Introduction:
Adolescents in India contribute to 22% of the country’s population.[1] WHO defines adolescence as the age group of 10 to 19 years.[2] They are further divided into early adolescence: (10-13 years), middle adolescence: (14-16 years) and late adolescence: (17-19 years).
This adolescent age group is a transient phase of life that requires adequate nutrition, education, care, counselling and guidance to ensure development into healthy adults. They are more susceptible to various preventable and treatable health issues like early and unintended pregnancy, unsafe sexual practices leading to STI/HIV/AIDS, nutritional disorders like anemia, malnutrition, overweight, tobacco, alcohol and drug abuse, mental health issues, injuries and violence.
The health scenario in this age group is a major determinant to India’s overall health, morbidity, mortality and population growth situation. Gynaecological disorders in adolescents are not similar to that in adults. However it has not been explored optimally.
Several studies from different parts of India have identified various gynaecological disorders like menstrual abnormality, white discharge, urinary infection, teenage pregnancy, early marriage, unmet need for contraception, sexually transmitted infections, unplanned teenage pregnancy and adverse pregnancy outcomes.[3-5] These disorders alter the quality of life, education, career and social life of the young girls. But they present late to the treating physician because of their embarrassment, poor knowledge, lack of information, unavailability or inaccessibility and lack of privacy to counselling services for sexual and reproductive health. Distribution of these health problems vary by age, marital status, social, economic factors, religious and cultural context.
Even though few studies in India have identified various health issues in adolescents, evidence with regard to gynaecological disorders among adolescents in the current geographic region is not available. Hence the present study was conducted to describe the gynaecological disorders among adolescent girls in a south Indian population and to analyse the factors associated with it.
Objectives of the Study:
To estimate the burden and to describe the pattern of gynaecological disorders among adolescent girls attending the outpatient and inpatient departments of a private medical college hospital in South India.
Materials and Methods:
Study design, setting and duration: This was a hospital based cross sectional analytical study done among adolescent girls of 10-19 years age group who attended the outpatient and inpatient department in a private medical college hospital in South India over a period of one year from December 2020 to December 2021.
Study population, Sample size and sampling: Study was conducted among 500 adolescent girls aged 10-19 years who attended the outpatient and inpatient department in a private medical college hospital in South India and was recruited into the study through consecutive sampling.
Procedure: Institute Ethical committee approval was obtained before initiation of the study. The study participants were informed about the objectives of the study and written informed consent was obtained from them. Informed consent from their parents was also obtained in girls aged less than 18 years. A pre-tested semi-structured questionnaire was used to collect data from the participants. First part of the questionnaire retrieved information on socio-demographic characteristics, second part of the questionnaire was used to collect information on the presence of gynaecological problems and the third part of questionnaire assess the knowledge of participants with regard to menstrual hygiene, sexual and reproductive health. Later part of the questionnaire included information on physical examination and investigations. Clinical examination was done after obtaining consent and secondary sexual characters were noted. Investigations such as complete haemogram, peripheral smear, bleeding time, clotting time, prothrombin time, activated partial thromboplastin time, thyroid function test and ultrasound were done if necessary.
Method of Statistical analysis: Data were entered in Microsoft excel sheet 2016 and Statistical analysis was done using IBM SPSS version 23. Descriptive analysis was done and categorical variables were expressed in frequency and percentage with 95% Confidence Interval. Continuous variables were expressed in Mean and Standard Deviation or Median and inter quartile range. Chi-square test or Fischer exact test was done to find the association between categorical variables. Variables significant in bivariate analysis were further analysed using Multivariate logistic regression. P value less than 0.05 was considered to be significant for all comparisons.
Results:
A total of 500 adolescent girls were included in the present study. Figure 1 shows the age distribution of the adolescent girls in the present study. Among the study participants, 94 (18.8%) were early adolescents (10-13 years), 171 (34.2%) were mid adolescents (14-16 years) and 235 (47%) were late adolescents (17-19 years) and it was illustrated in Figure 1. The mean age of study population was 15.94 ± 2.52 years. Of these 74% participants belonged to nuclear family and 26% belonged to joint family. The mean age at menarche was 12.5 ± 0.9 years. It ranges from 10 years to 17 years. Among the participants 97% were unmarried and 3% were married. The mean age at marriage was 17 ± 0.57 years. Among them 55% were normal weight; 37% were underweight; 7.4% were overweight and 0.6% were obese as per WHO BMI classification.
