Paediatric and Adolescent Gynaecology- Chapter 5:

Q 5. 1 Our baby has had a little vaginal bleeding. Is this worrying?

• It is quite common for baby girls to have a little bleeding a few days after they are born. During pregnancy, your oestrogen levels will have been high and some of this hormone will have reached the lining of your baby’s womb. After she was delivered, her oestrogen level will have fallen, resulting in a little bleeding for a few days. A similar situation will arise if you are breast feeding and take an oestrogen treatment – including the pill.

Q 5. 2 What are intersex states?

• Intersex states occur when there is ambiguity or uncertainty about physical sexual status. These conditions are extremely rare. Several factors determine the sex of an individual including the chromosomes, hormones and hormone receptors (Q2.8). In humans, there are 23 pairs of chromosomes with the twenty-third pair being responsible for gender. Females have two ‘X’ chromosomes and males have one ‘X’ and one ‘Y’ chromosome. During early embryonic development in females, the womb and Fallopian tubes develop from areas called “the Mullerian ducts”. The male produces anti-Mullerian hormone and testosterone. The anti-Mullerian hormone suppresses development of the tissues developed from the Mullerian ducts, and testosterone encourages development of the male organs.

• The intersex states arise when there is a problem in early embryonic sexual development. In male pseudohermaphroditism the genotype (chromosome pattern) is ‘XY’ but there is poor or absent male organ development. There are several causes of male pseudohermaphroditism the best known being testicular feminisation syndrome (Q 6.14).

Q 5. 3 Our toddler does not seem to have a normal opening down below. What should be done?

• Sometimes the genital lips of a little girl may be adherent to one another and understandably give rise to parental concern although the condition causes no symptoms. The anatomy will be otherwise normal; ultrasound may provide further reassurance. The adhesions are probably a result of low oestrogen levels and so topical oestrogen cream applied for two weeks will often release the adhesion. Surgery is rarely required and, even then, should be delayed until puberty.

Q 5. 4 My little girl has a vaginal discharge. What might be the cause?

• Vulvovaginitis (inflammation of the external genital area and vagina) is the only common gynaecological problem occurring before puberty. The genital area is red and sore and there may be discharge from the vagina. It can occur at any age but peaks around five years of age. Little girls are prone to poor hygiene as parental supervision is withdrawn and the child cleans herself inadequately: this can result in a little faecal matter entering the vagina. The natural chemical mechanism protecting the vagina from infection during reproductive years (Q22.1) is absent in the child so faecal contamination of the vagina will rapidly start infection.

• Careful hygiene after every bowel action is essential. Bland creams such as Sudocrem or E45 may provide some protection. Your daughter should be encouraged to wipe in a backward direction to avoid faecal contamination of the genital area. Chemical irritation must be avoided – her bath should be thoroughly cleansed and rinsed before she uses it and clothes should be rinsed after washing. Leggings and tights should be avoided as they may keep the genital area moist, and underclothes should not be worn at night.

• Young children have a tendency to explore their bodies and sometimes small objects may be introduced into the vagina. This may lead to a smelly, blood stained discharge. The doctor may be able to feel such an object by gently introducing a small finger into the rectum. Ultrasound examination may help to exclude a foreign body. If there is any doubt, there are times when the vagina can be checked with a tiny speculum although this usually requires an anaesthetic.

Q 5. 5 What is puberty?

• Puberty is that episode in development when a child develops into an adolescent with the physical ability to reproduce. For girls these changes include:-

• Breast development. The first sign of breast development (the “thelarche”) is enlargement of the nipples around the age of 11years (normal range 9-14). Full breast development takes about four years but may last as long as nine years. Frequently, one breast may seem to enlarge faster than the other although generally nature will ensure that they are equal when fully developed.

•  Pubic hairs start to show around the time of breast development and the axillary(armpit) hair follows about two years after the pubic hair.

•  The various parts of the vulva (Figure 2.2) and the vagina slowly enlarge during puberty.

• A growth spurt in height around the age of ten or eleven. Typically they grow between 6 and 12 cm a year for two years. This growth spurt stops with only one or two more centimetres being added yearly and then stopping by the age of fifteen or sixteen.

•  The menarche, which is the first period, is the most obvious landmark in puberty tending to occur about 30 months after the first signs of breast development and is therefore seen at any time between 10 and 16.

Q 5. 6 What is precocious puberty?

• Precocious puberty is diagnosed when puberty begins before the age of eight years. It occurs far more frequently in girls than boys. Although thorough investigation including MRI (Q4.9) scans of the pituitary gland are required, no specific cause can usually be identified. A variety of drugs have been used to suppress precocious puberty; GnRH analogues (Q33.46) are currently the most favoured.

Q 5.7 Our teenage daughter’s periods have not started yet. When should we seek medical advice?

• The first period has usually occurred by the age of sixteen. If pain occurs at monthly intervals but no menstrual loss is seen, medical advice should be sought earlier as this may indicate that periods are occurring but the blood is blocked from coming out (false amenorrhoea – Q6.3). There are many causes for absence of periods (amenorrhoea – Q 6.7).

