Dr.Anjalakshi Chandrasekar M.D.,D.G.O.,Ph.D Prof & HOD Dept.of Obstetrics & Gynaecology S.R.M.Medical College Potheri

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1 Dr.Anjalakshi Chandrasekar M.D.,D.G.O.,Ph.D Prof & HOD Dept.of Obstetrics & Gynaecology S.R.M.Medical College Potheri

2 Adolescent Adolescence is defined as Universal phenomenon of human development characterised by puberty changes which are pressed by inner psychological demands and cultural adjustments required by the community

3 Adolescence serves as the physical and mental transition period from childhood to early adulthood and is marked by changes 1.hormone fueled mood swings 2.hormone fueled sexual intrigue These developments can enhance and threaten adolescence and can have profound effect not only on the personality of the individual during adolescence but well into adulthood too no time is more complicated in persons life than adolescence

4 Reaction to puberty is the most unpredictable aspect of not only parents life but the individual who undergoes it. Biologically speaking it is a complex series of bodily occurrences that changes the body into an adult one capable of reproduction so puberty has everything to do with sexuality Sexuality is multidimensional construct and includes ethical, psychological,biological and cultural dimensions

5 Biological changes at puberty prime the adolescent brain and body for reproduction Individual and family psychodynamics influence sexual behaviour Therefore to not properly address puberty has a possible essential role in the development of psychosexual disorders

6 Adolescent sexual Behaviour 1.Intercourse: 75% of girls and young women have had intercourse by age of 20yrs in developed countries & it do not vary in different countries In US before the age of 15 yrs adolescents have shorter sexual relationships and have more than one partner

7 2.Masturbation: Seen in 59% of adolescents and 43% among girls 3.Homosexual behaviour: Boys more homosexuals than girls Because of un certainty about sexual orientation and gradually diminishes with age 26% at 12yrs to 5% at 18yrs 4.Lesbian: much less known about the adolescence of lesbian women 5.Noncoital sexual behaviour; oral 10% or anal 1% intercourse

8 Health consequences of adolescent sexual behaviour I.STI: 25% of STI are seen in adolescents due to anatomy of Cx cervical ectopy common and behavioural factors Asymptomatic STI seen both boys and girls easy spread of infection Barrier for routine screening and gynaec care (Newer Nucleotide amplification in urine do not require genital examination, help in screening asymptomatic cases)

9 Permanent damage by STI to RT esp. girls. Salpingitis due to chlamydia leading cause of acquired infertility HPV infection Ca Cx, vulva,anus & penis and genital warts 1/3 of sexually active girls are infected with this virus and most are completely asymptomatic Presence of HPV vaccine many infections and their consequences will be prevented

10 II. Unintended pregnancy one of the most socially significant issue Adolescent mother drop out of school, unemployment, poverty, rely on public assistance Children of adolescent mother have more health and social problem than children of adult women

11 III. Depression and suicide Common in adolescent population 5 to 6% in 6mths prevalence Life time prevalence 15 to 20% Homosexual sexual orientation is also a risk factor for suicide in adolescent because of social stigma Gays and lesbians are under considerable psychological stress 35% attempted suicide in previous 12 wks when compared to 10% of heterosexual youth

12 IV. Sexual victimisation Sexual abuse is a possibility if a adolescent have very early onset of sexual activity 8% of adolescent reported being victims of sexual abuse The prevalence rate of child and adolescent sexual abuse vary in literature depending on the definition of abuse.

13 Confidential reproductive health care for adolescent Parental involvement Extended cycle hormonal contraception studies have shown no endometrial abnormalities due to this method Protection against HPV infection prophylactic vaccine therapeutic vaccine PAP smear

14 Female sexual dysfunction Adolescence Sexual response is the psychosomatic process Definition : WHO ICD 10 the definition of SD includes the various ways in which an individual is unable to participate in a sexual relationship he or she would wish.

