Institutionalized disabled adolescents: gynecologic care. The pediatrician's role

Severely handicapped and institutionalized teenage girls have a variety of gynecologic problems that can be readily addressed by a physician with an interest in adolescent medicine who makes "home visits" to the institutions. Disabled teens are a unique group of adolescents whose needs intersect with those of normal teens. Educating and listening to the caretakers, who can then prepare the patients, is essential. Key topics include menses and menstrual calendars, adolescent development, the pelvic examination, and contraception. The clinical problems most frequently encountered are vaginal discharge, menstrual cycle dysfunction, and oligomenorrhea. Basic on-site management is described. In this population, severe chronic illness and subnormal weights for age are not necessarily associated with secondary amenorrhea. Patients, parents, and staff are satisfied when gynecologic needs are met in an empathetic and thorough fashion. A list of educational resources is appended.     

Prevalence of the female athlete triad syndrome among high school athletes

OBJECTIVE: To estimate the prevalence of the female athlete triad (disordered eating, menstrual irregularity, and low bone mass) among high school athletes. DESIGN: Observational cross-sectional study. SETTING: High school. PARTICIPANTS: Female athletes (n= 170) representing 8 sports were recruited from 6 high schools in southern California. MAIN OUTCOME MEASURES: Disordered eating and menstrual status were determined by interviewer-assisted questionnaires. Bone mineral density was measured by dual-energy x-ray absorptiometry of the hip, spine (L1-L4), and total body. RESULTS: Among all athletes, 18.2%, 23.5%, and 21.8% met the criteria for disordered eating, menstrual irregularity, and low bone mass, respectively. Ten girls (5.9%) met criteria for 2 components of the triad, and 2 girls (1.2%) met criteria for all 3 components. Oligomenorrheic/amenorrheic athletes had higher mean +/- SD eating restraint (1.55 +/- 1.60 vs 1.04 +/- 1.27; P = .02) and Eating Disorder Examination Questionnaire global scores (1.68 +/- 1.20 vs 1.33 +/- 1.14; P = .03) than eumenorrheic athletes. After controlling for age, age at menarche, body mass index, race/ethnicity, and sport type, athletes with oligomenorrhea/amenorrhea had significantly lower mean +/- SD bone mineral densities for the trochanter (0.884 +/- 0.090 g . cm(-2)) than eumenorrheic athletes (0.933 +/- 0.130 g . cm(-2); P = .04). CONCLUSIONS: The prevalence of the full female athlete triad was low in our sample; however, a substantial percentage of the athletes may be at risk for long-term health consequences associated with disordered eating, menstrual irregularity, or low bone mass. Preparticipation screening to identify these components should be encouraged as a preventive approach to identify high-risk athletes.     

Menstrual disorders during adolescence

During the post-menarcheal years several kinds of menstrual disorders can be observed, such as abnormal uterine bleeding, primary and secondary dysmenorrhea, premenstrual syndrome, primary and secondary amenorrhea and oligomenorrhea. Abnormal uterine bleeding and especially the subtype of dysfunctional uterine bleeding is the most urgent gynecological problem during adolescence, while dysmenorrhea is the most frequent one for which adolescents and their parents refer to a physician. Normal menstrual cycle physiology as well as definitions of all the above menstrual disorders is briefly mentioned before going on with dysfunctional uterine bleeding and dysmenorrhea.     

Gynecological concerns in young and adolescent physically active girls

Young girls should be advised to develop the regular exercise habit and to maintain it throughout life. Prepubertal athletes are more likely than their sedentary friends to experience menarcheal delay. Postmenarcheal athletes have increased susceptibility to oligomenorrhea and amenorrhea. Athletes with delayed puberty deserve examination and possibly further evaluation. Adolescent athletes with oligomenorrhea or amenorrhea deserve examination and hormonal evaluation. Hormonal replacement therapy is unnecessary prior to age 16, is optional between ages 16 and 18, and is recommended after age 18.     

