A woman’s body experiences numerous changes with age. Every stage in life is associated with hormonal, bodily and social changes.

1. Women and Adolescent Health
Dr Preeti Raheja
Consultant Obstetrics & Gyanecology
Paras Bliss, New Delhi

2. INTRODUCTION
• Adolescence refers to the stage from puberty to
adulthood, and includes the psychological
experiences of the child during this period.
Adolescence is described as being the teenage years
from thirteen to eighteen years of age; however,
puberty decides the onset of adolescence. Therefore,
adolescence occurs in some children as early as nine
years of age.

3. • During adolescence there is a large degree of
psychological growth as children make adjustments
in their personality due to the rapid physical and
sexual development which are characteristic of this
period of life. Adolescents face ongoing conflict and
difficulty adapting to the sudden upsurge of changes
in body. These changes cause unrest and confusion in
the adolescents’ inner selves and in the way they
perceive the world.

4. CONTENTS
• Physiological changes
• Menstruation
• Abnormalities and symptoms that require
consultation
• Aspects of nutrition
• Sexual Education
• Cervical cancer vaccination

5. PHYSIOLOGICAL CHANGES
• Rapid Growth
You can expect rapid growth in height and weight
during your child's adolescence. Girls experience
their growth spurt between the ages of 9 and 14, You
can also expect your teen to gain weight, as girls put
on fat. Variances in growth can cause teenagers to
feel self conscious about their bodies. Teens may feel
they are all limbs -- and at times, this could be true.

6. PHYSIOLOGICAL CHANGES
• STAGES OF PHYSIOLOGICAL CHANGES:
• Development of the breasts: Also known as Thelarche and
which marks the full development of the breasts from
minor buds by the age of 12.
• Pubarche starts between the age of 10-15, where in hair
growth starts around the pubic and axillary regions along
with the thickening of other hair.
• Menarche is the onset of the first menstruation marks the
beginning of puberty for girls. This can start anytime
between 10 and 15 years old, and this marks the beginning
of fertility. Menstruation typically starts two years after
breast buds develop, which can be as early as 8 year old.

7. PHYSIOLOGICAL CHANGES
• Hair Growth
• One of the more noticeable and celebrated changes
in teenagers is hair growth. Both males and females
can expect pubic hair to grow. This may start as much
as three years earlier in females, starting as early as
age 9 and reaching adult patterns by age 14. Armpit
and leg hair will also develop during this time.

8. PHYSIOLOGICAL CHANGES
• Body Odor and Acne
• Two disturbing changes during adolescence are the
occurrence of body odor and acne. Hormones that
cause sexual maturation and other body changes
also lead to increased oil production. Both males and
females will notice changes in their skin as it
becomes coarser and the sebaceous glands produce
more oil that can cause acne and blackheads. Sweat
glands also become more active, and the
combination of sweat and oils causes an odor,
making the use of deodorant a necessity. Teens need
to be more vigilant with hygiene to keep up with
their body changes.

9. MENSTRUATION
• Menarche typically occurs within 2–3 years after
thelarche (breast budding), at Tanner stage IV breast
development, and is rare before Tanner stage III
development. By age 15 years, 98% of females will
have had menarche. An evaluation for primary
amenorrhea should be considered for any adolescent
who has not reached menarche by age 15 years or
has not done so within 3 years of thelarche. Lack of
breast development by age 13 years also should be
evaluated.

10. Cycle Length and Ovulation
• Menstrual cycles are often irregular during adolescence,
particularly the interval from the first cycle to the second
cycle. Most females bleed for 2–7 days during their first
menses. Immaturity of the hypothalamic–pituitary–ovarian
axis during the early years after menarche often results in
an ovulation and cycles may be somewhat long; however,
90% of cycles will be within the range of 21–45 days,
although short cycles of less than 20 days and long cycles of
more than 45 days may occur. By the third year after
menarche, 60–80% of menstrual cycles are 21–34 days
long, as is typical of adults.

