February 23, 2011, 8:44 pm

MBBS(Ceylon), DCH(Ceylon), DCH(England), MD(Paediatrics), FRCP(Edinburgh), FRCP(London), FRCPCH(United Kingdom), FSLCPaed, FCCP, FCGP(Sri Lanka) Consultant Paediatrician

Everyone knows that the teenage years can be difficult, not only for teens but also for their parents and perhaps for everybody around them. 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). most issues teens confront when they start menstruating are completely normal. in fact, many girls and even many women, have had to deal with one or more of them at one time or another.

Young girls go through puberty at different rates. Some reach menarche, which is the medical term for the first period or the beginning of menstruation, as early as 9 or 10 years old and others do not have their first periods until they are well into their teenage years. thus if a girl is a "late bloomer," it does not necessarily mean that there is something wrong with her. the time at which girls get their periods actually depends a lot on genetics and to a lesser extent, on environmental influences. 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. it is advisable to seek medical attention if a girl has not got her period by age 15 or by 3 years after starting the body changes of puberty and development of secondary sexual characteristics.

Many girls experience abdominal cramps during the first few days of their periods. these are caused by a chemical in the body that makes the smooth muscle in the uterus contract. Pain resulting from these involuntary contractions can be either dull or sharp and intense. the good news is that cramps usually only last a few days. However, a medical opinion may be required if a girl has severe cramps that keep her home from school or from doing her usual activities with her friends.

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. in fact what is "regular" with reference to periods 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 45. Changing hormone levels might make a girl’s period last a short time during one month, may be for just a few days and a longer time the next, perhaps up to a week or more. She may skip months, get two periods almost right after each other or alternate between heavy and light bleeding from one month to another. However, any girl who is sexually active and skips a period should see a doctor to make sure 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, one needs to get some medical advice on the problem. it is also best to let the doctor know if her cycle is less than 21 days or more than 45 days or if she does not get a period for 3 months at any time after first beginning to menstruate.

The Pre-menstrual Syndrome (PMS) includes both physical and emotional symptoms that many females get right before their periods. these include worsening acne, a feeling of being bloated, fatigue, backaches, sore breasts, headaches, constipation, diarrhoea, food cravings, depression or feeling blue, irritability, problems with concentrating and difficulty handling stress. 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 it generally disappears soon after the period begins. But girls usually do not develop troublesome symptoms associated with PMS until several years after menstruation starts. Some of them of course are lucky enough not to develop them at all. Although the exact cause of PMS is unknown, it seems to occur because of changing hormone levels and their effect on chemicals 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 oestrogen drop. Some girls’ bodies seem to be more sensitive to these hormonal changes than others.

Although most period problems are harmless, a few conditions can be more serious and require medical attention. Girls who have not started their periods by the time they are 15 – 16 years old or 3 years after they have shown the first signs of puberty have primary amenorrhea which is usually caused by a genetic abnormality, a hormone imbalance or a structural problem. Hormones are also often responsible for secondary amenorrhea, which is when a girl who has 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, other things that can cause both primary and secondary amenorrhea include:

* significant weight loss or gain

* anorexia nervosa (amenorrhea can be a sign that a girl is losing too much weight and may have anorexia)

* stopping birth control pills

* other conditions that can affect hormone levels

Something that can also cause primary and secondary amenorrhea is excessive exercising such as 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 does not include the usual gym class or school sports team, even those that need girls to 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 in the diet.

It is normal for a girl’s period to be heavier on some days than others. But signs of excessively heavy or long periods can include soaking through at least one sanitary napkin or pad an hour for several hours in a row or periods that last longer than 7 days. Girls with this condition known as menorrhagia, sometimes stay home from school or social functions because they are worried they would not be able to control the bleeding in public. the most frequent cause of menorrhagia is an imbalance between the levels of oestrogen and progesterone in the body, which allows the lining of the womb to keep building up. when the lining is finally shed during menstruation, the resulting bleeding is particularly heavy.

