Menarche and adolescent

Gynaecology

INTRODUCTION
 Puberty is the transition from infancy to adolescent, marked by the growth of
breasts and secondary sexual hair, as well as the commencement of menstruation.
 Simultaneously, there is a period of rapid expansion.
 The age at which the changes occur varies, although it is unusual for there to be no
evidence of secondary sexual development by the age of 13 years.
 The starting point for the modifications is an increase in the frequency and
amplitude of gonadotrophin release pulses.
 The ovaries are then triggered to begin producing oestrogen, which works on the
breast tissue to promote growth.
 This normally begins at the age of 9 and lasts around 5 years.
 There is evidence that this is happening at a younger age, notably in African-
American girls, prompting a reconsideration of the age at which precocious puberty
should be studied.

Causes of precocious puberty

 Idiopathic;
 McCune–Albright syndrome (a genetic disorder of the
bone with café au lait spots, polyostotic fibrous dysplasia
and hormone excess);
 tumors of the adrenal or ovary-producing steroids;
 cerebral tumors;
 ingestion of exogenous estrogens.

 Pubic hair growth is stimulated by androgens released by

the ovary and the adrenal gland. (Androgens produced by the ovaries and adrenal gland
encourage pubic hair growth.)
Marshall and Tanner staging
Stage Breast Pubic hair
I Pre-adolescent, elevation of papilla only No pubic hair
II Breast bud – elevation of breast and papilla as Sparse growth of long downy hair along the labia
small mound; enlargement of areolar diameter
III Further enlargement but no separation of the contours Hair coarser, darker and more curled; over mons
IV Projection of the areola and papilla to form a Adult-type hair but no spread to thighs
secondary mound above the level of the breast
V Mature; areola recessed to general contour of breast Adult, with horizontal upper border and spread to
thighs

 Breast development often begins before pubic hair growth in most females.
 Even before these changes become apparent, there is an acceleration in
growth, which is typically accompanied by a quick increase in shoe size.
 The peak height velocity of roughly 8 cm/year comes right before menstruation,
which occurs on average around the age of 12 years.
 Because oestrogen causes the epiphyses to close, the ultimate height is
normally reached approximately 2 years following menarche.
 Menarche happens 2.3 1 years after breast development begins.
 The average age of menarche in white females is currently 12.52 years and
12.06 years in African-American girls.
 Improved diet and genetic effects are among the causes at work: daughters
frequently menstruate at the same age as their mothers.

SUMMARY
Puberty marks the change from childhood to adolescence, with the
development of breasts and secondary sexual hair and the onset of menstruation.
At the same time, there is a period of accelerated growth. The trigger for the
changes to start is an increasing frequency and amplitude of pulses of gonadotrophin
release.
This usually begins at around the age of 9 and takes about 5 years to be
completed.
Causes of precocious puberty include idiopathic, McCune–Albright syndrome,
tumours of the adrenal or ovary-producing steroids, cerebral tumours, and ingestion
of exogenous oestrogens.
Pubic hair growth is stimulated by androgens released by the ovary and the
adrenal gland. Growth charts indicate the range of normal ages at which these
stages are attained.

DELAYED PUBERTY
  The majority of referrals to gynaecologists are due to concerns about the beginning
of menstruation being delayed.
 To discover the most likely cause, it is necessary to first assess whether puberty is
delayed.
 A thorough history should be gathered, including questions about general health,
the age at which breast and pubic hair development began, and whether the girl has
had a growth spurt or appears to be expanding.
 Any chronic condition can cause a constitutional puberty delay.
 The age at which the mother and siblings reached puberty should be included in the
family history.
 Teenage girls may be reluctant to answer questions, and the mother typically
provides most of the background, but it is critical to address the girl rather than the
mother.
 The examination should include an accurate height measurement as well as an
assessment of the stage of breast and pubic hair development, which should be
charted on growth charts.
 The examination should be handled delicately - ask the girl if she wants her mother
to be present, as some people feel more uncomfortable with their mother present -
and just one portion of the body should be exposed at a time.
 An internal examination should not be conducted; a check of the external genitalia is
all that is required, as ultrasound screening of the pelvis will provide additional
assessment of the internal organs.