 |
Figure 1: Categorisation of Early, Mid and Late adolescents among study participants (n=500) |
Gynaecological abnormalities among the study participants were shown in Table 1. In the present study, the most common gynaecological abnormality was menstrual abnormalities. It constitutes to 60.6% (n=303) of the study population. There was always an overlap of menstrual abnormalities in an individual. The common menstrual abnormalities include dysmenorrhoea 44%, menorrhagia 26%, irregular menstruation 20.4%, hypomenorrhoea 5% and amenorrhoea 4%. Among the participants with amenorrhea, one participant had primary amenorrhoea due to MRKH syndrome and the others had secondary amenorrhoea. The other common gynaecological disorders include leucorrhoea, urinary tract infection, vulvovaginitis, hirsutism, polycystic ovarian disease, teenage pregnancy, hypothyroid, fibrocystic breast disease, ovarian cyst and Bartholin cyst.
| Table 1: Gynaecological abnormalities among study participants (n=500) |
| Gynaecological abnormalities |
N=500 [N (%)] |
Menstrual abnormalities |
303 (60.6%) |
Leucorrhoea |
240 (48%) |
Urinary tract infection |
68 (13.6%) |
Polycystic ovary syndrome |
54 (10.8%) |
Vulvovaginitis |
36 (7.2%) |
Hirsutism |
30 (6%) |
Hypothyroid |
20 (4%) |
Teenage pregnancy |
16 (3.2%) |
Fibrocystic breast disease |
5 (1%) |
Ovarian cyst |
1 (0.2%) |
Bartholin cyst |
1 (0.2%) |
Distribution of various gynaecological disorders among the early, mid and late adolescents was shown in Table 2. Menstrual irregularities were reported more among mid adolescents (94.7%) followed by late adolescents (76.17%). Menorrhagia and dysmenorrhoea were reported more among mid adolescents followed by late adolescents, 76 (44.4%) and 144(84.2%) in mid adolescents Vs 53 (22.6%) and 159 (67.9%) in late adolescents and this difference is statistically significant (p value=0.000). White discharge per vaginum was observed more among late adolescents 113 (48.3%) followed by early adolescents 57 (60%). Urinary Tract Infection was reported more among early adolescents 33 (34.7%) followed by late adolescents 24 (10.3%). Features of hirsutism was observed more among late adolescents 11 (4.7%) followed by mid adolescents 2 (1.2%) and all these differences were statistically significant.
| Table 2: Distribution of various gynaecological disorders among early, mid and late adolescents (n=500) |
Variables |
Early adolescents |
Mid adolescents |
Late adolescents |
Total |
Χ2 value |
P value |
N (95) |
% |
N (171) |
% |
N (234) |
% |
N (500) |
Menstrual irregularities |
No |
31 |
32.6 |
9 |
5.3 |
56 |
23.9 |
96 (19.2) |
35.56 |
0.000 |
Yes |
64 |
67.4 |
162 |
94.7 |
178 |
76.17 |
404 (80.8) |
Oligomenorrhea |
No |
75 |
78.9 |
128 |
74.9 |
186 |
79.5 |
389 (77.8) |
1.39 |
0.518 |
Yes |
20 |
21.1 |
43 |
25.1 |
48 |
20.5 |
111 (22.2) |
Menorrhagia |
No |
75 |
78.9 |
95 |
55.6 |
181 |
77.4 |
351 (70.2) |
27.21 |
0.000 |
Yes |
20 |
21.1 |
76 |
44.4 |
53 |
22.6 |
149 (29.8) |
Dysmenorrhea |
No |
39 |
41.1 |
27 |
15.8 |
75 |
32.1 |
141 (28.2) |
22.71 |
0.000 |
Yes |
56 |
58.9 |
144 |
84.2 |
159 |
67.9 |
359 (71.8) |
White discharge |
No |
38 |
40 |
100 |
58.5 |
121 |
51.7 |
259 (51.8) |
8.65 |
0.015 |
Yes |
57 |
60 |
71 |
41.5 |
113 |
48.3 |
241 (48.2) |
Urinary tract infection |
No |
62 |
65.3 |
160 |
93.6 |
210 |
89.7 |
432 (86.4) |
45.62 |
0.000 |
Yes |
33 |
34.7 |
11 |
6.4 |
24 |
10.3 |
68 (13.6) |
Regular menstrual cycles |
No |
20 |
21.1 |
43 |
25.1 |
42 |
17.9 |
105 (21) |
3.08 |
0.214 |
Yes |
75 |
78.9 |
128 |
74.9 |
192 |
82.1 |
395 (79) |
Genital itching |
No |
90 |
94.7 |
168 |
98.2 |
206 |
88 |
464 (92.8) |
15.97 |
0.000 |
Yes |
5 |
5.3 |
3 |
1.8 |
28 |
12 |
36 (7.2) |
Hirsutism |
No |
95 |
100 |
169 |
98.8 |
223 |
95.3 |
487 (97.4) |
7.95 |
0.018 |
Yes |
0 |
0 |
2 |
1.2 |
11 |
4.7 |
13 (2.6) |
Prevalence of awareness among adolescents regarding various aspects of menstruation, reproduction and contraception were shown in Table 3. Late adolescents were significantly (P value 0.000) more aware about physiology of menstruation, age at menstruation, fertile period, contraceptive methods, HPV, Rubella vaccination and about Sexually Transmitted Infections. Mid adolescents was significantly (P value 0.000) more about proper disposal of menstrual pads and about good touch and bad touch. Awareness among adolescents towards various aspects of menstruation, reproduction and contraception were shown in Table 3.