Because many adolescents have slight hormone imbalances during puberty, menorrhagia is not 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

* inflammation or infection in the vagina or cervix

Painful periods are referred to as dysmenorrhoea There are two types of such painful periods that can interfere with a girl’s ability to attend school, study, or sleep :-

1. Primary dysmenorrhoea is very common in teens and is not caused by a disease or other condition. Fortunately, these symptoms usually last for only a day or two.

2. Secondary dysmenorrhoea is pain caused by some physical condition like polyps or fibroids in the uterus, endometriosis, pelvic inflammatory disease (PID), or adenomyosis which is uterine lining tissue growing into the muscular wall of the uterus.

In endometriosis, tissue that is 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, dysmenorrhoea and general pelvic pain.

Although most period problems are not really a cause for alarm, certain symptoms do call for a trip to the doctor. This is particularly true if a girl’s normal cycle changes. Medical advice may be sought if a girl :-

* has not started her period by the time she is 15 – 16 or her period has not 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 one neds to let the doctor know if her cycle is less than 21 days or more than 45 days or if she does not 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 anaemia. 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 a girl is not able to participate in her normal activities, one needs to get a medical opinion. She might have a medical problem such as endometriosis, causing the pain.

To determine whether a problem requires treatment, the doctor may ask several questions and do a thorough physical examination. the doctor may do a pelvic examination, take specimens for examination and perhaps perform some blood tests. if a structural problem is suspected or some sort of growth, an ultrasound or CT or MRI scan may be necessary. 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 be treated with medications or surgery. if a hormone imbalance is to be blamed, the doctor will likely suggest hormone therapy or other hormone-containing medications. For menstrual pain with no underlying medical cause, anti-inflammatory medicines are the most effective treatment. Conditions like clotting disorders or thyroid problems may require treatment with medications as well.

It is very important for parents and very specially the mothers to be aware of the many problems that daughters get before and during their periods. when one’s daughter is experiencing a particularly bad bout of PMS or cramps, the mother can help to make her more comfortable. one may suggest that the child eats a balanced diet with lots of fresh fruit and vegetables, reduce the intake of salt which can cause water retention and caffeine which can make her jumpy and anxious. the child should be given foods with calcium, which may reduce the severity of her PMS symptoms and try over-the-counter pain relievers like paracetamol for cramps, headaches or back pain. For some girls, taking a brisk walk or bike ride may relieve stress and aches and also soaking in a warm bath or a hot water bottle on the abdomen may help to relieve some of the discomfort.

If one notices that a girl’s usual periods are causing her great discomfort and interfering with her life, it may be advisable to talk to a doctor to make sure nothing else is causing the problem and to see if anything can help. Even just reassurance from a doctor may really help in dealing with the problem. Sometimes, hormone treatment can help ease many symptoms associated with uncomfortable periods. However, the most important way in which one could help a 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. Parents need to show greater understanding when she is cranky and unhappy. after all, no one is at their best all the time and that includes all parents too.

= Girls start to menstruate at different ages.

= it is a sign of being a "woman"

= Quite a few of them develop the pre-menstrual syndrome

= Delay in the onset of menstruation beyond the age of 15 to 16 years needs medical attention

= Stoppage of regular periods after it has been established is also a thing to be taken seriously

= Periods associated with severe discomfort, particularly if the pain persists beyond the onset of menstruation, need to be investigated.

The writer would appreciate feedback from the readers. please e-mail him at

“I was, I guess, shocked, seeing people posting pictures of their grandchildren who are about the same age as my kids,” said Horwitz of Tuscaloosa.

Horwitz, 43, has a 4-year-old daughter and 2-year-old son. Statistics call her a “midlife mother,” one of a growing number of women who are becoming first-time mothers later in life.

Between 1970 and 2006, the number of first births to women age 35 and older increased nearly eight times, according to the National Center for Health Statistics. in 1970, 1 out of 100 first births were to women age 35 and older; in 2006, it was 1 out of 12. The birth rate for women ages 40 to 44 has more than doubled since 1981.

Women are having babies later in life because they are pursuing careers, marrying later, dealing with fertility issues, divorcing before having kids, waiting for mr. right, restarting motherhood, and living with partners before marriage, experts say.

