Common gynecological problems in adolescent Bongkot Chakornbandit, MD OB – GYN, HPC 10 Ubon Ratchathani

Gynecological problem Dysmenorrhea Abnormal bleeding per vagina Amenorrhea Leukorrhea Abnormal pubertal development

Hx taking Gynecological Menarche Cycle, pattern, volume Pain, other symptom Hormone exposure Sexual Sexual activity Contraception Previous Mx / Tx Psychological

Dysmenorrhea Primary dysmenorrhea Secondary dysmenorrhea

Primary dysmenorrhea No pathology in pelvis 50% in reproductive age 10% interfere routine activity 1-3 yr. after menarche, 15 – 25 yr. Cause : excessive prostaglandins (PG)

Secondary dysmenorrhea Pathology in pelvis Usually occur after 25 yr. Progressive pain Cause : depend on pathology ; PID, endometriosis, IUD, myoma uteri etc.

Management Warm compression Exercise Medication NSIADs Hormone (OCP) Find & Tx cause in secondary dysmenorrhea

Abnormal bleeding per vagina Normal menstruation in adolescent Interval days Duration < 7 days Volume 30 – 80 ml.

Cause Pregnancy related bleeding Abortion Blighted ovum Molar pregnancy

Vagina / Cervix Trauma Infection FB Neoplasm Abnormal uterine bleeding

FIGO classification of AUB PALM-COEIN (FIGO 2011) PALM (structural abnormality) Polyp Adenomyosis Leiomyoma Malignancy / hyperplasia

COEIN Coagulopathy Ovulatory dysfunction thyroid, eating disorder, chronic illness, medication Endometrium (HMB) Iatrogenic Not classified

Management Evaluate severity of bleeding Find & Tx cause

Amenorrhea Primary amenorrhea 13 yr. : absence of secondary sex characteristic 15 yr. : presence of secondary sex characteristic Secondary amenorrhea Absence of menses > 3 regular cycles Absence of menses 6 mo.

Physiological amenorrhea Prepuberty Pregnancy Postpartum / lactation Menopause

Cause Primary amenorrhea Cryptomenorrhea (outflow tract obstruction) Gonadal dysgenesis (XO, XY, XX) Mullerian agenesis Androgen insensitivity syndrome (AIS) / testicular ferminization (TF) Hypothalamic amenorrhea

Cause Secondary amenorrhea Compartment I : Uterus Compartment II : Ovary Compartment III : Pituitary gland Compartment IV : Hypothalamus Other cause : thyroid, DM, exogenous hormone

Cause Compartment I : Uterus Asherman’s syndrome Compartment II : Ovary Ovarian failure / dysfunction Compartment III : Pituitary gland Compartment IV : Hypothalamus

Cause Compartment I : Uterus Compartment II : Ovary Compartment III : Pituitary gland Hyperprolactinemia Prolactinoma Infarction (Sheehan’s syndrome) Compartment IV : Hypothalamus

Cause Compartment I : Uterus Compartment II : Ovary Compartment III : Pituitary gland Compartment IV : Hypothalamus Idiopathic Functional dysfunction : stress, exercise, eating disorder, chronic illness, Radiation / Trauma / Tumor

Management R/O pregnancy Refer to gynecologist

Leukorrhea Physiologic leukorrhea No symptom No abnormal odor Vary amount Ovulation Sexual arousal Pregnancy

Pathologic leukorrhea Other symptom : itch, pain, burn Abnormal odor Color : yellow, green, grey, white Characteristic : bubble, pus, curd-liked

Cause Infection : bacteria (BV), fungus (candida), trichomonas, virus Irritation / allergic response Foreign body Trauma Tumor

Management Physiologic leukorrhea Reassure Hygiene advice Pathologic leukorrhea Tx cause No SI during Tx Hygiene advice

Abnormal pubertal development  Delayed puberty  Precocious puberty

Delayed puberty 13 yr. : no secondary sex characteristic 15 yr. : no menstruation Not attained menarche > 5 yr. since onset of pubertal development Not attained menarche > 3 yr. since onset of breast / pubic hair development

Cause Genetic (constitutional delayed) Gonadal dysgenesis Gonadotropin deficiency Multiple hormone deficiency Hypothalamic-pituitary neoplasm Severe chronic illness / malnutrition Chemotherapy / radiation

Precocious puberty Pubertal development before 8 yr. (white 7 yr.) Menarche before 10 yr. Heterosexual precocity Isosexual precocity True sexual precocity : mature HPO axis Pseudoprecocity

Cause Idiopathic Genetic (constitutional) Exogenous hormone Hypothyroidism Ovarian tumor / adrenal gland tumor Congenital adrenal hyperplasia (CAH) CNS lesion (tumor / trauma / infection) Cushing’s syndrome McCune Albright syndrome

Management Refer to gynecologist