Puberty and Amenorrhea among Female child

Puberty and Amenorrhea among Female child Chandrakant Jamadar Assistant Professor, Dept of Psychology,Maharani’s Arts & Commerce womenn’s college Mysore Puberty and Amenorrhea Puberty is a slow process involving several years during which the physical growth and secondary sexual characters develop to maturity and the menstruation is established. The menarche, or time onset of menstruation, varies with race and family, but the average for most Girls is from 12 to 13 years of age. The early puberty seen in developed countries is due to improved nutritional status. During childhood, before the onset of puberty, oestrogen secretion is too small to cause development of the reproductive organs. At puberty the hypothalamus awakes and excites the pituitary to secrete gonadotrophins; these in turn stimulates the ovary to discharge ova and to secrete its hormones. Thus puberty begins at 10-14 years and is regarded as ending with the first menstrual period usually at 13- 15 years, the range being 10-15 years. At whatever age the menarche appears it is usually some years before regular, adult ovulatory menstrual cycles are established. The main changes which take place at puberty are - * Complete ovarian cycles occur, characterized by ovulation and corpus formation. * The uterus and vagina enlarge. The muscle fibres of the uterus increase in number and size, the mucous membrane thickens and the gland alveoli become larger. *The breasts begin to appear as a result of outgrowths of ducts from the nipple area, and an increase in the amount of fat, connective tissue, and blood vessels. *The secondary sexual characters develop; these include the female distribution of fat, giving the characteristic curves to the body, and appearance of hair in the axilla and on the pubes. *Important psychological changes take place as the girl matures mentally and emotionally through adolescence to young womanhood. Hormonal changes Until puberty, the hypothalamus and the anterior pitutory gland are under some inhibitory influence of a higher brain center. At puberty, this inhibition is gradually withdrawn and the hypothalamus starts secreting GnRH in a pulsatile manner initially during sleep, and later throughout 24 hours. Under the stimulus of GnRH, the anterior pituitary gland releases FSH(Follicular stimulating hormone) and later LH(Lutenising hormone), as well as the growth promoting hormone. This Growth promoting hormone causes a spurt in the height. The ovaries respond by developing Grafian follicles and secreting oestrogen. Oestrogen is responsible for breast development, female fat distribution, vaginal and uterine growth. Adrenal androgen causes pubic and axillary hair growth. Oestrogen causes proliferation of endometrium and brings about menstruation. The initial cycles may be irregular and anovulatory due to inadequate follicular maturation. Later, the cycles become regular and ovulatory. Precocious puberty Precocious puberty is the appearance of appropriate secondary sex characteristics before the age of 8 in girls. This occurrence is due to premature activation of the intact hypothalamus-pituitary-ovarian axis. However investigation can be done to find out the other causes of precocious puberty such as tumours in the brain, post inflammatory lesions such as meningitis, encephalitis, hypothyroidism , hormone secreting ovarian tumours like granulose and theca cell tumour, and adrenal lesions. Vaginal bleeding in young girls may be due to an occasional spurt in oestrogen secretion. In most cases, this is followed by normal growth pattern and normal onset of puberty at the expected age. Management comprises treatment of the cause. Delayed puberty This may be familial or idiopathic. Puberty is delayed for as long as five years, normal puberty and menarche have occasionally set in as late as 20 years. Though no treatment is advocated, it requires investigations and assurance to the patient. Amenorrhea Amenorrhea is the absence of menstruation. Amenorrhea is a normal feature in prepubertal, pregnant, and postmenopausal females. It may be physiological ( ie, prior to puberty or due to pregnancy, lactation, or the menopause), or secondary to a gynecological disorder or systematic diseases. About 10 and 20 percent of women complaining of infertility have amenorrhea. Primary Amenorrhea - It is the failure to establish menstruation. Such failure to is generally regarded as abnormal by the age of 14 years in girls without other signs of secondary