pain will resolve with a reduction in menstrual loss . The evidence for this comes from adolescents themselves . Among women with Mayer – Rokitansky – Küster – Hauser ( MRKH ) syndrome ( that is , no uterus ), there are no confirmed reports in the literature of endometriosis . Many young women with obstructive anomalies will have severe endometriosis because of substantial or complete retrograde menstruation from menarche . 32 Yet , with correction of the obstruction , this spontaneously resolves , or following menstrual suppression , the endometriosis will completely resolve by the time of their corrective surgery . The surgery is often deferred to allow them time to mature and to understand the |
Sakhavar N et al . Int J High Risk Behav Addict 2014 / CC BY 3.0 / bit . ly / 3AGwgQF |
carries a potential long-term impact if present in adolescence not being addressed if the label has been applied .
PATHOLOGICAL CYSTS / TUMOURS Ovarian dermoid cysts are the most common of the paediatric and adolescent pathological cysts . 40 These may present with acute pain and in association with ovarian torsion ( see earlier ). When these cysts are found incidentally , surgery is usually not undertaken unless the dermoid cyst itself measures greater than 3cm .
Other pathological cysts include a range of benign and malignant cysts and tumours . Tumour markers and specific features of the cyst / tumour provide information regarding the like-
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complexity of the surgery , with the |
lihood of malignancy and thus opti- |
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possible need for vaginal dilator use |
mal management . In benign ovarian |
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afterwards . |
cysts , conservative surgery consisting |
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There are ample studies that report |
of ovarian cystectomy is almost always |
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there are no symptoms diagnostic of endometriosis . 33 Among those with identical symptoms who undergo laparoscopy , only 30-50 % will have endometriosis identified ; regardless of the |
possible and essential to preserve fertility .
Delayed puberty
Delayed puberty is the absence of
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excision of endometriosis , more than 50 % of women will have a recurrence of their symptoms within 18 months ; and 20-30 % of women will have a new or increased pain post-laparoscopy . 34 There is increasing evidence the focus |
Figure 7 . Pelvic X-ray showing vaginal foreign body in a fouryear-old girl . |
thelarche by the age of 13 , the absence of menarche within three years of thelarche or the absence of menarche at age 15 . 41
The causes of delayed puberty include hypothalamic causes ( includ-
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should be on managing and treating the symptoms rather than focusing on the lesions . 35
Congenital Müllerian anomalies are responsible for between 3 % and 5 % of period-related pain . 22 The description of the pain is often one of pain worsening or extending beyond the end of the period . The coexistence of a renal
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Ed Uthman , MD / bit . ly / 3Vqbrm8 |
ing underweight , excess exercise , tumours , congenital or acquired from surgery or radiotherapy ); pituitary or ovarian , with gonadal failure from congenital causes ( for example , Turner syndrome and variants , galactosaemia ); chemotherapy ; surgery ; and radiotherapy .
