Adolescent Females
Pediatricians do not see adolescents as often as children under five years. When I do see female adolescents, certain questions commonly come up. One of the most frequently asked questions relates to the puberty. When will she have her first period? She has too few or too many menstrual periods. How do I know she is normal?
These questions are very important to parents and for their adolescents. This is a major milestone in a young women’s development and misinformation can lead to all types of problems.
During late childhood, important chemicals originating from the brain are released. These stimulate the ovaries to produce additional, essential chemicals like progesterones and estrogens. The first physical signs of puberty are breast budding. This appears around 11 years of age in about 85% of girls, but can be present as early as 8 or as late as 13 years. The appearance of public hair follows, although it may be the first sign of puberty for 15%- 20% of adolescents.
The estrogen release I mentioned earlier will change the character of the vagina and a thin, colorless, odorless fluid or discharge will precede the actual start of menstrual periods. This start of the menstrual cycle is called the menarche. Concern about this discharge is common. You can expect the menarche with menses in about 6 to 12 months following this early sign.
Menarche follows the breast budding or pubic hair of early puberty and will occur by about 12 to 16 years of age. Family history is very important. The date of onset of puberty of the mother corresponds to within one year of the age when puberty will begin for her daughter. In other words, the age when mom started her puberty is an accurate predictor of the age of puberty of her daughter.
During the first 6 to 12 months after menses begins, no egg is shed from the ovary. Because of this, it is common to notice that the periods are very irregular. Some girls may only experience one or two periods the first year while other girls will have regular monthly periods. If there has been no period by the age of 16 then I recommend a thorough evaluation by a pediatric endocrinologist or a gynecologist.
Last reviewed May 18, 2007
Primary dysmenorrhea is the most common adolescent gynecological complaint. It is a painful period without any disease of the pelvis or obvious cause. Usually the first signs of dysmenorrhea appear with the first few periods.
Secondary dysmenorrhea is caused by
some disease process and appears after a regular ovulatory cycle or cycles. Secondary dysmenorrhea follows a long period of painless menses. Conditions that contribute to this dysmenorrhea are infections like pelvic inflammatory disease, complications of pregnancy, endometriosis or uterine or vaginal congenital conditions which cause blockage or adhesions.
At least 60% of adolescent females have menstrual pain. Half of these women have moderate or severe pain and 1/8th of all painful periods contribute to missed days of school and work.
Special points:
Other conditions can mimic painful periods or dysmenorrhea such as tumors, spontaneous abortions, pelvic infections, inflammatory bowel disease, and urinary tract infections. You should contact my office if the cramps don’t get better and interfere with activities. The period should not last more than 10 days. If the flow is very heavy requiring more than 6 pads a day, this is abnormal. Be concerned if one period is missed after they were regular and you believe pregnancy is possible. She should see a doctor if she becomes sexually active or see believes she could have any sexually transmitted diseases.
Adolescents can get relief with over the counter pain relievers like ibuprofen (Advil™), aspirin or Tylenol™. Regular exercise and heat applied to the lower abdomen do help and should be tried. For those with moderate to severe pain, nonsteroidal anti-inflammatory drugs help about 75% of the time. For those who are helped little by this treatment, a pelvic exam is recommended. I refer to a gynecologist if that is necessary.
Oral contraceptives are used in some cases, especially sexually active adolescents. This method reduces pain by stopping ovulation and reducing endometrial growth.
Skin oils and secretions often accumulate under the skin of the uncircumcised penis. This may accumulate and irritate the surrounding skin and lead to an infection. The skin can swell, turn red and interfere with the normal flow of urine.
If you notice the foreskin actually balloon, filling with urine, then medical attention is necessary. Urinary tract infections are more likely to occur.
If the foreskin can easily be retracted, a regular program of hygiene will decrease the chances of secondary infections. If you can not easily retract the foreskin, then no attempt should be made. The majority of children will have no difficulty retracting the foreskin after three or 4 years of age. If there is still difficulty retracting the skin do not attempt it because it will eventually loosen enough as the child grows older so that cleaning the area is easier. Return the foreskin to its normal position over the head of the penis. Sometimes the foreskin is so tight it cannot be pulled back. This is a problem and you should get my help if I am in my office or go directly to the Children’s emergency room. The blood supply to the end of the penis can become impaired. This is not only painful but could cause permanent damage to the tip of the penis.
Discharges from the urinary opening are rare before adolescence and require attention at any age. If there is a build up of natural oils it may appear as an infection. Some occasions occur where an infection develops and drainage is necessary. Soaking the area in a warm water bath often enables the child or parent loosen the foreskin, permitting drainage of the oils or a minor infection. If this can not be accomplished I encourage you to seek my consultation.
A common problem with boys is getting the foreskin caught in the zipper. The child is often a 3 to 6 year old. This occurs most often when parents are in a hurry and zip up a younger child. One of the potential calamities of not wearing underwear, adolescents start wearing jeans with buttons or religiously wear underwear if this happens to them. Removal of the zipper can be achieved with one of these methods: soak the zipper and foreskin with mineral oil for 10 minutes then gently pull the foreskin free. If you have a heavy metal cutter you can split the medial bar of the zipper mechanism that will cause the zipper to fall apart and free the foreskin.
Last reviewed May 18, 2007
New parents are sometimes shocked to find blood coming from the vagina of their week-old infant. This bleeding is caused by hormonal stimulation of the baby’s uterus by the mother’s hormones after pregnancy. When a baby is born, she is no longer exposed to these hormones and a small menstrual flow occurs. This is the same situation that will occur in adolescence when she enters her puberty. Do not be concerned if you see a small amount of vaginal bleeding in the first two weeks of life.
The normal time for your daughter’s first menstrual period is quite variable. Nine to 16 years of age is the range I consider the normal. I encourage you to contact our office if a period begins earlier. After periods begin, cycles are seldom regular for the first two years. The amount of flow may vary widely. These variations usually last for several years after menarche or the beginning of menstruation. Medical help may be needed if the periods are very heavy, painful, prolonged, frequent or have stopped for more than 4 months.
Young women who have had regular periods for several years may have occasional missed periods. An emotionally upsetting experience, severe exercise or pregnancy are frequently the cause. Severe dieting may also affect the regularity of menstrual periods.
Approximately 15% of all women experience some premenstrual symptoms. These symptoms can include headache, irritability, abdominal bloating, breast tenderness, and thirst. Five percent of women can have severe pain during menstruation. Crampy, lower abdominal or back pains begin shortly before the cycle and last about 24 hours. Over-the-counter medications including Tylenol™ or Advil™ work well in most cases.
Sexually active adolescents should have yearly physical exams which include a vaginal and Pap exam. Because I do these infrequently I would advise a visit with a gynecologist.
Vaginal discharge
Prepubertal and pubertal girls have vaginal discharges that are normal. This discharge is white or slightly yellow without other symptoms. Adult hormones cause increased amounts of discharge. Discharges are also common during the first few weeks of life or in mid-cycle after the onset of menses.
Poor hygiene may contribute to vaginal discharge in children. Infestations of pinworms that migrated to the vagina may result in vaginal discharge after intense irritation or secondary infections occur. Another cause of discharges are yeast or candidal infections. These infections commonly occur while a child is on antibiotics.
Last reviewed May 18, 2007