Pediatric Annals

Healthy Baby/Healthy Child 

Gynecologic Concerns in the Adolescent Girl

Teri A. Merens, MD

Abstract

The ever-evolving role of the health care provider can present a variety of challenges, not the least of which is becoming familiar with basic knowledge of other specialties, including gynecologic care. The primary care office provides a comfortable, familiar environment in which the patient can seek medical attention. It is essential that most pediatric offices be equipped to deal with basic adolescent gynecologic care, and that their patients have access to sensitive and confidential care. [Pediatr Ann. 2016;45(1):e4–e7.]

Abstract

The ever-evolving role of the health care provider can present a variety of challenges, not the least of which is becoming familiar with basic knowledge of other specialties, including gynecologic care. The primary care office provides a comfortable, familiar environment in which the patient can seek medical attention. It is essential that most pediatric offices be equipped to deal with basic adolescent gynecologic care, and that their patients have access to sensitive and confidential care. [Pediatr Ann. 2016;45(1):e4–e7.]

As the preadolescent enters puberty, the physical changes that accompany this stage of development may vary from what is expected by the girl and her parents. The first signs of puberty vary according to ethnicity and race, as well as the body habitus of the child. White and Hispanic girls tend to begin puberty with breast development, whereas African American girls may show adrenarche as the first indication that puberty has arrived.1 The mean age of the onset of puberty for girls is approximately age 10.5 years, with African American and girls who are overweight showing a slightly earlier onset in some studies.2 Any signs of puberty before age 8 years should be brought to the physician's attention and a thorough history and physical, as well as potential laboratory and imaging studies performed.3

Signs of Puberty

Breast Development

Breast development typically marks the beginning of the pubertal process. As the breast bud develops directly under the nipple, the patient may note this area to be slightly enlarged but almost always tender. She may be well aware that this represents the beginning of puberty or may be fearful that this is abnormal. The mother may also be concerned, either that puberty is approaching too soon or that the lesion is possibly malignant, especially if there is a family history of breast cancer. An office visit and brief description of the normal progression of the process will ease their worries. A complete examination and discussion initiated by the provider during a routine physical will prevent these emergent visits and prepare the patient for the changes ahead. The recommendation of age-appropriate reading materials is also quite helpful and the mother and daughter should be encouraged to explore these together. It should be explained that the initial breast bud can be unilateral or bilateral and may regress or enlarge as puberty takes hold. It should be emphasized that although most girls experience puberty in a predictable fashion, every human being is unique and some variation should be anticipated.

Vaginal Discharge and Other Changes

Another concern that will prompt an office visit or an urgent phone call is the appearance of vaginal discharge in the girl approaching puberty. As the levels of circulating estrogens begin to rise, the vaginal tissues respond by secreting a thick whitish tinged discharge. In some girls, this can be quite copious and confused with an infectious process. Reassurance that this is the result of the pubertal process is essential so as to avoid the use of unnecessary over-the-counter medications. It is important to mention that cyclic vaginal discharge is a normal part of the future menstrual cycle and will likely recur on a somewhat regular basis.

Variation in the normal process of puberty may also be evident in the appearance of the external genitalia. As the labial tissues become estrogenized and undergo physiologic hypertrophy, they often become asymmetric, and prominence of the labia minora can occur. Although this is not a functional issue, it can be of cosmetic and comfort concern for the adolescent. The clinician should reassure the patient that the progression of puberty may bring further anatomic changes, but any desire for surgical intervention on the part of the patient should be discouraged until well after the completion of puberty.

Menstruation

The age of menarche can vary greatly, with most girls achieving this milestone between ages 9 and 15 years, with average age being 12.5.4 Although the interval between the start of puberty and the first menstrual flow is typically about 2.5 years, there can be some variation. When menarche seems delayed, the parent and patient should be asked specifically as to the timing of breast development and the appearance of pubic hair, especially if there has not be a recent examination in which Tanner staging was documented. Primary amenorrhea, the absence of menses by age 15 years in the presence of normal growth and secondary sexual characteristics or the absence of secondary sexual characteristics by age 13 years, demands a thorough history and physical, with close attention to linear growth, Tanner staging, and any constitutional symptoms.

