Menstrual Problems and Precocious Puberty in Young Girls

Normal Puberty

Normal age of puberty is 10-12 years. First sign of puberty is physical growth. First specific sign is breast growth (Thelarche)and other signs are like pubic , axillary hair (Pubarche) followed by increase in height (linear growth) followed by periods (menses).

No Periods

If there are no periods till 13 years?

• It is called delayed

If there are no periods but pubic hair is present

• It is called delayed at 15 years

Early periods

If the periods comes before and equal 9 years

Precocious puberty

If the periods before and equal to 8 years

Prepubertal vaginal bleeding

Neonatal bleeding

It's normal to have vaginal bleeding in the first few days because the baby has some estrogen from her mother, that makes some endometrial growth and movement the baby detached from the mother, the maternal estrogen stops coming to her circulation and that’s what causes the estrogen withdrawal.   

Pathological Causes of Prepubertal Bleeding (2 years - 9 years)

• Severe UTI- is often the cause. Patient complain of pain in the perineum, discomfort and in severe UTI there is urethral bleeding
• Rectal bleeding - because of the constipation
• Anal fissures - hard stools can tear rectum, anus and cause fissure
• Irritable bowel syndrome- 
• Abuse- it is common at any age especially with vulvo vaginal symptoms or if there is severe bleeding
• Condyloma secondary to maternal HPV
• Lichen sclerosus - can be seen in young girls also. Less estrogen in young girls causes dryness in the vagina. Due to dryness there is itching and scratching, which cause local injuries and bleeding 
• Foreign body- can cause purulent or blood. Management- Do per rectal and milk out the foreign body
• Vaginal tumors- Most common in pubertal age (Embryonal Rhabdomyosarcoma)
• Trauma- accidents

 Vaginal discharge between young and adolescent Girl

Precocious Puberty

If the period starts before 8 years in the absence of secondary sexual characters, pubic hair starts before 7 years and breasts before 6 years. Breast could be unilateral enlargement. Once puberty happens there is premature closure of the epiphyseal plates. When periods start, the height growth stops. 

Aetiology of Precocious Puberty

• Mostly idiopathic
• CNS lesions like a hypothalamic hamartoma etc
• Elevation of FSH and LH (LH:FSH >1.0)
• GnRH analogues (GnRH give rise to FSH and LH). If GnRH analogues are given at high dose in depot form, that causes desensitization or downregulation of pituitary will happen. There will no FSH or LH, no follicles, no estrogen or progesterone, so no periods
• Growth hormone use is controversial

Pelvic Masses in Young Girls

• Germ cell tumors in prepubertal
• Germ cell tumors, pregnancy in adolescents
• Functional cysts- Follicular cyst may be present 

Adolescent Bleeding Patterns

During the first 2-5 years of periods, the cycles are anovulatory (irregular). If the cycles are delayed, they are not much beyond 45 days and if they are early , they are 21 days. Mean duration for most is 7 days and >80 ml is excess

Abnormal 

If the cycle is > 42 days or < 21 days or bleeding > 7 days

 Other Causes

• Hematological abnormalities like Von Willebrands
• Infections- Chlamydia, STDs
• PCOS
• Anatomic causes- like vaginal septum, didelphys etc present now

Anovulation Bleeding Management

1. First line drugs- Tranexamic acid, NSAIDS
2. Hormones- Oral contraceptive pills (artificial cycle). Combined pills suppress FSH and LH
3. Progesterones - is a 10 day regime
4. No endometrial biopsy- because a pubertal girl will have anovulatory cycles, and that’s the most obvious cause of the irregular cycle 

Confirm Sexual Activity

Adolescents - hold back info about sex and they avoid contraception, which cause increase chances of unwanted pregnancies and unwanted abortions

Long Term Menstrual Suppression

Required for Coagulopathies, malignancy requiring chemotherapy, developmental disabilities (impaired intelligence, not aware of taking care of themselves).

Management

• Suppression is done by giving long term progestins like Norethindrone, medoxy progesterone acetate. The side effects are metrorrhagia (spotting). Giving long term progesterone causes atrophy of the endometrium but there can be breakthrough bleeding. 
•  long term COCPs. By giving continuous pills in low doses suppress the cycle.  
• Injections of DMPA- cause atrophy of the endometrium 
• GnRHa-depot preparation, that causes downregulation of the pituitary. Has least side effects. High dose one injection can be given once in 3 months. Most preferable with patients having malignancies or mentally disabled patients. 
• LNG IUD- better than the other options because there are ©

And that is everything you need to know about precocious puberty. For more interesting and informative articles like this, download the PrepLadder app now.