Investigations usually include:

● measurement of gonadotrophins – follicle stimulating hormone (FSH) and luteinizing

hormone (LH) – and estrogen;

● karyotyping;

● ultrasound scan of the pelvis to confirm the presence of the uterus and ovaries;

● possibly X-ray to determine bone age.

Additional biochemical tests to assess thyroid function, prolactin and 17-α-

hydroxyprogesterone may be appropriate.

SUMMARY
Most referrals to gynaecologists are due to concern about delay in the onset
of menstruation.
To determine the likely cause for this, a detailed history should be taken,
asking about general health, the age at which breast and pubic hair development
started, and if the girl has had a growth spurt or still appears to be growing.
The family history should include the age when mother and siblings went
through puberty.
 Examination should include accurate measurement of height, together with
assessment of the stage of breast and pubic hair development, and these should be
plotted on growth charts.
Investigations usually include measurement of gonadotrophins, karyotyping,
ultrasound scan of the pelvis, and possibly X-ray to determine bone age.
Additional biochemical tests to assess thyroid function, prolactin and 17--
hydroxyprogesterone may be appropriate.

ABSENT BREAST AND PUBIC HAIR DEVELOPMENT

Hypogonadotrophic hypogonadism

 The majority of girls with low gonadotrophins experience constitutional puberty

delay; there is frequently a family history of delayed puberty.
 Another option is that it is caused by a persistent condition, such as cystic fibrosis.
 Girls with anorexia nervosa have low gonadotrophin levels and, if the condition
develops at a young age, lack or have poorly developed secondary sexual features.
 A similar condition may be observed in many sporty ladies, with gymnasts being the
typical example, who have a low bodyweight and very little body fat.
 This can result in the 'female athletic trifecta,' which includes disordered diet,
amenorrhea, and osteopenia, as well as an increased risk of stress fractures.
 Congenital gonadotrophin deficiency is more uncommon; it is recognised as
Kallman's syndrome when it is coupled with anosmia owing to hypoplasia of the
olfactory lobes.
 Brain imaging will be required to confirm this diagnosis.
 Acquired deficit can occur as a result of trauma, a tumour such as a
craniopharyngioma, irradiation, or infection, and is commonly due to hydrocephalus.
 Haemochromatosis can also cause infiltration of these organs, which can be caused
by transfusions for sickle cell disease or thalassaemia, as well as Wilson's disease.
 In all of these cases, ultrasonography will reveal an underdeveloped uterus and tiny,
inactive ovaries.
 Because bone age lags after chronological and height age, it can assist distinguish
cases of constitutional delay.
 If there are no evidence of spontaneous puberty, treatment may be necessary;
nevertheless, most females with constitutional delay will grow normally if left
untreated.
 A study of untreated females found that they had significant distress, which
hampered their academic, occupational, and social achievement; 50% would have
wanted to get therapy.
 Pulsatile gonadotrophins have been utilised, but they are difficult to maintain since
they require a subcutaneous injection connected to a portable pump for several
months.
  The most popular method The more common way is to provide 1-2 mg/day of
ethinyl oestradiol for 3-6 months, or a 25 g transdermal patch divided into eighths or
quarters.
 If spontaneous sexual maturation does not occur, the dosage is gradually raised over
several years.

SUMMARY
Hypogonadotropic hypogonadism is a condition in which girls with low
gonadotrophins have constitutional delay in puberty.
This may be due to a family history of delayed puberty, chronic illness, or
anorexia nervosa.
Acquired deficiency may be associated with anosmia due to hypoplasia of the
olfactory lobes.
Ultrasound will confirm the presence of an immature uterus and small,
inactive ovaries.
Treatment may be required if there are no signs of spontaneous onset of
puberty, but most girls with constitutional delay will proceed to normal
development if left untreated.
Pulsatile gonadotrophins have been used but are difficult to sustain, while the
more widely used approach is to give low doses of
ethinyl estradiol 1–2 mg/day for 3–6 months,
or a
25 g transdermal patch cut into eighths or quarters. Frequently, spontaneous
sexual maturation then occurs, but if not, the dose is gradually increased over

Hypergonadotrophic hypogonadism

 This occurs when gonadal development fails.

