THE ADOLESCENT

FEMALE
Women health disorders – Module 1
Dr Sarah Ehsan (BSPT, PP-DPT)
Learning Objectives
• Discuss Menstruation process
• Describe Amenorrhea, its causes and management
• Discuss Dysmenorrhea, its causes and management
• Discuss Polycystic Ovarian syndrome
https://create.kahoot.it/share/quiz/0a0e73b1-
bb17-4791-aceb-6892706cb633
Define adolescence?
• Menstrual disorders in adolescent age are quite different than in adult
women, both for diagnostic and therapeutic management.
• The young and sexually nonactive age precludes vaginal examination
and transvaginal sonography—the current mainstays of accurate
gynecological diagnosis.
MENSTRUATION IN ADOLESCENCE
• Causes for early menarche?
• Weight gain
• Urban
• Environmental estrogens in chemicals, pesticides and hair products.
Normal menstrual cycle length 33 days avg.
The commonest menstrual disorders observed in this age are:
Dysmenorrhea (painful menstruation)
Amenorrhea or oligomenorrhea (absent or reduced menstruation)
Dysfunctional uterine bleeding (DUB),
menorrhagia (excessive and/or irregular menstruation).
• The initiation of menstruation is a relatively complicated and
sometimes frightening event for the young adolescents.
• Young adolescent girls are quite curious of knowing this mechanism
through which menstrual cycle occurs.
Activity: Explain the menstrual cycle in
detail
Menstrual cycle
Dysmenorrhea
• Dysmenorrhea is one of the common gynecological complaints during
adolescence.
• Around 60% of girls of 12–17 years age group complain of
dysmenorrhea; however, only 15% of these seek medical assistance.
• Girls on average miss out 25% more classes in school compared to
boys due to pain during menses.
• First few periods are generally pain
free due to anovulation. A heavy
dragging pelvic pain is more
common than actual dysmenorrhea
during periods.
• This pain is due to the new
phenomenon of pelvic vascular
engorgement under the effects of
sex steroids.
Causes
• Primary dysmenorrhea  within first 2 years of menarche
• Pain is usually described as crampy and lasts from a few hours to a couple of
days. Often quoted cervical stenosis does not appear to be playing any role in
primary dysmenorrhea.
• Girls who are overweight have twice the risk of having severe and prolonged
cramping compared to girls who are not over weight
• Secondary dysmenorrhea may occur many years after menarche
• The pain is usually more severe and can precede periods by several days. The
common conditions leading to secondary dysmenorrhea are endometriosis,
genital infections and congenital genital tract malformations. Colicky pain
before the flow and relieved with menstruation is classic presentation of
secondary dysmenorrhea.
Treatment Approach
• detailed explanation about the pathophysiology of primary
dysmenorrhea
• Diet: Salt restriction, reduced caffeine intake, sugar, and alcohol may
be beneficial. Increased amount of fish in diet may help reduce
menstrual pain.
• Exercise in moderation and back massage appears to reduce
menstrual pain. Stress reduction, acupressure, Yoga and meditation
are all helpful in selected cases
Treatment Approach
• Hot packs
• Simple analgesic like paracetamol is effective (about 30% relieved) in
case of milder discomfort
• Laparoscopy to treat endometriosis or PID.
• Psychologist’s help may at times be sought.
Activity: Is there any role of physical activity
in dysmenorrhea management
https://academic.oup.com/ptj/article/99/10/13
71/5608544?login=true
AMENORRHEA
• Primary amenorrhea  a girl does not start menstruation by age of
16.
• By age 14, if the girl has never menstruated, one needs to conduct a
preliminary clinical check-up and an ultrasound scanning to rule out
major problems like general endocrine disorders, cryptomenorrhea,
absence of uterus, etc.
• Once reassured of absence of these, a more detailed check-up is
deferred up to 16 years.
• Secondary amenorrhea is diagnosed when there is an absence of
menstruation for 6 continuous months; however, for clinical purposes,
one should start investigating the case whenever menses is more than
3 months delayed.
Evaluation of Amenorrhea
Causes of Amenorrhea
• Central nervous system disorders: Hypothalamic: Systemic illness/chronic disease, tumors
(e.g. craniopharyngioma, glioma), mass lesions like granuloma, central nervous system
irradiation, congenital lack of GnRH-anorexia nervosa, drugs (antihypertensives,
antidepressants, chemotherapeutic drugs and narcotic drugs), OC pills, competitive athletes,
athletic triad, stress.
• Pituitary: Hypopituitarism, tumors (e.g. prolactinoma), hemochromatosis.
• Thyroid dysfunction: Both hyperthyroidism as well as hypothyroidism.
• Adrenal dysfunction: Congenital adrenal hyperplasia, tumor, Cushing syndrome.
• Ovarian: Premature ovarian failure, gonadal dysgenesis, 47XXX, polycystic ovary (PCO),
androgen producing tumors (arrhenoblastoma, theca cell tumor).
• Outflow tract dysfunction: Uterine agenesis, Asherman’s syndrome, cervical/vaginal agenesis,
imperforate hymen.
• Pregnancy in sexually active teenage girls should always be suspected.
Clinical Features of Amenorrhea/
Oligomenorrhea
• H/O  The discrepancy between bone age and chronological age,
presence of chronic illness, genitourinary anomaly or history of sexual
activity, recent weight change or medication use.
• obesity, exercise levels and emotional stress levels.
• Detailed exam
• US
• Eating disorders
• Female athlete triad
Management
• Sympathy and gentleness are very necessary to ease the extreme
anxiety
• These girls should be counseled for change in habits, especially for
exercise and food intake when necessary.
• Estrogen + progesterone is used in sequential manner.
• A combined OCP should generally be avoided as occasional post-pill
amenorrhea is noted.
Polycystic Ovaries and
Polycystic Ovarian Syndrome
• Polycystic ovaries is an ultrasound diagnosis, whereas polycystic
ovarian syndrome (PCOS) is a clinical syndrome involving a PCO with
either amenorrhea, oligomenorrhea, hirsutism, anovulation and other
signs of androgen excess like acne and crown pattern of baldness.
• Oligomenorrhea, amenorrhea and prolonged erratic menstrual
bleeding are all aspects of the menstrual disturbances that occur in
PCOS.
• Although the majority of girls having anovulation will have PCOS,
weight-related amenorrhea and hyperprolactinemia should be
considered as part of the differential diagnosis.
• The prevalence of PCO in asymptomatic volunteers is 21–23% and in
these cases of PCO the PCOS is present to the tune of about 59–76%.
Concept of Spectrum
• There is continuum or spectrum of clinical
presentations.
• At one end of the spectrum are the
women who may have PCO and yet ovulate
and who have no dermatological
manifestations such as acne or hirsutism.
• At the other end of the spectrum there
may be women with menstrual
disturbances, oligoamenorrhea, increased
hair growth, acne, crown pattern of
baldness and evidence of insulin resistance
• Related to lifestyle and BMI
Diagnosis
• Labs
• Testorsterone
• LH/FSH
• Prolactin
• 24Hr free cortisol
• SHBG
• IR tests

• What is the role of prolactin in PCOS?

Pathogenesis
Insulin resistance and PCOS
Management
• Group Activity: Discuss the latest evidence based management of
PCOD
• https://www.asrm.org/globalassets/asrm/asrm-content/news-and-
publications/practice-guidelines/for-non-members/
recs_from_the_international_evidence-based_guideline_for_pcos.pdf
Treatment of PCOS in adolescents