RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

Synopsis of Dissertation

“A PROFILE OF GYNAECOLOGICAL PROBLEMS

OF ADOLESCENT GIRLS”

Submitted by:
Dr. JYOTIRMOY HAJRA, MBBS
POSTGRADUATE STUDENT IN OBSTETRICS AND GYNAECOLOGY

Department of Obstetrics and Gynaecology

Adichunchanagiri Institute of Medical Sciences,
B.G. Nagar, Nagamangala Taluk, Mandya District -571 448
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
 BANGALORE, KARNATAKA
ANNEXURE II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 NAME OF THE CANDIDATE Dr. JYOTIRMOY HAJRA

AND ADDRESS
(in block letters)
2. NAME OF THE INSTITUTION
POSTGRADUATE STUDENT IN OBSTETRICS AND
GYNAECOLOGY,
ADICHUNCHANAGIRI INSTITUTE OF
MEDICAL SCIENCES, B.G.NAGARA,
MANDYA DISTRICT – 571448.
ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES,
B.G.NAGARA

COURSE OF STUDY AND

3. M.S. IN OBSTETRICS & GYNAECOLOGY
SUBJECT
DATE OF ADMISSION TO
4. 1ST JUNE 2007
COURSE
“A PROFILE OF GYNAECOLOGICAL PROBLEMS
5. TITLE OF THE TOPIC OF ADOLESCENT GIRLS”

6.
BRIEF RESUME OF INTENDED WORK
6.1 NEED FOR THE STUDY

Adolescence is the most vital period of growth. This is the age group when a girl child grows
into an adult woman. It’s a period of dynamic change. In India very little attention is given to the
specific needs of the adolescent girls, who comprise 22% of the female population. Patients in this age
group seek gynaecological services for many specific problems that demand empathetic and
professional care. Moreover, data is also lacking regarding the exact magnitude of the gynaecological
problems of adolescents, as studies conducted in this field have been very few. A few studies that have
been done have not covered all the gynaecological problems and their correlation with various
psychological, cultural and environmental factors. The present study aims to assess the magnitude and
variety of gynaecological problems in this region, so that effective guidelines can be set regarding
clear-cut management protocols for this special group of patients.
6.2 REVIEW OF LITERATURE

Adolescence is the time period between 10 and 19 years of age (1), (2), (22), (23) during which, along with
physiological changes, psychological and socio-behavioural changes also occur. It is imperative to have a
thorough knowledge of the normal changes occurring in this age-group, as also of the demographic pattern
of distribution and prevalence of specific gynaecological problems in order to offer quality medical/surgical
services to this group of patients.

Timing of pubertal changes are influenced by many factors including general health, nutrition,
exercise, genetic influences and socio-economic conditions (3).

The major changes are appearance of secondary sex characters and also those due to the maturation of
reproductive system (4)

(a) Thelarche and Puberche (Breast and hair development):

Breast development is one of the first secondary sexual characteristics to be noticed. One useful tool
used for measuring this is Tanner Sexual maturity Rating (SMR) Scale (4). Normal puberty involves a
fairly regular sequence of events between the ages of 10 and 16 years and abnormal puberty can be
defined as any disturbance in this.(5)

(b) Menarche:
Menarche usually occurs between SMR 3 and 4. The chronological onset of menarche may range
from 10 to 16.5 years (4).

The various gynaecological disorders in adolescents are as follows:

1) Menstrual Problems:
a) Dysmenorrhoea:
Dysmenorrhoea is the most common gynaecological problem occurring in about 52% of post
pubescent women with 10% of them missing school regularly because of this problem.

b) Premenstrual Syndrome:
The premenstrual syndrome is a group of interrelated symptom-complexes with different
pathophysiologic mechanisms (5). In a survey of 207 adolescents, however, 89% reported at least one
PMS symptom that the teens considered moderately severe, 59% reported at least one symptom
considered severe, and 43% reported at least one symptom considered extreme. (6)

c) Abnormal uterine bleeding:

Abnormal uterine bleeding is a relatively common menstrual problem during adolescence.
Menorrhagia is a frequent presentation. In a study group 74% of adolescents with bleeding sufficient
to require hospitalization did not have any organic pathology. (7). Among the rest, 19% were
secondary to coagulopathies and 7% included pregnancy complications, OCP use etc.
Polymenorrhoea or too frequently occurring periods cause great inconvenience for the girls in this
age group and hampers with social and academic performance.
 d) Amenorrhoea:
The incidence of primary amenorrhoea has been reported to range from 0.65% to 83.3% in different
series (8) (9) in the adolescents.

e) Leucorrhoea:
This is frequent and embarrassing problem especially in low socio-economic population. Infection is
the most likely cause and vaginitis is more commonly diagnosed than that caused by physiologically
excess discharge. Increased levels of endogenous estrogen lead to marked overgrowth of the
endocervical epithelium which may encroach outward, and produce ectocervical erosion leading to
excess discharge. (10)

f) Ovarian Tumours in Adolescents:

Ovarian tumour in childhood and adolescence rare, accounting for approximately 1% of all
malignant neoplasms found in the age group 0-17 years (11). In a review literature, ovarian tumours in
the 0-20 year’s age group comprised 6% of all ovarian tumours (12).

g) Benign Lesions of Vulva and vagina:

Different benign lesions of vulva and vagina also presents in this age group, such as cysts: Gartner’s
and Paraurethral, Inclusion cysts and Paramesonephric cysts; and Polyps.

h) Malignant tumors of Vulva and Vagina:

Malignant tumors of Vulva are rare and most of them are sarcomas. A report describes the first
known case of Endodermal sinus Tumour of the vulva in a 14 year old girl whose uterus, tubes and
ovaries were normal (13). Malignant tumours comprise carcinoma of Vagina and sarcoma of Vagina.

i) Benign tumours of Uterus and cervix:

These lesions are rare in adolescents. Benign papillomas of cervix (14) have been reported. A cervical
leiomyoma was reported by Snyder in 1976. Uterine leiomyoma also have been reported (14).

j) Malignant Tumors of Uterus and Cervix:

 Carcinoma Of Cervix:
Carcinoma of cervix is rare in this age group, and when it occurs, it is often glandular or
adenomatus. In most reported cases, the lesions were invasive at the time of detection (13).
However, with the age of initial intercourse having decreased, squamous cell carcinoma
may become more prevalent in future. This has been reflected in the number of
intraepithelial neoplasms found in young adolescents (15)

 Carcinoma of body of uterus:

The world’s literature contains less than 10 cases of this lesion (14).
 k) Pelvic Inflammatory Disease:
The incidence of Pelvic Inflammatory Disease is on the rise. Acute salpingitis has been reported as
20 per 1000 in association with STDs, Multiple or frequently changed partners, Inrauterine device
use, and probably poor socioeconomic factor. The use of condoms, diaphraghm, Spermicidals and
OCPs has increased the chance of PID. The topic of IUD-use and upper genital tract infection has
recently been reviewed in some literatures.

l) Vulvo-vaginitis:
In recent years, with increasing and earlier onset of sexual activity, STDs, Vulvovaginitis and
pregnancies have become common problems (16). The adolescents tend to have herpetic
vulvovaginitis and more than one STDs at one time. Current leading causes of vaginal discharge are
Hemophilus Vaginalis Vaginitis, endocervicitis (Chlamydia, Gonnorrhoea, Trichomonas), Herpetic
Ulcer, Candida-vaginitis and Trichomonal vaginitis.

m) Foreign Bodies:
In adolescents, the most common foreign body is a forgotten tampon. A patient may use paraffin
candle, electric vibrators etc for masturbation.

n) Vulval Skin Diseases:

Generalized skin diseases have a vulval expression, since this area is exposed to warmth, moisture,
maceration and secondary infection due to scratching. Seborrhic dermatitis and Condylomas may
involve vulva.

