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Dr. Eranthi SamarakoonDr. Eranthi Samarakoon
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Is the time a girl becomes sexually mature and functionally able to reproduce .
The changes which occur at puberty are the development of secondary sexual characteristics and onset of menstruation
Puberty is the physical & mental development of the girl child to reach womanhood.
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Begins around 09 years of age.
Includes the following aspects of physical
development,
Formation of the breast buds which go on to
complete development of the breasts.
Growth spurt.
Development of axillary & pubic hair.
Occurrence of menstrual periods.
Mental development from a child to an adolescent
teenager & a woman. ( Interest in personal
appearance, cosmetics, clothes & opposite sex.)
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TIME SCALE (YEARS)
9½ - 13 Breast buds appear
13 – 14 Growth of axillary & pubic
hair
10 – 14 Growth spurt
11½ - 15 Developed feminine
contours
13 – 16 Ovulation
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Menarche is the occurrence of the first
menstrual period, known in our society
as “attaining of age”. It is one aspect of
the pubertal process. In Sri Lanka the
normal age of menarche is between 9 to
15 years.
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The occurrence of puberty and menstruation require proper functioning of,
Hypothalamus
Pituitary
Ovary
Uterus
And the out flow tract
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SOME TRUE FACTS REGADING
MENARCHE It is a natural occurrence & is only another
mile stone in the girl’s life.
It should not be allowed to change the life
style of the girl who should be allowed to
blossom out in to a young woman gradually
during the ‘teenage’ period.
There are no taboos associated with
menarche or subsequent menstrual periods.
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Any type of food can be consumed.
Athletes, swimmers & dancers can
continue training at menarche & during
subsequent menstrual periods.
Social & cultural festivities should be kept
to minimum & the child should be made
to feel important and happy.
She should resume schooling in 2-3 days
after menarche.
Bathing can be continued
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Pregnancy can occur at any time after
menarche
Regular monthly periods may or may
not occur soon after menarche
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Menstruation•Occur once in 25 – 32 days•Is not a cleansing or an excretory process of the body•It only indicates a cycle during which an ovum (egg) is released on the 14th day by the ovary and ends with the uterus shedding its endometrial lining (which becomes thick during the menstrual cycle due to the hormones) with the release of about 60ml of blood•It is not essential for life but indicates that ovulation has occurred ( an egg has been released) during the month
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Problems associated with puberty & adolescence
Primary amenorrhoea
precocious puberty
Irregular & excessive bleeding
Primary dysmenorrhoea
Vaginal discharge
Secondary amenorrhoea
Oligomenorrhoea
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Medical attention should be sought
if menarche occurs before 09 years
or does not occur till 16 years
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Irregular & excessive bleeding Increased bleeding and short cycles are common in teenagers and is not due to an illness but due to lack of maturity of the hormones. Immediate medical treatment is necessary to avoid anaemiaAbdominal examination, FBC and USS should be doneThe diagnosis is dysfunctional uterine bleeding unless proved otherwise
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Treatment for Irregular & excessive bleeding
Combined oral contraceptive pills for 01 -03
cycles
Norethisterone 05mg b.d for 21 days (01-
03 cycles)
Tranexemic acid and /or mefenemic acid is
used only to reduce bleeding in regular
menorrhagia
Oral iron therapy
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Primary dysmenorrhoea
First day pain is normal
May be accompanied by vomiting and
fainting
May start a few years after menarche
Cannot be cured but should be controlled
with analgesics which should be commenced
with the onset of the period before the pain
begins
Paracetamol 500mg 06 hourly and/or
mefenemic acid 500 mg 06 hourly are used
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Vaginal discharge
Increased vaginal discharge is normal
it does not require treatment, if not
blood stained or associated with itching
or burning.
It does not cause weight loss,
abdominal pain or backache
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ABSENCE OF MENSTRUATION
Absence of menstruation for several months is common in teenagers. it is not due to an illness.