 Normal gonadotrophin secretion occurs, but because the gonad does not respond,
there is no negative feedback to modulate gonadotrophin levels.
 Turner's syndrome (45X) or other genetic issues are the most prevalent causes.
 Other reasons include ovarian damage from irradiation, surgery, chemotherapy, or
infection.
 Galactosemic is also related with ovarian failure, and its treatment is difficult since
oral estrogen and progesterone preparations include lactose.
 Other autoimmune illnesses such as Addison's disease, vitiligo, and hypothyroidism
may be related with autoimmune ovarian failure.
 A 17--hydroxylase deficiency is one of the less prevalent causes of congenital
adrenal hyperplasia. Because this enzyme is essential for both estrogen and
testosterone production,
  As a result, virilization does not occur at birth, but secondary sexual traits do not
emerge.
 Once endometrial growth has been promoted, the therapy comprises of gradually
increasing amounts of estrogen replacement mixed with progesterone to cause
withdrawal bleed.

SUMMARY
Ovarian failure is a condition caused by failure of gonadal development.
It can be caused by Turner's syndrome (45X), damage to the ovaries by
irradiation, surgery, chemotherapy or infection, and galactosemic.
Autoimmune ovarian failure may be associated with other autoimmune disorders.
One of the less common causes of congenital adrenal hyperplasia is the deficiency of
17--hydroxylase, which is required to produce both estrogen and testosterone.
Treatment consists of gradually increasing levels of estrogen replacement,
combined with progesterone to induce withdrawal bleed once endometrial
development has been stimulated.

NORMAL BREAST AND PUBIC HAIR DEVELOPMENT

Anatomical causes

 If puberty progressed correctly but the girl did not menstruate, an anatomical
defect, such as Müllerian agenesis, is the most probable explanation.
 Girls with an imperforate hymen or transverse vaginal septum frequently appear
with cyclical stomach discomfort and occasionally a palpable abdominal lump.
 The obstruction restricts the passage of menstrual blood, and a tight blue bulge is
frequently seen at the introitus.
 Ultrasound screening may reveal a dilated vagina with blood and normal ovaries.
 When there is a thin imperforate hymen, therapy is simple: an incision allows the
blood to escape and the mass to dissolve.
 Treatment with a thicker and perhaps taller septum is more complicated and is best
handled at a tertiary referral hospital, as it is risky.
 Inadequate excision can cause stricture development, which is difficult to cure and
can cause significant intercourse issues.

Hyperprolactinaemia
  This is most commonly a cause of secondary amenorrhea, although it can also
appear as primary amenorrhea with or without galactorrhea.
 A high prolactin level should trigger a pituitary adenoma inquiry.
 The treatment is the same as in the older female, with dopamine agonists such as
cabergoline causing the beginning of menstruation.

Congenital adrenal hyperplasia

 Menarche is frequently delayed with this disease, and menstruation might be

irregular.
 Poor control of the illness, frequently owing to noncompliance with therapy, might
be the cause.
 On scan, the ovaries frequently show a polycystic look.
 Fertility rates in these women are low for a variety of reasons, including occasional
ovulation, difficulty achieving penetrative intercourse, and inability to build
partnerships.

NORMAL BREAST BUT SCANTY OR ABSENT PUBIC

HAIR DEVELOPMENT

 This is the most common manifestation of androgen insensitivity syndrome.

 The karyotype is going to be XY.
 Pubic hair does not grow due to end-organ insensitivity to androgens, however
breast growth proceeds due to peripheral androgen conversion to oestrogen.
 There is no need for hormonal therapy.

