Pregnancy Care Hospital - Paras Bliss

Women and Adolescent Health Dr Preeti Raheja Consultant Obstetrics & Gyanecology Paras Bliss, New Delhi

INTRODUCTION • Adolescence refers to the stage from puberty to adulthood, and includes the psychological experiences of the child during this period. Adolescence is described as being the teenage years from thirteen to eighteen years of age; however, puberty decides the onset of adolescence. Therefore, adolescence occurs in some children as early as nine years of age.

During adolescence there is a large degree of psychological growth as children make adjustments in their personality due to the rapid physical and sexual development which are characteristic of this period of life. Adolescents face ongoing conflict and difficulty adapting to the sudden upsurge of changes in body. These changes cause unrest and confusion in the adolescents’ inner selves and in the way they perceive the world.

CONTENTS • Physiological changes • Menstruation • Abnormalities and symptoms that require consultation • Aspects of nutrition • Sexual Education • Cervical cancer vaccination

PHYSIOLOGICAL CHANGES • Rapid Growth You can expect rapid growth in height and weight during your child's adolescence. Girls experience their growth spurt between the ages of 9 and 14, You can also expect your teen to gain weight, as girls put on fat. Variances in growth can cause teenagers to feel self conscious about their bodies. Teens may feel they are all limbs -- and at times, this could be true.

PHYSIOLOGICAL CHANGES • STAGES OF PHYSIOLOGICAL CHANGES: • Development of the breasts: Also known as Thelarche and which marks the full development of the breasts from minor buds by the age of 12. • Pubarche starts between the age of 10-15, where in hair growth starts around the pubic and axillary regions along with the thickening of other hair. • Menarche is the onset of the first menstruation marks the beginning of puberty for girls. This can start anytime between 10 and 15 years old, and this marks the beginning of fertility. Menstruation typically starts two years after breast buds develop, which can be as early as 8 year old.

PHYSIOLOGICAL CHANGES • Hair Growth • One of the more noticeable and celebrated changes in teenagers is hair growth. Both males and females can expect pubic hair to grow. This may start as much as three years earlier in females, starting as early as age 9 and reaching adult patterns by age 14. Armpit and leg hair will also develop during this time.

PHYSIOLOGICAL CHANGES • Body Odor and Acne • Two disturbing changes during adolescence are the occurrence of body odor and acne. Hormones that cause sexual maturation and other body changes also lead to increased oil production. Both males and females will notice changes in their skin as it becomes coarser and the sebaceous glands produce more oil that can cause acne and blackheads. Sweat glands also become more active, and the combination of sweat and oils causes an odor, making the use of deodorant a necessity. Teens need to be more vigilant with hygiene to keep up with their body changes.

MENSTRUATION • Menarche typically occurs within 2–3 years after thelarche (breast budding), at Tanner stage IV breast development, and is rare before Tanner stage III development. By age 15 years, 98% of females will have had menarche. An evaluation for primary amenorrhea should be considered for any adolescent who has not reached menarche by age 15 years or has not done so within 3 years of thelarche. Lack of breast development by age 13 years also should be evaluated.

Cycle Length and Ovulation • Menstrual cycles are often irregular during adolescence, particularly the interval from the first cycle to the second cycle. Most females bleed for 2–7 days during their first menses. Immaturity of the hypothalamic–pituitary–ovarian axis during the early years after menarche often results in an ovulation and cycles may be somewhat long; however, 90% of cycles will be within the range of 21–45 days, although short cycles of less than 20 days and long cycles of more than 45 days may occur. By the third year after menarche, 60–80% of menstrual cycles are 21–34 days long, as is typical of adults.

Adolescents with cycles that are consistently outside of the range of 20 to 45 days should be evaluated for pathologic conditions, such as the polycystic ovary syndrome (PCOS), eating disorders, thyroid disease, hyper prolactinemia, or even such rare conditions as ovarian insufficiency (premature ovarian failure

ABNORMALITIES AND SYMPTOMS THAT REQUIRE CONSULTATION • Some of the common adolescent health issue that needs to be evaluated within time are: • Abnormal uterine bleeding • Ovarian cysts • Breast abnormalities