Once menarche occurs, menses can be quite irregular for a lengthy period of time or may be regular and predictable within a few short months. Tracking of menses is important so that one can identify the onset of ovulatory periods and possible fertility. Adolescents should be encouraged to take ownership of this process rather than allow a parent or guardian to do so. Several “apps” exist for mobile devices that make this task quite simple and allow quick recall of the information when required. Many of these applications have icons that are discrete when viewed on the device so as to prevent embarrassment and to encourage their use. Ovulatory menses are usually somewhat more painful and heavier in flow than their anovulatory predecessors, as well as more regular in occurrence. They may also tend to be associated with other symptoms that may have been absent at menarche such as headache, bloating, and premenstrual emotional lability.

Menstrual Irregularities

Menses that fail to become regular within 2 to 3 years of menarche or are widely spaced (more than 3 to 4 months) can represent oligomenorrhea or secondary amenorrhea. Both of these entities require further evaluation, which can be initiated by the pediatrician in the office setting.

Secondary amenorrhea is commonly defined as the absence of menses for 3 or more months 2 years after menarche. A detailed history, including the documentation of menarche, cycle length, presence of dysmenorrhea, characteristics, duration of menstrual flow, and weight changes, should be all completed. Activities of daily living such as sleep, diet, and exercise should be noted, as well as any current stressors or medication use. Physical examination should focus on body mass index, size of the thyroid gland, presence of acanthosis nigracans, and signs of hyperandrogenism such as acne and hirsuitism. Oligomenorrhea or the presence of menstrual cycles lasting more than 35 days can also be caused by conditions that are responsible for secondary amenorrhea. Laboratory evaluation, which should be performed as a morning blood draw (Table 1) as well imaging, can aid in diagnosis after the history and physical examinations are completed as outlined above.

Laboratory Studies for Diagnosis of Polycystic Ovary Syndrome

Table 1.

Laboratory Studies for Diagnosis of Polycystic Ovary Syndrome

Polycystic ovary syndrome. Although there are many causes of menstrual irregularities, the most common entities in most pediatric practices are likely to be polycystic ovary syndrome (PCOS), a variation of the female athlete triad, and hypomenorrhea or oligomenorrhea secondary to hormonal forms of contraception. Acne, hirsuitism, and laboratory results that demonstrate excess androgens are consistent with the diagnosis of PCOS. A multisystem disease, PCOS can result in decreased fertility, impaired glucose metabolism, obesity, and cardiovascular disease. Once identified, treatment modalities include a combination of oral contraceptives pills (OCPs) and the use of medications that help correct abnormal glucose tolerance if warranted. Lifestyle changes that promote weight loss are an essential component of treatment in girls who are overweight. OCPs correct the menstrual abnormalities and stop the progression of hirsuitism as well as improving acne. Hirsuitism that remains cosmetically unacceptable may respond to antiandrogenic medications such as spironolactone or require permanent removal. Endocrinologic consultation may be necessary for patients that do not meet diagnostic criteria for PCOS (Table 2), have signs of insulin resistance, or who are unresponsive to initial therapy.

Rotterdam Criteria for Diagnosis of Polycystic Ovary Syndrome

Table 2.

Rotterdam Criteria for Diagnosis of Polycystic Ovary Syndrome

Female athlete triad. The female athlete triad is commonly described as disordered eating, menstrual irregularities, and low bone mass. The menstrual disruption in this triad is usually secondary amenorrhea or oligomenorrhea; however, some girls will present with primary amenorrhea after age 16 years. Although frequently associated with runners, this syndrome can occur across many different types of athletes and across many ethnic and socioecomonic groups.5 A detailed history with careful questioning about eating habits, exercise, and sports participation performed in a sensitive and confidential setting may reveal etiology of the menstrual abnormality. Although OCPs will help correct the bone mass and menstrual component, nutritional and psychological counseling are needed to improve the overall health and well-being of the athlete. Many patients may show two of the symptoms described in the triad but are at risk for developing the complete entity if not treated and counseled appropriately. Compliance with the prescribed regimen must be closely monitored to insure complete and long-term nutritional restoration and to maximize bone density.

