Menstrual Problems and Precocious Puberty in Young Girls
Mar 20, 2023
Sometimes growing up quickly is not a good thing for the body. In young girls, when puberty begins before age 8 it is a sign of precocious puberty. This can lead to a host of problems in young girls. In general, girls are more prone to precocious puberty than boys. Let’s learn more about this condition.
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).
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
If the periods comes before and equal 9 years
If the periods before and equal to 8 years
Prepubertal vaginal 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)
Vaginal discharge between young and adolescent Girl
Inflammation and irritation causes Vaginal discharge
Primarily vulvitis. Vaginitis is secondary
Sexual abuse (especially if a FB is seen)
Mostly mixed organisms
Streptococcus, Rarely Shigella
Topical estrogens around 4 weeks and antibiotics
Focus on hygiene
In adults: women and adolescents girls
Vaginitis-typically is the primary finding with vulvitis occurring secondarily
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
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
If the cycle is > 42 days or < 21 days or bleeding > 7 days
Hematological abnormalities like Von Willebrands
Infections- Chlamydia, STDs
Anatomic causes- like vaginal septum, didelphys etc present now
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).
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.
And that is everything you need to know about precocious puberty. For more interesting and informative articles like this, download the PrepLadder app now.
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