Women and Adolescent Health

Dr Preeti Raheja
Consultant Obstetrics & Gyanecology
Paras Bliss, New Delhi

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.

 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.

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

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.

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.

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.

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.

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.

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 hypothalamicpituitary
ovarian 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

 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

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

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.

 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

 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.

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.

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

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.

 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.

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.

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.

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.

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.

 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.

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.

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.

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.

 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.

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.

 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.

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.

 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.

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.

 One can get HPV from sexual contact,

including vaginal, oral, and anal sex.Most
people infected with HPV don't know they
have itbecause they don't notice any
signs or problems.People do not always
develop genital warts, but the virus isstill
in their system and it could be causing
damage. This means thatpeople 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

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.