Gynaecological issues

in puberty

Dr Deepthy Sunil
House surgeon
Dept of Prasootitantra & Streeroga
PNNM AMC, Cheruthuruthy
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 CONTENTS
 Introduction
 Puberty
 Menarche
 Menstruation
 Gynaecological problems and puberty
 Discussion
 Conclusion
 Reference

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 INTRODUCTION

 Puberty - links childhood to adulthood.

 Adolescence - period between the onset of puberty &
adulthood ( 10-19 years as per WHO ).

Anaemia Common
Menstrual disturbances adolescent issues

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 PUBERTY

involves biological, morphological, and psychological

changes
lead to full sexual maturity and eventually fertility.

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 Morphological changes
oBetween 10 - 16 years.
oTanner & Marshall- staging

Beginning of the growth spurt

Breast budding (Thelarche)

Pubic and axillary hair growth (Adrenarche)

Peak growth in height

Menstruation (Menarche)
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Breast
Prepubertal state, elevation of papilla only

Breast buds and papilla slightly elevated,

and side of labia areola begins to enlarge.
(Median age: 9.8 years)

Further enlargement of entire breast tissue

Secondary mound of areola and papilla

projecting above the breast tissue. (Median
age:
12.1 years)

Areola recessed to general contour of

breast. (Median age : 14.6 years)

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Pubic hair
No pubic hair present Stage I

Sparse, long hair on either majora. Stage II

(Median age:
10.5 years)

Darker, coarser and curly hair over the Stage III

mons pubis
Adult type hair covering the mons only. Stage IV
(Median age: 12.0 years)

Adult hair with an inverse triangle Stage V

distribution (female escutcheon)
covering the medial thighs. (Median age:
13.7 years)
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 MENARCHE
 Onset of first menstruation in life.
 Between 10-16 years; peak time being 13 years.
 Denotes:
Intact HPO axis
 Functioning ovaries
Responsive endometrium
Patent uterovaginal canal
 Ovulation & menstruation:-
May be irregular for a variable period
following menarche.
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 MENSTRUATION
It is the visible manifestation of cyclic physiologic uterine
bleeding due to shedding of the endometrium following
invisible interplay of hormones mainly through HPO axis.

Interval Amount
28 days MENSTRUATION 35 ml
(21-35days) (20-80 ml)

Duration
4-5 days
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Ovarian & endometrial cycle

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 Ayurvedic concept:
Raja srava:
oPrathama rajodarshanam:-
• Tath varshat dwadashadoordhwam……. (Su.Soo.14/6)
Age of menarche is 12 yrs.

oDuration:-
• Maasi maasi rajah streenam rasajam sravati
tryaham|| (AH.Sa.1/7)
For 3 days in every month
• Caraka – 5 days
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 GYNAECOLOGICAL
PROBLEMS AND PUBERTY

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COMMON GYNAECOLOGICAL PROBLEMS FACED
BY ADOLESCENT GIRLS:
Precocious puberty Amenorrhoea
Delayed puberty Leucorrhoea

Psychological issues Premenstrual syndrome

Menstrual migraine
Dysmenorrhoea
Ovular pain
Menstrual irregularities

PCOS
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 PRECOCIOUS PUBERTY
any secondary sex characteristics before the age of 8 or
menstruate before the age of 10.

Precocious
puberty in a
girl aged 2
years and 3
months
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Causes:
 Constitutional
GnRH dependent/
Complete/  Juvenile hypothyroidism
Central/ True
 CNS lesions

GnRH independent/  Excess estrogen or androgen

peripheral

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Other factors:
• Obesity
• Toxic stress in family life, etc.

Treatment:
oDepends upon the cause and speed of progress of the
disease.
oDrugs should be used upto the age of 11 yrs.
(Individualization is to be done.)
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DELAYED PUBERTY
 When the secondary sexual characters have not appeared by
13–14 years or menarche appears as late as 16 years.
Familial or idiopathic

Common causes:
o Ovarian failure o Constitutional delay
o Chronic illness o Gonadal dysgenesis
o Malnutrition o Imperforate hymen
o Primary hypothyroidism o Transverse vaginal septum
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Treatment:
oAssurance
oImprovement of general health
oTreatment of related disease
oCyclic estrogen – cases with hypogonadism

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 Ayurvedic concept:

Early puberty  Delayed puberty

o Causes:
oKapha medo dushti • Imbalance of tridosha
especially vata
• Agnimandya
oReduce kaphamedo o Leads to uttarottara
kara ahara viharas dhatwagnimandya
o Correction of agni

Dhatu poshana
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PSYCHOLOGICAL ISSUES RELATED
TO PUBERTY

Early puberty:
oDepression & anxiety
oSubstance use & abuse
oSelf harm
oEating disorders
oEarly sexual behaviour
oBreast cancer & heart disease risk

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 Delayed puberty:
oDepression o Reduced peer contact
oOppositional behaviour o Aggression towards peers
oLow self-esteem o General social immaturity, etc.