• Our baby girl has had a little vaginal bleeding. Is this worrying?
• What are intersex states?
• Our toddler does not seem to have a normal opening.What should be done?
• My little girl has a vaginal discharge.What might be the cause?
• What is puberty?
• What is precocious puberty?
• Our teenager has not started her periods. When should we seek advice?
• Our daughter’s periods are infrequent. When should we be concerned?
• What is adolescence?
• What is acne and what can be done about it?
• Our teenager has more body hair than expected. What should we do?
• Our daughter’s periods result in time away from school.What can be done?
• How does the doctor recommend treatment for teenage period problems?
• How long should treatment of teenage period problems be continued?
• Should a D&C be performed for a teenager with period problems?
• Are there any particular worries about a teenager having a pregnancy?
• What should be the purpose of sex education?
• My adolescent daughter is being difficult. Could she have a hormone problem?
• Are there any special contraceptive considerations for teenagers?
• What contraceptive options are available for adolescents?
• Are there worries if a teenager takes the pill?
• Can a teenager use emergency contraception?
• Where can I obtain further information?
• Could I have some recommended Web sites?

Q 5. 8 Our daughter’s periods are occurring infrequently. Should we be concerned?

• It is quite common for periods to be infrequent for the first two or three years. An ultrasound of the pelvis and some hormone tests may be worth considering for reassurance. One woman in five has polycystic ovaries and two thirds of women with polycystic ovaries seen on ultrasound will have no symptoms. There is no need for concern if polycystic ovaries are seen. There is a good chance that in the long-term there will be no problem and for those who continue to have symptoms there are several treatments (Chapter 7).

• Q 5. 1 Our baby has had a little vaginal bleeding. Is this worrying?

• Q 5. 2 What are intersex states?

• Q 5. 3 Our toddler does not seem to have a normal opening down below. What should be done?

• Q 5. 4 My little girl has a vaginal discharge. What might be the cause?

• Q 5. 5 What is puberty?

• Q 5. 6 What is precocious puberty?

• Q 5.7 Our teenage daughter’s periods have not started yet. When should we seek medical advice?

• Q 5. 8 Our daughter’s periods are occurring infrequently. Should we be concerned?

• Q 5. 9 What is adolescence?

• Q 5. 10 What is acne and what can be done about it?

• Q 5. 11 Our teenage daughter seems to have more body hair than we would expect. What should be done?

• Q 5. 12 Our teenage daughter’s periods are so heavy that she has to be absent from school. What can we do?

• Q 5. 13 How does the doctor determine the treatment of heavy periods for an adolescent?

• Q 5. 14 How long should treatment of heavy periods be continued with an adolescent?

• Q 5. 15 Should a ‘D & C’ (cervical dilatation and curettage Q24.12) be performed for an adolescent with period problems?

• Q 5. 16 Are there any particular worries about a teenager having a pregnancy?

• Q 5. 17 What should be the purpose of sex education?

• Q 5.18 My adolescent daughter is being difficult. Could she have an underlying hormone problem?

• Q 5. 19 Are there any special contraceptive considerations for teenagers?

• Q 5. 20 What contraceptive options are available to adolescents?

• Q 5. 21 Are there any medical worries if a young teenager takes the oral contraceptive pill?

• Q 5. 22 Can a teenager use emergency contraception?

• Q 5. 23 Where can I obtain more information?

• Q 5. 24 Could I have some useful Web sites?

• Women’s Health – Home Page

• Chapter 05 Adolescence

Q 5. 9 What is adolescence?

• Adolescence is the transitional time zone between dependent childhood and adult independence. Adolescence is a difficult, often turbulent, time as girls must rapidly come to terms with the physical and emotional changes associated with womanhood. Friction between parents and adolescent is a frequent occurrence, particularly when there is disagreement on the degree of independence that is warranted.

• Whilst there is some overlap with puberty, adolescence begins and finishes later. Gynaecological problems in childhood and adolescence may fall between the disciplines of paediatrics (the medical specialty of caring for babies and children) and gynaecology. There is a broad spectrum of normality. Parental anxieties may frequently compound the problems experienced at this difficult time.

• Q 5. 1 Our baby has had a little vaginal bleeding. Is this worrying?

• Q 5. 2 What are intersex states?

• Q 5. 3 Our toddler does not seem to have a normal opening down below. What should be done?

• Q 5. 4 My little girl has a vaginal discharge. What might be the cause?

• Q 5. 5 What is puberty?

• Q 5. 6 What is precocious puberty?

• Q 5.7 Our teenage daughter’s periods have not started yet. When should we seek medical advice?

• Q 5. 8 Our daughter’s periods are occurring infrequently. Should we be concerned?

• Q 5. 9 What is adolescence?

• Q 5. 10 What is acne and what can be done about it?

• Q 5. 11 Our teenage daughter seems to have more body hair than we would expect. What should be done?

• Q 5. 12 Our teenage daughter’s periods are so heavy that she has to be absent from school. What can we do?

• Q 5. 13 How does the doctor determine the treatment of heavy periods for an adolescent?

• Q 5. 14 How long should treatment of heavy periods be continued with an adolescent?

• Q 5. 15 Should a ‘D & C’ (cervical dilatation and curettage Q24.12) be performed for an adolescent with period problems?

• Q 5. 16 Are there any particular worries about a teenager having a pregnancy?

• Q 5. 17 What should be the purpose of sex education?

• Q 5.18 My adolescent daughter is being difficult. Could she have an underlying hormone problem?

