Faced with a mother and her daughter giving a story of heavy menstrual loss, it is important that the clinician takes an accurate history from the child if possible. This is often difficult if the mother is present throughout and it must be remembered that the perception of heavy menstruation is often not reflected in studies that have looked at actual menstrual loss. Normal menstrual loss should not exceed 80 ml during a period, although in 5% of individuals it is heavier than this and causes no trouble. The clinician is faced in these circumstances with attempting to assess whether or not the child truly has menstrual loss that is serious as a medical condition or menstrual loss that is irritating and distressing without being medically harmful. The best way to establish which of these is the case is to measure the haemoglobin. If the haemoglobin level is normal, that is, greater than 12 g/l, then an explanation should be given to the mother and child of the normal physiology of menstrual establishment that the manifestation of the menstrual loss is normal and that it may take some time for the cycle to be established. This condition requires no active treatment. However, it is imperative that the child is followed up at 6-monthly intervals until the pattern of menstruation is established as reassurance is the most important part of the management process of these girls.
In those girls with haemoglobin levels between 10 and 12 g/l it is apparent that they are losing more blood at menstruation than is desirable. Again, an explanation is required so that the mother and daughter understand the cause of the problem and the child should be administered iron therapy to correct what will be mild iron deficiency anaemia. In terms of management, menstrual loss needs to be reduced and this may be achieved by using either progestogens cyclically for 21 days in every 28-day cycle or to use the combined oral contraceptive pill. It would be unusual for either of these therapies to be unsuccessful in controlling the menstrual loss. If they are used, these therapies should be stopped on an annual basis so that assessment may be made as to whether or not the normal pattern of menstruation has been established through maturation of the hypothalamopituitary-ovarian access. Thereafter, the child requires no further medication. Again follow-up is essential if reassurance is to be given appropriately.
Finally, in the child with a haemoglobin count of less than 10 g/l, it is obvious that serious anaemia has resulted from menstrual loss. This again requires an explanation but more urgent attention from a medical point of view. Progestogens are very much less likely to be effective in this group and the oral contraceptive pill is by far the treatment of choice. It may be given continuously for a short period of time so that the anaemia can be corrected using oral iron and then the pill may be used in the normal way so that menstrual loss occurs monthly, if desired.
Any girl who continues to have menstrual loss which is reported to be uncontrolled by these management strategies should have an ultrasound scan performed to exclude a uterine pathology. These pathologies are extremely rare and the reader is referred to other texts for further information.
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The first trimester is very important for the mother and the baby. For most women it is common to find out about their pregnancy after they have missed their menstrual cycle. Since, not all women note their menstrual cycle and dates of intercourse, it may cause slight confusion about the exact date of conception. That is why most women find out that they are pregnant only after one month of pregnancy.