| Table 3: Awareness among adolescents towards menstruation, reproduction and contraception (n=500) |
| Variables |
Early adolescents |
Mid adole0scents |
Late adolescents |
Total |
Χ2 value |
P value |
N (95) |
% |
N (171) |
% |
N (234) |
% |
N (500) |
Physiology of menstruation |
No |
90 |
95 |
161 |
94.2 |
126 |
53.8 |
377 (75) |
110.2 |
0.000 |
Yes |
5 |
5 |
10 |
5.8 |
108 |
46.2 |
123 (25) |
Awareness about age at menstruation |
No |
42 |
44.2 |
67 |
39.2 |
55 |
23.5 |
164 (33) |
17.61 |
0.000 |
Yes |
53 |
55.8 |
104 |
60.8 |
179 |
76.5 |
336 (67) |
Awareness about proper disposal of Menstrual pads |
No |
50 |
52.6 |
70 |
41 |
11 |
47 |
131 (26) |
12.73 |
0.000 |
Yes |
45 |
47.4 |
101 |
59 |
223 |
53 |
369 (74) |
Awareness about fertile period |
No |
84 |
88.4 |
167 |
97.7 |
166 |
70.9 |
417 (83) |
52.8 |
0.000 |
Yes |
11 |
11.6 |
4 |
2.3 |
68 |
29.1 |
83 (17) |
Awareness about age at child birth |
No |
80 |
84.2 |
118 |
69 |
66 |
28.2 |
264(53) |
111.8 |
0.000 |
Yes |
15 |
15.8 |
53 |
31 |
168 |
71.8 |
236 (47) |
Awareness about contraceptive methods |
No |
89 |
93 |
125 |
73.1 |
79 |
33.8 |
293 (59) |
122 |
0.000 |
Yes |
6 |
7 |
46 |
26.9 |
155 |
66.2 |
206 (41) |
Awareness about HPV & Rubella vaccine |
No |
88 |
93 |
164 |
95.9 |
198 |
84.6 |
450 (90) |
26.9 |
0.000 |
Yes |
7 |
7 |
7 |
4.1 |
36 |
15.4 |
50 (9) |
Awareness about Good touch/bad touch |
No |
5 |
5 |
7 |
4.1 |
41 |
17.5 |
58 (12) |
22.3 |
0.000 |
Yes |
90 |
95 |
164 |
95.9 |
193 |
82.5 |
442 (88) |
Awareness about Sexually transmitted infections |
No |
88 |
93 |
105 |
61.4 |
94 |
40.2 |
287 (57) |
77.7 |
0.000 |
Yes |
7 |
7 |
66 |
38.6 |
140 |
59.8 |
213 (43) |
Adolescents were assessed regarding their awareness about various contraceptive methods and it was illustrated in Figure 2. Among the 315 adolescents who were aware about contraception, 145 (29%) were aware about condom followed by Oral contraceptive pills, 95 (19%).
 |
Figure 2: Awareness about various methods of contraception among adolescents (n=315) |
Distribution of Body Mass Index (BMI) and Haemoglobin (HB) levels among adolescents were shown in Table 4. It was observed that BMI values have an increasing trend in the adolescents as the age increases but the difference is not statistically significant. Haemoglobin values have a decreasing trend as the age increases and the difference is statistically significant (P value 0.000). Overall anaemia was found in 125 girls that constitute 25% of the study population, 96 girls had haemoglobin of 10-12 g/dl, 40 girls had haemoglobin of 8-9.9 g/dl and 3 girls had haemoglobin of less than 8 g/dl. Most of them were treated with oral iron supplements in form of tablets and syrup. Only three girls of puberty menorrhagia had haemoglobin less than 8 g/dl and received blood transfusion.