Abnormal Uterine Bleeding • Abnormal uterine bleeding (AUB) is any form of bleeding that is irregular in amount, duration, or frequency. It can be characterized by excessive uterine bleeding that occurs regularly (menorrhagia), by heavy bleeding at irregular times (metrorrhagia), or a combination of both (menometrorrhagia). It can also be intermittent bleeding or sparse cyclical bleeding (oligomenorrhea). Dysfunctional uterine bleeding (DUB) is a subset of AUB and is defined as excessive, prolonged, or unpatterned bleeding from the endometrium without an organic cause and is frequently used synonymously with an ovulatory bleeding. In adolescents, up to 95% of AUB is DUB. However, because DUB is a diagnosis of exclusion, other potential causes of abnormal bleeding must be ruled out.

Girls and adolescents with more than 3 months between periods should be evaluated. Although experts typically report that the mean blood loss per menstrual period is 30 ml per cycle and that chronic loss of more than 80 ml is associated with anemia, this has limited clinical use because most females are unable to measure their blood loss. Menstrual flow requiring changes of menstrual products every 1–2 hours is considered excessive, particularly when associated with flow that lasts more than 7 days at a time.

The diagnosis of pregnancy, sexual trauma, and sexually transmitted infections should be excluded, even if the history suggests the patient has not been sexually active.

Ovarian Cysts • The most common ovarian cyst among adolescent girls is PCOS. • Polycystic ovarian syndrome, or PCOS, is a condition in which there is an imbalance in the female sexual hormones. This leads to the growth of ovarian cysts (benign masses on the ovaries). PCOS can cause problems with a women’s menstrual cycle, fertility, cardiac function, and appearance.

Common characteristics of PCOS • Irregular menstrual periods • Unexplained Weight gain • Acne • Hirsutism- Appearance of thick and dense hair on the face • Mood swings • Infertility • Pelvic pain

Other types of cysts • Follicular cyst – A follicular cyst develops each month and contains the small egg within it. The sac ruptures during ovulation and the egg comes out of the cyst. Sometimes the cyst can grow larger than the normal size which is up to 3 cm. If the sac that holds the egg doesn’t break open to release the egg, it can grow, anywhere in size from 1 inch to 4 inches across. Usually this type of cyst disappears in one to three months and often does not cause pain.

Corpus luteum cyst – A corpus luteum cyst is normal and usually forms each month after the egg breaks out or ovulates. This type of cyst usually disappears by itself in a few weeks, but it can grow 3-4 inches across, and may bleed inside of the cyst or your belly. This type of cyst can cause pain in your abdomen (belly). • These problems can be cured by consulting a doctor on time.

Breast Abnormalities • Breast masses can cause anxiety for adolescent girls and their parents. • Breast masses can arise during any stage of puberty, so it is important to understand normal breast development. Thelarche (initiation of breast development) usually begins between the ages of 9 and 10 years.

Breast examination • Clinical breast examination. The American Cancer Society (ACS) in 2003 recommended that a clinical breast examination (CBE) be done at least every 3 years for women in their 20s and 30s.For adolescents, the CBE serves as an opportunity to increase their ease with their bodies and with the examination itself and to bring up any breast-related concerns. • Breast self-examination. Teaching and performance of the breast self-examination (BSE) in adolescents remains controversial, given that the incidence of breast cancer in adolescents aged 15 to 19 years is only 0.2 per 100,000. The American College of Obstetricians and Gynecologists does not recommend teaching adolescents BSE until the age of 19 years.

Common breast masses in adolescents • Fibrocystic changes. Breast lumps associated with cordlike thickenings are physiologic, hormone-induced breast changes and normal variants of regular breast tissue. Each month, they can become painful and enlarged during the week before menses, resulting in mastalgia.These breast changes are possibly related to the monthly hormone fluctuations of estrogen and progesterone.

Fibroadenomas. Fibroadenomas comprise 68% of breast masses in adolescents and are believed to be caused by an abnormal response to estrogen. Fibroadenomas present as 2 cm to 3 cm masses but can enlarge during the menstrual cycle. Physical examination demonstrates a firm, mobile, oval or round, nontender, rubbery mass, separate from the underlying breast tissue and usually located in the upper outer quadrants. On ultrasound, fibroadenomas normally appear as a well-circumscribed, homogeneous, hypoechoic mass with smooth distinct borders. Generally, the width of the fibroadenoma is greater than its height.

