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Biological and psychosocial issues



Menstrual Disorders


The median age of menarche is 12.8 years, and the normal menstrual cycle is 21 to 35 days in length.
Bleeding normally lasts for 3 to 7 days and consists of 30 to 40 mL of blood.
Cycles are abnormal if they are longer than 8 to 10 days or if more than 80 mL of blood loss occurs.
Soaking more than 25 pads or 30 tampons during a menstrual period is abnormal.

1. Pathophysiology

Regular ovulatory menstrual cycles often do not develop until 1 to 1.5 years after menarche. An ovulatory cycles typically cause heavier and longer bleeding.

Adolescents frequently experience irregular menstrual bleeding patterns, which can include several consecutive months of amenorrhea.

2. Amenorrhea

Primary amenorrhea is defined as the absence of menarche by age 16. Puberty is considered delayed and warrants evaluation if breast development (the initial sign of puberty in girls) does not begin by the age of 13.
The mean time between the onset of breast development and menarche is 2 years. Absence of menses within 2 to 2.5 years of the onset of puberty should be evaluated.

Secondary amenorrhea is defined as the absence of 3 consecutive menstrual cycles or 6 months of amenorrhea in patients who have already established regular menstrual periods.

Amenorrhea with pubertal delay

Hypergonadotropic hypogonadism is caused by ovarian failure associated with elevated gonadotropin levels.

Turner syndrome (XO) may cause ovarian failure and a lack of pubertal development. Females with Turner syndrome have streak gonads,absence ofone of the X chromosomes, and inadequate levels of estradiol.They do not initiate puberty or uterine development.
This syndrome is characterized by short stature, webbed neck, widelyspaced nipples, shield chest, high arched palate, congenital heart disease,renal anomalies, and autoimmune disorders. It may not be diagnosed until adolescence, when pubertal delay and amenorrhea occur together.

Ovarian failure resulting from autoimmune disorders or exposure to radiation or chemotherapy may also cause amenorrhea with pubertal delay associated with hypergonadotropic hypogonadism.

Abnormalities of the pituitary and hypothalamus, and other endocrinopathies (thyroid disease and Cushing syndrome) may present with pubertal delay and low gonadotropin levels.

Amenorrhea maybe caused byproblems at the level of the pituitary gland, such as congenital hypopituitarism, tumor (pituitaryadenoma),or infiltration (hemochromatosis).

Prolactin-secreting pituitary adenoma (prolactinoma) is the most common pituitary tumor. Prolactinomas present with galactorrhea, headache, visual fields cuts, and amenorrhea. Elevated prolactin levels are characteristic.

Craniopharyngioma is another tumor of the sella turcica that affects hypothalamic-pituitary function, presenting with pubertal delay and amenorrhea.

Other disorders associated with galactorrhea and amenorrhea include hypothyroidism, breast stimulation, stress associated with trauma or surgery, phenothiazines, and opiates.

Hypothalamic suppression is most commonly caused by stress, competitive athletics, and dieting (anorexia nervosa).

Hypothalamic abnormalities associated with pubertal delay include Laurence-Moon-Biedl, Prader-Willi, and Kallmann syndromes.
Laurence-Moon-Biedl and Prader-Willi present with obesity. Kallmann syndrome is associated with anosmia. D. Amenorrhea with normal pubertal development.

Pregnancy should be excluded when amenorrhea occurs in a pubertally mature female. Contraceptive-related amenorrhea occurs with depot medroxy progesterone (Depo-Provera); it does not require intervention; however, a pregnancy test should be completed.

Sheehan syndrome (pituitary infarction) is suggested by a history of intrapartum bleeding and hypotension.

Other disorders associated with amenorrhea and normal pubertal development. Ovarian failure, acquired abnormalities of the pituitary gland (prolactinoma), thyroid disease, and stress, athletics, and eating disorders may cause amenorrhea after normal pubertal development.

Polycystic ovarian disease, which is usually associated with irregular bleeding, can also present with amenorrhea.

Genital tract abnormalities

Imperforate hymen will appear as a membrane covering the vaginal opening. A history of cyclic abdominal pain is common, and a midline abdominal mass may be palpable.

Transverse vaginal septum may cause obstruction. It is diagnosed by speculum examination.
Agenesis of the vagina appears as a blind-ended pouch. Normal pubertal development of breast and pubic hair occurs, but menarche does not occur.

Breast development and a growth spurt occur, but little if any pubic or axillary hair is present. These women have an XY chromosomal pattern with intra-abdominal or inguinal testes that produce testosterone, but an X-linked inherited defect of the androgen receptor prevents response to testosterone.

Female-appearing external genitalia are present, but the uterus and vagina are absent. During puberty, breast development occurs because of conversion of androgens to estrogens.

The testes are at increased risk for developing tumors and must be removed. Hormone replacement therapy is provided to initiate puberty.

Polycystic ovary syndrome

PCO is the most common cause of persistent irregular menses. The most common symptom is irregular periods beginning with menarche; however, intervals of amenorrhea may also occur. Signs include hirsutism, acne, clitoromegaly, and obesity(50%). Insulin resistance, glucose intolerance, and lipid abnormalities are common.

Increased facial hair and midline hair over the sternum and lower abdomen are often present. If hirsutism is severe, an ovarian and adrenal tumor or adrenal enzyme deficiency should be excluded.