Oligomenorrhea. Although regulation of menses is considered by most girls to be a positive side effect of hormonal contraception, patients often do not recall being told that menses may be different while using these methods, despite the best efforts of their health care provider to explain this and other possible side effects. Light or absent menses as well as breakthrough bleeding may prompt an urgent visit as the girl may be convinced something “is wrong” or that she may be pregnant. A pregnancy test for sexually active teens done in the office may be reassuring as many adolescents are not confident in their ability to properly perform the at-home version. Once a negative result has been documented, the patient can be reassured that oligomenorrhea is a common and often desired effect and is not harmful in any way. Careful questioning about compliance and daily timing of the taking the pills may reveal the cause of breakthrough bleeding, as pills should be taken as close to the same time every day as possible. Other forms of hormonal birth control such as injectables and intrauterine devices can also cause disruption of menses so providers should take care to explain this to all adolescents using or planning to use such methods.

Dysmenorrhea. Dysmenorrhea during adolescence may be either physiologic or represent underlying pathology. The teenage patient that seeks relief of painful menses should be screened for endometriosis, a condition once thought to be uncommon in younger women. Endometriosis is the presence of ectopic endometrial tissue, most frequently located in the pelvis or abdomen.6 This functional tissue can cause chronic abdominal pain (noncyclic) as well as marked dysmenorrhea (cyclic), pelvic pain, and bowel or bladder symptoms. Left untreated, endometriosis can have a significant impact on fertility. Although the dysmenorrhea from this condition and physiologic menstrual pain can both be treated with OCPs, the establishment of a firm diagnosis is essential to prevent long-term sequelae. Any patient that does not respond to OCP therapy, has a family history of the disease, or has other noncyclic complaints should be referred to a gynecologist skilled in the care of adolescents. Girls that appear to have primary dysmenorrhea should respond well to OCPs or nonsteroidal anti-inflammatory drugs (NSAIDs) alone or in combination. The dosing and timing of NSAIDs should be thoroughly explained to the patient as medication started after the escalation of pain or in too low of a dosage will not offer maximum relief. OCPs will not only moderate the discomfort but will also likely provide more predictable, lighter, and shorter menses as well as protection against unwanted pregnancy. Adolescents should always be reminded that a condom is necessary each and every time they have intercourse, regardless of who the partner is and what other type of birth control is used.

Abdominal and Pelvic Pain

Abdominal and pelvic pain in the adolescent can be acute, subacute, or chronic and vary greatly in presentation and severity. A working knowledge of the diagnostic possibilities is essential for the pediatrician. Pain in the patient who has a positive pregnancy test should prompt an urgent referral to a gynecologist or an emergency department as complications of pregnancy can be potentially life threatening. These include ectopic pregnancy, acute placental abruption, and miscarriage. Patients who are not pregnant can be initially evaluated in the office if they are hemodynamically stable and their pain is not intractable.

