Adolescent Gynaecology Basics
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Direct answer
Adolescent gynaecology (WHO defines adolescence as 10-19 years) rests on knowing what is normal before treating what is not: cycles of 21-45 days are physiological for several years after menarche (mean age in India 12-13), most cycles are anovulatory in the first year, and cycles longer than 90 days are abnormal even in the first gynaecological year. The three presenting complaints structure the topic: dysmenorrhoea (commonest — NSAIDs first line, endometriosis when atypical or refractory), heavy bleeding (screen for bleeding disorder — von Willebrand disease in up to a fifth of hospitalised adolescents — and always pregnancy), and irregular bleeding from the immature hypothalamo-pituitary-ovarian axis; confidentiality, consent under POCSO and teenage-pregnancy prevention frame the Indian consultation.
What you must remember
- Normal parameters: menarche 10-16 years (mean 12-13); cycle 21-45 days; flow 3-7 days; by three years post-menarche most cycles are ovulatory — utter irregularity beyond 2-3 years needs a cause.
- The 90-day rule: cycles consistently over 90 days warrant evaluation even in the first year — polycystic ovary syndrome, thyroid, hyperprolactinaemia, eating disorder, pregnancy.
- Dysmenorrhoea: primary — NSAIDs (mefenamic acid, ibuprofen) 70-80 per cent effective, heat, TENS, combined pill; secondary suspects — endometriosis (never normalise disabling pain), genital tuberculosis in India, obstructed outflow anomalies.
- Heavy bleeding: pregnancy test first, then complete blood count, ferritin, thyroid, coagulopathy screen (von Willebrand panel — factor VIII, antigen and activity), since bleeding disorders underlie up to 20 per cent of hospitalised adolescents; treat with tranexamic acid, NSAIDs, a monophasic pill (three times daily in acute flooding, tapered), a levonorgestrel intrauterine system, plus iron.
- Adolescent polycystic ovary syndrome: diagnose cautiously — Rotterdam criteria plus at least two years post-menarche; weight management before drugs.
- Ovarian masses: functional cysts dominate and regress; torsion is the emergency (sudden pain, vomiting, Doppler); dermoid is the commonest adolescent ovarian tumour.
- The legal frame: POCSO 2012 criminalises all sexual activity under 18, even consensual, with mandatory reporting; the MTP Act requires guardian consent for a minor's termination — care, confidentiality and law must be balanced.
- Programme hooks: Rashtriya Kishor Swasthya Karyakram adolescent-friendly clinics with Saathiya peer educators, menstrual hygiene schemes, HPV vaccination at 9-14 years.
Two teenagers, two very different plans
Girl one, 14, eight months past menarche, bleeds every 35-50 days for eight days, haemoglobin 10.2, eats poorly. The plan: a menstrual diary, iron, nutrition, reassurance with review — the axis is maturing and the likeliest treatment is time, with the 90-day and two-to-three-year rules as tripwires. Girl two, 16, soaks a pad an hour for two days each cycle since menarche, haemoglobin 7.8, bruises easily; her mother had a hysterectomy at 30 for "bleeding". Her workup is different: pregnancy test, complete blood count and ferritin, thyroid, coagulopathy screen — bleeding from menarche plus family history raises von Willebrand disease, found in up to a fifth of hospitalised adolescents. Treatment layers: intravenous ferric carboxymaltose, tranexamic acid and mefenamic acid for the cycles, and a monophasic combined pill tapered from three times daily during floods to once daily — or a levonorgestrel intrauterine system for durable control. The contrast is the curriculum: same age, same complaint, one needs a calendar and iron, the other a haematologist.
The Indian adolescent clinic
Adolescent gynaecology in India carries burdens Western texts underweight. Teenage pregnancy remains substantial — roughly 7 per cent of women aged 15-19 in NFHS-5 were already mothers or pregnant — driven by early marriage despite law, stacking anaemia, hypertensive risk and dropout. Menstrual health is a public-health subject: school absenteeism during periods is documented, the government's menstrual hygiene scheme distributes subsidised pads through ASHAs and schools. The differential Western chapters forget: genital tuberculosis, endemic in India, causes pelvic pain and later infertility — consider it in refractory dysmenorrhoea. The legal frame shapes practice: POCSO's mandatory reporting sits uneasily with confidential adolescent care, and Indian guidance advises proceeding with treatment, counselling and child-protection assessment while meeting reporting duties; RKSK adolescent-friendly clinics with Saathiya peer educators are the system's answer to access. The viva trio: the 90-day rule, the coagulopathy screen, and the commonest cause of adolescent irregular bleeding (anovulation from the immature axis).
Frequently asked questions
When does adolescent menstrual irregularity need investigation?
Cycles consistently over 90 days (even in the first gynaecological year), heavy bleeding from menarche, persistent irregularity beyond 2-3 years.
What is first-line treatment for primary dysmenorrhoea?
NSAIDs such as mefenamic acid or ibuprofen started early, with heat and exercise; combined pills when NSAIDs fail or contraception is needed.
Why screen for von Willebrand disease in adolescent heavy bleeding?
Hereditary bleeding disorders, chiefly von Willebrand disease, underlie up to a fifth of hospitalised adolescents with heavy bleeding; hormones alone cannot manage what haematology must.
How is polycystic ovary syndrome diagnosed in adolescents?
Cautiously — Rotterdam features plus two years post-menarche; weight management and lifestyle before drugs.
What must a clinician know about POCSO in adolescent care?
Any sexual activity below 18 is legally an offence regardless of consent, with mandatory reporting; care proceeds alongside child-protection assessment under the Act.