It occurs because ovulation is irregular in young girls.
Medical attention may be sought to relieve the anxiety of the parents.
The possibility of a pregnancy can not be ignored.
Attention should be paid if the child is overweight as it may be due to PCOS.
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Polycystic Polycystic Ovarian Ovarian
SyndromeSyndrome(PCOS)(PCOS)
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PCOS is a syndrome of ovarian dysfunction with the cardinal features of
Obesity
Hyperandrogenism
Polycystic ovarian morphology
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DiagnosisPresence of two of the three following
criteria is diagnostic of the condition. Polycystic ovaries(either 12 or more
peripheral follicles) or increased ovarian volume (greater than 10 cm).
Oligo or anovulation. Clinical and/ or biochemical evidence of
hyperandrogenism.
A raised luteinising hormone/follicle-stimulating hormone ratio is no longer a diagnostic criteria for PCOS owing to its inconsistency.
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Differential diagnosisDifferential diagnosis
Diagnosis of PCOS require exclusion of
Hyperprolactinaemia
Androgen secreting ovarian or
adrenal tumours
Cushing’s syndrome
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Clinical Features Obesity Oligomenorrhoea/amenorrhoea Episodes of excessive bleeding after
a period of amenorrhoea Hirsutism Subfertility Recurrent miscarriage Acanthosis nigricans
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Laboratory testsLaboratory tests Elevated testosterone. Decreased sex hormone binding
globulin. Elevated LH. Elevated LH : FSH ratio. Increased fasting insulin. Increased prolactin . Increased oestrodiol , oestrone
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Ultra sound scanUltra sound scan
The USS criteria for the diagnosis of PCOS are,
8 or more subcapsular follicular cysts ~
10mm in diameter
increased ovarian stroma.
Ovarian volume greater than 10 cm3.
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TreatmentTreatment
There is no specific treatment for PCOS.
Treatment is directed at the symptoms.
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Exercise & weight Exercise & weight controlcontrol
Is the most important aspect of treatment.
Causes spontaneous resumption of ovulation
Improves fertility. Increases sex hormone binding globulin
levels. Reduces insulin resistance. Normalizes the glucose metabolism.
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Menstrual disturbances
Progesterone for the last 10 days of
the cycle.
Cyclical treatment with
progesterone.
Cyclical treatment with combined
oral contraceptive pills.
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Role of MetforminRole of Metformin
Improves obesity.
Increases ovulation rates.
Improves hirsutism.
Improves fertility.
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Hirsutism
Cyproterone acetate
Metformin
Cosmetic treatment
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Anovulation & InfertilityAnovulation & Infertility
Weight reduction
Metformin
Ovulation induction
- Clomiphene citrate
- hCG injections
Ovarian drilling
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Long-term metabolic consequences
Diabetes mellitus
Dyslipidaemia
Hypertension
Cardiovascular disease
Endometrial carcinoma
Gestational diabetes mellitus
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NUTRITIONAL REQUIREMENTS OF THE ADOLESCENT
Adequate nutrition should be provided to the girl child for,GrowthTo restore the blood loss during menstruationTo prepare her to deliver a healthy baby without any complications during the pregnancyThe following dietary items are nutritious, cheap and readily available. Each meal should be rich in carbohydrates, protiens, vitamins and minerals
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Rice (carbohydrates)* dhall, greengram(mung), gram(kadala), cowpea, soya, eggs, sprats, fish, meat (proteins and minerals) – fish and meat should be added where economically possible.* Green vegetables, bananas and other fruits. (vitamins and minerals) – even common cheap fruits such as jambu and lime are rich in vitamin C.* Milk is not essential* School snacks & tiffings should be prepared at home.* Avoid sausages, other artificial & tinned food.* Encourage to eat fruits for dessert.* Drink plenty of water. Avoid sweetened artificial drinks. Prepare fruit juices at home.* Advertisements which appear in the TV regarding food items are better disregarded
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