Dr. Eranthi SamarakoonDr. Eranthi Samarakoon

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.

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.)

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

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.

The occurrence of puberty and menstruation require proper functioning of,

Hypothalamus

Pituitary

Ovary

Uterus

And the out flow tract

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.

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

Pregnancy can occur at any time after

menarche

Regular monthly periods may or may

not occur soon after menarche

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

Problems associated with puberty & adolescence

Primary amenorrhoea

precocious puberty

Irregular & excessive bleeding

Primary dysmenorrhoea

Vaginal discharge

Secondary amenorrhoea

Oligomenorrhoea

Medical attention should be sought

if menarche occurs before 09 years

or does not occur till 16 years

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

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

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

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

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.

Polycystic Polycystic Ovarian Ovarian

SyndromeSyndrome(PCOS)(PCOS)

PCOS is a syndrome of ovarian dysfunction with the cardinal features of

Obesity

Hyperandrogenism

Polycystic ovarian morphology

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.

Differential diagnosisDifferential diagnosis

Diagnosis of PCOS require exclusion of

Hyperprolactinaemia

Androgen secreting ovarian or

adrenal tumours

Cushing’s syndrome

Clinical Features Obesity Oligomenorrhoea/amenorrhoea Episodes of excessive bleeding after

a period of amenorrhoea Hirsutism Subfertility Recurrent miscarriage Acanthosis nigricans

Laboratory testsLaboratory tests Elevated testosterone. Decreased sex hormone binding

globulin. Elevated LH. Elevated LH : FSH ratio. Increased fasting insulin. Increased prolactin . Increased oestrodiol , oestrone

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.

TreatmentTreatment

There is no specific treatment for PCOS.

Treatment is directed at the symptoms.

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.

Menstrual disturbances

Progesterone for the last 10 days of

the cycle.

Cyclical treatment with

progesterone.

Cyclical treatment with combined

oral contraceptive pills.

Role of MetforminRole of Metformin

Improves obesity.

Increases ovulation rates.

Improves hirsutism.

Improves fertility.

Hirsutism

Cyproterone acetate

Metformin

Cosmetic treatment

Anovulation & InfertilityAnovulation & Infertility

Weight reduction

Metformin

Ovulation induction

- Clomiphene citrate

- hCG injections

Ovarian drilling

Long-term metabolic consequences

Diabetes mellitus

Dyslipidaemia

Hypertension

Cardiovascular disease

Endometrial carcinoma

Gestational diabetes mellitus

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

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