| Table 4: Distribution of Body Mass Index (BMI) and Haemoglobin (HB) levels among adolescents (n=500) |
| Variables |
Mean & Standard Deviation |
P value |
Early adolescents
(10-13 years)
(N=95) |
Mid adolescents
(14-16 years)
(N=171) |
Late adolescents
(17-19 years)
(N=234) |
BMI |
18.9 ± 2.84 |
18.76±3.01 |
21.28±3.19 |
.772 |
HB |
10.9±1.04 |
10.5±0.90 |
9.4±1.44 |
.000 |
The social problems such as stress, addiction to electronic gadgets and junk foods were seen in almost 20 to 25% of adolescent girls. Hormone treatment such as progesterone therapy and oral contraceptive pills were received by 6% (n=30) of these girls with puberty menorrhagia. Surgical treatment such as detorsion with ovarian cystectomy, Bartholin cyst marsupialization and suction evacuation was done in three girls constituting 0.8% of the study group.
Discussion:
The current study was conducted among 500 adolescent girls in a Tertiary care hospital to identify the gynaecological disorders among them. Menstrual abnormalities were reported in 303 (60.6%) girls followed by 240 (48%) girls had leucorrhoea, 68 (13.6%) had urinary tract infection and 54(10.8%) had PCOS. Menstrual irregularities were reported more among mid adolescents (94.7%) followed by late adolescents (76.17%). Menorrhagia and dysmenorrhoea were reported significantly (p value – 0.000) more among mid adolescents followed by late adolescents.
Menarche is the hallmark of female puberty. It is mainly due to the hypothalamic pituitary ovarian axis activation. The mean age of menarche is 12 to 13 years. The cycle ranges from 21 to 45 days. Menstrual bleeding lasts for 2 to 7 days with average of 30 to 80 ml blood loss.[6] Menstrual abnormalities are the most common gynaecological disorder in adolescent girls contributing 60.6%. This was similar to Rathod et al. where 84.88% of adolescent girls had menstrual disorders.[4] In Goswami Sebanti et al study, 58.06% had menstrual disorders.[7] In Chand Karki et al study, menstrual disorder was seen in 23.80% girls.[8]
In the present study, of the menstrual abnormalities, dysmenorrhoea constitutes 44%, menorrhagia constitutes 26%, irregular menstruation constitutes 20.4%, hypomenorrhoea constitutes 5% and amenorrhoea constitutes 4%. Amenorrhoea was found in 20 girls. Of these one participant had primary amenorrhoea due to MRKH syndrome. Others had secondary amenorrhoea due to polycystic ovary syndrome. This finding is similar to study by Goswami Sebanti et al that found the common menstrual disorders as dysmenorrhoea, menorrhagia, irregular menstruation and amenorrhoea.[7]
Leucorrhoea which is the excessive vaginal discharge was the chief complaint in 48% of the girls. In studies by Jagannath et al. and Rathod et al. leucorrhoea was present in 13.10% and 8.85% girls respectively.[4,9] Urinary symptoms such as burning micturition, urgency and frequency was reported in 13.6% girls. This is comparable with study by Rathod et al. in which urinary infection was reported in 5.4% girls.[4] White discharge per vaginum was observed significantly more among late adolescents 113 (48.3%) followed by early adolescents 57 (60%). Urinary Tract Infection was reported significantly more among early adolescents [33 (34.7%)] followed by late adolescents [24(10.3%)] and mid adolescents [11 (6.4%)]. This may be due to their lack of awareness on the physiology of body changes in puberty and hygiene practices.
In the current study, polycystic ovarian syndrome was seen in 54 girls constituting 10.8% and 6% of girls presented with hirsutism. It was observed that BMI values have an increasing trend in the adolescents as the age increases but the difference is not statistically significant. This possibly explains the reason of statistically significant rise in incidence of menstrual irregularities and hirsutism in the late adolescent group. In Joshi et al study 14% of girls had PCOD.[10] In studies by Jaganath et al. and Prasad et al. 2.76% and 10% of girls had acne and hirsuitism.[9,11]
Hypothyroid was seen in 4% of girls. This is similar to the studies by Prachi Koranne et al, Shanti Sri et al and Manaswini Khuntiaet al.[12-14] In Patil SS et al study, thyroid abnormality was found in 19.5% and idiopathic thrombocytopenic purpura was seen in 4.8% of girls.[15]
In the present study, none of the adolescent girls had bleeding disorders like Idiopathic thrombocytopenic purpura, von Willebrand disease, etc. In Rathod et al study 11.76% of girls had bleeding disorders.[4] In Shanti Sri et al and Gillani et al studies 8.6% of girls had thrombocytopenia and 2.8% girls had von Willebrand disease.[13,16] In Prasad et al study, 35 % of girls had hemostatic disease.[17]
Medical management was given for almost all girls with gynaecological disorders. First line drugs like tranexamic acid, mefenamic acid and ethamsylate were given to those with dysmenorrhoea and menorrhagia. Hormonal treatment such as regesterone, oral contraceptive pills were received by 30 girls constituting 6%.