Approach to adolescent polycystic ovary syndrome (PCOS) in the pediatric endocrine community in the U.S.A

OBJECTIVE: Polycystic ovarian syndrome (PCOS) is the most common endocrinopathy in adult women, and is emerging as a common cause of menstrual disturbances in the adolescent population. Insulin resistance, which is considered one of its underlying causes, has increased substantially in the past decade, putting more adolescent girls at risk for PCOS and its complications. Our objective was to survey pediatric endocrinologists' approach to diagnosis and treatment of PCOS in the adolescent population, as there is presently no structured recommended approach to this emerging problem. DESIGN/METHODS: A questionnaire survey was sent to 839 members of the Lawson Wilkins Pediatric Endocrine Society (LWPES). A total of 176 (21%) responses was received and analyzed. REDULTS: The majority of the participants would consider initiating work-up in an adolescent with oligomenorrhea or secondary amenorrhea 12-24 months after menarche. The following work-up was selected as a baseline for a teenager with oligomenorrhea or secondary amenorrhea by more than 50% of participants: LH and FSH, total and free testosterone, prolactin, 17-OH-progesterone, DHEAS and glucose/insulin measurements. For treatment of PCOS, the majority of surveyed endocrinologists suggested estrogen/progesterone combination. Metformin was considered appropriate treatment in the general adolescent population with PCOS by 30% and in obese teenagers with PCOS by 68% of surveyed endocrinologists. CONCLUSIONS: Our findings indicate the trend among pediatric endocrinologists towards earlier work-up of menstrual irregularities in adolescents--unlike the traditional practice of waiting for 2 years after menarche. Most pediatric endocrinologists would consider evaluation for insulin resistance using glucose/insulin measurement, but only a small percentage considers performing OGTT in these patients. Even though using estrogen/progesterone combination is the preferred therapeutic approach, 30% of surveyed endocrinologists consider metformin therapy for the general adolescent population with PCOS, and 68% would consider using it in obese adolescents with PCOS.     

Adolescent menstrual health

Attention to pubertal development and menstrual health is an important aspect of primary care for adolescents. Textbooks may not provide sufficient evidence-based guidance to facilitate the early detection of gynecologic disease states and conditions. Conversely, the typical guidelines for pubertal development may lead to over-evaluation of normal girls. Chaotically irregular and unpredictable bleeding is NOT the norm during adolescence. On the contrary, although many early menstrual cycles are anovulatory, most adolescents have menstrual cycles that fall within the parameters of 21-45 days. Adolescents with menstrual bleeding that is less frequent than every 45 days, is prolonged > 7 days, or is excessively heavy should be evaluated in order to detect conditions such as eating disorders, polycystic ovary syndrome, and von Willebrand disease. Clinicians who attend to adolescent menstrual cycles can help set the stage for future health.     

New concepts in anorexia nervosa

Anorexia nervosa (AN), a psychosomatic disorder, has serious negative effects on multiple organs and systems of the human body. A large number of endocrine and metabolic anomalies have been described, including amenorrhea/oligomenorrhea, delayed puberty, hypothyroidism, hypercortisolism, and alterations in the growth hormone (GH) axis and bone metabolism. The role of different peptides, including ghrelin, leptin, neuropeptide Y and serotonin, in the regulation of appetite is discussed. In addition, isolated hypogonadotropic hypogonadism that occurs in these patients is analyzed in detail, as well as the abnormalities in the growth hormone axis. Alterations in bone mineral density, bone markers and the degree of osteopenia in these patients, depending on the age at which amenorrhea began and its duration, are also discussed. Finally, our current understanding of the possible benefits of treatment with estrogens and progestogens is also analyzed.     

An epidemiological study of anorectic and bulimic symptoms in adolescent girls: implications for pediatricians.

