Shortened menstrual cycles (Hypomenorrhea) in two adolescents: Diagnostic and reproductive implications

Abstract

The purpose of these 2 case reports is to stimulate the attention of physicians on a ignored aspect of adolescent gynaecology. Knowledge of the length and variation of the menstrual cycle is necessary for patient education and for identifying deviations from normal to guide clinical evaluation. Cycles that
fall outside of the norm should be evaluated for underlying pattern of loss (presence of clots and flooding). Charting the menstrual cycle on a calendar can be helpful to clarify “normal versus abnormal” cycles. Finally, further studies on normal endometrial physiology as it pertains to the regulation of menstruation
are essential to understand better disorders of menstruation.

Full text

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experienced menarche at the age of 13 years. There was no
family history (FH) of menstrual flow disorders, gynecological
tumors or other gynecological problems was.
On examination; she was well developed (height and weight:
25th and 35th percentile for age respectively). Blood pressure
was 110/50 mmHg. She did not have palpable goiter, acne or hir-
sutism. Breasts were at Tanner’s stage 4 and pubic hair at
Tanner’s stage 5 of development. External genitalia was normal
with normal tenderness on pelvic examination.
Urine pregnancy test was negative. The pictorial blood loss
assessment chart used for 3 months confirmed the normal men-
strual interval and the presence of short duration of menstrual
flow. The basal body temperature (BBT) taken orally with a digi-
tal thermometer at the same time, every morning for 2 menstrual
cycles, showed a normal biphasic curve.
The abdominal and pelvic ultrasound revealed normal uterus and
ovaries. The endometrium thickness in the proliferative phase of
the menstrual cycle (days 6-14) was 5 mm and in the late proli-
ferative (periovulatory) phase was 7 mm.
Introduction
Regular ovulatory menstrual cycles (MC) occur every 21 to 35 days
and last up to 7 days, with an average blood loss of 25 to 69 mL
(1). A multicenter study conducted on a large, population-based
sample of Italian high school girls (n = 3,783), using a self-admi-
nistered questionnaire, reported that by the mean age of 17.1
years, 3% of the subjects had MC shorter than 21 days and 3.4%
had MC longer than 35 days. A MC shorter than normal bleeding
period (< 4 days) was reported by 3.2% of the sample population
and a longer bleeding period (> 6 days) by 19% of the girls (3).
While there are multiple causes for disturbances of menstrual fre-
quency, little is known about the short duration of menstrual flow
[“hypomenorrhea” in the old terminology] (Table 1) (2). This
report describes two adolescents with short duration of men-
strual flow and discuss the diagnostic and its possible reproduc-
tive implications.
Case reports
Patient 1
A 17.2- year old female was accompanied by her mother com-
plaining of “light periods” (1-2 days), since menarche (at age 12
years). In the past, she believed that her menstrual flow had been
"more or less" regular because of the “young menstrual age”.
However, recently she expressed her concerns to the mother:
“Am I normal ? Why my periods are too light and too short?”.
Her personal history was unremarkable. The menstrual intervals
were 28 days ± 5 days. There was no history of emotional stress,
digestive disorders, sharp weight loss or intense physical activity.
Dysmenorrhea was present in the first two days of menstrual
cycle and acetaminophen was occasionally taken. Her mother
Shortened menstrual
cycles (Hypomenorrhea)
in two adolescents:
Diagnostic and
reproductive implications
Summary
The purpose of these case reports is to stimulate the
attention of physicians to a neglected aspect of adolescent gynaeco-
logy. Knowledge about the average variations, including length and
amount, of the menstrual cycle is necessary for patient education and
for identifying deviations from normal to guide clinical evaluation.
Further studies on normal endometrial physiology as it pertains to the
regulation of menstruation are essential to understand better disorders
of menstruation. The exact biologic mechanism/s underlying the link
between short menstrual cycles and fertility reported in the literature
remains to be elucidated.
Key words: Shortened menstrual cycles, hypomenorrhea diagnosis,
reproductive implications, adolescents.
Due adolescenti con cicli mestruali
di breve durata e scarsa entità
(ipomenorrea): Implicazioni
diagnostiche e sulla attività
riproduttiva
Riassunto
La conoscenza delle variazioni della frequenza e
durata del ciclo mestruale rappresenta un aspetto molto importante
sia dal punto di vista diagnostico che della educazione sanitaria del-
l’adolescente. Questo lavoro descrive due adolescenti di 15 e 17
anni con cicli mestruali di breve durata. Vengono trattati e discussi
gli aspetti diagnostici e le implicazioni sulla potenziale fertilità.
Parole chiave: Cicli mestruali di breve durata e scarsa entità, ipo-
menorrea, diagnosi, implicazioni riproduttive, adolescent.
Vincenzo De Sanctis 1, Ashraf T. Soliman 2,
Nada A. Soliman 3, Rania Elalaily 4, Giuseppe Millimaggi 5
1 1Pediatric and Adolescent Outpatient Clinic, Quisisana Hospital, Ferrara, Italy;
2 Department of Pediatrics, Division of Endocrinology,
Alexandria University Children's Hospital, Alexandria, Egypt;
3 Ministry of Health, Alexandria, Egypt;
4 Department of Primary Health Care, AbuNakhla Hospital, Doha, Qatar;
5 Radiology Clinic, Quisisana Hospital, Ferrar, Italy.
Case Report