Clinical examination to clarify if
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tract anomaly is often a good clue to |
there is evidence of adrenarche , as |
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the possibility of a Müllerian anomaly . |
well as the extent of oestrogenisa- |
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A careful expert gynaecological scan |
tion , is helpful . But as some of the pro- |
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may be required , and referral to a pae- |
cesses may start but then stall , such as |
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diatric and adolescent gynaecologist is |
with the onset of an eating disorder , |
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indicated . |
the clinical findings may not be con- |
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Persistent pelvic pain is an increas- |
clusive . The absence of pubic and axil- |
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ing problem , with non-validation and |
lary hair but good breast development |
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failure to actively manage repeated |
should raise suspicion regarding andro- |
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period pain , thought to be a significant predisposing factor . 25 In the setting of persistent pelvic pain and central sen- |
gen insensitivity syndrome ( AIS ) — in which case , FSH , oestrogen and testosterone are the key investigations . |
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sitisation , other pain syndromes are |
Usually , the key hormonal test |
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usually present , including irritable |
that influences decisions , presuming |
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bowel syndrome , painful bladder syn- |
the diagnosis is not apparent on his- |
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drome , fibromyalgia , chronic fatigue and migraines . 36 Poor sleep also contributes . A multipronged and multi- |
tory , is an FSH . If this is elevated , then the problem is loss of ovarian function , with Turner syndrome or mosaic |
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disciplinary approach is required to |
Turner syndrome the most common |
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tackle the various aspects , including |
cause . There are many other causes |
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mental health , poor sleep , gastroin- |
of premature ovarian insufficiency in |
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testinal tract and urinary symptoms , |
this young cohort , where presumed |
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as well as the pelvic pain . Many of the |
genetic causes are likely . If the FSH |
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pain syndromes will exacerbate cycli- |
level is low , then the problem is in the |
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cally with the release of inflammatory |
hypothalamus . |
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mediators associated with menstrual shedding , thus control of menses can be a helpful aspect in overall care . |
Figure 8 . Benign ovarian cyst . |
In the setting of absence of oestrogen with no breast development , then a pelvic ultrasound or MRI will |
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Ovarian cysts
Ovarian cysts ( see figure 8 ) may be
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abdominal pain as almost all adnexal torsion is associated with an enlarged |
ovulation ( by hormonal means ) can be helpful . |
menarche started at age 13 or older , with menstrual cycle disturbances also |
not offer any useful information as the uterus is very small and easily missed on imaging . |
detected antenatally , as an incidental finding , during investigation for childhood urinary symptoms , during other |
ovary ( or paratubal cyst ). Detorsion of a torted ovary results in a greater than 90 % likelihood of recovery of ovar- |
MULTIFOLLICULAR OVARIES VERSUS PCOS |
well documented to occur in the setting of stressors ( such as school exams or major environmental events ). Acne |
Primary amenorrhoea
Primary amenorrhoea may occur in
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imaging or may present with pain |
ian function independent of duration |
A follicle count of 26 / ovary in women |
is present in 90 % of teens . 39 |
association with delayed puberty or |
from ovarian torsion , or with abdomi- |
of symptoms or the colour , size and |
aged under 25 is considered normal . |
Labelling adolescents with PCOS |
because of the reasons listed earlier , |
nal distension . |
appearance of the ovary . 37 |
It is important not to consider this |
carries the risk that they will not use |
where pubertal processes start but |
Ovarian torsion is an important |
Ovulation cysts may be respon- |
ultrasound finding as a feature con- |
contraception because of the belief |
then fail or when there is an end-or- |
diagnosis to consider in the young |
sible for midcycle pain . The corpus |
sistent with PCOS in younger patients . |
they are infertile as a result of the diag- |
gan problem . |
girl or adolescent who presents with |
luteum cyst wall is highly vascular . |
Use of the PCOS label in adolescence |
nosis , and unplanned pregnancies are |
This may result from an imperfo- |
acute onset of pain with associated |
As there is a 10 % chance of those with |
is questionable in light of the over- |
well documented . Furthermore , low |
rate hymen , although this presenta- |
nausea , vomiting and dizziness . The |
heavy menses having a mild bleed- |
lap of normal features of adolescence |
mood is frequently attributed to PCOS ; |
tion is more commonly associated |
pain is often colicky . If the torsion |
ing disorder , such as platelet dysfunc- |
with features linked to this clinical |
this carries the risk of other potential |
with lower abdominal pain . Clinical |
involves the tube , usually with a paratubal cyst , the symptoms are similar but not as acute or severe . An ultra- |
tion or von Willebrand ’ s disease , it is not surprising that haemorrhagic corpus luteums develop more read- |
label ( that arises in the setting of adult women ). 38 Irregular menses can be a feature of the menstrual cycle dur- |
factors , such as bullying or abuse , being ignored . Online ‘ information ’ makes it clear that losing weight is ‘ impossi- |
examination is often possible , with a bulging hymen visible on gentle suprapubic pressure . Surgical correc- |
sound ( see figure 9 ) is an important |
ily and may occur recurrently in those |
ing adolescence for greater than four |
ble ’ with PCOS , which may result in |
tion in theatre is required . |
investigation in the setting of lower |
with heavy menses . Suppression of |
years , particularly in those whose |
the only feature of the condition that |
MRKH is a congenital variation |