• Q 5. 19 Are there any special contraceptive considerations for teenagers?

• Q 5. 20 What contraceptive options are available to adolescents?

• Q 5. 21 Are there any medical worries if a young teenager takes the oral contraceptive pill?

• Q 5. 22 Can a teenager use emergency contraception?

• Q 5. 23 Where can I obtain more information?

• Q 5. 24 Could I have some useful Web sites?

• Women’s Health – Home Page

• Chapter 05 Adolescence

Q 5. 10 What is acne and what can be done about it?

• The altered hormone balance in puberty may increase skin oil production from the sweat glands. If the ducts of these glands become blocked the glands may become infected leading to the typical spots seen in acne.

• Careful washing twice daily with water alone or perhaps with an antiseptic soap will usually suffice. Occasionally, regular antibiotics or hormonal treatments such as the pill may be required.

• Q 5. 1 Our baby has had a little vaginal bleeding. Is this worrying?

• Q 5. 2 What are intersex states?

• Q 5. 3 Our toddler does not seem to have a normal opening down below. What should be done?

• Q 5. 4 My little girl has a vaginal discharge. What might be the cause?

• Q 5. 5 What is puberty?

• Q 5. 6 What is precocious puberty?

• Q 5.7 Our teenage daughter’s periods have not started yet. When should we seek medical advice?

• Q 5. 8 Our daughter’s periods are occurring infrequently. Should we be concerned?

• Q 5. 9 What is adolescence?

• Q 5. 10 What is acne and what can be done about it?

• Q 5. 11 Our teenage daughter seems to have more body hair than we would expect. What should be done?

• Q 5. 12 Our teenage daughter’s periods are so heavy that she has to be absent from school. What can we do?

• Q 5. 13 How does the doctor determine the treatment of heavy periods for an adolescent?

• Q 5. 14 How long should treatment of heavy periods be continued with an adolescent?

• Q 5. 15 Should a ‘D & C’ (cervical dilatation and curettage Q24.12) be performed for an adolescent with period problems?

• Q 5. 16 Are there any particular worries about a teenager having a pregnancy?

• Q 5. 17 What should be the purpose of sex education?

• Q 5.18 My adolescent daughter is being difficult. Could she have an underlying hormone problem?

• Q 5. 19 Are there any special contraceptive considerations for teenagers?

• Q 5. 20 What contraceptive options are available to adolescents?

• Q 5. 21 Are there any medical worries if a young teenager takes the oral contraceptive pill?

• Q 5. 22 Can a teenager use emergency contraception?

• Q 5. 23 Where can I obtain more information?

• Q 5. 24 Could I have some useful Web sites?

• Women’s Health – Home Page

• Chapter 05 Adolescence

Q 5. 11 Our teenage daughter seems to have more body hair than we would expect. What should be done?

• Excess body hair (hirsutism) may be distressing for any lady and this may be particularly worrying for a teenager who is just becoming aware of her sexuality. The assessment, investigation and treatment of excess body hair is discussed in detail in Chapter 8. Frequently, examination will show that there is only marginal excess hair and some simple investigations of hormone levels and an ultrasound of the uterus and ovaries may provide reassurance that there is no major problem.

• Q 5. 1 Our baby has had a little vaginal bleeding. Is this worrying?

• Q 5. 2 What are intersex states?

• Q 5. 3 Our toddler does not seem to have a normal opening down below. What should be done?

• Q 5. 4 My little girl has a vaginal discharge. What might be the cause?

• Q 5. 5 What is puberty?

• Q 5. 6 What is precocious puberty?

• Q 5.7 Our teenage daughter’s periods have not started yet. When should we seek medical advice?

• Q 5. 8 Our daughter’s periods are occurring infrequently. Should we be concerned?

• Q 5. 9 What is adolescence?

• Q 5. 10 What is acne and what can be done about it?

• Q 5. 11 Our teenage daughter seems to have more body hair than we would expect. What should be done?

• Q 5. 12 Our teenage daughter’s periods are so heavy that she has to be absent from school. What can we do?

• Q 5. 13 How does the doctor determine the treatment of heavy periods for an adolescent?

• Q 5. 14 How long should treatment of heavy periods be continued with an adolescent?

• Q 5. 15 Should a ‘D & C’ (cervical dilatation and curettage Q24.12) be performed for an adolescent with period problems?

• Q 5. 16 Are there any particular worries about a teenager having a pregnancy?

• Q 5. 17 What should be the purpose of sex education?

• Q 5.18 My adolescent daughter is being difficult. Could she have an underlying hormone problem?

• Q 5. 19 Are there any special contraceptive considerations for teenagers?

• Q 5. 20 What contraceptive options are available to adolescents?

• Q 5. 21 Are there any medical worries if a young teenager takes the oral contraceptive pill?

• Q 5. 22 Can a teenager use emergency contraception?

• Q 5. 23 Where can I obtain more information?

• Q 5. 24 Could I have some useful Web sites?

• Women’s Health – Home Page

• Chapter 05 Adolescence

Q 5. 12 Our teenage daughter’s periods are so heavy that she has to be absent from school. What can we do?

• Teenagers are particularly reluctant to seek medical advice because of embarrassment. Frequently it is the mother who brings her daughter for advice particularly when school work is suffering.