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Rivista Italiana di Medicina dell’Adolescenza
Volume 13, n. 1, 2015
Shortened menstrual cycles (Hypomenorrhea) in two adolescents
Routine biochemical laboratory blood tests were normal.
Endocrine laboratory tests, performed in the early follicular phase
of the menstrual cycle, showed: total testosterone: 0.40 ng/ dl
(nv: 0-80 ng/dl), androstendione 1.6 ng/ml (nv: 0.4-2.7 ng/ml),
DHEA-S: 155  g/dl (nv: 16- 304 g/dl), 17-hydroxyprogesterone:
0.6 ng/ml (nv: 0.1-1.5 ng/ml), prolactin: 12 ng/dl (nv: 0-25 ng/ml),
LH: 2.9 mUI/ml (nv: 1.7-14mUI/ml), FSH: 3.3 mUI/ml (nv: 3.9-10
mUI/ml), estradiol: 46 pg/ml (nv: 30-150 pg/ml), TSH: 3.1 U/ml
(nv: 0.25- 4 U/ml), cortisol 18 g/dL (nv: 7-20 g/dL). Deamidated
gliadin peptide (DGP) antibodies, transglutaminase (TTG) anti-
bodies, faecal calprotectin and Mantoux test were all negative.
Follow-up
No significant variations of menstrual interval and menstrual flow
were observed during 3 years of follow-up.
Patient 2
A 15.5 - year old girl was referred to our Adolescent Outpatient
Clinic for a second opinion because of short duration of menstrual
flow. She stated “light periods” (2-3 small pads/day for 1 and half
- 2 days), since menarche that occurred at the age of 11.5 years.
Her personal history was unremarkable. The menstrual intervals
were normal (from 33 to 31 days). There was no history of emo-
tional stress, digestive disorders, sharp weight loss, intense phy-
sical activity or drug intake. She was not sexually active.
Her mother experienced menarche at the age of 11.2 years.
There was no FH of menstrual flow disorders, gynecological
tumors or other gynecological problems. Her grandmother had
obesity and diabetes mellitus type 2.
On physical examination, her height was at 5th percentile, weight
15th percentile. Her blood pressure was 100/55 mm/Hg. She had
not acne, hirsutism or muscular hypertrophy. Breasts and pubic
hair were at Tanner’s stage 5. Genitalia examination revealed nor-
mal outward appearance. The rest of her exam was normal.
Routine biochemical laboratory blood tests were in the normal
range. The patient was counselled for a hormonal work-up.Her
endocrine laboratory data, assayed in the early follicular phase of
the menstrual cycle, were as follows: total testosterone: 0.30 ng/ dl
(nv: 0-80 ng/dl), androstendione 1.3 ng/ml (nv: 0.4-2.7 ng/ml),
DHEA-S: 160  g/dl (nv: 16- 304  g/ dl), 17-hydroxyprogesterone:
0.5 ng/ml (nv: 0.1-1.5 ng/ml), prolactin: 14 ng/dl (nv: 4-25 ng/ml),
LH: 2.1 mUI/ml (nv: 1.7-14 mUI/ml.), FSH: 5.3 mUI/ ml (nv: 3.9-10
mUI/ml), estradiol: 41 pg/ml (nv: 30-150 pg/ml), TSH: 1.51  U/ml
(nv: 0.25-4  U/ml), cortisol 13  g/dL (nv: 7-20  g/dL). Deamidated
gliadin peptide (DGP) antibodies,transglutaminase (TTG) antibo-
dies, faecal calprotectin and Mantoux test all were negative.
Follow-up
A pelvic ultrasound was done one year later. She showed a nor-
mal uterus and ovaries with a thin endometrium. No significant
variations of menstrual interval and menstrual flow were obser-
ved during 2.5 years of follow-up.
Discussion
Knowledge of the length and variation of the menstrual cycle is
necessary for patient education and for identifying deviations
from normal to guide clinical evaluation. Therefore, it is important
for clinicians as well as young patients and their parents to
understand what a normal menstrual pattern is, in order to eva-
luate what constitutes an irregular cycle or abnormal flow.
Menstrual bleeding usually lasts from 4 to 6 days and average
blood loss is about 3.5 tablespoons (3-4 pads/tampons a day).
Clinical dimensions of menstruation and menstrual cycle Descriptive term Normal limits (5th-95th percentiles)
Frequency of menses, d Frequent < 24
Normal 24-38
Infrequent > 38
Regularity of menses: cycle-to-cycle variation over 12 months, d Absent No bleeding
Regular Varation ± 2-20
Irregular Variation > 20
Duration of flow, d Prolonged > 8.0
Normal 4.5-8.0
Shortened < 4.5
Volume of monthly blood loss, mL Heavy >80
Normal 5-80
Light < 6
Table 1.
Suggested “normal” limits for menstrual parameters in the mid-reproductive years (from Munro. FIGO system for abnormal uterine bleeding.
Am J Obstet Gynecol 2012).