“I was one that used to say that I wanted kids, but I wasn’t going to have kids at 40 or anything like that,” said Joan King of Tuscaloosa with a laugh.

But she had no idea that her first marriage would end in divorce and she’d wait until her second marriage to start a family.

Today she is the 47-year-old mother of a 6 year old.

Janice Smith has a similar story.

She was married for 13 years and dedicated to her job in politics.

“Both of us were career-

oriented,” said Smith, who served almost 10 years on a town council in new Jersey. “we both loved children but put (having children) on the back burner because of our careers.”

And then came the divorce.

Smith was 40 years old and began to think she may have missed the boat on motherhood. That is, until she took a trip to Nashville. That’s where she met her current husband, 30-year-old Billy Smith of Romulus.

“Billy and I met in Nashville and fell in love and wanted to immediately start a family,” said Smith, 46.

She became pregnant at 43. she left her job in new Jersey and moved to her husband’s

native Alabama to become a stay-at-home mom.

Because of Smith’s age, she was monitored closely during her pregnancy.

According to the American Congress of Obstetricians and Gynecologists, women’s fertility starts decreasing in their early 30s. That’s because ovulation occurs less often, an older woman’s eggs are not as easily fertilized and there is an increased chance of blocked fallopian tubes and endometriosis.

Doreen Nagle, author of, “but I Don’t Feel Too Old to Be a Mommy!: The Complete Sourcebook for Starting (and Re-Starting) Motherhood beyond 35 and After 40,” said while researching her book she came to the realization that women are ignorant of their own fertility timeline.

“they think, ‘well, I’m only a certain age, so, well, I can get pregnant next year or I can get pregnant four years from now,’ ”

Nagle said.

But experts and mothers agree that older women often have a harder time getting pregnant. All the mothers in this story had fertility treatments.

“I had difficulty getting pregnant,” Horwitz said. “it is harder. there is no guarantee in terms of being able to get pregnant.”

There are more risks for women who delay childbirth, risks such as high blood pressure and diabetes, premature births and birth defects.

Both of Horwitz’s children were premature, and she says her age may have contributed to that.

According to ACOG, at age 30, the risk of having a baby with a chromosomal abnormality is 2.6 births per 1,000; at age 35, it is 5.2 births; at age 40 it is 15.2 births; and at age 45 it is 47.6 births out of 1,000. this is why women older than 35 should have genetic counseling, said Dr. Gary Helmbrecht, a maternal fetal medicine specialist and member of ACOG. He sees about 500 women a month at the Prenatal Diagnosis Center in Virginia.

But with proper care, older women are having healthy babies every day, said Helmbrecht, who sees many pregnant women older than 40 and even some older than 50 at his practice. however, he said having a child with special needs “is a real consideration.”

“It’s something that’s very important for a couple to talk about, particularly if they have a child later in life,” Helmbrecht said. “I think everybody has to search their own souls in that regard. you have to decide for yourself, do I have the fabric in me to take care of a child with special needs?”

Helmbrecht, 53, speaks from experience. His 9-year-old child Wesley has the rare Rubinstein-Taybi syndrome.

“planning, planning, planning,” he said. “go into it with your eyes wide open.”

“(Older women) need to understand they may have to invest more time and effort in the pregnancy than their 22-year-old next-door neighbor,” Helmbrecht said.

That means more doctor visits, more ultrasounds, more tests and a closer evaluation of the fetus, he said. Women older than 35 are encouraged to get an amniocentesis at 15 to 20 weeks or chorionic villus sampling at 10 to 12 weeks to check for

abnormalities. The procedures involve extracting fluid from the mother’s abdomen or uterus

using a fine needle. there is a 1 percent chance of miscarriage with both, according to the Fetal Medicine Foundation in London.

In the past 15 years, some women in the U.S. have been able to get a nuchal translucency screening test in the first trimester. this is a non-invasive ultrasound done with high-

resolution equipment by specially trained doctors who are certified by the Fetal Medicine Foundation in London. Helmbrecht’s center performs the test, and he calls it “a major breakthrough in screening women over 35.”

