Anatomical alterations of the genitalia . The vast majority of prepubertal gynecological disorders can be included in three large groups, so far we have seen those that cause itching and discharge such as vulvovaginitis, we have also reviewed the group of “what bleeds” with all its possible causes, now we have to talk about those clinical entities that are characterized by abnormal appearance of the genitalia.
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- 1 Lip or vulva agglutination
- 2 Causes of lip and vulvar agglutination
- 3 Disorders of Puberty
- 4 Age and appearance of Puberty
- 5 Early Pubertal Development
- 6 Delayed pubertal development
- 7 Dysfunctional Uterine Bleeding (LDS)
- 8 anovulatory cycles
- 9 Etiology
- 10 Diagnosis
- 11 Basic laboratory tests
- 12 The long-term prognosis for adolescent girls with this condition
- 13 Source
Lip or vulva agglutination
Girls with lip or vulvar agglutination are usually brought to the doctor for the notable anatomical distortion that the alteration produces. Sometimes the agglutination is so complete that there appears to be no opening through which the patient can urinate.
The most common types of ambiguous genitalia are present from birth, while clumping is an acquired lesion. Ambiguous genitalia resulting from androgen excess in the early embryonic period, such as congenital adrenal hyperplasia, cause the labia minora to become incorporated. in the anterior vagina of the clitoris . In advanced labial and vulvar agglutination, it is always possible to find a line of demarcation between the critoid cap (foreskin) and the labia minora, which are located in the midline under the clitoris.
Causes of lip and vulvar agglutination
- The cause of lip and vulvar agglutination appears to be a combination of mild vulvitis and a state of hypoestrogenism.
- Many girls with agglutination are completely asymptomatic and more than 80% of cases resolve spontaneously in one year .
- If the patient has no symptoms, treatment will be limited to eliminating the irritant that caused vulvitis: a caustic soap or shampoo, whipworms, pinworms , candida]] or sexual abuse.
- When the girl shows symptoms due to problems related to uretritir or her training for the use of the sanitary service has become difficult (because urine accumulates above the agglutinated tissue , which keeps the vulva constantly moist), the topical application of estrogen cream during a short period (maximum two weeks) will resolve the agglutination.
- The girl with almost complete clumping should also be treated.
- Patience is important in treating this problem and family members require a lot of support. There is no place to manually force the separation of agglutinated tissues, as this causes undue pain for the girl.
We do not intend in this chapter to address the study of puberty and its aberrations, we only propose to remember some concepts and define the attitude to be taken with those patients who consult us due to alterations in this process.
There are many definitions and concepts about the etymological origin of the word puberty, all agree in accepting its root in the Latin word pubert, which for some means maturation, for others the appearance of public hair, etc. What everyone agrees on is that puberty, this time of life when secondary sexual characteristics begin to manifest, produces rapid growth and somatic and genital development, and the capacity for reproduction is acquired at the end of it. This transition from child to adult biochemical, anatomical and behavioral changes occur which show some degree of sexual diformism.
Age and appearance of Puberty
As we have already mentioned, it is not possible to set a strict limit for the appearance of pubertal changes, many determining factors, including genetics, sex , race, nutrition , environmental factors and others, will affect these changes. It is accepted that puberty should begin between 8 and 10 years of age and end 2 to 4 years after it begins, it is also accepted that it tends to appear earlier in women than in men, which is in part responsible for differences in height between the sexes.
Early Pubertal Development
- It is within pubertal disorders the most common cause of consultation in Infant / Juvenile Gynecology, it is more frequent in the female than in the male.The first thing we must determine is whether we are facing true precocious puberty or some process.
- Precocious puberty is considered to be when pubertal development begins before the age of 8 years in the girl and 9 years in the boys. It should be borne in mind that the new appearance of secondary non-sexual characteristics does not necessarily constitute evidence of the onset of true puberty; false puberty that superficially does not differ from the true ones.
In our experience, what has predominated are physiological variants of puberty such as Telarquia Precoz and Pubarqui Precoz, they almost always occur in isolation and do not constitute a danger to the reproductive life of the patient. In these cases, the girl should always be referred to a specialized gynecology consultation .
- Infant / Juvenile or Pediatric Endocrinology .