 Menstrual irregularities
following menarche,
misconceptions etc. may
also leads to mental
issues in adolescents.

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Treatment:
Counselling
Cognitive behavioural therapy
Psychoeducation, etc.

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 DYSMENORRHOEA
Painful menstruation of sufficient magnitude so as to
incapacitate day-to-day activities.

Primary dysmenorrhoea

Types

Secondary dysmenorrhoea

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Primary dysmenorrhoea
No identifiable pelvic pathology
Mostly in adolescents
Confined to ovulatory cycle
Starts with onset or just before
menses
Secondary dysmenorrhoea
Secondary to pelvic pathology
Elderly / parous women
Pain starts 7-10 days before the
onset of menstruation
No systemic discomfort
Intermenstrual period not
completely free of pain
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Primary dysmenorrhea

 Also known as Spasmodic

dysmenorrhoea

 Causes:
Prostaglandin • Dysrhythmic uterine contractions
E2 & F2 • Uterine hypoxia

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 Clinical features:
Pain:-
oBegins a few hours before or with onset of menses.
oDuration: few-24 hours or beyond 48 hours
oNature – Spasmodic pain (lower abdomen, back,
medial aspects of thighs)

Associated systemic discomforts

o Nausea o Diarrhoea
o Vomiting o Headache
o Fatigue o Tachycardia
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 Vasomotor changes:- o Pallor
o Cold sweats
o Occasional fainting
Severe cases – Syncope & collapse

 Treatment:
General health improvement
Psychotherapy – explanation & assurance
Drugs – PSIs, Oral contraceptives
Surgery – Nerve stimulation, nerve ablation, neurectomy
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  Ayurvedic concept Some internal
UDAVARTINI medications
• Vataja yonivyapad
oGandharvahastadi
• Vegarodha Vata vriddhi
Kashaya
Yoni
Krichrat phenila oSaptasaram Kashaya
prapeedanam
raja vimunchanam oAsokarishta
oAbhayarishta
• Chikitsa: oHinguvachadi choorna
oVatika yonivyapad chikitsa oDhanwantaram 101 A
(sneha, sweda,basti..) oMahanarayana thailam
sevyams
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ABNORMAL UTERINE BLEEDING
Any uterine bleeding outside the normal volume,
duration, regularity or frequency.

Common causes of AUB:

oHaematological disorders
oEndocrine dysfunction : PCOS, Hypo/hyperthyroidism
oInfections
oNeoplastic growth
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 DUB
A state of abnormal uterine bleeding without any clinically
detectable organic, systemic, and iatrogenic cause.

Ovular bleeding • Irregular ripening

(20%) • Irregular shedding
DUB

Anovular bleeding • Puberty menorrhagia

(80%)

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Management:
oGirl need adequate explanation, reassurance and
psychological support.
oRest and anaemia correction.
oTreatment with progestogens

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 Ayurvedic concept
Menorrhagia, metrorrhagia – Asrigdhara, rakta
pradara, arthava ativriddhi

• Ahara, vihara, Rakta pramana increase Garbhashaya gata

vyadhi sambandha iRRR
sira rakta vriddhi

Rajovaha
Rakta pradara Rajovriddhi with
srotovikriti
vata vriddhi

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 Some internal medications
• Treatment:
oRakta sthapaka o Musalikhadiradi kashaya
oushadham o Satavari kashaya
oVataladi yonivyapad o Guduchiadi kashaya
chikitsa o Tikthaka kashaya
oAdhoga raktapitta o Nyagrodhadi gana kashaya
chikitsa o Pushyanuga choorna
oRaktarshas chikitsa o Sarasija makarandadi choorna
oChaga paya, asoka o Chandraprabha vati
valkala ksheera o Satavari ghrita
prayoga o Mahatiktaka ghrita
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 Oligomenorrhea, hypomenorrhea –
Artavakshaya
• Lakshanas:
oYathochithakale adarshanam
oAlpatha Some internal medications
oYonivedana oTila kwatha
oSukumaram kashayam
• Chikitsa: oAsokarishta
oPittakara chikitsa oKumaryasava
oShodhana – Vamana –
Agneya dravyas
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 POLYCYSTIC OVARIAN SYNDROME
(PCOS)
Heterogenous, multisystem endocrinopathy in reproductive
women
with the ovarian expression of various metabolic disturbances
spectrum of clinical features such as:
 Obesity
Menstrual abnormalities
Hyperandrogenism

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 Rotterdam criteria – Diagnosis:-
Based upon the presence of any two of the following three
criteria (ASRM/ESHRE, 2003)
1. Oligo &/or anovulation
2. Hyperandrogenism (clinical &/or biochemical)
3. Polycystic ovaries
o _> 12 follicles (2-9 mm in diameter)
o>10 cubic cm (at least one ovary)

Laparoscopic view of polycystic

changes of the ovary 36
Aetiology:
oChange in lifestyle, diet and
stress
oGenetic and familial
environment factors

