SEMINAR PRESENTATION

BY
Dr HUMERA SADIYA
1ST YEAR P.G SCHOLAR
DEPT. ILMUL QABALAT
WA AMRAZE NISWAN

UNDER THE GUIDANCE OF

Dr. AISHA ANJUM. A
P.G CO-ORDINATOR & HOD
DEPT. ILMUL QABALAT WA AMRAZE NISWAN

UNDER THE SUPERVISION OF

Dr. K.TABASSUM
 PRESENTATION TOPICS

 Precocious puberty
 Cryptomenorrhoea
 Oligomenorrhoea
 Hypomenorrhoea
PUBERTY:

Definition:
puberty in girls is the period, which links
childhood to adulthood. It is the period of
gradual development of secondary sexual
characters. There are profound biological,
morphological and physiological changes
that lead to full maturity and eventually
fertility.
Morphological changes:

As described by the Tanner and Marshall,

five important physical changes are
evident during puberty . These are
breast, pubic and axillary hair
growth ,growth in the height, and
menstruation. Most of the changes
occur gradually but only the
menarche can be dated. Moreover ,
there is a lot of variations in the
timings of the events.
 The most common order is
beginning of the growth spurt
>breast budding(thelarche)>pubic
and axillary hair growth
(adrenarche)>peak growth in
height>menstruation (menarche)
All these changes are usually
completed between the age group
of 10 to 16 years.
 Important controlling factors for onset of
puberty are genetic, nutrition, body weight,
psycho logic state, and cultural background,
and exposure to light and others. A girl, living
in urban areas with good nutrition, adequate
body weight and whose mother and sisters
have early menarche, starts puberty early
Endocrinology in puberty
 The levels of gonadal steroids and
gonadotropins are low until the age of 6-8 years.
This is mainly due to the negative feedback
effect of estrogen to the hypothalamic pituitary
system.

 As puberty approaches this negative feedback

effect of estrogen is gradually lost. This results
in some significant changes in the endocrine
function of the girl.
Hypothalamopituitary gonadal axis:
The GnRH pulses from hypothalamus results in
pulsatile gonadotropin secretion
GnRH → FSH, LH → Estradiol
Thyroid gland
plays an active role in the hypothalamopituitary
gonadal axis,
Adrenal glands
Increase their activity of sex steroid synthesis
(androstenedione, DHA, DHAS) from about 7 years
of age. Increased sebum formation, pubic and axillary
hair, and change in voice are primarily due to adrenal
androgen production.
Gonadarche:
Increased amplitude and frequency of GnRH ↑
secretion of FSH and LH → ovarian follicular
development→↑ estrogen. Gonadal estrogen is
responsible for the development of uterus, vagina,
vulva, and also the breasts.
Leptin
A peptide, secreted in the adipose tissue is also
involved in pubertal changes and menarche.
Menarche
The onset of first menstruation in life is called
menarche. It may occur anywhere between 10 and
16years the peak time being 13 years. There is
endometrial proliferation due to ovarian estrogen
but when the level drops temporarily, the
endometrium sheds and bleeding is visible.
The first period is usually anovular. The
ovulation may be irregular for a variable period
following menarche and may take about 2 years for
regular ovulation to occur. The menses may be
irregular to start with.
Growth
Growth of height in an adolescent girl is mainly due
to hormones. The important hormones are growth
hormone, estrogen, and insulin-like growth factor-1
(IGF-1). The bone or skeletal age is determined by
X-ray of hand or knee
Tanner staging:

According to Tanner , breast and pubic hair

development at puberty are divided into five
stages
 Precocious puberty:
The term precocious puberty is reserved for
girls who exhibit any secondary sex
characteristics before the age of 8 (before age
7 in whites) or menstruate before the age of 10.
Precocious puberty may be isosexual where the
features are due to excess production of
estrogen. It may be heterosexual where
features are due to excess production of
androgen (from ovarian and adrenal
neoplasm).
 Causes of precocious
puberty
GnRH dependent 80%
 Juvenile primary hypothyroidism
 CNS lesions (30%): tumor, trauma, Infection
(tuberculosis ,encephalitis)
Incomplete
 Premature thelarche

 Premature puberche

 Premature menarche
GnRH independent(precocious puberty of peripheral
origin) (excess estrogen or androgen)

Ovary
 Granulosa cell tumor
 Theca cell tumor
 Leydig cell tumor
 Chorionic epithelioma
 Androblastoma
 McCune-Albright syndrome
Adrenal
 Hyperplasia
 Tumor

Liver
Hepatoblastoma

Iatrogenic
Estrogen or androgen intake
Etiopathology

Constitutional:

It is due to premature activation of hypothalamo-

pituitary-ovarian axis. There is secretion of gonado-
tropins and gonadal steroids due to premature
release of GnRH.
Bone maturation is accelerated, leading to
premature closure of the epiphysis and curtailed
stature. If menstruation occurs, they may be
ovulatory. The changes in puberty progress in an
orderly sequence.
Premature thelarche:
It is the isolated development of breast tissue
before the age of 8 and commonly between 2
and 4 years of age. Either one or both the
breasts may be enlarged .
There is no other feature of precocious
puberty. Life threatening neoplasms of ovary,
adrenal gland or CNS are excluded on
priority. Premature pubarche Premature
pubarche is isolated development of axillary
and/or pubic hair prior to the age of 8 without
other
Premature pubarche
Premature pubarche is isolated development
of axillary and/or pubic hair prior to the age
of 8 without other signs of precocious
puberty.
The premature hair growth I may be due to
unusual sensitivity of end organs to the usual
low level of hormones in the blood during
childhood. Rarely, there may be signs of
excess androgen production due to adrenal
hyperplasia or tumor or androgenic ovarian
tumor
Premature menarche

Premature menarche is an isolated

event of cyclic vaginal bleeding
without any other signs of
secondary sexual development. The
cause remains unclear but may be
related to unusual endocrine
sensitivity of the endometrium to
the low level of estrogens.
True Precocious :
Constitutional type is the most common one
but the rare one is to be kept in mind. The
diagnosis is made by:
 History of early menarche of mother and
sisters.
 The pubertal changes occur in orderly
sequence.
 Tanner stages.
 No cause could be detected in majority (90%).
Basic investigations for evaluation of a girl with
precocious puberty:
 Serum hCG , FSH, LH and prolactin.
 Thyroid profile (TSH, T₁).
 Serum estradiol , testosterone, 17-OH progesterone,
dehydroepiandrosterone (DHEA).
 USG, CT or MRI of the abdomen and pelvis to rule

out pathology of ovaries, adrenals or uterus.

 Skull X-ray, CT scan, or MRI brain to exclude

intracranial lesion.
Premature thelarche

 Breast buds enlarge to 2-4 cm.

 Somatic growth pattern is not accelerated.
 Bone age is not advanced,
 Nipple development is absent.
 Vaginal smear shows negative estrogen
effect.
Premature pubarche
It may be due to adrenal or ovarian or central
nervous system disease. As such, the
investigations are directed accordingly.
 An ovarian enlargement may not be palpable
clinically. Examination under anesthesia or
sonography is helpful.
 USG, CT or MRI scan is required to detect
ovarian or adrenal tumor.
 Estimations of serum 17-alpha -
hydroxyprogesterone, DHEA-S and serum
testosterone are to be done in suspected cases of
adrenal pathology.
Premature menarche

The other causes of vaginal bleeding,

such as foreign body or injury has to be
excluded. If the bleeding is cyclic, the
diagnosis is confirmed.
Treatment:

The treatment depends upon the cause and

the speed of progress of the disease.
The drugs used are;
GnRH agonist therapy arrests the pubertal
precocity and growth velocity significantly.
The agonists suppress the premature
activation of hypothalamopituitary axis due
to down regulation and thereby diminished
estrogen secretion.
Dose

Depot forms (goserelin or leuprolide)

once a month can be used. Dose is
adjusted to maintain the serum estradiol
below 10 pg/mL
 Medroxyprogesterone acetate--30 mg
daily orally or100-200 mg. IM weekly to
suppress gonadal steroids. It can
suppress menstruation and breast
development but cannot change the
skeletal growth rate.
 Danazol

lt produces amenorrhea and arrest breast

development. But there is no effect on growth
rate or skeletal maturation.
 Cryptomenorrhea
Cryptomenorrhea is a condition where the
menstrual blood fails to come out from the
genital tract due to obstruction in the passage.

It is an abnormal condition in which the

products of menstruation are retained with in
the vagina because of an imperforated hymen
or less often within the uterus because of an
occlusion of the cervical canal.
 causes:

 Imperforate hymen
 Mullerian duct anomalies
 Transverse Vaginal septum with functioning uterus
 Isolated Vaginal agenesis with functioning uterus
 Isolated Cervical agenesis with functioning uterus
 Stenosis
 Secondary vaginal Atersia
Clinical features

 The patient aged about 13-15 (congenital type)

complains of periodic pain lower abdomen.
 Hematocolpos is usually associated with urinary
problems to the extent of retention of urine.
 Abdominal examination reveals an uniform
globular mass in the hypogastrium.
 Vulvar inspection reveals the bulging hymen.
 Rectal examination confirms the fullness of the
vagina and uterine mass.
Investigations

► History collection
► Physical Examination
► USG
Treatment
► Imperforated Hymen - Excision drains retained
blood
► Vaginal septum - Z Plasty( is a plastic surgery
technique, used to elongate a contracted scar.)
► Vagino plasty removal of excess or damaged lining
from the canal
► Hemato salpinx - Laparotomy or laparoscopy
Complications