Our findings suggest that most cases of anorexia nervosa among high school girls are eventually recognized and treated. However, it is worrisome that a large number of girls suffering from early anorexia nervosa and an even greater number suffering from bulimia do not seek treatment for their disorder. In addition, it is clear that girls who do not meet criteria for the full syndromes may nonetheless be engaging in the cardinal behaviors associated with these disorders. Therefore, the pediatrician must actively inquire about weight control practices and binge-purge behavior during the course of routine examinations. These behaviors are sufficiently common that such inquiry should be incorporated into the routine evaluation of every girl, even when there is no obvious reason to be concerned. The vast majority of girls will express dissatisfaction with their weight and report that they have attempted to control their weight in some manner, most often with dieting, in the past year. Normative data from a cross-sectional study such as the one described provide some guidelines as to when such behavior is likely to be associated with other types of problems, such as depressive symptoms or amenorrhea. For example, our data suggest that weight loss of 10 lbs or more in the past year and fasting are more likely to be associated with depressive symptoms and menstrual irregularity than less severe forms of caloric restriction. Our findings also suggest that purging behavior (self-induced vomiting and laxative use), particularly in combination with binge eating, is associated with very high rates of both depressive symptoms and menstrual irregularity.(ABSTRACT TRUNCATED AT 250 WORDS)     

Anorexia nervosa, athletics, and amenorrhea

Menstrual dysfunction is common in adolescents who are involved in intensive athletic activity or who are limiting their nutritional intake excessively. The mechanism for hypothalamic amenorrhea in athletes and dieters is not yet fully understood. Other causes of menstrual dysfunction due to pregnancy, central lesions, hormone imbalance, or ovarian failure should be excluded in the athlete with amenorrhea. Amenorrheic patients who have sufficient estrogen effect on their endometrium to have withdrawal bleeding following exposure to progestins should be cycled with progestins on a regular basis to prevent endometrial hyperplasia. Estrogen replacement with cyclic progestin should be considered in the hypoestrogenic adolescent with prolonged amenorrhea. The long-term consequences of hypothalamic amenorrhea in adolescents remain to be determined.     

Intractable early childhood obesity as the initial sign of insulin resistant hyperinsulinism and precursor of polycystic ovary syndrome

OBJECTIVE: We report that intractable early childhood obesity may be associated with severe insulin resistance syndromes (pseudo-Cushing's syndrome and pseudo-acromegaly) and precede polycystic ovary syndrome (PCOS). STUDY DESIGN/RESULTS: Patient 1 had prepubertal obesity followed by early puberty and was diagnosed with pseudo-Cushing's syndrome and insulin resistance at 10.3 years. Oligomenorrhea, androgen excess, and type 2 diabetes mellitus (DM2) emerged at 13.5 years. Patient 2 developed intractable prepubertal obesity followed by atypical true sexual precocity and pseudo-Cushing's syndrome in early childhood. By 11.3 years, oligomenorrhea, androgen excess, and DM2 had appeared. Patient 3 had prepubertal overgrowth in weight and height and was diagnosed with pseudo-acromegaly, menstrual irregularity, androgen excess, and impaired glucose tolerance at 14.3 years of age. Patient 4 had prepubertal overgrowth that evolved into pseudo-acromegaly, insulin resistance, secondary amenorrhea, and androgen excess at 15.6 years. CONCLUSIONS: Intractable prepubertal obesity was recognized to culminate in early childhood pseudo-Cushing's syndrome or pseudo-acromegaly, which are manifestations of insulin-resistant hyperinsulinism, and to herald adolescent PCOS.     

Menstrual pattern and menstrual disorders among adolescents: an update of the Italian data

