Gynecological Disorders in The Adolescent Gynecological Disorders in The Adolescent

Gynecological
GynecologicalDisorders
Disorders
ininthe
theAdolescent
Adolescent
A Presentation by …..
Dr. Pushkala
Moderator : Dr Rajesh
Classification
• The gynecological problems of adolescence
can be grouped into:
• Common gynecological problems
• Atypical gynecological problems
Common gynecological problems
 Irregular menses
 Common due to Absence of ovulation (1 to 5 years)
 Polymennorhoea due to
 Physiological
 Psychological
 Metabolic
 Nutritional
 Dysmenorrhoea:
 Pain accompanying or preceding mensturation
 Starts on day 1-24 hours
 Occurs in ovulatory cycles
 PGE2; PGF2 alpha

 Excessive menstural bleeding
 Apart from polymenorrhea
 In cervical polyp, granulosa cell tumour, pelvic tuberculosis
 To r/o ITP and other hematological disorders

Leucorrhoea
 White discharge pv
 Causes:
 Pre or post menstural
 Constitutional like malnutrition,genital tb and Parasitic
 Trichomonas or monolial infection in sexually active girls
 Continuous sexual excitement and repeated masturbation
 Rarely a new growth in cervix and vagina

 Abdominal pain
 Appendicitis
 Acute urine retention due to hematocolpos hematometra
 Ectopic pregnancy
 Torsion of pedicle of benign ovarian cyst
 Rupture of corpus luteum cyst

Atypical gynecological problems
Common Causes of primary Amenorrhea
 Developmental defects of genital track :
 Complete absence of vagina, transverse vaginal septum, partial
absence of upper part of vagina and imperforate hymen.
 Chromosomal anomalies
 Hypothalamic, pituitary and ovarian causes
 Dysfunction of thyroid and adrenal cortex
 Unresponsive or absent endometrium

 Genital tract abnormalities
1. Absence of vagina : commonest cause of primary
amenorrhea
1. Normal gonads and normal female karyotype
2. Absent utreus and absent vagina
3. Fallopian tubes are normal anatomically and histologically
4. Medial end of each FT , two solid mullerian knobs connected by
a solid fibro-muscular band
1. Absence of vagina
5. Mullerian knobs maybe a remnant of endometrial tissue
6. Endocrine and ovulatory status are normal
7. They are grouped under common syndrome called Rokitansky-
Kuster-Hauser syndrome
8. Urinary track malformations are present
9. Vaginal reconstruction
10. Grafts , skin and amniotic membrane
2. Transverse vaginal septum
1. In middle third of vagina
2. Normal uterus and cervix
3. Hematocalpos and hematometra+
4. Periodic pain, lump in pelvis, and retention of urine
5. surgery
3. Agenesis of upper third of vagina
1. Resembles a transverse vaginal septum clinically
2. In TVS ,upper part of cervical,uterus and vaginal canal are patent
3. In agenesis, Cx is rudimentary and non canalised but the uterus
forms hematometra requiring Sx
4. Cryptomenorrhea(hidden mensturation)
1. Due to imperforate hymen
2. Amenorrhea + low abdominal pain + retention of urine
occasionally
3. L/E:bluish bulge on the obstructing membrane visible in
introitus
4. Hematocolpos and hematometra
5. Cruciate incision and removal of hymen and drainage of blood in
uterus and vagina
 Chromosomal abnormalities:
1. Turners syndrome:45XO
1. sexual infantilism,growth retardation, cubitus valgus,webbed
neck,shield chest,high arched palate,low set
ears,deafness,pigmented soles and coarctation of aorta
2. Incidence of amenorrhea is 35% with deletion of long arm and is
10-15%with short arm.
3. Compared to 45XO/46XX those with 45XO/45XY are at a higher
risk of seminoma and due to malignant disposition-
gonadectomy
Chromosomal abnormalities:
2. Androgen insensitivity tumor:46XY

