WOMEN AND ADOLESCENT HEALTH - PARAS BLISS

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Women and Adolescent Health Dr Preeti
Raheja Consultant Obstetrics Gyanecology Paras
Bliss, New Delhi
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INTRODUCTION

• Adolescence refers to the stage from puberty to
  adulthood, and includes the psychological
  experiences of the child during this period.
  Adolescence is described as being the teenage
  years from thirteen to eighteen years of age
  however, puberty decides the onset of
  adolescence. Therefore, adolescence occurs in
  some children as early as nine years of age.

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• During adolescence there is a large degree of
  psychological growth as children make adjustments
  in their personality due to the rapid physical
  and sexual development which are characteristic
  of this period of life. Adolescents face ongoing
  conflict and difficulty adapting to the sudden
  upsurge of changes in body. These changes cause
  unrest and confusion in the adolescents inner
  selves and in the way they perceive the world.

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CONTENTS

• Physiological changes
• Menstruation
• Abnormalities and symptoms that require
  consultation
• Aspects of nutrition
• Sexual Education
• Cervical cancer vaccination

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PHYSIOLOGICAL CHANGES

• Rapid Growth
• You can expect rapid growth in height and weight
  during your child's adolescence. Girls experience
  their growth spurt between the ages of 9 and 14,
  You can also expect your teen to gain weight, as
  girls put on fat. Variances in growth can cause
  teenagers to feel self conscious about their
  bodies. Teens may feel they are all limbs -- and
  at times, this could be true.

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PHYSIOLOGICAL CHANGES

• STAGES OF PHYSIOLOGICAL CHANGES
• Development of the breasts Also known as
  Thelarche and which marks the full development of
  the breasts from minor buds by the age of 12.
• Pubarche starts between the age of 10-15, where
  in hair growth starts around the pubic and
  axillary regions along with the thickening of
  other hair.
• Menarche is the onset of the first menstruation
  marks the beginning of puberty for girls. This
  can start anytime between 10 and 15 years old,
  and this marks the beginning of fertility.
  Menstruation typically starts two years after
  breast buds develop, which can be as early as 8
  year old.

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PHYSIOLOGICAL CHANGES

• Hair Growth
• One of the more noticeable and celebrated changes
  in teenagers is hair growth. Both males and
  females can expect pubic hair to grow. This may
  start as much as three years earlier in females,
  starting as early as age 9 and reaching adult
  patterns by age 14. Armpit and leg hair will also
  develop during this time.

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PHYSIOLOGICAL CHANGES

• Body Odor and Acne
• Two disturbing changes during adolescence are the
  occurrence of body odor and acne. Hormones that
  cause sexual maturation and other body changes
  also lead to increased oil production. Both males
  and females will notice changes in their skin as
  it becomes coarser and the sebaceous glands
  produce more oil that can cause acne and
  blackheads. Sweat glands also become more active,
  and the combination of sweat and oils causes an
  odor, making the use of deodorant a necessity.
  Teens need to be more vigilant with hygiene to
  keep up with their body changes.

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MENSTRUATION

• Menarche typically occurs within 23 years after
  thelarche (breast budding), at Tanner stage IV
  breast development, and is rare before Tanner
  stage III development. By age 15 years, 98 of
  females will have had menarche. An evaluation for
  primary amenorrhea should be considered for any
  adolescent who has not reached menarche by age 15
  years or has not done so within 3 years of
  thelarche. Lack of breast development by age 13
  years also should be evaluated.

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Cycle Length and Ovulation

• Menstrual cycles are often irregular during
  adolescence, particularly the interval from the
  first cycle to the second cycle. Most females
  bleed for 27 days during their first menses.
  Immaturity of the hypothalamicpituitaryovarian
  axis during the early years after menarche often
  results in an ovulation and cycles may be
  somewhat long however, 90 of cycles will be
  within the range of 2145 days, although short
  cycles of less than 20 days and long cycles of
  more than 45 days may occur. By the third year
  after menarche, 6080 of menstrual cycles are
  2134 days long, as is typical of adults.

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• Adolescents with cycles that are consistently
  outside of the range of 20 to 45 days should be
  evaluated for pathologic conditions, such as the
  polycystic ovary syndrome (PCOS), eating
  disorders, thyroid disease, hyper prolactinemia,
  or even such rare conditions as ovarian
  insufficiency (premature ovarian failure

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ABNORMALITIES AND SYMPTOMS THAT REQUIRE
CONSULTATION

• Some of the common adolescent health issue that
  needs to be evaluated within time are
• Abnormal uterine bleeding
• Ovarian cysts
• Breast abnormalities

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Abnormal Uterine Bleeding

• Abnormal uterine bleeding (AUB) is any form of
  bleeding that is irregular in amount, duration,
  or frequency. It can be characterized by
  excessive uterine bleeding that occurs regularly
  (menorrhagia), by heavy bleeding at irregular
  times (metrorrhagia), or a combination of both
  (menometrorrhagia). It can also be intermittent
  bleeding or sparse cyclical bleeding
  (oligomenorrhea). Dysfunctional uterine bleeding
  (DUB) is a subset of AUB and is defined as
  excessive, prolonged, or unpatterned bleeding
  from the endometrium without an organic cause and
  is frequently used synonymously with an ovulatory
  bleeding. In adolescents, up to 95 of AUB is
  DUB. However, because DUB is a diagnosis of
  exclusion, other potential causes of abnormal
  bleeding must be ruled out.

