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TEEN AGE MENSTRUAL PROBLEMS - GENITAL TUBERCULOSIS A STRONG POSSIBILITY
BS Bhayani*, A Singhal*, KG Tripathy*, U Saraiya*
*Dept. of Obst. and Gynaecology, Cama and Albless Hospital, Mumbai 400 001
This is a study of adolescent menstrual problems in 2 years period at Cama and Albless Hospital. The various causative factors of diagnostic pitfalls are discussed and importance of early diagnosis and treatment emphasised. Genital tuberculosis was found to be cause number 1 in this socioeconomic class.INTRODUCTION
Adolescence is a very important phase in every woman’s life. This is a stage where the carefree and immature girl child blossoms into a mature and a responsible adult woman. These changes are mediated by complex neuroendocrine mechanisms which are sequential and interlinked with each other. The adolescent girl is highly susceptible to exogenous and endogenous influences at this crucial juncture.
Teenage menstrual problems are diverse in aetiology, if detected early they can be remedied. For example genital tuberculosis is very common in our country. The early diagnosis can cure the patients with minimal damage to her future fertility potential, but mostly it is a late diagnosis.
The adolescent girl is a very shy person and often hesitates to seek help regarding her problems. Social customs and taboos regarding menstruation hamper our efforts in establishing an early diagnosis. The virginal status of these patients makes examination a difficult task. The inclusion of sono screening services for adolescent girls will be of immense value in early detection of gynaecological problems. In the SAARC decade for the girl child we must make every effort to improve the status of the girl child, who is the mother of tomorrow. This paper presents a review of 53 patients who had presented themselves in the gynaecology OPD of a leading teaching Hospital from June’89 to June’91.
Most of the investigations were done for congenital anomalies and hormonal factors. Genital tuberculosis was an incidental finding but to our surprise it stood as a number one cause.
MATERIAL AND METHODS
A prospective study was carried out in the Gynaecology OPD of Cama Hospital from June’89 to June’91 involving 53 adolescent girls who had come with various menstrual complaints. All these girls were between 13 and 19 years age. As the age at marriage is less for Indian girls, married teenagers were also included in this study.
A detailed history was taken as regards chief complaints, present and past menstrual history, age at menarche and menstrual history of mother and siblings. History suggestive of tuberculosis hypothyroidism/bleeding tendency was asked. History of treatment taken in the past and its effect was noted. A detailed general and systemic examination was performed giving special attention to height, weight, secondary sex characters and anaemia. Pelvic examination was performed per rectum in virgins and per vaginum in others.
Laparoscopy though invasive, was performed in
CBC, ESR Coagulation studies Blood sugar, urea Bleeding time, Clotting Mantoux test time Chest X-ray Prothrombin time, X-ray spine, IVP, HSG Platelet count Pelvic and abdominal, USG S. FSH/LH/Progesterone S.T3/T4/TSH Karyotyping Laparoscopy Hysteroscopy Cytological evaluation all patients suspected to have tuberculosis or congenital malformation for a quicker and a surer diagnosis. Hormonal assays are costly and beyond fiscal reach of most patients. Most of the patients in this study did not require them.
Cytological evaluation :
In selected cases, the lateral vaginal wall smears were taken every alternate day for determining the hormonal status.[1]
Observation (53 cases)
Chief complaints No. of cases Primary amenorrhoea 12 Secondary amenorrhoea 6 Menorrhagia 11 Oligomenorrhoea 3 Irregular and heavy bleeding 18 Abdominal pain 9 Abdominal lump 9
Marital Status Patients Married 13 Unmarried 40
Height of patients (cm) No. of cases 125-135 9 136-145 18 146-155 24 156-160 2
Weight No. of cases 30-40 Kg 19 41-50 Kg 28 51-60 Kg 6
Hb gm% No. of cases 6 8 7-9 20 9.5-11 9 11 16
Tenner’s stages Breast changes Pubic hair changes I — — II 2 2 II 19 19 IV 17 13 V 15 19
Laparoscopy (25 cases) Laparoscopy findings No. of cases Tuberculosis 15 Absent uterus 4 Bicornuate uterus 3 Uterus diadelphys 1 Normal uterus 1 R-Ovarian cyst 1
Karyotyping No. of cases 46 XX 4 45 XO 2
Final Diagnosis No. of cases Genital tuberculosis 15 Anovulatory 11 Mullerian anomalies 9 Cryptomenorrhoea 6 Primary hypothyroidism 4 Bleeding disorders 3 Turner’s 2 Ovarian tumour 3 DISCUSSION
Genital tuberculosis is very rampant in our country and is usually secondary to a primary focus elsewhere in the body. Pelvic tuberculosis accounts for 0.75 to 1% of all gynaecological admission.[2] In this study 15 patients had genital tuberculosis. Tuberculosis causes a spectrum of menstrual disorders like menorrhagia/irregular periods/oligomenorrhoea/amenorrhoea with a history of low grade fever, loss of appetite and weight and lower abdominal pain.