ABSTRACT: BACKGROUND: The most striking event in the whole process of female puberty is the onset of menstruation. To our knowledge, no large population-based studies have been performed on the topic of menstrual health among Italian adolescents in recent years. The aims of this study were to produce up-to-date information on the menstrual patterns of Italian girls secondary school, and to estimate the prevalence of menstrual cycle abnormalities in this population. METHODS: This was a cross-sectional study on a population-based sample of Italian adolescents aged 13-21 years attending secondary school. Only girls who had already started menstruating were requested to participate. Information was collected by means of a questionnaire that included items on the girls' demographic details, anthropometrics, smoking and drinking habits, use of contraceptive pills, and socioeconomic status. The questions on the girls' menstrual pattern concerned their age at menarche, duration of the most recent menstruation intervals (<21, 21-35, >35 days, variable), average days of bleeding (<4, 4-6, >6 days), and any menstrual problems and their frequency. RESULTS: A total of 6,924 questionnaires were administered and 4,992 (71%) were returned. One hundred girls failed to report their date of birth, so 4,892 subjects were analyzed. The girls' mean age was 17.1 years (SD +/-1.4); their mean age at menarche was 12.4 (+/-1.3) years, median 12.4 years (95%CI 12.3-12.5). In our sample population, 3.0% (95%CI 2.5%-3.4%) of the girls had menstruation intervals of less than 21 days, while it was more than 35 days in 3.4% (95%CI 2.9%-3.9%). About 9% of the girls (95%CI 7.7%-9.4%) said the length of their menstruation interval was currently irregular. Short bleeding periods (<4 days) were reported in 3.2% of the sample population (95%CI 2.7%-3.7%), long periods (>6 days) in 19% (95%CI 17.9%-20.1%). Menstruationrelated abdominal pain was reported by about 56% of our sample. About 6.2% of the girls (95%CI 5.4%-7.0%) were suffering from dysmenorrhea. CONCLUSIONS: In conclusion, to the best of our knowledge, this is one of the largest studies on menstrual patterns and menstrual disorders among Italian adolescent girls. Adolescent girls referring persistent oligomenorrhoea, in first two years from menarche, had a higher risk for developing a persistent menstrual irregularity. They had longer bleeding periods (>6 days) and this has practical implications because it makes these adolescents potentially more susceptible to iron deficiency anemia. Clinicians need to identify menstrual abnormalities as early as possible in order to minimize their possible consequences and sequelae, and to promote proper health information. We recommend that adolescents should be encouraged to chart their menstrual frequency and regularity prospectively from the menarche onwards.     

Urban-rural differences in menstrual problems and practices of girl students in Nagpur,India

Menstruation in adolescent girls is often associated with menstruation related problems and poor practices. The study was planned to investigate the menstrual related problems and menstrual practices among school going adolescent girls. The study was a community based cross sectional study in a girls’ school in Nagpur. Majority of menstrual practices were significantly better in urban girls as compared to rural girls (P<0.05). Majority of the girls (71.83%) had at least one problem related to menstrual cycles. There was a significant difference in proportion of menstrual problems in rural and urban girls (P<0.01). Menstrual problems are a common source of morbidity in this population.     

Anorexia nervosa, athletics, and amenorrhea

We examined menstrual function in two groups of patients meeting the DSM III criteria for anorexia nervosa who differed only in their physical activity. Sixteen athletes with anorexia nervosa were compared with eight sedentary patients who had anorexia nervosa. Athletic patients with anorexia were found to have lower gonadotropin levels, a longer period of amenorrhea both before significant weight loss and after weight rehabilitation, and a higher weight at the time of resumption of menses than patients with anorexia who were sedentary. However, both groups were markedly undernourished, had amenorrhea before significant weight loss and after weight rehabilitation, and had lower gonadotropin levels than normal subjects. These data suggest that the increased physical activity often seen in patients with anorexia nervosa worsens, but does not cause, menstrual dysfunction.     

Hypogonadotropic hypogonadism and hematologic phenotype in patients with transfusion-dependent beta-thalassemia