Abdominal or pelvic pain may or may not be of gynecological origin and may require imaging as well as laboratory studies to arrive at a definitive diagnosis or exclude more serious entities. Chronic or subacute pain may be due to menstrual disorders such as mittelschmerz or ovulatory pain and dysmenorrhea. A thorough history and a pain log tracking menses will often reveal the cause of the pain. Although more often of acute onset, rare cases of ovarian torsion can cause subacute discomfort as the ovary may intermittently twist and reverse itself. Torsion of the ovary should be considered in the adolescent girl with acute onset of lower quadrant lateral pain who is postmenarchal. Slightly more common on the right side for unexplained reasons, torsion may be difficult to distinguish from appendicitis as both can present with pain, nausea, and vomiting.6 Fever may help distinguish these two entities but ultrasound or computed tomography scanning may be required. Ovarian cysts that rupture can also cause acute pain or contribute to ovarian torsion. Ultrasound can easily define these structures. In a sexually active patient with lower abdominal pain, pelvic inflammatory disease (PID) as well as pregnancy must be considered. Not all adolescents with PID have fever but a history consistent with purulent vaginal discharge, worsening pain with exercise, movement, or sexual activity can be present. A pelvic examination will make this diagnosis quite apparent and should be performed by a provider experienced with this skill.8 Urinary tract infection, common in sexually active girls, can present with fever and abdominal discomfort but will also be accompanied by dysuria, urgency or frequency. An in-office urinalysis and culture will reveal this diagnosis and antibiotic therapy can be initiated.

Concluding Thoughts

As pediatricians strive to be a complete medical resource for their patients, we must focus on the basics of subspecialty care that may be needed to properly diagnose, treat, or refer adolescent girls. Office diagnostic capability coupled with basic laboratory studies, knowledge of appropriate imaging centers, and a working relationship with a gynecologic colleague who has interest in adolescent care are essential to providing a skilled and confidential environment for adolescent girls.

References

  1. Sun SS, Schubert CM, Chumlea WC, et al. National estimates of the timing of the sexual maturation and racial differences among US children. Pediatrics. 2002;110:911–919.
  2. Harlan WR, Grillo GP, Cornoni-Huntley J, Leaverton PE. Secondary sex characteristics of girls 12 to 17 years of age: the U.S. Health Examination Survey. J Pediatr. 1979;95:293–297.
  3. Euling SY, Herman-Giddens ME, Lee PA, et al. Examination of US puberty timing data from 1940 to 1994 for secular trends: panel findings. Pediatrics. 2008;121(Suppl3):S172–S191.
  4. Herman-Giddens ME, Slora EJ, Wasserman RC, et al. Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings network. Pediatrics. 1997;99:505–512.
  5. Nichols JF, Rauh MJ, Lawson MJ, Ji M, Barkai HS. Prevalence of the female athlete triad syndrome among high school athletes. Arch Pediatr Adolesc Med. 2006;160(2):137–142.
  6. Laufer MR. Gynecological pain: dysmenorrhea, acute and chronic pelvic pain, endometriosis and premenstrual syndrome. In Emans SJ, Laufer MR, (eds). Pediatric and Adolescent Gynecology. 6th ed. Philadelphia, PA: Wolters Kluwer Lippincott Williams & Wilkins; 2012:238.
  7. Rotterdam ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Revised 2003 consensus on diagnostic criteria and long term health risks related to polycystic ovarian syndrome. Fertil Steril. 2004;81:19–25.
  8. Schraga ED, Fleischer AC. Ovarian torsion. http:emedicine.medscape.com/article/2026938-overview. Accessed December 16, 2015.

Laboratory Studies for Diagnosis of Polycystic Ovary Syndrome

Luteinizing hormone

Follicle-stimulating hormone

Free and total testosterone

Dehydroepiandrosterone sulfate

Hemoglobin A1C

17-hydroxyprogesterone

Estradiol

Prolactin

Fasting glucose

Lipid profile

Rotterdam Criteria for Diagnosis of Polycystic Ovary Syndrome

Oligoovulation or anovulation

Clinical or biomedical signs of hyperandrogenism

Polycystic ovaries on ultrasound

Authors

Teri A. Merens, MD, is an Assistant Professor of Clinical Pediatrics, Northwestern University Feinberg School of Medicine; and an Attending Physician, General and Academic Medicine, Lurie Children's Hospital of Chicago.

Address correspondence to Teri A. Merens, MD, 1950 Dempster Street, Evanston, IL 60202; email: TBMKpeds@gmail.com.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/00904481-20151216-01

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