Common Gynecological Conditions
Interviewed: Amy Sass, MD, MPH, Adolescent Medicine Physician, Children's Hospital Colorado
Assistant Professor of Pediatrics, Universityof Colorado
Adolescent gynecology is a delicate business, as physicians treat a population whose bodies are in a constant state of transition. Furthermore, teens may feel uncomfortable speaking about their changing bodies and expressing their concerns when there may be a problem. Potentially complicating the conversation are issues that the physician might need to address - like sexual activity, birth control and sexual abuse. These sensitive topics and concerns about confidentiality may make the teen feel shy and less forthcoming, especially with a parent present.
Given these potential challenges, it is helpful for a primary care provider (PCP) to familiarize his or herself with common, adolescent gynecologic problems. Amy Sass, MD, MPH, an adolescent medicine physician at Children's Hospital Colorado, outlined four conditions that PCPs may encounter in their offices.
The single-most common gynecological complaint teenage girls present to their PCPs is dysmenorrhea – any discomfort that accompanies the menstrual cycle. Commonly reported symptoms include lower abdominal cramping, breast tenderness, irritability and headaches. For most females, dysmenorrhea lasts for the first two to three days of the menstrual cycle.
Up to 90% of adolescent girls and teens experience dysmenorrhea. The prevalence of dysmenorrhea increases with gynecologic age (time from menarche) due to its association with ovulatory cycles. Because most teens don’t ovulate regularly for one to two years after menarche, they may be surprised when symptoms appear.
Classic symptoms are cyclical and correlate with the menstrual cycle, typically starting one to two days before menstrual bleeding and persisting through the first two to three days of the period before resolving. In addition to the severity of symptoms, it can be helpful to ascertain the degree of daily function impairment the young woman might experience and need alleviated (e.g. number of missed school days of each month from pain).
Dr. Sass encourages teens to consistently track their periods on a menstrual calendar. This helps them better predict their next period and develop skills to “listen to the subtle signs of their bodies.” It is preferable to proactively treat symptoms of dysmenorrhea when they are mild rather than waiting until they become more severe. If teens can anticipate their next period, they may start medicating a few days ahead of time.
Nonsteroidal anti-inflammatory medications (NSAIDs), like Ibuprofen and Naproxyn (as directed) are first-line therapies, as potent prostaglandins are the mediators of dysmenorrhea. Dr. Sass prefers Naproxen over Ibuprofen for ease with twice daily dosing which allows for better coverage during sleep without re-dosing. NSAIDs are typically continued through the first few days of bleeding. Some teens may have some improvement with NSAID therapy but still describe significant symptoms. These women are candidates for medications – such as hormonal contraceptive methods – to suppress ovulation as the next step in treatment.
If symptoms are persistent and not markedly improved following three months of hormonal contraception and NSAID use around the period, further evaluation for secondary causes of dysmenorrhea may be necessary. These secondary causes include anatomical abnormalities, endometriosis and myofascial pain. If the young woman is sexually active, pregnancy and related disorders, sexually transmitted infections and pelvic inflammatory disease are always in the differential diagnosis of pelvic pain.
Polycystic Ovarian Syndrome (PCOS)
PCOS is the most common endocrine disorder of reproductive-aged women. It occurs in up to 6% of adolescents and 12% of adult women. PCOS is characterized by ovarian dysfunction, disordered gonadotropin secretion and hyperandrogenemia, which causes amenorrhea, hirsutism and acne. Many adolescents with PCOS are overweight and the association of PCOS with insulin resistance is well established. Adolescents with PCOS face increased risk for obesity-related morbidities including Type 2 diabetes mellitus, dyslipidemia and cardiovascular disease, low self esteem, and adult reproductive health problems such as infertility and endometrial cancer.
The adolescent with PCOS usually presents with oligomenorrhea or secondary amenorrhea, acne and hirsutism. In addition to the typical laboratory evaluation for secondary amenorrhea including pregnancy test, follicle stimulating hormone (FSH) and Prolactin, the standard initial laboratory evaluation for PCOS includes total and free testosterone, and dehydroepiandrosterone sulfate. Excessively elevated testosterone levels (>200ng/dL) and/or DHEAS (>700ug/dL) are concerning, as they may indicate an adrenal or ovarian tumor. PCPs should conduct pelvic and adrenal imaging to evaluate for a possible tumor.
If other etiologies of androgen excess such as late-onset congenital adrenal hyperplasia (history of premature pubarche, high DHEAS, cliteromegaly) are suspected, the PCP should collect a first morning 17-hydroxyprogesterone to look for 21-hydroxylase deficiency. If the physician suspects Cushing's syndrome, he or she should conduct urine cortisol or a dexamethasone suppression test. If the patient is overweight and/or has acanthosis nigricans, a fasting insulin, lipid panel and two-hour oral glucose challenge test are recommended. A simple fasting glucose is less ideal, as many women with PCOS have normal fasting glucose results but impaired postprandial tests. Consultation with a pediatric endocrinologist can assist in further evaluation and management of significantly elevated androgens and endocrinopathies.
"A woman can reverse this," says Dr. Sass, explaining that treatment requires lifestyle modification to encourage weight loss. Encouraging lifestyle changes that will promote weight loss is a primary goal of therapy for PCOS in adolescents.
Weight loss is associated with improved menstrual regulation and decreased symptoms of hyperandrogenemia, obesity related comorbidities and infertility. Combination estrogen/progesterone hormonal contraceptives improve menstrual regularity by increasing sex hormone binding globulin, which effectively decreases free androgen exposure. There is also a role for the use of insulin-sensitizing medications such as Metformin if the adolescent has glucose intolerance.