MENORRHAGIA AND DYSMENORRHOEA

 Menstrual periods are typically painless since they are anovular, however bleeding
may be extended.
 Girls are frequently sent to gynecologists owing to concerns about missing school,
especially when preparing for state exams, as a result of heavy and painful periods.
 Almost always, kids are accompanied by a mother who will tell you about her period
issues.
 It is critical to speak with the girl directly to see if there is a true problem and to
attempt to quused.
The quantity of pads used each day might be deceiving, and because most women d
on't realise how much loss is typical, it can be dangerous.
 It is critical to speak with the girl directly in order to determine if there is a true
problem and to attempt to quantify the loss based on the degree of soakage of the
pads used.
 The quantity of pads used each day can be deceiving, and because most women
don't realise how much loss is usual, it can be dangerous.
 for a girl to determine whether she is suffering excessive bleeding.
 Excessive menstrual loss frequently results in a drop in hemoglobin levels, and in
rare cases, the loss is so severe that emergency hospitalization and transfusion are
necessary.
 Many of these girls will have a medical condition.
 It is critical to exclude out coagulation disorders including von Willebrand's disease
and platelet dysfunction, which may be present in one-third of these instances.
 There might be no personal or family history of bleeding problems. If such a problem
is discovered, the girl may be able to be treated with desmopressin on a cyclical
basis.
 The oral contraceptive pill is typically administered, and when substantial blood loss
occurs on a regular basis, it might be beneficial to prescribe this constantly for three
or more cycles to lessen the frequency of withdrawal bleeds.
 Several studies, however, have found that the number of days of bleeding is not
significantly different from traditional cyclic dosage.
 The levonorgestrol intrauterine system (Mirena) has also shown to be effective.
 To allow insertion, the uterine cavity must be at least 5-6 cm wide, and a general
anaesthesia is likely to be necessary.
 Girls do occasionally come with life-threatening bleeding.
 Treatment options include
medroxyprogesterone acetate 5 mg orally every 1-2 hours for 24 hours, followed by
20 mg daily for 10 days, or a 50 g oral contraceptive pill taken 6-hourly for 48 hours,
then once daily for the following three days.
 Intravenous estrogen (40 mg 4-hourly for 24 hours) has also been used in
conjunction with a highly pregestational oral contraceptive pill, however it is not
widely accessible in many pharmacies.
 A diagnostic curettage is almost never required.
 Simple analgesia or oral contraceptives are typically effective in treating
dysmenorrhea.
 However, if these precautions fail, it is vital to consider the potential of partial
restriction of menstrual flow.
 A number of examples with blocked hemivagina and uterine horn coupled with
ipsilateral renal agenesis have been documented.
 The most common symptom is intense cyclical pain with an abdominal mass caused
by a hemihaematometra and haematocolpos.
 The removal of the blocked vaginal septum enables for drainage and symptom
alleviation.
 Many of these patients have endometriosis, which is most likely due to the forced
retrograde menstrual flow.
 Chronic pelvic discomfort in young women can be caused by a variety of
circumstances, including psychological problems.
  It is critical to recognize that endometriosis should be ruled out in cases of chronic
pelvic discomfort that has not responded to modest remedies.
 Laparoscopy may be required.
 The symptoms are frequently not those seen in older women.

SUMMARY
Girls are often referred to gynecologists due to concern about missing school
due to heavy and painful periods.
It is important to speak to the girl herself to establish if there is a genuine problem,
and to quantify the loss by the degree of soakage of the pads used.
Excessive menstrual loss can result in a fall in the haemoglobin level, and may require
emergency admission and transfusion.
Many of these girls will have an underlying medical disorder, such as von
Willebrand’s disease or a platelet dysfunction, which may be present in a third of
these cases.
If such a disorder is found, it may be possible to treat the girl with desmopressin on a
cyclical basis.

The oral contraceptive pill is usually prescribed and, where blood loss is recurrently
excessive, it can be helpful to prescribe this continuously for three or more cycles to
reduce the frequency of withdrawal bleeds.
The levonorgestrol intrauterine system (Mirena) has also been used successfully.
Occasionally girls present with life-threatening haemorrhage, and the options for
treatment include medroxyprogesterone acetate 5 mg orally every 1–2 hours for 24
hours and then 20 mg daily for 10 days, or a 50 g oral contraceptive pill taken 6-
hourly for 48 hours, then reduced to once daily over the next 3 days.
Intravenous oestrogen has also been used (40 mg 4-hourly for 24 hours) combined
with a highly progestational oral contraceptive pill.
It is rarely necessary to perform a diagnostic curettage.
Dysmenorrhoea usually responds to simple analgesia or oral contraceptives, but
where these measures fail, it is important to bear in mind the possibility of partial
obstruction of menstrual flow.

.
EBM
All girls with menorrhagia who are found to be
anaemic should be investigated for a bleeding
disorder, including testing for von Willebrand’s
disease and platelet function defects.

KEY POINTS
● Secondary sexual characteristics
start to develop in most girls by the
age of 14 years.
● Menarche normally occurs 2 years
after breast development has
commenced.
● Ovarian failure is the commonest
cause of delayed puberty –
karyotyping and gonadotrophins are
essential investigations.
● Tests for bleeding disorders should be
performed for any girl with moderate to
severe menorrhagia.
● Endometriosis can occur in teenagers.