Reproductive health in adolescent girls with special emphasis on menstrual disorders, bone health, sexuality and social factors

Menstrual disturbances are common during adolescence, especially within the first 1-3 years after menarche, and are often explained by immaturity of the hypothalamic-pituitary-gonadal axis. However, little is known about the underlying mechanisms, long-term medical consequences and other reproductive health issues in teenagers.

The general aim of this thesis was to investigate aspects of reproductive health in adolescent girls and boys visiting a youth clinic. Endocrine mechanisms of menstrual disorders, eating behavior and long-term medical consequences, including bone mass, were specifically evaluated. The aim was also to study sexuality and social factors in adolescent girls in comparison with boys.

The mechanisms of menstrual disorders were studied in 203 girls, 117 with secondary amenorrhea and 86 with oligomenorrhea. Hypothalamic amenorrhea dominated in the girls with secondary amenorrhea, whereas hyperandrogenism, i.e. polycystic ovary syndrome (PCOS) was the main mechanism in the oligomenorrheic group. Eating disorders were common (53%); anorectic behavior in the secondary amenorheic group and bulimic type more frequent in the oligomenorrheic group. A follow-up study was performed six years later among 87 of the originally investigated girls; 52 with previous secondary amenorrhea and 35 with previous oligomenorrhea. Menstrual disturbances were still present in 62% of the subjects not using hormonal contraception; 59% of them fulfilled the criteria for PCOS, which was the main mechanism explaining persistent menstrual disorder. Recovery from anorectic eating beahvior was a strong predictor of resumption of regular menstruation.

Bone mineral density (BMD) was assessed in the 87 women participating in the follow-up and measured with whole-body dual energy X-ray absorptiometry (DXA). The frequency of osteopenia/osteoporosis was 52%; 3 women had osteoporosis. Those with previous secondary amenorrhea had significantly lower BMD in pelvis and lumbar spine than those with previous oligomenorrhea. Restrictive eating disorder in adolescence was the strongest predictor of low BMD and the most important counteraction was high physical activity at follow-up and a BMI ≥ 22. Persistent menstrual dysfunction (PCOS) was associated with a lower frequency of osteopenia. Aspects of life quality and sexuality were studied in 480 girls and 108 boys by means of a questionnaire survey. Girls were less satisfied with life, their bodies and sexuality than boys. Weight control behavior was notably common among girls and may indicate an eating disorder. The overall results show that a proportion of the girls and boys constitute a risk group for adverse reproductive health due to alcohol abuse, non-use of contraception and family problems.

We conclude that eating disorder is the most important underlying cause of menstrual dysfunction in adolescence. PCOS was the main mechanism explaining persistent menstrual disorder in adulthood. Anorectic behavior in adolescence was the strongest predictor of low bone mass at follow-up. We found clear gender differences in life quality, life style and sexual experiences. A youth clinic with interdisciplinary competence provides good opportunity for adequate medical care and treatment of reproductive health issues in girls and boys.

List of scientific papers

I. Wiksten-Almströmer M, Hirschberg AL, Hagenfeldt K (2007). Menstrual disorders and associated factors among adolescent girls visiting a youth clinic. Acta Obstet Gynecol Scand. 86(1): 65-72
https://pubmed.ncbi.nlm.nih.gov/17230292

II. Wiksten-Almströmer M, Hirschberg AL, Hagenfeldt K (2008). Prospective follow-up of menstrual disorders in adolescence and prognostic factors. Acta Obstet Gynecol Scand. 87(11): 1162-8
https://pubmed.ncbi.nlm.nih.gov/18956264

III. Wikström-Almströmer M, Lindén Hirschberg A, Hagenfeldt K (2009). Reduced bone mineral density in adult women diagnosed with menstrual disorders during adolescence. Acta Obstet Gynecol Scand. 88(5): 543-9
https://pubmed.ncbi.nlm.nih.gov/19353333

IV. Wikström-Almströmer M (1970). Gender differences in sexuality and life quality among young people visiting a Swedish youth clinic. Int J Adolesc Med Health. 21(1): 29-39