• There is a wide spectrum of normality in menstrual loss around puberty. The periods are rarely regular and consistent from the start. About 95% of girls will have their first period between the ages of eleven and fifteen.

• The first period and those that immediately follow do not generally follow ovulation (egg release). The ovaries have started to produce oestrogens resulting in thickening of the lining of the uterus (endometrial lining); and a point is reached when the oestrogen levels are inadequate to maintain this lining and a period occurs. When periods are excessive in amount or frequency, painful or infrequent, medical advice should be sought. When the periods are too frequent, it may be difficult to determine whether each loss is a period or bleeding between periods (intermenstrual bleeding).

• It is essential to take a full history. A general examination is usually conducted, but a pelvic examination can be withheld if this would cause embarrassment or discomfort. The management of heavy and irregular periods is discussed elsewhere (Chapter 24). Ultrasound examination of the pelvic organs will usually provide reassurance that the womb and ovaries appear normal.
• When periods are heavy from their outset, assessment of the blood clotting mechanism may be required.

• Q 5. 1 Our baby has had a little vaginal bleeding. Is this worrying?

• Q 5. 2 What are intersex states?

• Q 5. 3 Our toddler does not seem to have a normal opening down below. What should be done?

• Q 5. 4 My little girl has a vaginal discharge. What might be the cause?

• Q 5. 5 What is puberty?

• Q 5. 6 What is precocious puberty?

• Q 5.7 Our teenage daughter’s periods have not started yet. When should we seek medical advice?

• Q 5. 8 Our daughter’s periods are occurring infrequently. Should we be concerned?

• Q 5. 9 What is adolescence?

• Q 5. 10 What is acne and what can be done about it?

• Q 5. 11 Our teenage daughter seems to have more body hair than we would expect. What should be done?

• Q 5. 12 Our teenage daughter’s periods are so heavy that she has to be absent from school. What can we do?

• Q 5. 13 How does the doctor determine the treatment of heavy periods for an adolescent?

• Q 5. 14 How long should treatment of heavy periods be continued with an adolescent?

• Q 5. 15 Should a ‘D & C’ (cervical dilatation and curettage Q24.12) be performed for an adolescent with period problems?

• Q 5. 16 Are there any particular worries about a teenager having a pregnancy?

• Q 5. 17 What should be the purpose of sex education?

• Q 5.18 My adolescent daughter is being difficult. Could she have an underlying hormone problem?

• Q 5. 19 Are there any special contraceptive considerations for teenagers?

• Q 5. 20 What contraceptive options are available to adolescents?

• Q 5. 21 Are there any medical worries if a young teenager takes the oral contraceptive pill?

• Q 5. 22 Can a teenager use emergency contraception?

• Q 5. 23 Where can I obtain more information?

• Q 5. 24 Could I have some useful Web sites?

• Women’s Health – Home Page

• Chapter 05 Adolescence

Q 5. 13 How does the doctor recommend the best treatment for teenage period problems.

• Explanation and reassurance may be all that is required. Medical treatment will depend on the severity of the problem in combination with patient preference or that of the parents for the younger adolescent. The commonest reason for heavy and irregular periods in teenage menstrual cycles is anovulation (eggs are not being released). Typically the endometrium becomes particularly thickened before the period as there has been no progesterone to counter the oestrogen (Q 24.17). Progestogen therapy (24.17B) is likely to prove beneficial. In adolescence, as the heavy periods are usually related to anovulation, the progestogen can be taken from about the 16th day of the cycle for ten or eleven days. A period can be expected two or three days later.
• If this regimen does not suffice the progestogen can be taken from earlier in the cycle (Q 24.17).

• The combined oral contraceptive pill is generally the most successful hormone therapy although some parents may have understandable reservations about their daughter starting this even for menstrual control. When sexual activity has begun, the combined oral contraceptive pill may be the preferred choice. If there is reluctance to commence hormonal treatment, tranexamic acid (Q 24.17C) and mefenamic acid (24.17D) may be effective. Tranexamic acid is taken during heavy period days and will reduce the flow. Mefenamic acid reduces the flow and is also beneficial when periods are painful (dysmenorrhoea). It has been estimated that one adolescent in six will have significant dysmenorrhoea. Occasionally, bleeding may be extremely heavy warranting hospital admission.

• Q 5. 1 Our baby has had a little vaginal bleeding. Is this worrying?

• Q 5. 2 What are intersex states?

• Q 5. 3 Our toddler does not seem to have a normal opening down below. What should be done?

• Q 5. 4 My little girl has a vaginal discharge. What might be the cause?

• Q 5. 5 What is puberty?

• Q 5. 6 What is precocious puberty?

• Q 5.7 Our teenage daughter’s periods have not started yet. When should we seek medical advice?

• Q 5. 8 Our daughter’s periods are occurring infrequently. Should we be concerned?

• Q 5. 9 What is adolescence?

• Q 5. 10 What is acne and what can be done about it?

• Q 5. 11 Our teenage daughter seems to have more body hair than we would expect. What should be done?

• Q 5. 12 Our teenage daughter’s periods are so heavy that she has to be absent from school. What can we do?

• Q 5. 13 How does the doctor determine the treatment of heavy periods for an adolescent?

• Q 5. 14 How long should treatment of heavy periods be continued with an adolescent?

• Q 5. 15 Should a ‘D & C’ (cervical dilatation and curettage Q24.12) be performed for an adolescent with period problems?

