Everyone knows the teen years can be difficult — for both teens and parents. All those physical changes during puberty can make adolescents feel awkward and unsure of themselves.

This is particularly true for girls when it comes to menstruation. For a girl, getting her first period is a physical milestone and a sign of becoming a woman. But it can also be confusing and scary, particularly if she encounters certain problems like irregular periods or premenstrual syndrome (PMS).

Common Menstrual Problems

Most issues teens confront when they start menstruating are completely normal. In fact, many girls and women have had to deal with one or more of them at one time or another:

Premenstrual Syndrome (PMS)

PMS includes both physical and emotional symptoms that many females get right before their periods, such as:

• acne
• bloating
• fatigue
• backaches
• sore breasts
• headaches
• constipation
• diarrhea
• food cravings
• depression or feeling blue
• irritability
• difficulty concentrating
• difficulty handling stress
• feeling tense or anxious

Different girls may have some or all of these symptoms in varying combinations. PMS is usually at its worst during the 7 days before the period starts and disappears soon after it begins. But girls usually don't develop symptoms associated with PMS until several years after menstruation starts — if ever.

Although the exact cause of PMS is unknown, it seems to occur because of changing hormone levels in the body, and changing chemical levels in the brain. During the second half of the menstrual cycle, the amount of progesterone in the body increases. Then, about 7 days before the period starts, levels of both progesterone and estrogen start to drop.

Some girls' bodies seem to be more sensitive to these hormone changes than others. Talk to your daughter's doctor if her symptoms are severe or interfere with her normal activities.

Other Conditions

Cramps

Many girls experience abdominal cramps during the first few days of their periods. They're caused by prostaglandin, a chemical in the body that makes the smooth muscle in the uterus contract. These involuntary contractions can be either dull or sharp and intense.

The good news is that cramps usually only last a few days. But call your daughter's doctor if she has severe cramps that keep her home from school or from doing stuff with her friends. Also let the doctor know if the cramps do not improve with over-the-counter ibuprofen.

Irregular Periods

It can take 2 to 3 years from a girl's first period for her body to develop a regular cycle. During that time, the body is essentially adjusting to the influx of hormones unleashed by puberty. And what's "regular" varies from person to person. The typical cycle of an adult female is 28 days, although some are as short as 21 days and others are as long as 35.

Changing hormone levels might make a girl's period last a short time during one month (just a few days) and a long time the next (up to a week). She may skip months, get two periods almost right after each other, or alternate between heavy and light bleeding from one month to another.

But any girl who's sexually active and skips a period should see a doctor to make sure she's not pregnant. And if your daughter's period still hasn't settled into a relatively predictable pattern after 3 years, or if she has four or five regular periods and then skips her period or becomes irregular, make an appointment with her doctor to check for possible problems.

Also let your daughter's doctor know if her cycle is less than 21 days or more than 45 days, or if she doesn't get a period for 3 months at any time after first beginning to menstruate.

Delayed Menarche

Girls go through puberty at different rates. Some reach menarche (the medical term for the first period or the beginning of menstruation) as early as 9 or 10 years old and others don't have their first periods until they're well into their teen years. So, if your daughter is a "late bloomer," it doesn't necessarily mean there's something wrong with her.

When girls get their periods actually depends a lot on genetics. Girls often start menstruating at approximately the same age their mothers or grandmothers did. Also, certain ethnic groups, on average, go through puberty earlier than others. For instance, African-American girls, on average, start puberty and get their periods before Caucasian girls do.

Let your daughter's doctor know if she hasn't gotten her period by age 15, or by 3 years after starting puberty.

Problems That May Be Cause for Concern

Although most period problems are harmless, a few conditions can be more serious and require medical attention:

Amenorrhea (the Absence of Periods)

Girls who haven't started their periods by the time they're 15 years old or 3 years after they've shown the first signs of puberty have primary amenorrhea, which is usually caused by a genetic abnormality, a hormone imbalance, or a problem with the way the reproductive organs developed.

Hormone imbalances also can lead to secondary amenorrhea, which is when a girl who had normal periods suddenly stops menstruating for more than 6 months or three of her usual cycles.

Since pregnancy is the most common cause of secondary amenorrhea, it should always be ruled out when a girl skips periods. In addition to hormone imbalances and pregnancy, other things that can cause both primary and secondary amenorrhea include:

• stress
• significant weight loss or gain
• anorexia (amenorrhea can be a sign that a girl is losing too much weight and may have anorexia)
• stopping birth control pills
• thyroid conditions
• ovarian cysts
• other conditions that can affect hormone levels

Something else that can also cause primary and secondary amenorrhea is excessive exercising (often distance running, ballet, figure skating or gymnastics) combined with a poor diet, which usually results in inappropriate weight loss or failure to gain weight during growth.

But this doesn't include the usual gym class or school sports team, even those that practice often. To exercise so much that she delays her period, a girl would have to train vigorously for several hours a day, most days of the week, and not get enough calories, vitamins, and minerals.

