Girls with delayed onset of periods require assessment

Dear doctor, Am 19 years old and I have never had my menses. What went wrong?

You are right in getting concerned about the lack of periods at your age. Periods will normally start between the ages of 11 and 13 years. It is however not unusual for some girls to start earlier, and others later. The age of 16 is regarded as the latest when periods should have started. Having no periods beyond that is abnormal, and warrants a medical review to work out why there has been a delay.

The reasons for delays in the onset of periods are many, and a specific diagnosis can only be worked out after a thorough gynecological assessment. The chronology of pubertal development usually gives a clue about the potential causes. Those who appear to have all the developmental features expected with puberty usually just have a delayed onset of periods which is self-correcting. Others may have delayed pubertal development, suggesting several potential causes ranging from genetics to complex medical syndromes.

The first step is to arrange an appointment with a gynecologist. However bizarre it may sound, a pregnancy test is usually advised in order not to miss out an obvious and common cause. You will then have a full physical exam to assess the stage of your pubertal development. This will be followed by some tests to assess appropriate production of female hormones, and imaging to confirm the presence of internal genital organs like the womb and ovaries. Still further tests may be advised depending on what is apparent, and these might include genetic tests as well.

If a simple cause for the delay of your periods is found, then all you need is simple remedies to correct the situation. Simple remedies might include optimization of weight, which usually corrects some common hormonal imbalances and leads to spontaneous menses. Some may be found to have abnormal production of certain hormones, only requiring specific treatment to correct the situation.

Some girls will be diagnosed with rare and complex conditions. Such diagnoses may include absence of internal genital organs, or genetic syndromes leading to failure of production of female hormones. Some may physically look like girls, but are genetically males. Such diagnoses require prolonged treatment and follow-up with specialized gynecological teams. External hormones are usually required to replace what is deficient, and induce menstruation in a controlled manner. There are usually additional implications with fertility and reproduction.

For the majority, the delay with onset of menses will end up with a simplistic explanation, and an equally simple remedy. A few girls will have to endure a prolonged evaluation, eventually having to contend with a diagnosis that has major reproductive consequences. A medical explanation, and an appropriate remedy, should always be sought if there is a delay in the onset of menses.

Dr Alfred Murage is a Consultant Gynecologist and Fertility Specialist. amurage@mygyno.co.ke