• Q 5. 16 Are there any particular worries about a teenager having a pregnancy?

• Q 5. 17 What should be the purpose of sex education?

• Q 5.18 My adolescent daughter is being difficult. Could she have an underlying hormone problem?

• Q 5. 19 Are there any special contraceptive considerations for teenagers?

• Q 5. 20 What contraceptive options are available to adolescents?

• Q 5. 21 Are there any medical worries if a young teenager takes the oral contraceptive pill?

• Q 5. 22 Can a teenager use emergency contraception?

• Q 5. 23 Where can I obtain more information?

• Q 5. 24 Could I have some useful Web sites?

• Women’s Health – Home Page

• Chapter 05 Adolescence

Q 5. 14 How long should treatment of heavy periods be continued with an adolescent?

• As tranexamic acid and mefenamic acid can be taken at times when periods are heavy or painful, the patient can continue these as long as they are required. They can also be offered as a back-up when hormonal therapy is about to be withdrawn. Hormonal treatments are best taken for a few months and can be withdrawn on a trial basis at a time that is socially convenient such as during a school holiday.

• Dysmenorrhoea (painful periods) in adolescents tends to occur when ovulation (egg-release) is occurring. Mefenamic acid (Q24.17) may reduce pain as well as the amount of blood that is lost. The combined oral contraceptive pill suppresses ovulation and is probably the most effective treatment. Treatment may be required for some years.

• Q 5. 1 Our baby has had a little vaginal bleeding. Is this worrying?

• Q 5. 2 What are intersex states?

• Q 5. 3 Our toddler does not seem to have a normal opening down below. What should be done?

• Q 5. 4 My little girl has a vaginal discharge. What might be the cause?

• Q 5. 5 What is puberty?

• Q 5. 6 What is precocious puberty?

• Q 5.7 Our teenage daughter’s periods have not started yet. When should we seek medical advice?

• Q 5. 8 Our daughter’s periods are occurring infrequently. Should we be concerned?

• Q 5. 9 What is adolescence?

• Q 5. 10 What is acne and what can be done about it?

• Q 5. 11 Our teenage daughter seems to have more body hair than we would expect. What should be done?

• Q 5. 12 Our teenage daughter’s periods are so heavy that she has to be absent from school. What can we do?

• Q 5. 13 How does the doctor determine the treatment of heavy periods for an adolescent?

• Q 5. 14 How long should treatment of heavy periods be continued with an adolescent?

• Q 5. 15 Should a ‘D & C’ (cervical dilatation and curettage Q24.12) be performed for an adolescent with period problems?

• Q 5. 16 Are there any particular worries about a teenager having a pregnancy?

• Q 5. 17 What should be the purpose of sex education?

• Q 5.18 My adolescent daughter is being difficult. Could she have an underlying hormone problem?

• Q 5. 19 Are there any special contraceptive considerations for teenagers?

• Q 5. 20 What contraceptive options are available to adolescents?

• Q 5. 21 Are there any medical worries if a young teenager takes the oral contraceptive pill?

• Q 5. 22 Can a teenager use emergency contraception?

• Q 5. 23 Where can I obtain more information?

• Q 5. 24 Could I have some useful Web sites?

• Women’s Health – Home Page

• Chapter 05 Adolescence

Q 5. 15 Should a ‘D & C’ (cervical dilatation and curettage Q24.12) be performed for an adolescent with period problems?

• Modern investigations including ultrasound and hormone tests provide us with the information required. Whereas some years ago the ‘D & C’ with the accompanying opportunity to examine the pelvic organs under anaesthetic, was more frequently undertaken we would now rarely consider this investigation in a young woman. The ‘D & C’ is an investigation and not a treatment.

• Q 5. 1 Our baby has had a little vaginal bleeding. Is this worrying?

• Q 5. 2 What are intersex states?

• Q 5. 3 Our toddler does not seem to have a normal opening down below. What should be done?

• Q 5. 4 My little girl has a vaginal discharge. What might be the cause?

• Q 5. 5 What is puberty?

• Q 5. 6 What is precocious puberty?

• Q 5.7 Our teenage daughter’s periods have not started yet. When should we seek medical advice?

• Q 5. 8 Our daughter’s periods are occurring infrequently. Should we be concerned?

• Q 5. 9 What is adolescence?

• Q 5. 10 What is acne and what can be done about it?

• Q 5. 11 Our teenage daughter seems to have more body hair than we would expect. What should be done?

• Q 5. 12 Our teenage daughter’s periods are so heavy that she has to be absent from school. What can we do?

• Q 5. 13 How does the doctor determine the treatment of heavy periods for an adolescent?

• Q 5. 14 How long should treatment of heavy periods be continued with an adolescent?

• Q 5. 15 Should a ‘D & C’ (cervical dilatation and curettage Q24.12) be performed for an adolescent with period problems?

• Q 5. 16 Are there any particular worries about a teenager having a pregnancy?

• Q 5. 17 What should be the purpose of sex education?

• Q 5.18 My adolescent daughter is being difficult. Could she have an underlying hormone problem?

• Q 5. 19 Are there any special contraceptive considerations for teenagers?

• Q 5. 20 What contraceptive options are available to adolescents?

• Q 5. 21 Are there any medical worries if a young teenager takes the oral contraceptive pill?