11. • Adolescents with cycles that are consistently outside
of the range of 20 to 45 days should be evaluated for
pathologic conditions, such as the polycystic ovary
syndrome (PCOS), eating disorders, thyroid disease,
hyper prolactinemia, or even such rare conditions as
ovarian insufficiency (premature ovarian failure

13. ABNORMALITIES AND SYMPTOMS
THAT REQUIRE CONSULTATION
• Some of the common adolescent health issue that
needs to be evaluated within time are:
• Abnormal uterine bleeding
• Ovarian cysts
• Breast abnormalities

14. Abnormal Uterine Bleeding
• Abnormal uterine bleeding (AUB) is any form of bleeding
that is irregular in amount, duration, or frequency. It can
be characterized by excessive uterine bleeding that
occurs regularly (menorrhagia), by heavy bleeding at
irregular times (metrorrhagia), or a combination of both
(menometrorrhagia). It can also be intermittent bleeding
or sparse cyclical bleeding (oligomenorrhea).
Dysfunctional uterine bleeding (DUB) is a subset of AUB
and is defined as excessive, prolonged, or unpatterned
bleeding from the endometrium without an organic
cause and is frequently used synonymously with an
ovulatory bleeding. In adolescents, up to 95% of AUB is
DUB. However, because DUB is a diagnosis of exclusion,
other potential causes of abnormal bleeding must be
ruled out.

15. • Girls and adolescents with more than 3 months
between periods should be evaluated. Although
experts typically report that the mean blood loss per
menstrual period is 30 ml per cycle and that chronic
loss of more than 80 ml is associated with anemia,
this has limited clinical use because most females are
unable to measure their blood loss. Menstrual flow
requiring changes of menstrual products every 1–2
hours is considered excessive, particularly when
associated with flow that lasts more than 7 days at a
time.

16. • The diagnosis of pregnancy, sexual trauma, and
sexually transmitted infections should be excluded,
even if the history suggests the patient has not been
sexually active.

19. Ovarian Cysts
• The most common ovarian cyst among adolescent
girls is PCOS.
• Polycystic ovarian syndrome, or PCOS, is a condition
in which there is an imbalance in the female sexual
hormones. This leads to the growth of ovarian cysts
(benign masses on the ovaries). PCOS can cause
problems with a women’s menstrual cycle, fertility,
cardiac function, and appearance.

20. Common characteristics of PCOS
• Irregular menstrual periods
• Unexplained Weight gain
• Acne
• Hirsutism- Appearance of thick and dense hair on
the face
• Mood swings
• Infertility
• Pelvic pain

21. Other types of cysts
• Follicular cyst – A follicular cyst develops each month
and contains the small egg within it. The sac ruptures
during ovulation and the egg comes out of the cyst.
Sometimes the cyst can grow larger than the normal
size which is up to 3 cm. If the sac that holds the egg
doesn’t break open to release the egg, it can grow,
anywhere in size from 1 inch to 4 inches across.
Usually this type of cyst disappears in one to three
months and often does not cause pain.

22. • Corpus luteum cyst – A corpus luteum cyst is normal
and usually forms each month after the egg breaks
out or ovulates. This type of cyst usually disappears
by itself in a few weeks, but it can grow 3-4 inches
across, and may bleed inside of the cyst or your belly.
This type of cyst can cause pain in your abdomen
(belly).
• These problems can be cured by consulting a doctor
on time.

23. Breast Abnormalities
• Breast masses can cause anxiety for adolescent girls
and their parents.
• Breast masses can arise during any stage of puberty,
so it is important to understand normal breast
development. Thelarche (initiation of breast
development) usually begins between the ages of 9
and 10 years.

24. Breast examination
• Clinical breast examination. The American Cancer
Society (ACS) in 2003 recommended that a clinical
breast examination (CBE) be done at least every 3
years for women in their 20s and 30s. For adolescents,
the CBE serves as an opportunity to increase their ease
with their bodies and with the examination itself and
to bring up any breast-related concerns.
• Breast self-examination. Teaching and performance of
the breast self-examination (BSE) in adolescents
remains controversial, given that the incidence of
breast cancer in adolescents aged 15 to 19 years is
only 0.2 per 100,000. The American College of
Obstetricians and Gynecologists does not recommend
teaching adolescents BSE until the age of 19 years.

25. Common breast masses in
adolescents
• Fibrocystic changes. Breast lumps associated with
cordlike thickenings are physiologic, hormone-
induced breast changes and normal variants of
regular breast tissue. Each month, they can become
painful and enlarged during the week before menses,
resulting in mastalgia. These breast changes are
possibly related to the monthly hormone
fluctuations of estrogen and progesterone.

26. • Fibroadenomas. Fibroadenomas comprise 68% of
breast masses in adolescents and are believed to be
caused by an abnormal response to estrogen.
Fibroadenomas present as 2 cm to 3 cm masses but
can enlarge during the menstrual cycle. Physical
examination demonstrates a firm, mobile, oval or
round, nontender, rubbery mass, separate from the
underlying breast tissue and usually located in the
upper outer quadrants. On ultrasound,
fibroadenomas normally appear as a well-
circumscribed, homogeneous, hypoechoic mass with
smooth distinct borders. Generally, the width of the
fibroadenoma is greater than its height.

