February 27, 2020

Vasilios Tanos MD, PhD, Prof in Obstetrics and Gynaecology, Aretaeio Hospital, Nicosia

Bleeding Irregularities in the adolescent are mainly due to aberrations in the Hypothalamic Pituitary ovarian (HPO) axis. Prolactinoma, thyroid disease, hyperandrogenic anovulation (PCOS), CAH and Cushing syndrome are the main endocrinopathies causing bleeding anomalies. Abnormal bleedings with normal HPO axis happens mainly due to Pregnancy and Bleeding disorders.

CDC Guidelines for Adolescent Preventive Services and ACOG define as adolescence age the 13 -15 y old. Experts from different disciplines led to conclusion that primary health threats to adolescents are behavioral rather than biomedical. CDC-GAPS report concludes that many adolescents are engaged in multiple health risks simultaneously, including unsafe sexual practices, substance use/abuse, (alcohol, RTA) and violence (CDC Atlanta 2011).
Adolescents have the highest rates of gonorrhea and HPV of any age group and 50% of the sexually active (15 -19 ys) will have PID. CDC recommends routine screening for Chlamvdia for all sexually active adolescents, regardless of other risk factors. Hepatitis B is the only completely preventable STD. American Academy of Pediatrics and ACOG advisory committee on Immunization Practices recommends hepatitis B vaccination series at age 11 to 12. Treatment of STDs among adolescents is identical to those for adults (effort for single dose regimes).

Pregnancy in adolescents in western world is decreasing mainly due to sex education at school and OC. However programs for prevention of unwanted pregnancies and how to manage pregnant adolescents are still not fully implemented in many European countries.

Early menarche and short menstrual cycles increase risk of endometriosis (Cramer DW, Missmer SA AnnNY Acad Sci 2002, MissmerSA et al Am I Epidem 2004). 50% among teens with chronic pelvic pain or dysmenorrhea associated with endometriosis (Mahmood TA, Templeton A Hum Reprod 1991, Sangi H, Poindexter III AN Obst Gyneco 1995) Below the age of 17, chronic pelvic pain is associated with mullerian anomalies and cervical vaginal obstruction (Huffman JW Pediatr Ann 1981) Dyspareunia also is associated with endometriosis (Reese KA et al J Pediatr Adolesc 1996, Many adolescents suffer from endometriosis, however due their age many physicians deny to establish the diagnosis due to lack of scientific evidence about disease prognosis. However today trans vaginal laparoscopy can offer reliable and accurate diagnosis and treatment of endometriotic subtle lesions as well as evacuation and ablation of endometriomas upto 3 -4 cm. Conventional laparoscopic surgery techniques on small endometrioma might cause more destruction to healthy ovarian tissue. The instruments tips are too big for such a small lesions.

The incidence of ovarian cysts in adolescence is 2-5 / 100,000 girls / year and the major symptom is abdominal pain. Tumor Markers such as Ca 125, alfa-fetoprotein and beta hCG and abdominal ultrasound are usually included in the workup. TVU is performed in 40%, CTS in 21% and MRI in 20% of the cases. Benign functional cysts are 30%, cystic teratomas 26% while malignant cysts present 1% of all cancers in children and adolescents. Fertility sparing surgery is the target in these cases preserving the ovarian hilus and avoiding destruction of mesosalpings, ie the microvascularization (Cass DL et al J Paediat Surg 2001, Templeman C et al Obst Gynecol 2000, Bristow RE J Adolesc Health 2006).

Adolescents are diagnosed with PCOS using the same criteria for adults. Menstrual irregularity is a common feature, often the earliest clinical manifestation, difficult to distinguish from anovulation associated with puberty. Hyperandrogenism presents with severe acne and/or hirsutism, best measure androgen excess. Diagnosis of PCO poses difficulties in adolescents. Ovarian appearance and volume may vary due to abdominal US and obesity. The current epidemic of childhood obesity may increase the severity of symptoms of PCOS and underscores the importance of its early and accurate diagnosis. In patients with well-defined hyperandrogenemia, a metabolic workup should be performed. When diagnosis is not clear, follow up and repeat evaluation in 6 to 12 months (Rev Obstet Gynecol 2011).

When a suspected foreign body or vaginal abnormality and or congenital anomaly is suspected then a diagnostic non-invasive procedure saving virginity and preserving hymen should be applied. Perineal US and Hysteroscopy are the best options. Once a congenital uterine anomaly (CUA) is suspected, it is important to establish complete diagnosis as soon as possible. No need of invasive diagnostic methods but 3D US and MRI will diagnose the vast majority of CUA. More severe the uterine anomaly the risk of urological malformations is increased. The impact on self esteem and psychosocial development of the adolescent / teenage will direct the type and timing of management to be followed.