sexual development or by the age of 16 in the presence of normal secondary sexual characteristics. Secondary Amenorrhea – It is defined as the absence of menstruation for 3 consecutive months in a woman who has previously had regular periods or 6 months in case of the periods were irregular . The differential diagnosis of Amenorrhea is broad and can range from genetic abnormalities to endocrine disorders and psychological, environmental, and structural anomalies. In case of Primary Amenorrhea, one can wait until the age of 16, hoping that one is dealing with delayed puberty. However, if the secondary sex characters have developed by age 14, but menstruation has not begun, one should start investigating. General examination rules out anemia, malnutrition, abnormal weight and height. Tuberculosis and thyroid disease can be ruled out by X-ray chest, ESR, and T3,T4,TSH (Thyroid stimulating hormone) estimation. Well developed secondary sex characters and normal height point out to genital tract abnormalities. Ultrasound confirms the diagnosis. Hirsutism indicates adrenal gland disease, ovarian tumour or polycystic ovarian disease. 17 keto –steroid estimation and ultrasound should be done. Average level of 17- ketosteroids is 5-15 mg/24 hour urine. The level is raised to 50-100 mg in virilizing conditions. Breasts are not developed in hormonal disturbance. Galactorrhea demands prolactin estimation. Abdominal tumour indicates either an ovarian tumour or cryptomenorrhea.Ultrasound identifies the swelling. Absent vagina is seen in testicular feminizing or Rokitansky syndrome- chromosomal study is required. Absent of secondary sex characters indicate hormonal disturbance in hypothalamus-pituitory-ovarian axis. X-ray pituitary fossa CT scan identify pituitary lesion. Estimation of FSH/LH Normal FSH is seen in hypothalamic lesion. Raised FSH shows ovarian failure. Low FSH is due to pituitary failure. Raised LH/FSH ratio is seen in PCDO. Laparoscopy is required to evaluate a pelvic mass. Hysteroscopy will be helpful to diagnose and treat Asherman’s syndrome. D/C rules out tubercular endometritis. Hormone therapy to observe withdrawal bleeding assures a young girl of normal genital tract and may indicate constitutional delay in menarche. Blood sugar will confirm or refute diabetes. Treatment of Amenorrhea Treatment of Amenorrhea is based on treating the cause. No treatment is advised if pregnancy is not desired by the woman. Inducing cyclical menstrual bleeding in such a case is a waste of money except that it may have some psychological benefit. Some common primary amenorrhea Turner syndrome- The girl will be short stature, sexual immaturity, webbed neck, shield shaped chest, high arched palate, low set ears, cubitus valgus, aortic coarctation, normal internal and external genitalia. Tests can be done for raised FSH, XO, XO/XX or XO/XY, karyotype. X-ray for cardiovascular and genital urinary abnormalities. Treatment includes combination pill to induce cyclic bleeding and development of secondary sex characters and prevent osteoporosis. Gonadectomy is required if Y chromosome is present. Testicular feminization – There will be normal breast , but no axillary or pubic hair, no galactorrohea, blind short vagina, no uterus or cervix, inguinal hernia. Tests can be done to see testosterone level in male range, XY karyotype. Treatment includes Gonadectomy, hormone replacement therapy, and vaginoplasty. Vaginal agenesis/septum- There will be normal secondary sex characters, no galactorrohea, presence of blind vagina, and palpable mass. Tests can be done for karyotype XX, Testosterone normal, IVP to exclude urinary malformations. Therapy includes Vaginoplasty. Mullerian agenesis- There will be normal secondary sex characters, no galactorrohea, and blind vagina. Tests can be done for karyotype XX, IVP, laparoscopy, ultrasound. Therapy includes Vaginoplasty, and counseling. References: Peter Mayle, Arthur Robins,(1975) What is happening to me.Kensington publishing corp, Newyork. Edited by , V.G Padubri, Shirish N. Daftary(1999),12th Edition, Shaw’s Text book of Gynaecology, B.I Churchill Livingstone Pvt Ltd, New Delhi. Revised by,Cyril A. Keele, Eric Neil,(1965),11th Edition, Samson Wright’s Applied Physiology,Oxford university press, London. Dr.Eve Ashby, Puberty survival guide for girls,Universe Inc. Newyork. Edited by , S, Atul Rhaj, Ashok Grover, Vinay Aggarwal, Sharda Jain,(2005), Text book of Family Medicine,1st Edition, I.M.A college of general Practitioners,Chennai-44 5