1. Deficiency of cytosol androgen receptor in target cells
2. Referred to as male intersex
3. Females with normal skeletal development+scanty axillary and pubic hair+short
blind vagina+absent uterus+both testis in inguinal canal labia major or the ovarian
fossa
4. Immature germ cells sertoli cells and predominantly leydig cells.MIF of the testis +
5. Plasma testosterone is identical to that of post pubertal males.
6. Removal of gonads(after completion of growth or 20 years),excision of enlarged
phallus and hrt
 Dysfunction of hypothalamus pituitary ovarian axis:
1. HYPOTHALAMIC:
– Functional:
1. Anorexia nervosa:growth and secondary sexual characterestics
are normal and subsequently regress due to effect of low body
mass on pulsatile gnrh secretion
2. Primary amenorrhea:atheletes-overexercise
1. HYPOTHALAMIC
– Organic:
1. hypopitutarism:short stature,obesity,adiposogenital distribution
of fat.
2. The laurence moon beidl will also have
polydactyly,MR,coarctation of aorta,retinitis pigmentosa.
3. Treatment is unsatisfactory
1. HYPOTHALAMIC
– Olfactogenital or Kallman syndrome
1. The hypothalamus lacks ability to secrete GNRH and is
hypogonadotrophic hypogonadism.The patient has anosmia due
to genetic or sporadic defect.
2. PITIUTARY CAUSES:
– Empty sella turcica syndrome:
1. GNRH is normally secreted from hypothalamus but FSH is not
adequately secreted due to absence of adequate pituitary tissue
2. So the patients are hypogonadotrophic
3. Identified on CT pituitary or MRI
 Tumors
1. Craniopharyngioma:rathke pouch tumor
1. Occurs from embryonic squamous rest cells which persist after
migration of stomadial epithelium to the anterior pitiutary
2. Visual,neurological,hypopitutarism and primary amenorrhea
3. CT,MRI and craniotomy
 Tumors
2. pituitary adenoma
1. A rare type of pituitary adenoma due to acromegaly due to
increased secretion of GH(99%) and due to GNRH(1% cases)
2. Neurological manifestations and gonadal dysfunction causing
amenorrhea and hyperprolactinemia
3. Surgical excision of tumor and radiotherapy
 Tumors
3. Prolactinoma
1. Primary or secondary amenorrhea+galactorrhea
2. Indication for CT or MRI
3. Abnormal coned down view of sella turcica
4. S prolactin>100ng/dl
5. Headache and visual problems
6. Rx bromocriptine
 Ovarian cause of primary amenorrhea
1. PCOD
2. Ovarian insensitivity tumour
1. PCOD
1. Irregular menses/ secondary amenorrhea, hirsutism, acne, obesity, AN
2. Hyperandrogenism (adrenals, ovaries)
3. Increased androstenedione, free testosterone, total testosterone,
DHEAS
4. Increased gonadotropins
5. LH/FSH >3
6. Infertility
7. Elevated lipids
8. Insulin resistance
9. Increased risk for type 2 DM
10. Increased risk for CV disease
2. Ovarian insensitivity tumors (savage syndrome)
1. Normal stature, increased gonadotrophin levels ,secondary
sexual characteristics with variable no of primordial follicles
identified by USG or ovarian biopsy
2. Increased gonadotrophin is due to cell membrane receptor
defect+autoimmune failure(asso with Addison or Hashimoto
disease)
3. Leads to secondary more than primary amenorrhea
4. For pregnancy-IVF with oocyte donation programme
 Thyroid and Adrenal disorders causing primary
amenorrhea:
1. Thyroid causes
1. This includes primary thyroid atrophy , post ablative
hypothyroidism and sporadic athyrotic cretinism
2. Assoc with hyperprolactinemia and galactorrhea
3. On going hypothyroidism leads to declining dopamine levels in
hypothalamus leading to unapposed action of TRH on pitiutery
calls to secrete prolactin
4. Rx is replacement therapy with L thyroxine
 Thyroid and Adrenal disorders causing primary amenorrhea:
2. Adrenal causes:
CAH
1. Ambiguous external genitalia at birth without externally palpable
gonads
2. Hirsuitism,clitoromegaly,non canalisation of urogenital sinus
3. Test shows an elevation of 17 alpha hydroxy progesterone and
testosterone
4. This is due to the deficiency of 21 hydroxylase and 17 B
hydroxylase causing elevated ACTH and cortisol precursors which
are converted via 17 alpha hydroxy progesterone to androgens
5. Rx is plastic reconstruction of external genitalia and
dexamethasone suppression of excess ACTH
 Endometrial causes of primary amenorrhea
1. Intrauterine adhesions leading to primary amenorrhea
consequent to TB is common in India.
2. Occasionally in the absence of uterine adhesions , endometrial
tissue is scanty or absent and the uterus size is reduced
3. Due to a deficiency of estrogen receptors in the endometrium
and myometrium.
4. Hysteroscopy and endometrial biopsy help to confirm the
diagnosis
 Hirsuitism
 Excessive hair growth in the abnormal sites such as chin,back
intermammary fold,abdomen,proximal and distal limbs,upper lip,ears.
Virilisation
 appearance of male sexual characteristics in females such as change of
voice,enlargement of clitoris,temporal recession of hair and the atrophy of breasts
 Etiology
1. The source of androgen in females is via the adrenal cortex,
ovary and peripheral tissues.
2. The no of hair follicles is fixed at birth- lanugo hair , vellus hair
and terminal hair.
3. At puberty ,fine unpigmented villous hair pigment and become
coarser to form terminal hairs in response to excessive androgen
production or increased end organ response.
4. It is important to find the cause of hirsuitism-familial or acquired.
H/O regarding onset age and progress , prior administration of
any drugs , virilisation or infertility to be taken . Clinical
examination of distribution and coarseness of hair , virilisation of
voice , enlargement of clitoris and balding of scalp.
References
• Clinical Gynecology (Fourth Edition)
By Bhasker Rao
• Nelson textbook of pediatrics 18 th Edition
• Internet

Gynecological Disorders in The Adolescent Gynecological Disorders in The Adolescent

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Gynecological

 Common due to Absence of ovulation (1 to 5 years)

 Starts on day 1-24 hours

 Occurs in ovulatory cycles

 PGE2; PGF2 alpha

 In cervical polyp, granulosa cell tumour, pelvic tuberculosis

 To r/o ITP and other hematological disorders

 Pre or post menstural

 Constitutional like malnutrition,genital tb and Parasitic

 Trichomonas or monolial infection in sexually active girls

 Continuous sexual excitement and repeated masturbation

 Rarely a new growth in cervix and vagina

 Acute urine retention due to hematocolpos hematometra

 Torsion of pedicle of benign ovarian cyst

 Rupture of corpus luteum cyst

 Hypothalamic, pituitary and ovarian causes

 Dysfunction of thyroid and adrenal cortex

 Unresponsive or absent endometrium

2. Androgen insensitivity tumor:46XY

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