• Q 5. 22 Can a teenager use emergency contraception?

• Q 5. 23 Where can I obtain more information?

• Q 5. 24 Could I have some useful Web sites?

• Women’s Health – Home Page

• Chapter 05 Adolescence

Q 5. 16 Are there any particular worries about a teenager having a pregnancy?

• There are several problems associated with teenage pregnancy including social, economic, cultural, educational and political issues. Both pregnancy and adolescence are times of emotional upheaval and when the two are combined there is need for support and counselling. When an adolescent becomes a parent her education will, at best, be delayed but more usually it will be discontinued. Her employment opportunities are reduced, her income is likely to be low, long-lasting relationships are infrequent and there is often need for prolonged welfare support. Many adolescent mothers, whilst aware of their own needs, may be less sensitive to the needs of their child.

• Teenage pregnancy is becoming a serious public health problem, particularly in less developed countries where obstetric facilities are limited. Teenage pregnancies are associated with increased risks of miscarriage, premature labour, blood pressure problems (pre-eclampsia), small-for-dates babies and perinatal mortality (death of the baby before birth or in the first week of after delivery) is increased.

• Prevention of unplanned pregnancy in adolescents has become an international medical priority.

• Q 5. 1 Our baby has had a little vaginal bleeding. Is this worrying?

• Q 5. 2 What are intersex states?

• Q 5. 3 Our toddler does not seem to have a normal opening down below. What should be done?

• Q 5. 4 My little girl has a vaginal discharge. What might be the cause?

• Q 5. 5 What is puberty?

• Q 5. 6 What is precocious puberty?

• Q 5.7 Our teenage daughter’s periods have not started yet. When should we seek medical advice?

• Q 5. 8 Our daughter’s periods are occurring infrequently. Should we be concerned?

• Q 5. 9 What is adolescence?

• Q 5. 10 What is acne and what can be done about it?

• Q 5. 11 Our teenage daughter seems to have more body hair than we would expect. What should be done?

• Q 5. 12 Our teenage daughter’s periods are so heavy that she has to be absent from school. What can we do?

• Q 5. 13 How does the doctor determine the treatment of heavy periods for an adolescent?

• Q 5. 14 How long should treatment of heavy periods be continued with an adolescent?

• Q 5. 15 Should a ‘D & C’ (cervical dilatation and curettage Q24.12) be performed for an adolescent with period problems?

• Q 5. 16 Are there any particular worries about a teenager having a pregnancy?

• Q 5. 17 What should be the purpose of sex education?

• Q 5.18 My adolescent daughter is being difficult. Could she have an underlying hormone problem?

• Q 5. 19 Are there any special contraceptive considerations for teenagers?

• Q 5. 20 What contraceptive options are available to adolescents?

• Q 5. 21 Are there any medical worries if a young teenager takes the oral contraceptive pill?

• Q 5. 22 Can a teenager use emergency contraception?

• Q 5. 23 Where can I obtain more information?

• Q 5. 24 Could I have some useful Web sites?

• Women’s Health – Home Page

• Chapter 05 Adolescence

Q 5. 17 What should be the purpose of sex education?

• Adolescents have a right to information. This information should not be confusing or laced with contradictory attitudes. Whilst the risks of sexual activity, unplanned pregnancy and sexually transmitted diseases, need explanation, emphasis on relationships and sharing should be encouraged. Provision of contraceptive and sex education in schools may raise ethical concerns.
• There is no evidence that these programmes encourage earlier sexual activity and in Holland there is some evidence to the contrary.

• Most teenagers, although by no means all of them, are aware of the need for contraception and assume that all sexually transmitted diseases can be treated. There seems to be inadequate emphasis on the need for barrier contraception to reduce the risks of virus infection that may cause AIDS (Q20.14) and pre-malignant conditions of the cervix (Q21.5).

• Q 5. 1 Our baby has had a little vaginal bleeding. Is this worrying?

• Q 5. 2 What are intersex states?

• Q 5. 3 Our toddler does not seem to have a normal opening down below. What should be done?

• Q 5. 4 My little girl has a vaginal discharge. What might be the cause?

• Q 5. 5 What is puberty?

• Q 5. 6 What is precocious puberty?

• Q 5.7 Our teenage daughter’s periods have not started yet. When should we seek medical advice?

• Q 5. 8 Our daughter’s periods are occurring infrequently. Should we be concerned?

• Q 5. 9 What is adolescence?

• Q 5. 10 What is acne and what can be done about it?

• Q 5. 11 Our teenage daughter seems to have more body hair than we would expect. What should be done?

• Q 5. 12 Our teenage daughter’s periods are so heavy that she has to be absent from school. What can we do?

• Q 5. 13 How does the doctor determine the treatment of heavy periods for an adolescent?

• Q 5. 14 How long should treatment of heavy periods be continued with an adolescent?

• Q 5. 15 Should a ‘D & C’ (cervical dilatation and curettage Q24.12) be performed for an adolescent with period problems?

• Q 5. 16 Are there any particular worries about a teenager having a pregnancy?

• Q 5. 17 What should be the purpose of sex education?

• Q 5.18 My adolescent daughter is being difficult. Could she have an underlying hormone problem?

• Q 5. 19 Are there any special contraceptive considerations for teenagers?