► Hematometra -collection of blood in the uterine

cavity
► Hemato salpinx - collection of blood in the tubes
► Endometriosis
► Infertility (if severe, untreated)
 OLIGOMENORRHEA
Menstrual blood occurring more than 35 days apart and which
remains constant at that frequency is called oligomenorrhea.
CAUSES
 Age related: during adolescence and preceeding menopause
 Weight related: obesity
 Stress and exercise related
 Oligomenorrhea can be a sign of several underlying health
conditions, including:
 Pelvic inflammatory disease
 Polycystic ovarian syndrome (PCOS)

 Hyperprolactinemia (elevated levels of prolactin in the blood)

 Thyroid disorders

 Obstructions of the uterus, cervix, and vagina

SYMPTOMS

The symptoms of oligomenorrhea include:

 Going longer than 35 days without a period
 Having fewer than nine periods in a year
 Menstrual cycles that are irregular
 Periods that are lighter than usual
 When the different bleeding happens, you may
have other symptoms of your period, such as
premenstrual syndrome, cramps, and bloating.
You may have no other symptoms at all.
 The blood may be dark brown, red, or a faint
light pink color. You may notice clots or mucus
when you wipe, on a pad or tampon, or in your
underwear.
TREATMENT
Which treatment is right for you will depend on the cause as
well as your overall health. Some types of treatments may
not be right for you even if they work well for other people.
 Lifestyle Changes
If oligomenorrhea is related to something in your
lifestyle, such as your weight, exercise routine, or stress
levels, your doctor can help you get the resources and
support you need to make changes. You may find that the
problems with your period get better on their own after you
return from a vacation, start a new work schedule, or gain
weight if you are underweight.
 Hormone therapy
 Treating underlying disease condition
 HYPOMENORRHEA
In some women, menstruation lasts for only 1-2
days, and the blood loss is so scanty that she may
need a change of just one to two sanitary pads.
Scanty menses, which is otherwise regular, may not
be pathological because its regularity pre-supposes a
normal H-P-O relationship.
CAUSES:

 A small hypoplastic uterus,

 genital tuberculosis
 partial Asherman syndrome also cause
hypomenorrhoea and need investigation and
treatment.
 Oral combined pills also cause hypomenorrhoea.
 Scanty periods may precede menopause.
 Anemia
RCOG guidelines for precocious puberty:

The Royal College of Obstetricians and

Gynaecologists (RCOG) guidelines define
precocious puberty as pubertal development
occurring before 8 years in girls and 9 years in boys,
requiring careful evaluation and potential
management by a pediatric endocrinologist.
Normal Variants:
Premature Thelarche:
Isolated breast development, usually in girls
younger than 3 years.
Premature Adrenarche :
Early development of pubic hair without other
signs of puberty in girls or boys younger than 7-8
years.
Management:

Monitoring: Regular follow-up and growth

monitoring are essential to assess the progression of
puberty and its impact on growth.

Treatment: In some cases, treatment with GnRH

agonists (like leuprolide) may be considered to
delay puberty and improve final height.
 The RCOG provides guidance on the
management of precocious puberty, including the
assessment, diagnosis, and treatment of both central
and peripheral forms.
 The RCOG's "Paediatric and Adolescent
Gynaecology (PAG)" guidelines offer specific
information on the management of vulval
symptoms, vaginal discharge, abnormal bleeding,
and pelvic masses in pre-puberty and adolescence.
 The RCOG also provides guidance on sex steroid
treatment for pubertal induction and replacement in
children, which can be relevant in the context of
precocious puberty.
RCOG guidelines for cryptomenorrhea

The RCOG (Royal College of Obstetricians and

Gynaecologists) guidelines for cryptomenorrhea, a
condition caused by a blocked vaginal outflow tract,
typically focus on surgical management, especially
for conditions like imperforate hymen or transverse
vaginal septum, to restore proper menstrual
function.
Causes and Presentation:
Imperforate Hymen:
A common cause of cryptomenorrhea, especially in
adolescent girls, presents with cyclical abdominal
pain and primary amenorrhea.
Transverse Vaginal Septum:
Another cause, also presenting with cyclical pain
and amenorrhea, can be associated with Mullerian
abnormalities.
Other Mullerian Abnormalities:
Cryptomenorrhea can also be associated with other
congenital abnormalities of the reproductive tract.
Management:

Surgical Intervention:
Hymenotomy (incision of the hymen) is the standard
treatment for imperforate hymen.
Other Surgical Procedures:
Depending on the underlying cause, other
procedures like excision of a transverse vaginal
septum or reconstruction of the vagina may be
necessary.
Virginity Preservation:
Hymenotomy is often performed in a way that
preserves virginity.

Drainage of Hematocolpos:
Large volumes of hematocolpos should be drained
with caution, considering potential complications.
 References
 Howkins and Bourne SHAW’S
textbook of Gynaecology,17th
Edition.

 DC Dutta’s textbook of
Gynaecology, Hiralal Konar, 8th
Edition.

 RCOG guidelines for Precocious

puberty