PCO is probably an autosomal recessive disorder that affects ovarian steroidogenesis.

Clinical evaluation of amenorrhea

Chronic or systemic illness, eating disorders, and drug use, including hormonal contraception, should be excluded. Tanner staging, pelvic examination, and possibly pelvic ultrasonography should be completed.

Absence of the uterus, vagina, or both requires a chromosomal analysis, which can determine if the karyotype is XX or XY, and it can help differentiate between mullerian agenesis and androgen insensitivity.

Pregnancy must always be excluded if the individual is mature pubertally.

Free-T4, TSH, and prolactin levels are checked to exclude hypothyroidism and hyperprolactinemia. Ifthe prolactin level is elevated, an MRI is necessary to exclude prolactinoma.

Hirsutism and acne are indicative of androgen excess and polycystic ovary.Total testosterone and dehydroepiandrosterone sulfate (DHEAS) levels are necessaryto exclude ovarian and adrenal tumors.

An ovulation and the resulting lack of progesterone increases the risk of endometrial hyperplasia and endometrial cancer.Oral medroxyprogesterone or an oral contraceptive (OCs) should be prescribed to eliminate this risk. Oral progestins can be given cyclically for 12 days every month or every third month.

PCO is treated with OCs to regulate menses and to decrease androgen levels. Electrolysis and spironolactone (50 mg tid) can decrease hirsutism.

Hypoestrogenic and an ovulatory patients with hypothalamic suppression caused by anorexia, stress,or strenuous athletics should modify their behavior and be prescribed calcium and hormonal replacement therapy to reduce the risks of osteoporosis.

3. Abnormal vaginal bleeding

Abnormal vaginal bleeding is characterized by excessive uterine bleeding or a prolonged number of days of bleeding.
The most common cause of abnormal vaginal bleeding in adolescence is an ovulation. Abnormal bleeding is common during the first 1 to 2 years after menarche because an ovulatory cycles are frequent.

Differential diagnosis of abnormal vaginal bleeding

Pregnancy, pregnancy-related complications, sexually transmitted diseases, pelvic inflammatory disease, and retained tamponsshould be excluded.
Vaginal tumors, uterine or cervical carcinoma, and uterine myomas are rare in adolescents.
Blood dyscrasias or coagulation defects may occasionally be the initial presentation of abnormal vaginal bleeding.
Hormonal contraceptives are a common cause of breakthrough bleeding.

Clinical evaluation of irregular vaginal bleeding

Age of menarche, menstrual pattern, amount of bleeding, symptoms of hypovolemia, history of sexual activity, genital trauma, and symptoms of endocrine abnormalities or systemic illness should be evaluated.
Postural vital signs may suggest hypovolemia. A pelvic examination should assess pelvic anatomy and exclude trauma, infection, foreign body, or a pregnancy-related complication. Pelvic ultrasonography can be used to further assess pelvic anatomy.

Laboratory evaluation

A pregnancy test and complete blood count should be completed.
A history of a very heavy period with menarche or repeated prolonged or heavy menses warrants a prothrombin time and partial thromboplastin time to screen for bleeding abnormalities; a bleeding time and von Willebrand screeningpanel will identify more specific coagulation disorders.
Signs of androgen excess indicate a need to exclude Polycystic ovaries.
Chronic irregular vaginal bleedingmandates that prolactinoma and endocrine abnormalities (thyroid disease) be excluded.

Treatment of irregular vaginal bleeding

Mild bleeding or shortened cycles associated with a normal physical examination and normal vital signs requires only reassurance.

If the hematocrit is less than 7-8 mg/dL or if vital signs are unstable,hospitalization is recommended. Conjugated estrogen therapy is followed immediately by iron therapy. Blood transfusion is warranted only if the patient is severely symptomatic. Dilatation and curettage is used as a last resort; however, it is rarely necessary.

Antiprostaglandin medications (NSAIDs) decrease menstrual blood loss significantly by promoting platelet aggregation and vasoconstriction.

4. Dysmenorrhea

Fifty percent of adolescents experience dysmenorrhea.

Primary dysmenorrhea consists of crampy lower abdominal and pelvic pain during menses that is not associated with pelvic pathology.

It is the most common form of dysmenorrhea, usually beginning 6 months to 1 year after menarche.

Secondary dysmenorrhea is defined as painful menses associated with pelvic pathology(bicornate uterus, endometriosis, PID, uterine fibroids and polyps, cervical stenosis, ovarian neoplasms).
If dysmenorrhea is severe, obstructing lesions of the genital tractshould be excluded.

Endometriosis is the most common cause (50%) of chronic pelvic pain in adolescents.

Evaluation of dysmenorrhea

Gynecologic history should determine the relationship of the pain to the menstrual cycle, severity, and sexual activity.

Severe pain requires a pelvic examination to exclude genital tract obstruction, adnexal and/or uterosacral pain (endometriosis), PID, or a mass.Ultrasonographyis useful for evaluating pelvic abnormalities or obstruction.

Treatment of dysmenorrhea

Initial treatment consists of a prostaglandin synthesis inhibitor, initiated with the onset of bleeding and continued for as long as pain lasts. Gastric irritation can be reduced by taking the drug with food.

Oral contraceptives are also very effective and can be added if the antiprostaglandin is not fully effective.


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