1. PUBERTY and MENARCHE
Dr. Eranthi Samarakoon

2. PUBERTY
Is the time a girl becomes sexually mature and functionally able to reproduce .
The changes which occur at puberty are the development of secondary sexual characteristics and onset of menstruation
Puberty is the physical & mental development of the girl child to reach womanhood.

3. PUBERTY Begins around 09 years of age.
Includes the following aspects of physical development,
Formation of the breast buds which go on to complete development of the breasts.
Growth spurt.
Development of axillary & pubic hair.
Occurrence of menstrual periods.
Mental development from a child to an adolescent teenager & a woman. ( Interest in personal appearance, cosmetics, clothes & opposite sex.)

4. TIME SCALE (YEARS)
9½ Breast buds appear
13 – Growth of axillary & pubic hair
10 – Growth spurt
11½ Developed feminine contours
13 – Ovulation

5. Menarche
Menarche is the occurrence of the first menstrual period, known in our society as “attaining of age”. It is one aspect of the pubertal process. In Sri Lanka the normal age of menarche is between 9 to 15 years.

6. The occurrence of puberty and menstruation require proper functioning of,
Hypothalamus
Pituitary
Ovary
Uterus
And the out flow tract

8. SOME TRUE FACTS REGADING MENARCHE
 It is a natural occurrence & is only another mile stone in the girl’s life.
It should not be allowed to change the life style of the girl who should be allowed to blossom out in to a young woman gradually during the ‘teenage’ period.
There are no taboos associated with menarche or subsequent menstrual periods.

9. Any type of food can be consumed.
Athletes, swimmers & dancers can continue training at menarche & during subsequent menstrual periods.
Social & cultural festivities should be kept to minimum & the child should be made to feel important and happy.
She should resume schooling in 2-3 days after menarche.
Bathing can be continued

10. Pregnancy can occur at any time after menarche
Regular monthly periods may or may not occur soon after menarche

11. Menstruation
Occur once in 25 – 32 days
Is not a cleansing or an excretory process of the body
It only indicates a cycle during which an ovum (egg) is released on the 14th day by the ovary and ends with the uterus shedding its endometrial lining (which becomes thick during the menstrual cycle due to the hormones) with the release of about 60ml of blood
It is not essential for life but indicates that ovulation has occurred ( an egg has been released) during the month

13. Problems associated with puberty & adolescence
Primary amenorrhoea
precocious puberty
Irregular & excessive bleeding
Primary dysmenorrhoea
Vaginal discharge
Secondary amenorrhoea
Oligomenorrhoea

14. Medical attention should be sought if menarche occurs before 09 years or does not occur till 16 years

15. Irregular & excessive bleeding
Increased bleeding and short cycles are common in teenagers and is not due to an illness but due to lack of maturity of the hormones.
Immediate medical treatment is necessary to avoid anaemia
Abdominal examination, FBC and USS should be done
The diagnosis is dysfunctional uterine bleeding unless proved otherwise

16. Treatment for Irregular & excessive bleeding
Combined oral contraceptive pills for cycles
Norethisterone 05mg b.d for 21 days (01-03 cycles)
Tranexemic acid and /or mefenemic acid is used only to reduce bleeding in regular menorrhagia
Oral iron therapy

17. Primary dysmenorrhoea
 First day pain is normal
May be accompanied by vomiting and fainting
May start a few years after menarche
Cannot be cured but should be controlled with analgesics which should be commenced with the onset of the period before the pain begins
Paracetamol 500mg 06 hourly and/or mefenemic acid 500 mg 06 hourly are used

18. Vaginal discharge Increased vaginal discharge is normal
it does not require treatment, if not blood stained or associated with itching or burning.
It does not cause weight loss, abdominal pain or backache

19. ABSENCE OF MENSTRUATION
Absence of menstruation for several months is common in teenagers. it is not due to an illness.
It occurs because ovulation is irregular in young girls.
Medical attention may be sought to relieve the anxiety of the parents.
The possibility of a pregnancy can not be ignored.
Attention should be paid if the child is overweight as it may be due to PCOS.

20. Polycystic Ovarian Syndrome (PCOS)

21. PCOS is a syndrome of ovarian dysfunction with the cardinal features of
Obesity
Hyperandrogenism
Polycystic ovarian morphology

22. Diagnosis
Presence of two of the three following criteria is diagnostic of the condition.
Polycystic ovaries(either 12 or more peripheral follicles) or increased ovarian volume (greater than 10 cm).
Oligo or anovulation.
Clinical and/ or biochemical evidence of hyperandrogenism.
A raised luteinising hormone/follicle-stimulating hormone ratio is no longer a diagnostic criteria for PCOS owing to its inconsistency.

23. Differential diagnosis
Diagnosis of PCOS require exclusion of
Hyperprolactinaemia
Androgen secreting ovarian or adrenal tumours
Cushing’s syndrome

24. Clinical Features Obesity Oligomenorrhoea/amenorrhoea
Episodes of excessive bleeding after a period of amenorrhoea
Hirsutism
Subfertility
Recurrent miscarriage
Acanthosis nigricans

25. Laboratory tests Elevated testosterone.
Decreased sex hormone binding globulin.
Elevated LH.
Elevated LH : FSH ratio.
Increased fasting insulin.
Increased prolactin .
Increased oestrodiol , oestrone

26. Ultra sound scan The USS criteria for the diagnosis of PCOS are,
8 or more subcapsular follicular cysts ~ 10mm in diameter
increased ovarian stroma.
Ovarian volume greater than 10 cm3.

27. Treatment There is no specific treatment for PCOS.
Treatment is directed at the symptoms.

28. Exercise & weight control
Is the most important aspect of treatment.
Causes spontaneous resumption of ovulation
Improves fertility.
Increases sex hormone binding globulin levels.
Reduces insulin resistance.
Normalizes the glucose metabolism.

29. Menstrual disturbances
Progesterone for the last 10 days of the cycle.
Cyclical treatment with progesterone.
Cyclical treatment with combined oral contraceptive pills.

30. Role of Metformin Improves obesity. Increases ovulation rates.
Improves hirsutism.
Improves fertility.

31. Hirsutism
Cyproterone acetate
Metformin
Cosmetic treatment

32. Anovulation & Infertility
Weight reduction
Metformin
Ovulation induction
- Clomiphene citrate
- hCG injections
Ovarian drilling

33. Long-term metabolic consequences
Diabetes mellitus
Dyslipidaemia
Hypertension
Cardiovascular disease
Endometrial carcinoma
Gestational diabetes mellitus

34. NUTRITIONAL REQUIREMENTS OF THE ADOLESCENT
Adequate nutrition should be provided to the girl child for,
Growth
To restore the blood loss during menstruation
To prepare her to deliver a healthy baby without any complications during the pregnancy
The following dietary items are nutritious, cheap and readily available. Each meal should be rich in carbohydrates, protiens, vitamins and minerals

35. Rice (carbohydrates)
* dhall, greengram(mung), gram(kadala), cowpea, soya, eggs, sprats, fish, meat (proteins and minerals) – fish and meat should be added where economically possible.
* Green vegetables, bananas and other fruits. (vitamins and minerals) – even common cheap fruits such as jambu and lime are rich in vitamin C.
* Milk is not essential
* School snacks & tiffings should be prepared at home.
* Avoid sausages, other artificial & tinned food.
* Encourage to eat fruits for dessert.
* Drink plenty of water. Avoid sweetened artificial drinks. Prepare fruit juices at home.
* Advertisements which appear in the TV regarding food items are better disregarded

36. Thank you