"The biggest misconception that teens have about PCOS is that they are infertile," says Dr. Sass. Although decreased fertility can be a consequence of PCOS, this misconception could lead to devastating consequences. PCPs should remind the sexually active adolescent to use condoms and birth control consistently.
Dysfunctional Uterine Bleeding (DUB)
DUB results from irregular endometrial sloughing accompanying anovulatory cycles. It is more commonly seen in younger adolescents during the first one to two years following the first menstrual period as their hypothalamic-pituitary-ovarian axis is maturing. It may be characterized by menorrhagia (prolonged bleeding that occurs at regular intervals) or menometrorrhagia (heavy prolonged bleeding that occurs irregularly and more frequently than normal).
In addition to anovulatory cycles, the differential diagnosis of DUB includes: pregnancy complications, sexually transmitted infections and pelvic inflammatory disease, bleeding disorders (e.g., von Willebrand deficiency, platelet function abnormalities, thrombocytopenia), endocrine disorders such as thyroid dysfunction, trauma to the vagina or foreign body in the vagina, and use of exogenous hormones (e.g., borrowing a friend’s oral contraceptive pills).
In addition to a menstrual and sexual history, the bleeding pattern should be characterized, including cycle length, duration and quantity of bleeding (e.g., number of soaked pads or tampons in 24 hours and number of menstrual accidents). Bleeding for more than ten days is usually considered abnormal. The PCP should assess the patient for symptoms of anemia, including fatigue, lightheadedness, syncope, tachycardia, and for other abnormal bleeding (gingivae, stool and easy bruising).
The physical exam includes an assessment hemodynamic stability with orthostatic heart rate and blood pressure measurements. The PCP should evaluate mucous membranes and skin for pallor; the heart for tachycardia and murmur; the abdomen for organomegaly, and the external genitalia for signs of trauma or congenital anomalies. If the patient has never been sexually active, a pelvic exam is usually unnecessary. For a sexually experienced female, the PCP should conduct a pelvic and bimanual exam to examine the vagina, cervix/uterus and adnexae. Initial laboratory tests include: urine pregnancy test, CBC with differential, reticulocyte count and PT/PTT. Additional labs to consider include: TSH, von Willebrand panel, platelet function analysis, iron studies and Chlamydia and Gonorrhea testing if sexually active.
The severity of DUB is determined by hemodynamic status and degree of anemia, and classified as mild (HgB>12 g/dL), moderate (HgB 9-12 g/dl) or severe (HgB <9). The goals of treatment include:
1. Establishment and/or maintenance of hemodynamic stability
2. Correction of acute or chronic anemia
3. Resumption of normal menstrual cycles
4. Prevention of recurrence
5. Prevention of long-term consequences of anovulation
Management depends on the severity of the problem and its specific etiology. Oral contraceptive pills are typically used QD-QID to control bleeding. As an alternative, Dr. Sass also likes to use Norethindrone Acetate, 5-10 mg QD-BID, alone or in addition to a daily oral contraceptive. This helps control bleeding, as there is much less nausea associated with the progestin compared to taking multiple pills containing estrogen every day. Supplemental iron is typically prescribed as 2-6 mg/kg day in divided doses depending on the degree of anemia. Patients with severe anemia and any signs of hemodynamic instability may need an emergency room evaluation, facing possible hospitalization for further evaluation and aggressive treatment.
It is important to remind adolescents and their families of the vital importance of compliance with medications to control bleeding and treat anemia. PCPs should treat adolescents until the anemia resolves. Often they continue treatment for at least six months if there is an underlying problem, such as platelet function abnormality or von Willebrand disease.
Non-Herpetic Vulvar Ulcers
“We have seen an increased incidence of non-herpetic vulvar ulcers in the community during the last six years,” says Dr. Sass. These “tremendously painful and distressing” vulvar lesions look like quarter-sized canker sores on the labia manora near the vaginal opening and often appear in conjunction with fever and a non-specific viral illness. Dr. Sass and her colleagues have been following nearly 50 teen girls who have developed these ulcers. According to Dr. Sass, these patients are typically, “otherwise wonderfully healthy, active kids with low social risk factors.”
Although pediatric researchers and caregivers are currently investigating the etiology of vulvar ulcers, current theory suggests they are a manifestation of aphthosis, temporally precipitated by stress from a variety of insults, including Epstein Bar virus and other nonspecific viral infections.
“Almost half of our patients have a history of oral aphthous ulcers,” says Dr. Sass. “And almost a third have had recurrent vulvar ulcerations.” Further evaluation to rule out Behçet’s disease, such as biopsy and rheumatologic and ophthalmologic consults, should be considered for patients with recurrent oral and genital lesions or significant extra-genital involvement.
Pain management and supportive care are the mainstays of treatment. Dr. Sass describes treatment as “half handholding and half trouble shooting,” with a regimen of frequent sitz baths, anti-inflammatory pain medicating, and frequent use of topical lidocaine. Oral antibiotics and/or steroids have not been shown to help. The ulcers are self-limited and typically resolve within two to three weeks without scarring. Almost one-third of Children’s patients experience recurrent lesions.
While PCPs can easily treat vulvar ulcers, they should closely monitor for concerning symptoms such as wound and perineal super-infection, and labial edema that can compromise adequate blood flow to the mucosa or obstruct urination. Dr. Sass and the adolescent medicine physicians at Children's Hospital Colorado can help providers manage these serious cases.
To consult with an adolescent medicine specialist at Children’s, please call the department at (720) 777-6131 or through One Call at (720) 777-3999 or (800) 525-4871.