There are no needles and no chance of causing a miscarriage, and it has a higher success rate because it is more sensitive and specific than the other procedures, he said. Yet there are “very few” places in the U.S. that offer the NT, Helmbrecht said, because the quality assurance is so rigorous and a certification process was devised only four years ago.

Smith, after genetic counseling, had CVS done.

“if there were any major issues, I wanted to be prepared for it,” Smith said.

But there were none. Her pregnancy was healthy and so was her son Brent, born at 7 pounds, 7 ounces, three years ago.

Horwitz has done the math. if her son waits until he’s 41 — like his mother — to have children, she will be 82 when his child is born.

King thinks about it, but doesn’t dwell on it. she has only to think of her 92-year-old grandmother, who lives independently, for inspiration.

“Young people also die,” said Nagle, who adopted a baby in her 40s. “so we can’t jump ahead and assume we won’t see our grandchildren. you can’t let that stop you, because if you did there would be little we could accomplish.”

In Nagle’s book, she writes, “Anyone in our age group considering motherhood knows we are anything but old. With our looks, intelligence, creativity, spirit and wisdom, we certainly don’t see ourselves that way and neither does anyone we know.”

“I’m comfortable with my age,” said Smith, who said she works out, eats healthy and feels great. “Age is a number. It’s just your mindset.”

But being an older mom does come with guilt.

“The guilt is going to be there partly because you are wanting to do the best job in the world so you’re holding yourself up to very high standards,” said Linda Lisi Juergens, executive director of the National Association of Mothers’ Centers, whose programs offer support for mothers nationwide.

According to experts and moms who are living it, midlife mom guilt looks like this: worrying about having the energy to keep up with your kids, juggling menopause symptoms (hot flashes, sleepless nights and hormonal changes) with parenting demands, wanting to remain emotionally, physically and financially available for your children, hoping to know your grandchildren and praying no one mistakes you for your child’s grandmother.

“if you are 50 years old and you are running around after a 2-year-old, that is really physically hard to do,” Juergens said. “That’s when mothers need to realize their limits and you kind of have to roll with that.”

For example, enlist a younger relative or friend to play ball with your child, she said.

“I had a friend whose feelings were hurt,” King said. “She’s 44 or 45 with dark hair that’s graying. Her children were 2, and a young mother in her 20s asked if they were her grandchildren.”

King said, though she recognizes signs of perimenopause, she absolutely does not feel her age.

“I do think, yeah, I would have had a whole lot more energy 10 years earlier than I do now,” Horwitz said. “but I don’t regret that. I like my life. I like the way it turned out.”

Secure, sandwiched in

Many moms say having kids in your 40s is sometimes an advantage because it means you are financially secure.

With a long career behind her, Smith is retired, receives a pension and is able to stay at home and raise her son.

“I couldn’t be writing my own ticket in my career right now if I didn’t have something to build on,” Horwitz said.

She also serves as a member of the Tuscaloosa City Board of Education.

Older moms report feeling wiser about being parents. Smith said she doesn’t get caught up in “the mom race,” competing with other moms, although two decades ago, she may have. she said she also feels more confident talking with doctors than she did in her youth and thus feels she is a better advocate for her child.

King, who works part time as an adjunct professor at the University of Alabama, found herself in an unexpected situation when, six years ago, she became the primary caregiver for her sick mother.

Older mothers are part of what is being called the “Sandwich Generation” because they find themselves caring for aging parents as well as their children. King’s mother was diagnosed with a brain tumor at the same time her son was born. as her mother’s health declined, she found she was driving both her child and mother to doctor’s appointments, feeding and bathing them, and waking up in the middle of the night to meet both of their needs.

“it was physically and emotionally exhausting,” said King, whose mother passed away three years ago.

The bottom line, Nagle said, is that deciding what age to have children is a very personal decision.

“For some people, 35 may be too old. For some people, 65 may not be,” she said.

“Motherhood is rewarding at any age,” Horwitz said. “there are pros and cons. The debate will go on as long as there are parents.”