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• Girls and adolescents with more than 3 months
  between periods should be evaluated. Although
  experts typically report that the mean blood loss
  per menstrual period is 30 ml per cycle and that
  chronic loss of more than 80 ml is associated
  with anemia, this has limited clinical use
  because most females are unable to measure their
  blood loss. Menstrual flow requiring changes of
  menstrual products every 12 hours is considered
  excessive, particularly when associated with flow
  that lasts more than 7 days at a time.

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• The diagnosis of pregnancy, sexual trauma, and
  sexually transmitted infections should be
  excluded, even if the history suggests the
  patient has not been sexually active.

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Ovarian Cysts

• The most common ovarian cyst among adolescent
  girls is PCOS.
• Polycystic ovarian syndrome, or PCOS, is a
  condition in which there is an imbalance in the
  female sexual hormones. This leads to the growth
  of ovarian cysts (benign masses on the ovaries).
  PCOS can cause problems with a womens menstrual
  cycle, fertility, cardiac function, and
  appearance.

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Common characteristics of PCOS

• Irregular menstrual periods
• Unexplained Weight gain
• Acne
• Hirsutism- Appearance of thick and dense hair on
  the face
• Mood swings
• Infertility
• Pelvic pain

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Other types of cysts

• Follicular cyst  A follicular cyst develops each
  month and contains the small egg within it. The
  sac ruptures during ovulation and the egg comes
  out of the cyst. Sometimes the cyst can grow
  larger than the normal size which is up to 3 cm.
  If the sac that holds the egg doesnt break open
  to release the egg, it can grow, anywhere in size
  from 1 inch to 4 inches across. Usually this type
  of cyst disappears in one to three months and
  often does not cause pain.

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• Corpus luteum cyst  A corpus luteum cyst is
  normal and usually forms each month after the egg
  breaks out or ovulates. This type of cyst usually
  disappears by itself in a few weeks, but it can
  grow 3-4 inches across, and may bleed inside of
  the cyst or your belly. This type of cyst can
  cause pain in your abdomen (belly).
• These problems can be cured by consulting a
  doctor on time.

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Breast Abnormalities

• Breast masses can cause anxiety for adolescent
  girls and their parents.
• Breast masses can arise during any stage of
  puberty, so it is important to understand normal
  breast development. Thelarche (initiation of
  breast development) usually begins between the
  ages of 9 and 10 years.

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Breast examination

• Clinical breast examination. The American Cancer
  Society (ACS) in 2003 recommended that a clinical
  breast examination (CBE) be done at least every 3
  years for women in their 20s and 30s. For
  adolescents, the CBE serves as an opportunity to
  increase their ease with their bodies and with
  the examination itself and to bring up any
  breast-related concerns.
• Breast self-examination. Teaching and performance
  of the breast self-examination (BSE) in
  adolescents remains controversial, given that the
  incidence of breast cancer in adolescents aged 15
  to 19 years is only 0.2 per 100,000. The American
  College of Obstetricians and Gynecologists does
  not recommend teaching adolescents BSE until the
  age of 19 years.

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Common breast masses in adolescents

• Fibrocystic changes. Breast lumps associated with
  cordlike thickenings are physiologic,
  hormone-induced breast changes and normal
  variants of regular breast tissue. Each month,
  they can become painful and enlarged during the
  week before menses, resulting in mastalgia. These
  breast changes are possibly related to the
  monthly hormone fluctuations of estrogen and
  progesterone.  

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• Fibroadenomas. Fibroadenomas comprise 68 of
  breast masses in adolescents and are believed to
  be caused by an abnormal response to estrogen.
  Fibroadenomas present as 2 cm to 3 cm masses but
  can enlarge during the menstrual cycle. Physical
  examination demonstrates a firm, mobile, oval or
  round, nontender, rubbery mass, separate from the
  underlying breast tissue and usually located in
  the upper outer quadrants. On ultrasound,
  fibroadenomas normally appear as a
  well-circumscribed, homogeneous, hypoechoic mass
  with smooth distinct borders. Generally, the
  width of the fibroadenoma is greater than its
  height.

