
  • Anatomical congenital anomalies: Sometimes structural problems present since birth can prevent the menstrual blood from coming out. Imperforate hymens and vaginal agenesis are common causes that may need surgery. 
  • Turner syndrome: A type of chromosomal anomaly in which one, instead of the usual two, X chromosomes is present in the female.
  • Hypothyroidism can cause hormonal imbalances in the body delaying puberty 
• Secondary amenorrhea or the absence of menstrual periods for three consecutive months or more after the start of menarche: Sometimes young girls reach menarche but stop menstruating for months due to underlying problems such as:
  • Polycystic Ovarian Syndrome: An imbalance of hormones occurs which causes cysts to form in the ovaries and ovulation to stop, impeding the menstrual cycle. Periods can be irregular or stop altogether (amenorrhea). 
  • Excessive weight loss
  • Stress
• Heavy menstrual bleeding: Changing sanitary pads or tampons every 2 hours or less, passing large blood clots or bleeding for longer than a week can indicate an underlying problem involving a growth in the uterus, hormonal problems or a bleeding disorder.
• Dysmenorrhea or very painful periods
• Menstrual periods that occur too frequently (every 21 days or sooner)
• Menstrual periods that occur too infrequently (every 40 days or later)
  
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