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Volume 13, n. 1, 2015
Dewhurst et al. (4) analyzed 368 menstrual periods and found
that the menstrual flow lasted between 3 and 7 days in 88% of
the cycles, with an average length of 5 days. In a larger series
described by Widholm and Kantero (5), short periods of 2–3 days
occurred in 8.8% of the girls during the first menstrual year, but
this figure dropped to 3.7% by the fifth year. Four hundred and
fifty six girls (mean age 16 ± 0.93 years-age range 14-19 years)
were surveyed by Gumanga and Kwame-Aryee (6). Seventy one
percent had menses lasting from 3 to 5 days and 27.2% had
menses lasting for more than five days. The mean duration of
menstrual flow was 4.9 days with a median of 5 days. None had
a menstrual flow duration less than 2 days.
In another study performed by Yassin in 900 adolescent students
(age range 12-18 years), in a secondary schools of Egypt, the
prevalence of menstrual flow duration of 2 day duration was
reported in only 0.8 % of adolescent girls (7).
Shortened menstrual bleeding is very uncommon and is defined
as menstrual bleeding of < 2 days in duration. The bleeding is
also usually light in volume and is uncommonly associated with
serious disease.(2) Short and light bleeding (hypo menorrhea)
may be caused by one of the following conditions:
•Disorders of hypothalamic- pituitary axis.
•Ovulation problems are the most common cause of irregular
and infrequent periods. Polycystic ovary syndrome (PCOS)
is the most common ovulation disorder.
•Psychogenic factors such as stress due to exams, or exces-
sive excitement about an upcoming events (travel, relation-
ships, family problems) may cause short and light bleeding
•Eating disorders (anorexia and bulimia) and malabsorption
disorders like celiac disease, Crohn’s disease or ulcerative
colitis.
Figure 1.
The uterine lining slowly thickens from day 5 through day 28.
•Excessive exercise like gymnasts and ballet dancers) and
crash dieting can cause scanty menstrual periods when the
proportion of body fat drops beneath a certain level. It may
cause also a secondary amenorrhea.
•Estrogen-secreting tumors usually produce disturbances of
menstrual frequency prior to the development of other types
of abnormal bleeding.
•Intrauterine adhesions (Asherman’s syndrome) and endo-
metrial tuberculosis.
•Use of oral contraceptives may result in decreased men-
strual flow.
•Hyperthyroidism and cervical stenosis may be the cause of
light flow.
In our adolescent patients the above causes were excluded and
the uneventful follow up for years confirmed the diagnosis of
“idiopathic” hypomenorrhea.
The endometrium is composed of the basal and functional
layers. Only the functional layer of endometrium is shed with
each cycle. The basal layer contains the progenitor cells that
regenerate the functional layer in each cycle. Endometrial tissue
responds to sex steroid hormones produced in the follicular and
luteal phases of the ovarian cycle. In addition, numerous growth
factors hormones regulate the growth of the endometrium during
the menstrual cycle (8).
During menstruation, the endometrium appears as a thin, echo-
genic line 1-4 mm in thickness. Once the proliferative phase of
the menstrual cycle (days 6-14) begins, the endometrium beco-
mes thicker (5-7 mm) (9). In the late proliferative (periovulatory)
phase, the endometrium develops a multilayered appearance. In
this stage, the endometrium may measure up to 11 mm in thick-