Delayed pubertal development
Delayed puberty can be defined as the lack of sexual development, at least two standard deviations below the mean age of onset of puberty for the sex of the subject, 13 years are considered for girls and 14 years for boys. We must emphasize that in the case of women it is not the absence of menstruation, but rather the non-appearance of any sign of pubertal development, which is why we can affirm that it is a rare entity.
When we are consulted for this reason, the first thing to define is whether it is a true delayed puberty or a simple constitutional delay and above all to define whether or not this delay is related to a problem of short stature. In these patients we must assess the following aspects :
- Age and Pubertal Stage (Tanner).
- Breast development.
- Vulva .
- Pubic hair.
- Chronology of the Ponderal Statistical Outbreak.
- Relationship of these signs with Age.
Given all suspicions of possible pubertal delay, it is necessary to refer the patient to a specialized consultation, we must reassure and talk with the mother and family, bear in mind that patience is the most appropriate initial therapy, another element to consider is psychological disorders They are associated with both early development and pubertal delay, which often have more negative consequences than the disease process itself.
Dysfunctional uterine bleeding (LDS)
Dysfunctional uterine bleeding is the most frequent gynecological emergency of the adolescent , this disorder is defined as prolonged and irregular excessive bleeding, which comes from the endometrium and is not related to anatomic lesions of the uterus. It is estimated that 10-15% of patients Gynecologicals have dysfunctional uterine bleeding during adolescence.
- 55% – 82% —- 2 years after menarche
- 30% – 55% —- 2-4 years after menarche
- 20% after menarche
The normal menstrual cycle has been defined as an average interval of 28 days (+7 days) with blood loss of four days duration (± two or three days) .The normal menstrual flow is almost 30 ml per cycle, with a limit normal maximum of 60 to 80 ml. Therefore, bleeding that occurs less than 21 days, more than 7 days and more than 80 ml is considered abnormal.
In almost 95% of cases, it is the result of the slow maturation of the hypothalamic-pituitary-ovarian axis in adolescents, which causes anovulatory agents. In general, these patients lack positive feedback necessary to initiate sudden LH secretion and subsistent ovulation. despite the fact that they have increased follicular estrogen levels. Altchek describes two types of irregular anovulatory bleeding, both painless. Most often, the patient presents amenorrhea for three to four months, then bleeds for three to four weeks, and then the cycle repeats. There are ovulatory patients with breakthrough bleeding whose mechanism is uncertain. In ovulation – Normal decrease in estrogen concentration mid-cycle. Hemorrhage, Irregular – Subnormal concentrations of FSH and estradiol in the follicular phase, with yellow body dysfunction, luteal cyst, prostaglandin imbalance.
It is a diagnosis of exclusion, that is why before the patient with genital bleeding , we must answer three questions:
- Is the bleeding uterine?
- It is ambulatory.
Does it occur in ovulatory cycles (perhaps they have an organic cause)? To get to clear these questions we must follow the following steps:
- Detailed medical history.
- Complete physical examination.
- Classification of menstrual abnormality.
- Cyclical irregular menstrual bleeding or bleeding from menarche.- Coagulation disorders.
- Regular cyclical menstruation with breakthrough loss.- Trauma, polyp, cervical injury, infection.
- Menarche .
- Linear growth.
- Sexual history.
- General conditions.
- Medications .
- History of bleeding disorders.
Basic laboratory tests
- Complete bleeding
- Coagulation and bleeding
- Hormonal quantification (TSH, FSH).
The goals of clinical treatment depend on a correct causal diagnosis: the initial diagnostic and therapeutic measures will meet two goals: Immediate control of bleeding, especially when it is abundant and constitutes a threat to health. Prevention of similar subsequent episodes usually by restoring cyclical bleeding.
The long-term prognosis for adolescent girls with this condition
It is accepted that around 5% of them will never ovulate, others will suffer recurrent dysfunctional bleeding with the discomforts that these cause.Patients who regulate their cycles after treatment have a more favorable prognosis, however we must always bear in mind that the adolescent If you have dysfunctional uterine bleeding, you will have an increased risk of anemia, infertility, miscarriage, endometrial hyperplasia, and endometrial carcinoma.