o) Breast problems:
Breast problems of teenagers remain an often neglected aspect of adolescent care. All growing
female children develop some concern about their changing bodies, particularly with reference to
their breasts. Congenital anomalies like polythelia, polymastia; inverted nipples, breast asymmetry,
mammary hyperplasia, atrophy of the breasts and benign lesions of the breast are commonly
observed. Carcinoma of the breasts is very rare in adolescents, although it should be kept in mind
when an adolescent presents with a suspicious breast lesion (17). Infection of the breasts, non-
lactational mastitis, Mondor’s disease, duct ectasia, galactorrhoea and premature breast development
comprise the other forms of presentation.

p) Premarital sex:
With the advent of globalization, the topics of premarital and adolescent sexuality deserve special
consideration. Earlier age at first intercourse is experiencing an increasing trend. As a consequence,
sexually transmitted diseases and failed contraception have increasingly being encountered in
gynaecological practices.

q) Adolescent pregnancy:
This is a common problem of developing countries like India. Enough data is currently lacking to
measure the exact extent of this problem in our country, where this is a prevalent practice among the
uneducated and low socio-economic population. In the US at least 75% of adolescent pregnancies
are unintended (18), one half of which ends in abortion (19).
 (20)
Approximately one in three young women will experience a pregnancy before 20 years of age . In
a study recently conducted in Banaras Hindu University Institute of Medical science, teenage
pregnancy was found to be associated with a significantly higher risk of PIH, PET, and eclampsia,
premature onset of labor, fetal deaths and premature delivery. Increased neonatal morbidity and
mortality were also seen in babies delivered to teenage mothers. Younger teenager group (< 17 years)
was most vulnerable to adverse obstetric and neonatal outcomes (21).

6.3 OBJECTIVES OF THE STUDY

 The main objective of this study is to identify presence of the gynaecological problems in adolescent
girls in this part of Karnataka.

 To study the extent or enormity of the problems of adolescent girls of rural Karnataka, as this
institution is the only one in Karnataka that caters the health care needs of the rural population.

 To analyze the relationship of the gynaecological problems to the socio-economic, psychological,

cultural and environmental factors.

7 MATERIALS AND METHODS

7.1 Source of Data :

The study involves all adolescent girls aged 10 to 19 years with gynaecological problems attending the
outpatient department of Obstetric and Gynaecology, Sri Adichunchanagiri Hospital and Research Centre,
BG Nagara, including those getting admitted for treatment and/or investigations.

7.2 Method of Collection of Data : (Including the Sampling Procedure if any)

The proposed study will be conducted at Sri Adichunchanagiri Hospital and Research centre, BG Nagara
from December 2007 onwards. Data will be collected by:
1. Detailed history taking, including socio-economic, cultural and environmental history.
2. General physical examination.
3. Systemic examination.
4. Gynaecological examination.
5. Obstetrical examination.
6. Baseline and Special investigations.
 Inclusion Criteria :
All women aged between 10 and 19 years presenting with gynaecological problems.

Exclusion Criteria :
Women aged less than 10 years or more than 19 years.

7.3 Does the study require any investigations Routine and special investigations to arrive at a correct
or interventions to be conducted on diagnosis, without affecting the management of the patient. This
patients, if so please describe briefly is not an interventional study.