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• Two options exist for management of
  fibroadenomas. They can be monitored via serial
  clinical examinations every 3 to 6 months because
  up to 50 of lesions decrease in size or
  disappear after 5 years. Alternatively, referral
  to a surgeon for an excisional biopsy is
  indicated for patients whose fibroadenomas
  continue to grow or who are uncomfortable with
  only clinical monitoring.

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ASPECTS OF NUTRITION

• Eating healthy food is important at any age, but
  its especially important for teenagers.
• As your body is still growing, its vital that
  you eat enough good quality food and the right
  kinds to meet your energy and nutrition needs.
• Boys require an average of 2,800 calories per
  day.
• Girls require an average of 2,200 calories per
  day.

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Important Nutrients

• Protein
• Proteins are the most essential body building
  sources, which are very important to be included
  in the diets of an adolescent. The densest
  sources of protein include teenage favorites such
  as Chicken, Fish, Eggs and Cheese.

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• Carbohydrates
• In planning meals, we want to push
  complex-carbohydrate foods and go easy on simple
  carbohydrates. Complex carbs provide sustained
  energy that's why you often see marathon runners
  and other athletes downing big bowls of pasta
  before competing. As a bonus, many starches
  deliver fiber and assorted nutrients too. They
  are truly foods of substance filling yet low in
  fat.
• Most nutritionists recommend that complex
  carbohydrates make up 50 to 60 of a teenager's
  caloric intake.
• Simple carbs, on the other hand, seduce us with
  their sweet taste and a brief burst of energy but
  have little else to offer and should be minimized
  in the diet.

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• Dietary Fat
• Fat should make up no more than 30 of the diet.
  Fat supplies energy and assists the body in
  absorbing the fat-soluble vitamins A, D, E, and
  K. But these benefits must be considered next to
  its many adverse effects on health. A teenager
  who indulges in a fat-heavy diet is going to put
  on weight, even if he's active.

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• Dietary fat contains varying proportions of three
  types
• Monounsaturated fat the healthiest kind found
  in olives and olive oil peanuts, peanut oil and
  peanut butter cashews walnuts and walnut oil,
  and canola oil.
• Polyunsaturated fat found in corn oil, safflower
  oil, sunflower oil, soybean oil, cottonseed oil,
  and sesame-seed oil.
• Saturated fat is the most cholesterol laden of
  the three found in meat and dairy products like
  beef, pork, lamb, butter, cheese, cream, egg
  yolks, coconut oil, and palm oil.

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• Vitamins and Minerals
• Adolescents tend to most often fall short of
  their daily quotas of calcium, iron, zinc, and
  vitamin D.
• Unless blood tests and a pediatrician's
  evaluation reveal a specific deficiency, it's
  preferable to obtain nutrients from food instead
  of from dietary supplements.

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SEXUAL EDUCATION

• Adolescent girls should be at the heart of a
  life course approacha young adolescent girl is
  still a child, but often she will soon become a
  mother. Adolescent pregnancy is associated with
  higher risk of maternal mortality and morbidity,
  stillbirths, neonatal deaths, preterm births, and
  low birth weight. In addition to actions to
  prevent adolescent pregnancy and encourage
  pregnancy spacing, efforts are required to ensure
  that pregnant and lactating teenage mothers are
  adequately nourished.

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• Psychological and social aspects of adolescents
  development are less often described in
  connection with adolescent health than their
  physical growth and maturation characteristics.
• Girls aged between 12-14 years are more likely to
  be talked or forced into having unplanned and
  unprotected sex giving way to teenage
  pregnancies. About two thirds of teen pregnancies
  occur in girls aged between 18-19 years.

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CERVICAL CANCER VACCINATION

• Cervical cancer is one of the most common cancers
  in females in our country. The main causative
  agent for most these cancers are due to HPV. It
  is a cancer which affects the females of later
  age group. Primary prevention for this cancer is
  possible through the HPV vaccine. Young girls in
  the age group of 11-13 are advised to take this
  vaccine in order to protect them from cervical
  cancer at later age.

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• One can get HPV from sexual contact, including
  vaginal, oral, and anal sex. Most people infected
  with HPV don't know they have it because they
  don't notice any signs or problems. People do not
  always develop genital warts, but the virus
  is still in their system and it could be causing
  damage. This means that people with HPV can pass
  the infection to others without knowing it.
• Because HPV can cause problems like genital warts
  and some kinds of cancer, a vaccine is an
  important step in preventing infection and
  protecting against the spread of HPV.

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END NOTE

• The health and nutrition statuses of women and
  children are intimately linked. Improving the
  health of women and children, therefore, begins
  with ensuring the health and nutritional status
  of women throughout all stages of life, and it
  continues with women being providers for their
  children and families.

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