15 Diagnostic and statistical manual of mental disorders (DSM-IV) which is specifically limited to psychiatric disorders, defines FSD as the disturbances in sexual desire and in the psycho physiological changes that characterise the sexual response cycle and cause marked distress and interpersonal difficulty

16 FSD is disorders of libido, arousal, orgasm and sexual pain that lead to personal distress or interpersonal difficulties It is multi factorial in etiology with physiological and psychological roots

17 Sexual dysfunction in adolescent SD not well studied in adolescent FSD in adults is 40% Unknown in adolescent ½ of the adolescent are sexually active SD term is not universally accepted among general public as well as researchers Research in FSD typically starts with the age of 18yrs or over

18 Types of sexual dysfunction Consensus classification system Hypoactive sexual desire disorder Sexual aversion disorder Sexual arousal disorder Orgasmic disorder Sexual pain disorders dyspareunia vaginismus other sexual pain disorder

19 Overlap of female sexual disorders Sexual desire disorders dyspareunia Sexual arousal disorder vaginismus Orgasmic disorder

20 Causes for FSD 1.Medical disorder 2.Gynaecological problem which starts from adolescent age group 3.Psychiatric disorder 4.Complications of medications (selective serotonin receptor inhibitors SRRI, antipsychotics and other drugs)

21 Acceptance of high incidence of sexual dysfunction in all female population is necessary to appreciate this phenomenon in the adolescent cohort. Some gynaec diseases common for adolescent age and can cause SD Some sexual dysfunction require immediate treatment including surgical in case of congenital anomaly, ovarian cyst or tumour

22 Approach to adolescent FSD Open discussion with the pt Are you sexually active? Have you noticed any change in your sexual interest? Sexual problem is generally considered dysfunction only when it causes significant personal distress

23 Physical examination: Detailed vascular and neurological exam Careful and systematic examination of ext genitalia (magnifying surgical loop & cotton bud) vestibular adenitis and neuropathies & other local lesions Other system examination and pelvic examination

24 Laboratory testing: Routine biochemistry, Lipid profile vascular risk factorsdyslipidaemia, DM, RF Thyroid profile Integrity of HPO axis Androgens level including DHEA early morning in mid third of menstrual cycle Specialized diagnostic testing: Duplex Doppler USG Vaginal, clitoral temp & vibration sensory testing

25 Treatment Sex steroid hormone testosterone Hyperprolactinaemia bromocriptine,surgical ablation Iatrogenic/drug induced (SRRI psychotropic drug, neuroleptics, antipsychotic drugs) Anti androgens, GnRH agonist (endometriosis, infertility & fibroids) Psychogenic Counseling

26 Genital pain: Vestibulitis neuroma excision of affected area First line therapy: Oral vasoactive agents sildenafil,phentolamine(nonspecific B1 & B2 adrenergic antagonist),apomorphine,topical vasoactive agentsaprostadil and vacuum devices to improve blood flow II line & III line therapy when there is organic disease

27 Female Androgen Insufficiency Syndrome Androgens are essential for female reproduction as estrogen precursors Androgens affect bone density, libido,muscle mass strength, mood, energy and adipose tissue distribution. Low levels of androgens will alter these functions with detriment to overall wellbeing Female androgen insufficiency a pattern of clinical symptoms in the presence of decreased testosterone and normal estrogen

28 Seen in pts between 18 and 59yrs. The symptom complex of ADS are decreased libido, increased fatigability and diminished lubrication Causes of AIS: Ovarian insufficiency,adrenal insufficiency, HP insufficiency, drug related,chronic illness,acute stress, Increased SHBG & idiopathic Lab.testing: free androgen index, DHEA & DHEAS Androgen therapy testosterone patch, DHEAS

29 Summary Providing health care related to adolescent sexuality is one of difficult task of primary care clinician It demands in depth knowledge of pubertal,and psychosexual development,familiarity with the normal adolescent sexual behaviour, knowledge of pertinent gynaecologic and urologic medicine and superior communication skills. Adolescent are in great need of this type of care. The large majority wants to be sexually healthy and eventually to have children and raise healthy families themselves

30 THANK YOU