• Q 5. 20 What contraceptive options are available to adolescents?

• Q 5. 21 Are there any medical worries if a young teenager takes the oral contraceptive pill?

• Q 5. 22 Can a teenager use emergency contraception?

• Q 5. 23 Where can I obtain more information?

• Q 5. 24 Could I have some useful Web sites?

• Women’s Health – Home Page

• Chapter 05 Adolescence

Q 5. 18 My adolescent daughter is being difficult. Could she have an underlying hormone problem?

• It is true that hormones are responsible for the physical and emotional changes that occur during adolescence. The concept that your daughter’s hormones are out of balance and the cause of the family’s problems is highly unlikely. As an adolescent matures towards adulthood, nature provides the physical and to some extent the emotional development necessary for independent survival. Even children nurtured in a strong family unit may have difficulties realigning their role. Parents may find it difficult to accept rejection of their advice whilst the adolescent may find it difficult to realise that parenthood is for life. George Orwell once summarised the conundrum as follows – “Each generation imagines itself more intelligent than the one that went before it, and wiser than the one that comes after it.”

Q 5. 19 Are there any special contraceptive considerations for teenagers?

• Whatever our feelings and beliefs, the fact is that universally sexual activity is starting at an earlier age. According to a report published in 1992, first intercourse had occurred in 50% of sixteen-year-olds in the United Kingdom. The media of the twentieth century have flaunted sex, no doubt to increase ratings. Whilst sex should not be regarded as a taboo subject and sex education is to be welcomed, few young adolescents are mentally or emotionally ready for sexual experience. There is little evidence that contraceptive-based sex education programmes have resulted in reduced sexual activity or diminished teenage-pregnancy rates. Increased self-esteem and sense of responsibility are associated with greater caution. Those with inadequate family support are those most at risk of sexually transmitted disease and unplanned pregnancy. Pregnant teenagers are more likely to have a mother who had a teenage pregnancy and they are less likely to seek pregnancy termination.

• Informal youth clinics are often well received by adolescents. One of the more common reasons for first visits to this clinic is the fear of unplanned pregnancy; pregnancy testing and emergency contraception need to be readily available. A partnership between patient and health care providers is essential if long-term support is to be continued. These clinics should provide the full range of contraceptive services within a friendly atmosphere and there should be no suggestion that the staff are being judgemental.

• For those with the foresight to seek protection against unwanted pregnancy and sexually transmitted diseases, there are an ever increasing number of adolescent clinics catering for these special needs. Where confidential, readily available and friendly contraceptive services are available, contraceptive usage increases and teenage pregnancy rates are reduced. Dutch teenagers apparently have a great deal of trust in their medical services, which encourages them to seek early contraceptive advice. The teenage pregnancy rate in the United Kingdom is three times higher than in Holland and in the United states it is seven times higher. Health professionals must be aware of the rights of adolescents to confidentiality.

• In the UK, sexual intercourse before the age of consent (16 years of age) is against the law. Prosecutions are, however, rare if both partners are of similar age. A working party of the Royal College of Obstetricians and Gynaecologists has provided invaluable advice: “It is for the doctor to decide whether to provide contraceptive advice and treatment, and the Department of Health has advised that if he (or she) does so for a girl under the age of 16 years he is not acting unlawfully provided he acts in good faith in protecting the girl against potentially harmful effects of intercourse…” The Gillick judgement of 1985 upheld the view that doctors can lawfully prescribe contraceptives for under-16 year olds without parental consent in certain circumstances:

•  that the young person could understand the doctor’s advice and had sufficient maturity to understand what was involved in terms of the moral social and emotional implications;

•  that the doctor could neither persuade the young person to inform the parents, nor to allow him to inform them, that contraceptive advice was being sought;

•  that the young person would be very likely to begin, or to continue having, sexual intercourse with or without contraceptive treatment;

•  that, without contraceptive advice or treatment, the young person’s physical or mental health, or both, would be likely to suffer;

•  that the young person’s best interests required the doctor to give contraceptive advice, treatment, or both, without parental consent.

• “….We consider that young people under 16 who are sexually active require confidential professional counselling in relation to contraception. They need to be assured that the health professional they consult will respect their confidentiality in spite of their youth. The health professional has a responsibility to help the young person to understand the implications of sexual activity and the value of confiding in her parents. However, it is important to appreciate that the developing sexuality of young people creates a barrier between them and their parents that is part of the process of growing-up. A trained responsible outsider, such as a general practitioner or a family planning doctor or a family planning nurse, may be a more effective source of counselling than the parents.”

Q 5. 20 What contraceptive options are available to adolescents?

• The full range of contraceptive options should be available. The easiest contraceptive for them to obtain is condoms. These have advantages in the prevention of sexually transmitted disease but may not be the most effective contraceptive. Teenage sex is often unplanned and condom usage is therefore variable.

• The combined oral contraceptive pill is the most effective method and it is simple to use. The disadvantage is that it provides no protection against sexually transmitted disease. The combination of pill and condom is the ideal if suitable encouragement can be provided. Breakthrough bleeding on the pill may be due to poor compliance or perhaps pelvic infection. There is no definite evidence that the phasic pills (Q16.2) are less likely to cause this problem. Furthermore, the phasic pills do not lend themselves so easily to cycle adjustment such as taking two packets “back-to-back” to avoid menstruation at difficult times such as vacations. The combined oral contraceptive pill provides good cycle control and may have advantages in reducing menstrual flow and painful periods. An additional benefit is that acne and hirsutism may improve.