Surgical treatment such as detorsion with ovarian cystectomy, bartholin cyst marsupialization and suction evacuation was done in three adolescent girls constituting 0.8% of the study group. In Rathod et al. study, seven girls (41.17%) received oral progesterone and five girls (29.41%) received combined oral contraceptive pills.[4] In Manaswini Khuntia et al study, 7.1% girls received non-hormonal treatment, 92.91 % girls were treated with hormones and 2.6 % girls required surgical intervention.[14]
In the present study, haemoglobin values have a decreasing trend as the age increases and the difference is statistically significant (P value 0.000). In the present study three girls received blood transfusion due to severe anaemia caused by puberty menorrhagia. In Rathod et al. study, 17 girls with menorrhagia and severe anaemia received blood transfusion.[4] In PH Khosla et al. study 94 % of girls received blood transfusion and in the study by Prachi Koranne et al., 37 % of girls received blood transfusion.[12,18] In the present study 23.6% of the girls were aware about the physiology of menstruation. In studies done by Thakreet al. and Jain et al. 18% and 50% of the girls were aware of the physiology of menstruation.[19,20] In a study by Saradaet al. 78% of girls were aware of menstruation.[21]
In the present study about 97% of girls used sanitary pads and 74% were aware about proper disposal of sanitary pads. In a study by Jain et al. 78% used sanitary pads and in Sarada et al. study about 84% of girls used sanitary pads. 20, 21 In the present study only 25% of girls were aware of sexually transmitted diseases like HIV. In a study by Sarada et al. about 88% of study population knew about HIV and 50% of them did not know about other STDs like gonococci and syphilis.[21]
In the present study among the 315 girls who were aware about any form of contraception, 29% were aware about condoms and 19% about oral contraceptive pills. Many of the girls were not aware of the other methods of contraception. In Sarada et al. study, 50% of study population had knowledge about the contraceptive methods, but 84% of them did not know about best method for young people.[21] Overall in this study, late adolescents were significantly (P value 0.000) more aware about physiology of menstruation, age at menstruation, fertile period, contraceptive methods, HPV and Rubella vaccination and about Sexually Transmitted Infections. The information is mainly obtained from the teachers and peers.
This could be because of lack of access to health information and education on reproduction and sexual health. Health information on various aspects of adolescent health should be incorporated into the curriculum of students. Regular health education sessions can be conducted in schools and colleges to reduce the burden of gynaecological disorders among adolescents.
Conclusion:
This study described the common adolescent gynaecological problems in a particular geographic location and the factors associated with it. There is a high burden of gynaecological disorders and lack of awareness on various components of adolescent reproductive and sexual health among adolescents. So this study emphasizes the need of regular screening, continuous health education and health promotion activities in this age group.
Recommendation
Health care providers and policy makers need to be sensitized to the needs of adolescents and an enabling environment at health facilities should be provided for adolescents to improve their knowledge on prevention of common health problems in their age group. Improving the accessibility and availability to quality health services can help in early identification and treatment of these health problems. Parents and teachers can be trained regularly so that they can help and support the adolescents to grow in a healthy way.
Acknowledgement: We thank all the adolescent girls who participated in this study
Funding: Nil
Conflicts of Interest: Nil
Ethical Approval: Institute ethical committee approval was obtained and informed written consent obtained from study participants
References:
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- Thakre SB, Thakre SS, Reddy M, Rathi N, Phathak K, Ughade S. Menstrual hygiene: Knowledge, and practices among adolescent schoolgirls of Saoner, Nagpur district. J Clin Diagn Res. 2011;5:1027–33.
- Jain R, Anand P, Dhyani A, Bansal D. Knowledge and awareness regarding menstruation and HIV/AIDS among school going adolescent girls. J Family Med Prim Care. 2017;6:47-1.
- Mamilla S, Goundla S. Knowledge about menstrual hygiene, sexual health, and contraception in educated late adolescent age girls. J Family Med Prim Care. 2019;8(2):610-13.
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