Clinical features:
oIncreasing obesity
oMenstrual abnormalities
oInfertility
oHirsuitism
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oAcne
o HAIR-AN Syndrome
• Hyperandrogenism
• Insulin resistance
• Acanthosis nigricans

Management:
oDepends on her presenting symptoms
oPatient counselling
oCorrection of biochemical abnormalities
oInfertility treatment 38
 Ayurvedic concept
JATAHARANI PUSHPAGHNI
• PCOS condition featured with hirsuitism
• Obese PCOS – Vata kapha roga
• Lean PCOS – Vatapaittika roga

Some internal medications

oKanasatahwadi kashaya
oKulatthadi kashaya
oSaptasara kashaya
oTila kwatha
oVaranadi kashaya 39
 AMENORRHOEA
Absence of menstruation
A symptom, not a disease

Primary amenorrhoea: A young girl who has not

yet menstruated by 16 years of age; not delayed
Types puberty

Secondary amenorrhoea: Absence of

menstruation for 6 months or more in normal
menstruating woman
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Treatment:
oGeneral health improvement
oAssurance
oTreat the cause

Ayurvedic concept:
NASHTARTHAVA
• Kaphavata avarana of artavavaha srotas
• No pitta involvement
• No complete destruction of artava but not visible in every month
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• Chikitsa:
Vatakaphahara dravyas
Pittala upacharas

Some internal medications

oKanasatahwadi Kashaya o Saptasaram Kashaya
oKulatthadi Kashaya o Hinguvachadi churna
oTila kwatha o Pancakola churna
oSatavaryadi kashaya o Rajapravartini vati

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 LEUCORRHOEA
Among abnormal vaginal discharges,
Leucorrhoea - commonly in adolescent girls

Leucorrhoea is an excessive normal vaginal discharge.

Ill health, anaemia ,etc. may have the effect.

Excessive secretion is due to:-

 Physiologic excess
 Cervical cause
 Vaginal cause
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 Physiologic excess:
Normal secretion increase in conditions of high estrogen levels.
Such conditions are:-

oDuring puberty:
Endocervical Encroach
Increased Produce Increased
epithelium onto the
estrogen erosion secretion
overgrowth ectocervix
oOther conditions:-
– menstrual cycle, pregnancy, sexual excitement 44
Treatment:
• General health improvement Some internal
• Maintenance of local hygiene medications
• Treatment according to the
cause
oLodradi Kashaya
oMusalikhadiradi Kashaya
Ayurvedic concept: oAsokarishta
SWETAPRADARA oPushyanuga curna
• Kaphaja roga oDhatryadi ghrita
• Kaphaja yonivyapad chikitsa oSatavari gulam
(rooksha ushna oushada)
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 PREMENSTRUAL SYNDROME (PMS)
PMS/ Premenstrual tension is a psychoneuro-endocrine
disorder :-
Of unknown aetiology
Cyclic appearance of symptom complex
occurs 7-10 days prior to menstruation
Resolves after menses
Severe form – Premenstrual dysphoric disorder (PMDD)
Comprises physical, psychological & behavioural changes
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 Clinical features:

 Physical  Psychological  Behavioural

• Abdominal bloating • Irritability • Fatigue
• Breast tenderness • Depression • Tiredness
• Swelling of • Mood swings • Insomnia
extremities • Increased appetite
• Weight gain • Tearfulness
• Anxiety
• Confusion
• Headache
• Anger
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Treatment:
 Lifestyle modifications – regular exercise, healthy foods, enough
sleep, etc.
 Cognitive behaviour therapy
 Various drugs - used with varying success rates

Ayurvedic concept:
 Shotahara chikitsa
 Virechanam
 Punarnavadi kashaya
 Saptasaram kashaya
 Gandharvahastadi erandam
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 MENSTRUAL MIGRAINE
Attack of migraine that occurs either:-
 perimenstrually or
 both perimenstrually & also at other times
Treatment:-
 Drugs used for migraine – analgesics, triptan,etc.
 NSAIDS

Sirashoola chikitsa & vatanulomana oushada

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 MITTELSCHMERZ’S SYNDROME /
OVULAR PAIN
One-sided, lower abdominal pain associated with ovulation
Cause:- unknown

Clinical features:
 Appears in mid menstrual period.
 Pain:-
• In hypogastrium or in either of the iliac fossa
• Side depends upon the side of ovary is ovulating
• Rarely lasts more than 12 hours
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  may be associated with:
• slight vaginal bleeding or
• excessive mucoid vaginal discharge

Treatment:
 Effective with assurance and analgesics
 Obstinate cases – making the cycle anovular with
contraceptive pills

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 DISCUSSION
Importance of rajaswala charya

Current lifestyle and its effect on the reproductive

health

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 CONCLUSION
Menstrual problems - commonest reason for gynecological
OPD consultation among adolescent girls.

Health education classes to create awareness regarding

adolescent gynecological problems
- conducted regularly in school and colleges.

Healthy life style, yoga, etc.

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Thank You
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