OBJECTIVE: To determine the prevalence and risk factors of hypogonadotropic hypogonadism in transfusion-dependent patients with thalassemia. PATIENTS AND METHODS: The authors examined 29 patients with thalassemia major aged 15 years or older. Luteinizing hormone-releasing hormone tests were performed and beta-thalassemia mutations were analyzed by direct sequencing. RESULTS: The prevalence of hypogonadotropic hypogonadism was 72%. Failure of puberty was observed in 5 of 11 (45%) boys and 7 of 18 (39%) girls. Arrested puberty was noted in two boys (18%) and five girls (28%). Ten girls (56%) did not menstruate, two (11%) had regular menstrual cycles, one (6%) had irregular menstrual cycles, and five (28%) developed secondary amenorrhea. Twenty-one and eight patients had the beta 0/beta 0 and beta 0/beta+ hematologic phenotypes, respectively. beta 0-thalassemia mutation alleles involved IVS II-654 (C-T), codons 41/42 (-TCTT), codons 27/28 (+C), and codons 17 (A-T). beta+-thalassemia mutations alleles were -28 (A-G) and HbE (codons 26(GAG-AAG)). Hematologic phenotype (odds ratio, 28.50; P = 0.002) was the only risk factor identified in the logistic regression analysis. CONCLUSIONS: In patients with thalassemia major, genetic differences may influence their susceptibility to hypogonadotropic hypogonadism, possibly as a result of differences in the amounts of blood transfused and/or their vulnerability to free radical damage. The hematologic phenotype is a main determinant of the severity of thalassemia major; hence, it may influence the need for and frequency of blood transfusion and the patient's iron-overload status.     

Delayed sexual maturation

Absence of any sign of gonadal development (i.e. increase in size of the testes or presence of breast budding) before the age of 13 years in girls and 14 years in boys represents the condition of delayed sexual maturation. After this age, the patient should be thoroughly clinically examined and a basic biological work-up should be performed. Pathological conditions such as hypergonadotropic hypogonadism with a bone age usually greater than 13 years can be easily diagnosed. Hypogonadotropic hypogonadism is more difficult to differentiate from delayed adolescence of good prognosis. Means of diagnosis as well as therapy are discussed. In addition, micropenis and primary amenorrhea are frequent clinical observations.     

Menstruation in girls and adolescents: using the menstrual cycle as a vital sign

Young patients and their parents often are unsure about what represents normal menstrual patterns, and clinicians also may be unsure about normal ranges for menstrual cycle length and amount and duration of flow through adolescence. It is important to be able to educate young patients and their parents regarding what to expect of a first period and about the range for normal cycle length of subsequent menses. It is equally important for clinicians to have an understanding of bleeding patterns in girls and adolescents, the ability to differentiate between normal and abnormal menstruation, and the skill to know how to evaluate young patients' conditions appropriately. Using the menstrual cycle as an additional vital sign adds a powerful tool to the assessment of normal development and the exclusion of pathological conditions.     

Weight and menstrual function in patients with eating disorders and cystic fibrosis

Many patients with eating disorders have menstrual dysfunction. In patients with anorexia nervosa, amenorrhea has been linked to weight loss. However, many patients with bulimia nervosa, even those of average or greater than average weight, also experience menstrual abnormalities, including amenorrhea. It was hypothesized that low weight per se is not responsible for menstrual dysfunction in patients with eating disorders. First, 16 patients with bulimia nervosa of average weight and 29 patients with cystic fibrosis of below average weight of similar menstrual age were compared. Of the patients with bulimia nervosa, 11 (73%) had had secondary amenorrhea at some time compared with 8 (28%) of the patients with cystic fibrosis (P less than .01). At the time of study, 6 (40%) of the patients with bulimia nervosa and 21 (78%) of the patients with cystic fibrosis were having regular cycles (P less than .01). Next 18 patients with anorexia nervosa were compared with 18 patients with cystic fibrosis matched for weight and menstrual age. Although 18 (100%) of the patients with anorexia nervosa had had secondary amenorrhea, only 6 (33%) of the patients with cystic fibrosis had amenorrhea. Although only 1 (6%) of the anorexia nervosa group was currently having regular cycles, 14 (78%) of the patients with cystic fibrosis were (P less than .0001). Closer approximation to ideal body weight was associated with regular menses only in the cystic fibrosis group. Exercise did not appear related to regularity of menstruation in any group. Body weight is not the major factor responsible for menstrual abnormalities in patients with eating disorders.     