Two options exist for management of fibroadenomas. They can be monitored via serial clinical examinations every 3 to 6 months because up to 50% of lesions decrease in size or disappear after 5 years. Alternatively, referral to a surgeon for an excisional biopsy is indicated for patients whose fibroadenomas continue to grow or who are uncomfortable with only clinical monitoring.

ASPECTS OF NUTRITION • Eating healthy food is important at any age, but it’s especially important for teenagers. • As your body is still growing, it’s vital that you eat enough good quality food and the right kinds to meet your energy and nutrition needs. • Boys require an average of 2,800 calories per day. • Girls require an average of 2,200 calories per day.

Important Nutrients • Protein Proteins are the most essential body building sources, which are very important to be included in the diets of an adolescent. The densest sources of protein include teenage favorites such as Chicken, Fish, Eggs and Cheese.

Carbohydrates In planning meals, we want to push complex-carbohydrate foods and go easy on simple carbohydrates. Complex carbs provide sustained energy; that's why you often see marathon runners and other athletes downing big bowls of pasta before competing. As a bonus, many starches deliver fiber and assorted nutrients too. They are truly foods of substance: filling yet low in fat. Most nutritionists recommend that complex carbohydrates make up 50% to 60% of a teenager's caloric intake. Simple carbs, on the other hand, seduce us with their sweet taste and a brief burst of energy but have little else to offer and should be minimized in the diet.

Dietary Fat Fat should make up no more than 30% of the diet. Fat supplies energy and assists the body in absorbing the fat-soluble vitamins: A, D, E, and K. But these benefits must be considered next to its many adverse effects on health. A teenager who indulges in a fat-heavy diet is going to put on weight, even if he's active.

Dietary fat contains varying proportions of three types: • Monounsaturated fat —the healthiest kind; found in olives and olive oil; peanuts, peanut oil and peanut butter; cashews; walnuts and walnut oil, and canola oil. • Polyunsaturated fat —found in corn oil, safflower oil, sunflower oil, soybean oil, cottonseed oil, and sesame-seed oil. • Saturated fat —is the most cholesterol laden of the three; found in meat and dairy products like beef, pork, lamb, butter, cheese, cream, egg yolks, coconut oil, and palm oil.

Vitamins and Minerals Adolescents tend to most often fall short of their daily quotas of calcium, iron, zinc, and vitamin D. Unless blood tests and a pediatrician's evaluation reveal a specific deficiency, it's preferable to obtain nutrients from food instead of from dietary supplements.

SEXUAL EDUCATION Adolescent girls should be at the heart of a life course approach—a young adolescent girl is still a child, but often she will soon become a mother. Adolescent pregnancy is associated with higher risk of maternal mortality and morbidity, stillbirths, neonatal deaths, preterm births, and low birth weight. In addition to actions to prevent adolescent pregnancy and encourage pregnancy spacing, efforts are required to ensure that pregnant and lactating teenage mothers are adequately nourished.

Psychological and social aspects of adolescents’ development are less often described in connection with adolescent health than their physical growth and maturation characteristics. • Girls aged between 12-14 years are more likely to be talked or forced into having unplanned and unprotected sex giving way to teenage pregnancies. About two thirds of teen pregnancies occur in girls aged between 18-19 years.

CERVICAL CANCER VACCINATION • Cervical cancer is one of the most common cancers in females in our country. The main causative agent for most these cancers are due to HPV. It is a cancer which affects the females of later age group. Primary prevention for this cancer is possible through the HPV vaccine. Young girls in the age group of 11-13 are advised to take this vaccine in order to protect them from cervical cancer at later age.

One can get HPV from sexual contact, including vaginal, oral, and anal sex. Most people infected with HPV don't know they have it because they don't notice any signs or problems. People do not always develop genital warts, but the virus is still in their system and it could be causing damage. This means that people with HPV can pass the infection to others without knowing it. • Because HPV can cause problems like genital warts and some kinds of cancer, a vaccine is an important step in preventing infection and protecting against the spread of HPV.

END NOTE • The health and nutrition statuses of women and children are intimately linked. Improving the health of women and children, therefore, begins with ensuring the health and nutritional status of women throughout all stages of life, and it continues with women being providers for their children and families.

Pregnancy Care Hospital - Paras Bliss