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Rivista Italiana di Medicina dell’Adolescenza
Volume 13, n. 1, 2015
Shortened menstrual cycles (Hypomenorrhea) in two adolescents
pattern of loss (presence of clots and flooding). Charting the
menstrual cycle on a calendar can be helpful to clarify “normal
versus abnormal” cycles. Finally, further studies on normal endo-
metrial physiology as it pertains to the regulation of menstruation
are essential to understand better disorders of menstruation.
References
1. Lee PA. Normal Pubertal Development. Chapter 5 - In: Goldfarb AF
(ed). Clinical Problems in Pediatric and Adolescent Gynecology. New
York: Chapman & Hall, 1996, pp. 49-60
2. Munro MG, Critchley HO, Fraser IS. The FIGO systems for
nomenclature and classification of causes of abnormal uterine
bleeding in the reproductive years: who needs them? Am J Obstet
Gynecol. 2012; 207:259-65.
3. Rigon F, De Sanctis V, Bernasconi, et al. Menstrual pattern and
menstrual disorders among adolescents: an update of the Italian
data. Ital J Pediatr. 2012; 38:38.
4. Dewhurst CJ, Cowell CA, Barrie LC. The regularity of early menstrual
cycles. J Obstet Gynaecol Br Commonw. 1971; 78:1093-5.
5. Widholm O, Kantero RL. A statistical analysis of the menstrual
patterns of 8,000 Finnish girls and their mothers. Acta Obstet
Gynecol Scand. 1971; 14 (Suppl 14):1-36.
6. Gumanga SK, RA Kwame-Aryee RA. Menstrual Characteristics in
Some Adolescent Girls in Accra, Ghana. Ghana Med J. 2012; 46:3-7.
7. Yassin SAT. Herbal remedy used by rural adolescent girls with
menstrual disorders. J Am Sc. 2012; 8:467-73.
8. Nair AR, Taylor HS. The Mechanism of Menstruation(Chapter 2) In
N.F. Santoro and G. Neal-Perry (eds.), Amenorrhea: A case-Based,
Clinical Guide, Contemporary endocrinology.
9. Fleischer AC. Sonographic assessment of endometrial disorders.
Semin Ultrasound CT MR 1999; 20:259-66.
10. Hall DA, Yoder IC. Ultrasound evaluation of the uterus. In: Callen PW,
ed. Ultrasonography in obstetrics and gynecology. 3rd ed.
Philadelphia, Pa: Saunders, 1994; 586-614.
11. Small CM, Manatunga AK, Klein M, et al. Menstrual cycle
characteristics: associations with fertility and spontaneous abortion.
Epidemiology. 2006; 17:52-60.
12. Wise LA, Mikkelsen EM, Rothman KJ, et al. A prospective cohort
study of menstrual characteristics and time to pregnancy. Am J
Epidemiol. 2011; 174:701-9.
Corrispondenza:
Vincenzo de Sanctis, MD
Pediatric and Adolescent Outpatient Clinic
Private Accredited Quisisana Hospital
Viale Cavour, 128 - Ferrara, Italy
Phone: 0532 207622
E-mail: vdesanctis@libero.it
ness. The layered appearance usually disappears 48 hours after
ovulation. During the secretory phase, the endometrium beco-
mes even thicker (7-16 mm) and more echogenic. (9, 10).
In both our patients the echogenic line appeared thin. However,
the pelvic ultrasound was done just in one occasion (Figure 1).
The purpose of the endometrium is to provide protection and
nourishment for the early embryo. Although the exact biologic
mechanism underlying the link between short menstrual cycles
and fertility remains to be elucidated, these findings suggest that
menstrual cycle length may serve as a useful clinical marker of
fertility potential. A thorough understanding of the mechanisms
that underlie this process is important to understand the basis
and treatment of disorders in this complex physiologic process.
To our knowledge, there are no studies investigating the joint
effects of short and light bleeding (= or < 2 days) on fecunda-
bility. Small et al. (11) prospectively studied 470 women to deter-
mine whether cycle length or menstrual bleeding length were
associated with fertility disorders and/ or spontaneous abortion.
Cycles with lengths of 30 to 31 days and with 5 days of menstrual
bleeding had the highest fecundity. On the other hand, cycles
with up to 4 days of bleeding had lower fecundity. Spontaneous
abortion was less likely in women whose MC bleeding was grea-
ter than 5 days (OR = 0.4 [0.1-1.1] ) when compared with 5-day
bleeding. The authors concluded that the menstrual cycle cha-
racteristics appeared to be associated with fertility and sponta-
neous abortion.Similar results were reported by Wise et al. These
authors found that women with shorter MC lengths had reduced
fecundability (12). Neither study reported data on intensity of
menstrual flow.
In summary, the purpose of these 2 case reports is to stimulate
the attention of physicians on a ignored aspect of adolescent
gynaecology. Knowledge of the length and variation of the men-
strual cycle is necessary for patient education and for identifying
deviations from normal to guide clinical evaluation. Cycles that
fall outside of the norm should be evaluated for underlying
pathology. Accurate judging about heaviness of menstrual loss
is not easy because it is usually based on personal norm (past
experience of periods), number of sanitary protection used and