Menorrhagia (Extremely Heavy, Prolonged Periods)

It's normal for a girl's period to be heavier on some days than others. But signs of menorrhagia (excessively heavy or long periods) can include soaking through at least one sanitary napkin (pad) an hour for several hours in a row or periods that last longer than 7 days. Girls with menorrhagia sometimes stay home from school or social functions because they're worried they won't be able to control the bleeding in public.

The most frequent cause of menorrhagia is an imbalance between the levels of estrogen and progesterone in the body, which allows the endometrium (the lining of the uterus) to keep building up. When the endometrium is finally shed during menstruation, the resulting bleeding is particularly heavy.

Because many adolescents have slight hormone imbalances during puberty, menorrhagia isn't uncommon in teens. But in some cases, heavy menstrual bleeding can be caused by problems such as:

• fibroids (benign growths) or polyps in the uterus
• thyroid conditions
• clotting disorders
• inflammation or infection in the vagina or cervix

If your daughter has heavy periods, or periods that last longer than 7 days, talk to her doctor.

Dysmenorrhea (Painful Periods)

There are two types of dysmenorrhea, which is painful menstruation that can interfere with a girl's ability to attend school, study, or sleep:

1. Primary dysmenorrhea is very common in teens and is not caused by a disease or other condition. Instead, the culprit is prostaglandin, the chemical behind cramps. Some prostaglandin can lead to mild cramps. But large amounts of prostaglandin can lead to nausea, vomiting, headaches, backaches, diarrhea, and severe cramps. Fortunately, these symptoms usually only last for a day or two.
   
   
2. Secondary dysmenorrhea is pain caused by some physical condition like polyps or fibroids in the uterus, endometriosis, pelvic inflammatory disease (PID), or adenomyosis (tissue that usually lines the uterus growing into the muscular wall of the uterus).

Having cramps for a day or two each month is common, but if your daughter has symptoms severe enough to keep her from her normal activities, or cramps that last for more than 3 days, discuss it with her doctor.

Endometriosis

In this condition, tissue normally found only in the uterus starts to grow outside the uterus — in the ovaries, fallopian tubes, or other parts of the pelvic cavity. It can cause abnormal bleeding, dysmenorrhea, general pelvic pain, and lower back pain.

Treating Menstrual Problems

To determine whether a problem requires treatment, the doctor will ask several questions and do a thorough physical exam. The doctor may do a pelvic exam, blood tests, or urine tests. If there might be a structural problem, an ultrasound or CAT scan may be performed. Together, these tests can help the doctor determine how a condition should be handled.

Growths such as polyps or fibroids can often be removed and endometriosis can often be treated with medications or surgery. If a hormone imbalance is to blame, the doctor may suggest hormone therapy with birth control pills or other hormone-containing medications. Conditions like clotting disorders or thyroid problems may require treatment as well.

And for menstrual pain with no underlying medical cause, anti-inflammatory medicines are the most effective treatment.

When to Call the Doctor

Although most period problems aren't cause for alarm, certain symptoms do call for a trip to the doctor. This is particularly true if a girl's normal cycle changes.

So take your daughter to her doctor if she:

• hasn't started her period by the time she's 15 or her period hasn't become regular after 3 years of menstruating. The most likely cause is a hormone imbalance (which may need treatment), but this also might point to another medical problem.
  
• stops getting her period or it becomes irregular after it has been regular. Also let your daughter's doctor know if her cycle is less than 21 days or more than 45 days, or if she doesn't get a period for 3 months at any time after first beginning to menstruate.
  
• has heavy or long periods, especially if she gets her period frequently. In some cases, significant blood loss can cause iron-deficiency anemia. Also, heavy bleeding could be a sign of a growth in the uterus, a thyroid condition, an infection, or a blood clotting problem.
  
• has very painful periods. Having cramps for a couple of days is normal, but if your daughter isn't able to participate in her normal activities, or has cramps for more than 3 days, let the doctor know. She might have a medical problem, such as endometriosis, causing the pain.

Helping Your Daughter

When your daughter's experiencing a particularly bad bout of PMS or cramps, you can help make her more comfortable. Suggest that she:

• eat a balanced diet with lots of fresh fruit and vegetables
• reduce her intake of salt (which can cause water retention) and caffeine (which can make her jumpy and anxious)
• include foods with calcium, which may reduce the severity of her PMS symptoms
• try over-the-counter pain relievers like acetaminophen or ibuprofen for cramps, headaches, or back pain
• take a brisk walk or bike ride to relieve stress and aches
• soak in a warm bath or put a hot water bottle on her abdomen, which may help her relax

If you notice that your daughter's periods are causing her great discomfort or interfering with her life, talk to her doctor to make sure nothing else is causing the problem and to see if anything can help. Sometimes hormone treatment, often in the form of birth control pills, can help ease many symptoms associated with uncomfortable periods.

But the most important way you can help your daughter feel more at ease about her period is to talk to her and explain that most annoying or uncomfortable conditions that accompany menstruation are normal and may improve over time. And be understanding when she's cranky and unhappy. After all, no one's at her best all the time.

Reviewed by: Larissa Hirsch, MD
Date reviewed: September 2011