7.4 Has the ethical clearance been obtained

from your institution in case of 7.3 NA
8. LIST OF REFERENCES
(1)World health Organization; 1998: Proceedings of the WHO South Asia Conference on Adolescence.
(2) World Health Organization, Internet: Website of DEPARTMENT OF CHILD AND ADOLESCENT HEALTH
AND DEVELOPMENT; (http://www.who.int/child-adolescent-health) Accessed November 9, 2007
(3) Rees M, Menarche when and why? Lancet 342: 1375-1376, 1993
(4) Marshall WA, Tanner JM. Variations in patterns of pubertal changes in girls; Arch Dis Child 1969;44:291-303
(5) Adam Balen, Disorders of puberty. In: Shaw RW, Soutter WP, Stanton LS; Gynaecology. Philadelphia: Churchill
Livingstone, 2003:215
(5) Chakmakijan ZH: A critical assessment of therapy for the premenstrual tension syndrome. J. Reprod. Med. 28:532-
538, 1983
(6) Fisher M, Trieller K, Napelitano B: Premenstrual Syndrome in Adolescents; Journal of Adolescent Health Care;
10:369-375, 1989
(7) Claessens EA, Cowell CA: Acute Adolescent Menorrhagia; American Journal of Obstetrics and Gynaecology;
139:277-228, 1981
(8) Radhwanska E, Dwyer GM: Journal of Obs. Gynaec, British Commonwealth; 81:107; 1974
(9) Goswami S, Dutta R, Sengupta S, A profile of adolescent girls with gynaecological problems; Journal of
Obstetrics and gynaecology of India; 55:4:353-355
(10) Datta DC, Konar H, Textbook of Gynaecology; Kolkata, India: Central, 2007:504
(11) Acosta a, Kaplan A, Kauffman R: Gynecolocic cancer in children; Am J. Obstet. Gynecol; 112:944, 1972
(12) Norris H, Jensen R: Relative frequency of ovarian neoplasm in children and adolescents: Cancer; 30:713; 1972
(13) Beller FK et al.: Endodermal germ cell carcinoma in infant girls. J. Cancer Res. Clin. Oncol. 3:94, 1979
(14) Huffman JW: The Gynaecology of Childhood and Adolescence; Philadelphia, Saunders, 1968
(15) Synder RN et al. Dysplasia and carcinoma in situ of the uterus in very young women; Am J Obstet. Gynaecol.;
124: 751-756; 1976
(16) Altcheck A: Adolescent Vulvovaginitis, Pediatr. Clin. Of North Am.; 19:735, 1972
(17) Dudgeon BL: Pediatric breast lesions: take the conservative approach; Contemporary paediatrics; 2:61-73;1985
(18) Henshaw SK.: Unintended pregnancy in the United States. Family planning perspectives: 30:24-29;1998
(19) Teen sex and pregnancy (fact-sheet) New York: The Alan Guttmatter Institute; 1999
(20) National campaign to Prevent Teenage Pregnancy. Fact sheet: available at:
http://www.teenpregnancy.org/resources/reading/pdf/35percent.pdf ; February 2004; Accessed November 29,
2004
(21) Kumar A, Singh T, Basu S, Pandey S, Bhargava V: Outcome of teenage pregnancy; Indian Journal of Pediatrics:
74.10:927-931; 2007
(22) World Health Organization: Young people’s health – a challenge for society: Report of a Study Group on Young
People and Health for All by the Year 2000, Technical Report Series, No. 731. Geneva: World Health Organization,
1986. Available at: http://whqlibdoc.who.int/trs/WHO_TRS_731.pdf; (Accessed September 8, 2003).
(23) American Academy of Paediatrics: Council on Child and Adolescent Health. Age limits of paediatrics.
Paediatrics; 81:736; 1988
9. SIGNATURE OF THE CANDIDATE

The number of adolescent girls attending gynaecological

clinic is increasing all over the world. This study is going to
give an insight into the problems faced by them. As this
10. REMARKS OF THE GUIDE
institution is a rural-based institition, it may be interesting to
know the variety, profile and enormity of the gynaecological
problems of the adolescents.

NAME & DESIGNATION OF Prof. Dr. NAGALAKSHMI BHTTACHARYYA,

MBBS, DGO, MD
(IN BLOCK LETTERS)
PROFESSOR,
11.1 GUIDE DEPARTMENT OF O.B.G.,
11. A.I.M.S., B.G.NAGARA.

11.2 SIGNATURE

11.3 CO-GUIDE (IF ANY) NA

11.4 SIGNATURE NA
Prof. Dr. S. VIJAYALAKSHMI,

11.5 HEAD OF DEPARTMENT PROFESSOR AND HEAD,

DEPARTMENT OF O.B.G.,
A.I.M.S., B.G.NAGARA.