Q 5. 21 Are there any medical worries if a young teenager takes the oral contraceptive pill?

• There is no evidence that the pill will stunt growth. Indeed there are no additional dangers for a teenager taking the pill than for an adult. The risks relate to emotional development and dangers of sexually transmitted disease but not specifically to the pill itself.

• Progestogen-only pills, the “mini-pill” have a higher failure rate than the combined pill. They do not inhibit ovulation and the margin of safe pill taking is down to three hours rather than the twelve hours of the combined pill. These pills do not provide good cycle control and compliance may be poor. They are recommended for young breast-feeding mothers.

• Long-acting hormone methods, including injections of Depo-Provera at twelve week intervals, may be attractive to teenagers as they are convenient, reasonably reliable and provide secrecy from the family. Irregular or absent periods are common reasons for changing to another method.

• The conventional IUCD is associated with an increased risk of pelvic inflammatory disease and subsequent infertility. They may also increase menstrual flow and pain.

• Our baby girl has had a little vaginal bleeding. Is this worrying?
• What are intersex states?
• Our toddler does not seem to have a normal opening.What should be done?
• My little girl has a vaginal discharge.What might be the cause?
• What is puberty?
• What is precocious puberty?
• Our teenager has not started her periods. When should we seek advice?
• Our daughter’s periods are infrequent. When should we be concerned?
• What is adolescence?
• What is acne and what can be done about it?
• Our teenager has more body hair than expected. What should we do?
• Our daughter’s periods result in time away from school.What can be done?
• How does the doctor recommend treatment for teenage period problems?
• How long should treatment of teenage period problems be continued?
• Should a D&C be performed for a teenager with period problems?
• Are there any particular worries about a teenager having a pregnancy?
• What should be the purpose of sex education?
• My adolescent daughter is being difficult. Could she have a hormone problem?
• Are there any special contraceptive considerations for teenagers?
• What contraceptive options are available for adolescents?
• Are there worries if a teenager takes the pill?
• Can a teenager use emergency contraception?
• Where can I obtain further information?
• Could I have some recommended Web sites?

Q 5. 22 Can a teenager use emergency contraception?

• The usual emergency methods (Q 17.20) are available for teenagers. When emergency contraception is required the ‘Yuzpe method’ is generally used. Pills with 100 micrograms of ethinyl oestradiol are taken after a meal and within 72 hours of intercourse and the dose is repeated after 12 hours. Failures are often due to a previous episode of sexual activity. An IUCD (‘coil’) introduced post-coitally may be effective more than 72 hours after intercourse.

• Our baby girl has had a little vaginal bleeding. Is this worrying?
• What are intersex states?
• Our toddler does not seem to have a normal opening.What should be done?
• My little girl has a vaginal discharge.What might be the cause?
• What is puberty?
• What is precocious puberty?
• Our teenager has not started her periods. When should we seek advice?
• Our daughter’s periods are infrequent. When should we be concerned?
• What is adolescence?
• What is acne and what can be done about it?
• Our teenager has more body hair than expected. What should we do?
• Our daughter’s periods result in time away from school.What can be done?
• How does the doctor recommend treatment for teenage period problems?
• How long should treatment of teenage period problems be continued?
• Should a D&C be performed for a teenager with period problems?
• Are there any particular worries about a teenager having a pregnancy?
• What should be the purpose of sex education?
• My adolescent daughter is being difficult. Could she have a hormone problem?
• Are there any special contraceptive considerations for teenagers?
• What contraceptive options are available for adolescents?
• Are there worries if a teenager takes the pill?
• Can a teenager use emergency contraception?
• Where can I obtain further information?
• Could I have some recommended Web sites?

Q 5.23 Where can I obtain more information?

• The American Academy of Child and Adolescent Psychiatry.

• Our baby girl has had a little vaginal bleeding. Is this worrying?
• What are intersex states?
• Our toddler does not seem to have a normal opening.What should be done?
• My little girl has a vaginal discharge.What might be the cause?
• What is puberty?
• What is precocious puberty?
• Our teenager has not started her periods. When should we seek advice?
• Our daughter’s periods are infrequent. When should we be concerned?
• What is adolescence?
• What is acne and what can be done about it?
• Our teenager has more body hair than expected. What should we do?
• Our daughter’s periods result in time away from school.What can be done?
• How does the doctor recommend treatment for teenage period problems?
• How long should treatment of teenage period problems be continued?
• Should a D&C be performed for a teenager with period problems?
• Are there any particular worries about a teenager having a pregnancy?
• What should be the purpose of sex education?
• My adolescent daughter is being difficult. Could she have a hormone problem?
• Are there any special contraceptive considerations for teenagers?
• What contraceptive options are available for adolescents?
• Are there worries if a teenager takes the pill?
• Can a teenager use emergency contraception?
• Where can I obtain further information?
• Could I have some recommended Web sites?

Q 5.24 Could I have some useful Web sites?

• Evaluation of the quality of Web sites is discussed in Q4.27.
• You may find that several general women’s health sites may help you (Q4.28).
• The following are more specialised Web sites on topics found in this chapter.