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foreign body or tumour ( benign or malignant ). Referral is appropriate .
Precocious puberty
Puberty is the transition from childhood
to adulthood and is characterised by physical maturation and attainment of fertility . Adolescence encompasses both the physical changes of puberty as well as the
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Danny S / CC BY-SA 4.0 / bit . ly / 3AtMFYB |
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psychological and social changes | ||||
that occur at the same time , with the | ||||
latter extending for a longer time . | ||||
Puberty includes the maturation and | ||||
activation of both the gonadal and | ||||
adrenal hormonal axes , whose triggers | ||||
appear to be independent of | ||||
each other . | ||||
Adrenarche — the maturation | ||||
process of the adrenal hormonal | ||||
axis — leads to the development of | ||||
pubic and axillary hair , as well as | ||||
other features . This is considered | ||||
precocious if it occurs before the age | ||||
of eight . Adrenarche occurs independently | ||||
of the other pubertal | ||||
changes associated with the hypothalamus | ||||
– pituitary – ovarian axis , | ||||
which in females , leads to oestrogen | ||||
production . This process is recognisable | ||||
with breast development | ||||
( thelarche ) from the age of eight , | ||||
and if it begins prior to that , it is | ||||
considered precocious . | ||||
If these events occur , then referral | ||||
to and investigation by either a | ||||
paediatric endocrinologist or a paediatric | ||||
and adolescent gynaecologist |
is appropriate to ensure there is no significant underlying problem . |
Figure 3 . Threadworm . |
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For precocious adrenarche , adrenal |
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sources — including non-classical congenital adrenal hyperplasia and other androgen sources — need to be considered . For precocious thelarche , ovarian lesions require consideration , so a pelvic ultrasound is a useful starting point .
ADOLESCENT GYNAECOLOGY
CONSULTATION with a teenager
requires a non-threatening and confidential approach if rapport and a clear understanding of the young person ’ s
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Leung AK et al . Cureus 2021 / CC-BY 4.0 / bit . ly / 3LyEaBF |
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health circumstances are to be appreciated | ||||
and incorporated into their | ||||
management . The HEADSS assessment | ||||
( Home , Education , Activities / | ||||
Employment , Drugs , Suicidality , Sex ) | ||||
is a useful tool to ensure the practitioner | ||||
covers all topics . Ensuring at | ||||
least some of the consultation occurs | ||||
without a parent / carer in the room is | ||||
important . Explaining confidentiality , | ||||
with the usual exceptions , ensures |
the young person understands that their consultation is respected and |
Figure 4 . Hymenal tag . |
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private . |
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Identifying the adolescent who |
adolescent health risks that may |
Both physical and environmental |
but may also be due to mild bleed- |
platelet function testing or refer to a |
is sexually active is crucial to ensure |
impact on general and reproductive |
stress may disturb the cycle , thus it |
ing disorders . Pathological prob- |
haemtologist for assessment . |
that appropriate contraception and |
health — for example , the adoles- |
is recognised that stressed students |
lems , such as fibroids , are very |
Also check ferritin and haemo- |
STI protection are in place . These |
cent who is stressed because of psy- |
doing final exams may experience |
uncommon in adolescents . |
globin levels . There is no value in |
issues are beyond the scope of this |
chosocial issues either at home or at |
irregular menses . 17 |
Heavy menses is defined as men- |
hormonal tests apart from poten- |
article , but failure to identify these young people and to discuss these important issues means the young |
school ; the elite athlete who has very high exercise levels ; the young person with depression or an eating disorder |
The management of menstrual irregularities is determined by the impact these issues are generating . |
strual loss that is heavy enough to impact on quality of life , but in practical terms , this is often the require- |
tially TSH . Tranexamic acid is firstline management with or without NSAIDs . If this is inadequate , then |
person is left at risk of unplanned |
or one who is transgendered . |
For the adolescent who is becoming |
ment to change pads more than two |
hormonal approaches are required . |
pregnancy and STIs . Offer opportunistic screening for STIs , including syphilis , when seeing sexually active |
Irregular menses
Menstrual cycles usually take some
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iron deficient or anaemic , intervention is required .
Initially , use tranexamic acid
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hourly or experiencing menstrual flooding . 18 The latter term is not an expression that adolescents may |
The levonorgestrel-releasing intrauterine system is an option for young menstruating adolescents . 19 |
adolescents . All contraception options available to adult women can be used in young |
time before they become ovulatory and regular . The earlier the onset of menarche , the sooner the |
( reduces loss by 30-50 %) or non-steroidal anti-inflammatories ( reduces menstrual loss by 30 %); otherwise , |
understand , with ‘ period disasters ’ possibly better understood .
Ask about a bleeding tendency
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Dysmenorrhoea
Up to 90 % of young people expe-
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adolescents , including all long-acting |
cycle becomes ovulatory — so a |
hormonal interventions may be nec- |
using an online internationally vali- |
rience dysmenorrhoea , with 20 % |
reversible contraception ( LARC ), such |
10-year-old is likely to have regular |
essary . Blood transfusion and iron |
dated self-bleeding assessment test , |
reporting a significant impact on |
as intrauterine devices . Use depo provera with care because of the potential impact on accrual of bone density . The use of HEADSS also enables the identification of a range of other |
menses within the year following menarche , whereas the adolescent who has menarche at 14 or 15 may take 4-5 years before most cycles are ovulatory . |
infusions may be required .
Heavy menstrual bleeding
Heavy menstrual bleeding may
occur because of anovulatory cycles
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such as the Self-BAT . If this results in an abnormal score , then order a prothrombin time , activated partial thromboplastin time , von Willebrand studies , factor VIII and |
their participation in school , sports and social activities . 20 Young people still regularly report that their symptoms are not validated , are normalised and that they are not being |