11.6 SIGNATURE

12.2 REMARKS OF THE CHAIRMAN

12.
AND PRINCIPAL

12.2 SIGNATURE

APPENDIX-IID
 PROFORMA APPLICATION FOR ETHICS COMMITTEE APPROVAL

SECTION A

“A PROFILE OF GYNAECOLOGICAL PROBLEMS

A Title of the study
OF ADOLESCENT GIRLS”

Dr. JYOTIRMOY HAJRA

POSTGRADUATE STUDENT IN OBSTETRICS AND
Principle investigator GYNAECOLOGY,
B
(Name and Designation) ADICHUNCHANAGIRI INSTITUTE OF
MEDICAL SCIENCES, B.G.NAGARA,
MANDYA DISTRICT – 571448.
Prof. Dr. NAGALAKSHMI BHTTACHARYYA,
MBBS, DGO, MD
Co-investigator
c PROFESSOR,
(Name and Designation)
DEPARTMENT OF O.B.G.,
A.I.M.S., B.G.NAGARA.
Name of the Collaborating
d NO
Department/Institutions
Whether permission has been obtained from the
e heads of the collaborating departments & NA
Institution
Section – B
Kindly see Sl. No. 6 in Annexure II
Summary of the Project
Section – C
Kindly see Sl. No. 6.3 in Annexure II
Objectives of the study
Section – D
Kindly see Sl. No. 7 in Annexure II
Methodology
DEPARTMENT OF O.B.G.
A Where the proposed study will be undertaken
S.A.H. & R.C., B.G. NAGARA

B Duration of the Project 18 MONTHS

Nature of the subjects:
Does the study involve adult patients? YES
Does the study involve Children? YES
C NO
Does the study involve normal volunteers?
Does the study involve Psychiatric patients? NO
Does the study involve pregnant women? YES
If the study involves health volunteers
i Will they be institute students?
D ii Will they be institute employees? NA
iii Will they be Paid?
iv If they are to be paid, how much per session?
E Is the study a part of multi central trial? NO
F If yes, who is the coordinator? NA
 (Name and Designation)

Has the trail been approved by the ethics NA

Committee of the other centers?

If the study involves the use of drugs please NA

indicate whether.

I. The drug is marketed in India for the indication NA

in which it will be used in the study.

II. The drug is marketed in India but not for the NA

indication in which it will be used in the study

III. The drug is only used for experimental use in NA

humans.

IV Clearance of the drugs controller of India has NA

been obtained for:

 Use of the drug in healthy volunteers NA

 Use of the drug in-patients for a new
indication. NA
 Phase one and two clinical trials NA
 Experimental use in-patients and healthy NA
volunteers.

How do you propose to obtain the drug to be used

in the study?
- Gift from a drug company
G NA
- Hospital supplies
- Patients will be asked to purchase
- Other sources (Explain)

Funding (If any) for the project please state

- None
H - Amount NONE
- Source
- To whom payable

Does any agency have a vested interest in the out

I NO
come of the Project ?

Will data relating to subjects /controls be stored in

J NO
a computer?
 Will the data analysis be done by
K - The researcher? YES
- The funding agent NO
Will technical / nursing help be required form the YES
staff of hospital.

If yes, will it interfere with their duties? NO

Will you recruit other staff for the duration of the

study? NO

L If Yes give details of

I. Designation
II. Qualification NA
III. Number NA
IV. Duration of Employment NA
NA

Will informed consent be taken? If yes YES

Will it be written informed consent: YES
Will it be oral consent? NO
M
Will it be taken from the subject themselves? YES, (ADULTS)
Will it be from the legal guardian? If no, give
reason: YES,( MINORS)

N Describe design, methodology and techniques Kindly see Sl. No. 7 in Annexure II

Ethical clearance has been accorded.

Chairman,
Postgraduate Training–Cum Research Committee,
A.I.M.S., B.G. Nagara
Date :
Abbreviations used :
NA – Not Applicable;
OCP: Oral Contraceptive Pills;
PIH: Pregnancy Induced Hypertension;
PET: Pre-Eclamptic Toxaemia
STD: Sexually Transmitted Diseases;
(NOTE: PREVIOUS REGN NO: 01_M009_186)