Isolated menses in prepubertal girls

Seventeen prepubertal girls 1 to 8 years of age were studied for the complaint of vaginal bleeding of apparent uterine origin. The bleeding was considered as isolated menses because it lasted two to five days and no other signs of sexual development or any detectable vaginal or uterine abnormalities were found. Eleven girls had two or more apparent menstrual periods, six experienced only one period. Height and bone age were not significantly different from normal. Laparoscopy or ultrasonography showed normal prepubertal uterine size, with either prepubertal ovaries or ovaries containing follicular cysts. Plasma gonadotrophins and their response to luteinizing hormone-releasing hormone were at prepubertal levels. Plasma estradiol level was significantly above the normal prepubertal range, suggesting transient ovarian activity and instability of the pituitary-gonadal axis in these girls. Isolated menses occurred mainly during the months of September to January, thus leading us to speculate about possible seasonal variations of hormonal regulation.     

Genital bleeding secondary to chemotherapy in adolescent girls]

Severe genital bleeding during adolescence can occur in the event of thrombocytopenia related to chemotherapy. Preventive hormonal treatment to induce therapeutic amenorrhea is recommended by some clinicians. Nevertheless, the adverse effects of oestroprogestative treatment, such as thromboembolic risk or hepatic toxicity, could potentialize the adverse effects of some chemotherapies. AIM OF THE STUDY: To assess retrospectively the risk of genital bleeding associated with thrombocytopenia secondary to chemotherapy in a population of adolescent girls for whom therapeutic amenorrhea was induced or not. PATIENTS AND METHODS: Among 140 girls, 12 to 18 years old, who were subjected to chemotherapy between 1991 and 1998, 24 girls presented at least one thrombocytopenic event (platelet level < 20 x 10(9) l(-1)) and were included. RESULTS: Six out of 24 adolescent girls received hormonal therapy to induce amenorrhea. Only one bleeding event was observed, in a girl who had not received preventive oestroprogestative treatment. Vital prognosis was preserved. Furthermore, spontaneous amenorrhea occurring before chemotherapy was observed in 33% of the patients and permanent secondary ovarian insufficiency in 17% of the patients. CONCLUSION: The risk of genital bleeding among adolescent population at risk of chemotherapy-induced thrombocytopenia is low. The high frequency of amenorrhea, secondary to weight loss or to chemotherapy toxicity, should raise questions as to the usefulness of preventive oestroprogestative treatment.     

Decreased bone density in adolescent girls with anorexia nervosa

Osteoporosis develops in women with chronic anorexia nervosa. To determine whether bone mass is reduced in younger patients as well, bone density was studied in a group of adolescent patients with anorexia nervosa. With single- and dual-photon absorptiometry, a comparison was made of bone mineral density of midradius, lumbar spine, and whole body in 18 girls (12 to 20 years of age) with anorexia nervosa and 25 healthy control subjects of comparable age. Patients had significantly lower lumbar vertebral bone density than did control subjects (0.830 +/- 0.140 vs 1.054 +/- 0.139 g/cm2) and significantly lower whole body bone mass (0.700 +/- 0.130 vs 0.955 +/- 0.130 g/cm2). Midradius bone density was not significantly reduced. Of 18 patients, 12 had bone density greater than 2 standard deviations less than normal values for age. The diagnosis of anorexia nervosa had been made less than 1 year earlier for half of these girls. Body mass index correlated significantly with bone mass in girls who were not anorexic (P less than .05, .005, and .0001 for lumbar, radius, and whole body, respectively). Bone mineral correlated significantly with body mass index in patients with anorexia nervosa as well. In addition, age at onset and duration of anorexia nervosa, but not calcium intake, activity level, or duration of amenorrhea correlated significantly with bone mineral density. It was concluded that important deficits of bone mass occur as a frequent and often early complication of anorexia nervosa in adolescence. Whole body is considerably more sensitive than midradius bone density as a measure of cortical bone loss in this illness.(ABSTRACT TRUNCATED AT 250 WORDS)