9 patients had tuberculosis in the past. 6 cases were diagnosed now. Laparoscopy confirmed the diagnosis. These patients were started on anti-koch’s treatment and they were followed up with a monthly weight chart and ESR. Patients of prolonged secondary amenorrhoea did not resume menses at the end of treatment. The rest returned to normal cycles. Indian girls with genital tuberculosis are more prone to irreversible endometrial damage.
Cryptomenorrhoea : 6 patients in this study had cryptomenorrhoea. These patients had normal secondary sex characters, had cyclic abdominal pain, amenorrhoea and abdominal mass. USG confirmed the diagnosis of haematocolpos due to imperforate hymen. The haematocolpos was drained and patients followed up in the OPD.
Hypothyroidism : 4 anaemic girls presented with irregular bleeding. They all had a small goitre on examination. They gave history of constipation and lethargy and poor scholastic performance since last 6 months. These patients were diagnosed by their elevated serum TSH levels and lowered T3/T4 levels. Alongwith correcting anaemia, these patients received oral thyroxine tablets and at present have normal cycles.
Ovarian Tumours : Three patients in this study were found to have ovarian tumours. 2 patients presented with a slowly growing lower abdominal mass with frequency of micturition. USG confirmed the diagnosis of a unilateral ovarian tumour. Laparotomy with enucleation of tumour was done. Histopathology showed the tumours to be benign serous cystadenoma of the ovary. The third patient had similar complaints and USG revealed a 10 cm diameter right ovarian cyst. Laparoscopic cyst aspiration was performed. The cyst subsided and patient was followed up for 3 cycles and had no recurrence. The diagnosis of atretic follicular cyst was made.
Bleeding Disorder : 3 patients presented with severe bleeding at menarche. They were hospitalised due to anaemia and were diagnosed to have idiopathic thrombocytopenic purpura on the basis of their coagulation profile. They were treated with corticosteroids and blood transfusion and are following up with haematology OPD. Bleeding disorders account for 19% of acute adolescent menorrhagias.[3]
Turner’s Syndrome : Two patients in this study were diagnosed to have Turner’s syndrome. These patients presented with primary amenorrhoea, poor secondary sex characters, short stature with webbing of neck, Karyotype of both these patients was 45 XO. After ruling out associated cardiac anomalies, the patients received cyclical oestrogen and progesterone for development of secondary sex characters and monthly withdrawal bleeding.
Mullerian Anomalies : In 9 patients with Mullerian anomalies following was the diagnosis.
Bicornuate uterus 3 patients Septate uterus 1 patient Double uterus 1 patient Mullerian agenesis 4 patients 4 patients had primary amenorrhoea and 5 had menorrhagia. Patients of bicornuate/septate/double uterus presented with menorrhagia and anaemia. They had normal sex characters. Laparoscopy/hysteroscopy/HSG helped in the diagnosis.
4 patients with Mullerian agenesis, presented with primary amenorrhoea and had normal secondary sex characters with absent vagina. Rectal examination revealed absence of uterus. Ovaries were normal on USG. IVP revealed pelvic kidney in one patient and unilateral renal agenesis in another.
Various authors have found renal anomalies in patients of Mullerian agenesis to be 30%.
Anovulatory Cycles : 11 patients in this study had anovulatory cycles. These are common during adolescence (Nearly 55.77% of the menstrual cycles).[4] These patients presented with anaemia and heavy bleeding. Hypothalamopituitary development has to be completed for the positive response from ovary had uterus. Inappropriate feed back during puberty leads to anovulation. Anovulation causes heavy bleeding which is generally oestrogen withdrawal/breakthrough bleeding.
8 patients with anovulatory cycles had Hb of less than 9 gm%. These patients had normal T3, T4, TSH levels. They were treated with cyclical oestrogen and progesterone and asked for follow up. At the end of 9 cycles all patients had normal cycles
CONCLUSIONS
1. A 2 year survey of OPD patients sorted out 53 adolescent menstrual disorder patients.
2. Genital tuberculosis was found to be most common cause (28.3%).
3.The other causes were the anovulatory cycles (20.75%), Mullerian anomalies (16.9%), Primary hypothyroidism (7.54%), Cryptomenorrhoea (11.3%), Bleeding disorders (5.66%), Ovarian tumours (5.66%), Turner’s syndrome (3.77%)
4. Of the genital tuberculosis patients 20% were diagnosed early and 80% were diagnosed late. In the late cases the prognosis would be bad as by this time endometrial damage had already occurred.
Laparoscopy is the most important method for early diagnosis.
REFERENCES
1. Novak’s gynaecologic and Obstetric pathology with clinical and endocrine Correlation. Novak and woodruff, 8th edition. 1979.
2. Krishna U, Parulekar S, Salvi V. The adolescent girl 1st edition. 1991.
3. Claessons E, Cowell C. Acute Adolescent menorrhagia. AJ Obst and Gynaecol 1982; 139 : 277.
4. Altcheck et al. DUB in adolescene - COG. 1977; 20 : 633.
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