27. • Two options exist for management of
fibroadenomas. They can be monitored via serial
clinical examinations every 3 to 6 months because up
to 50% of lesions decrease in size or disappear after
5 years. Alternatively, referral to a surgeon for an
excisional biopsy is indicated for patients whose
fibroadenomas continue to grow or who are
uncomfortable with only clinical monitoring.

28. ASPECTS OF NUTRITION
• Eating healthy food is important at any age, but it’s
especially important for teenagers.
• As your body is still growing, it’s vital that you eat
enough good quality food and the right kinds to
meet your energy and nutrition needs.
• Boys require an average of 2,800 calories per day.
• Girls require an average of 2,200 calories per day.

29. Important Nutrients
• Protein
Proteins are the most essential body building sources,
which are very important to be included in the diets of
an adolescent. The densest sources of protein include
teenage favorites such as Chicken, Fish, Eggs and
Cheese.

30. • Carbohydrates
In planning meals, we want to push complex-
carbohydrate foods and go easy on simple
carbohydrates. Complex carbs provide sustained
energy; that's why you often see marathon runners
and other athletes downing big bowls of pasta before
competing. As a bonus, many starches deliver fiber and
assorted nutrients too. They are truly foods of
substance: filling yet low in fat.
Most nutritionists recommend that complex
carbohydrates make up 50% to 60% of a teenager's
caloric intake.
Simple carbs, on the other hand, seduce us with their
sweet taste and a brief burst of energy but have little
else to offer and should be minimized in the diet.

31. • Dietary Fat
Fat should make up no more than 30% of the diet.
Fat supplies energy and assists the body in absorbing
the fat-soluble vitamins: A, D, E, and K. But these
benefits must be considered next to its many adverse
effects on health. A teenager who indulges in a fat-
heavy diet is going to put on weight, even if he's
active.

32. Dietary fat contains varying proportions of three
types:
• Monounsaturated fat —the healthiest kind; found in
olives and olive oil; peanuts, peanut oil and peanut
butter; cashews; walnuts and walnut oil, and canola
oil.
• Polyunsaturated fat —found in corn oil, safflower oil,
sunflower oil, soybean oil, cottonseed oil, and
sesame-seed oil.
• Saturated fat —is the most cholesterol laden of the
three; found in meat and dairy products like beef,
pork, lamb, butter, cheese, cream, egg yolks, coconut
oil, and palm oil.

33. • Vitamins and Minerals
Adolescents tend to most often fall short of their
daily quotas of calcium, iron, zinc, and vitamin D.
Unless blood tests and a pediatrician's evaluation
reveal a specific deficiency, it's preferable to obtain
nutrients from food instead of from dietary
supplements.

34. SEXUAL EDUCATION
Adolescent girls should be at the heart of a life
course approach—a young adolescent girl is still a
child, but often she will soon become a mother.
Adolescent pregnancy is associated with higher risk
of maternal mortality and morbidity, stillbirths,
neonatal deaths, preterm births, and low birth
weight. In addition to actions to prevent adolescent
pregnancy and encourage pregnancy spacing, efforts
are required to ensure that pregnant and lactating
teenage mothers are adequately nourished.

35. • Psychological and social aspects of adolescents’
development are less often described in connection
with adolescent health than their physical growth
and maturation characteristics.
• Girls aged between 12-14 years are more likely to be
talked or forced into having unplanned and
unprotected sex giving way to teenage pregnancies.
About two thirds of teen pregnancies occur in girls
aged between 18-19 years.

36. CERVICAL CANCER VACCINATION
• Cervical cancer is one of the most common cancers
in females in our country. The main causative agent
for most these cancers are due to HPV. It is a cancer
which affects the females of later age group. Primary
prevention for this cancer is possible through the
HPV vaccine. Young girls in the age group of 11-13
are advised to take this vaccine in order to protect
them from cervical cancer at later age.

37. • One can get HPV from sexual contact, including
vaginal, oral, and anal sex. Most people infected with
HPV don't know they have it because they don't
notice any signs or problems. People do not always
develop genital warts, but the virus is still in their
system and it could be causing damage. This means
that people with HPV can pass the infection to others
without knowing it.
• Because HPV can cause problems like genital warts
and some kinds of cancer, a vaccine is an important
step in preventing infection and protecting against
the spread of HPV.

38. END NOTE
• The health and nutrition statuses of women and
children are intimately linked. Improving the health
of women and children, therefore, begins with
ensuring the health and nutritional status of women
throughout all stages of life, and it continues with
women being providers for their children and
families.