17.1 Puberty, Menstrual Disorders & Gynecologic Primary Care

Sexual and reproductive health is clinical category #10 on the PNCB CPNP-PC outline. Domain II wants Tanner staging you can describe, amenorrhea you can time against thelarche, and a pelvic complaint you can sort without importing adult gynecology onto a 14-year-old. Domain III wants scheduled NSAIDs for primary dysmenorrhea, a cautious PCOS label, topical estrogen for selected labial adhesions, and a screening rule that does not move: do not Pap average-risk adolescents under 21 (USPSTF/ACOG), even when they are sexually active. You are not running a reproductive-endocrinology service. You are deciding which 15-year-old with no menses already meets a definition, which first-year irregular cycle is still physiology, and which preschool discharge is hygiene versus a foreign body versus maltreatment.

Clinic opening. A 16-year-old is sexually active. Her mother wants "the Pap and the full pelvic today so we know her cervix is okay." If you speculum-and-cytology that average-risk adolescent because adult well-woman care starts at coitarche, you missed this section.

Quick Answer: Female puberty begins with thelarche (Tanner 2). Menarche follows about 2.5 years later, usually at Tanner 3–4. Primary amenorrhea: no menses by 15, or 3 years after thelarche, or no secondary sexual characteristics by 13. Secondary: no menses for 3 months if previously regular (about 6 months if irregular). Pregnancy-test. PCOS needs oligo-anovulation plus hyperandrogenism — not every irregular first-year cycle is PCOS. Primary dysmenorrhea: NSAIDs, then combined OCPs. Prepubertal vulvovaginitis: hygiene, foreign body, pinworm, GAS; STI in a prepubertal child is maltreatment until proven otherwise. Labial adhesions: observe if asymptomatic; topical estrogen if symptomatic — do not peel. Physiologic gynecomastia is common in early male puberty. No average-risk Pap before 21.

Tanner staging is a physical finding, not a birthday

Sexual maturity rating (SMR, Tanner) is how you document puberty. Recite the landmarks you can see and measure.

Typical female sequence: thelarche → pubarche → peak height velocity → menarche about 2.5 years after thelarche (a 2–3 year teaching range). Menarche usually occurs at Tanner 3–4, not as the first event. You do not need an unpublished national mean menarche age to the tenth of a year. Typical male sequence: testicular enlargement first, then penile growth, pubic hair, a later peak height velocity than in girls, voice change, and often transient gynecomastia.

Families hear typical onset windows in promotion visits: girls about 8–13 years, boys about 9–14 years. Precocious puberty (girls before 8, boys before 9) and delayed puberty (no female secondary characteristics by 13; no testicular enlargement by 14) leave office counseling and enter the endocrine workup (Chapter 16). Here you still stage, plot growth, and time menarche against thelarche. A 14-year-old whose breasts have been Tanner 2 for a month is not "late menarche" — she has barely started.

Adrenarche (odor, acne, pubic/axillary hair from adrenal androgens) can precede gonadarche. Isolated premature adrenarche is not the same as true central precocious puberty with progressive breast or testicular change. Isolated thelarche that then progresses is not "just chubby." Palpate a true breast bud versus adipose.

In clinic, stage in good light with a chaperone, privacy, and an explanation before clothing comes down. Document breast and pubic hair separately (Tanner 3 breast / 2 pubic hair is a real combination). In males, orchidometer or long-axis measurement beats guessing from a glance at the penis.

Primary versus secondary amenorrhea

Primary amenorrhea: no menarche by age 15 in a girl who has otherwise typical secondary sexual development, or no menarche 3 years after thelarche, or no secondary sexual characteristics by age 13. Secondary amenorrhea: no menses for 3 consecutive months after previously regular cycles, or about 6 months if cycles were irregular.

Always obtain a urine hCG in an adolescent who could be pregnant — including secondary amenorrhea, including irregular bleeding, and including a "I never had sex" historian when the story is incomplete. Pregnancy is the most common cause of secondary amenorrhea in sexually active adolescents. Missing it is a missed ectopic and a missed options conversation, not a polite extra lab.

Office first steps after the definition is met: pregnancy test, growth and Tanner review, TSH, then a targeted path — pelvic ultrasound for suspected obstruction or absent uterus; gonadotropins and karyotype when puberty itself failed; prolactin when indicated. You do not need an adult reproductive-endocrinology panel on hour one. You do need to refer outflow obstruction, suspected Turner, and unclear primary amenorrhea rather than repeating "come back in six months" after the clock has already rung.

PCOS: hyperandrogenism plus irregular menses — with a first-year trap

Polycystic ovary syndrome in adolescents is a clinical diagnosis built on oligo-anovulation and hyperandrogenism (hirsutism, moderate–severe acne, androgenetic hair loss, or biochemical androgen excess). Obesity and insulin resistance are common companions, not required tickets. Lean PCOS exists. Adult Rotterdam ovarian ultrasound morphology is unreliable in adolescents because multifollicular ovaries are often normal at this age. Do not diagnose from an incidental "polycystic-appearing" ovary on an ultrasound obtained for pain.

Not every irregular cycle in the first year after menarche is PCOS. Anovulatory, unpredictable bleeding is expected while the hypothalamic-pituitary-ovarian axis matures — often through the first 1–2 gynecologic years. Labeling a 13-year-old whose dates wander in year one as PCOS because she also has a few comedones and a BMI at the 85th percentile is how you overdiagnose. Wait for persistence (cycles still far apart, commonly discussed as persistently >90 days apart or still infrequent beyond that first post-menarche year) plus true hyperandrogenism, and exclude pregnancy, thyroid disease, and nonclassical CAH when the androgen picture is strong.

Primary-care management: lifestyle (sleep, activity, nutrition — intensity of obesity disease management lives in the nutrition chapter), combined hormonal contraception to regulate bleeding and raise SHBG, acne care, and metformin in selected insulin-resistant adolescents with endocrine collaboration when indicated. Screen blood pressure, lipids, and glucose risk. Do not start spironolactone as a casual add-on without teratogenicity counseling and contraception. Do not tell her fertility is already ruined.

Dysmenorrhea and abnormal uterine bleeding

Primary dysmenorrhea is prostaglandin-mediated cramping without pelvic pathology. It typically begins once ovulatory cycles appear, often 6–12 months after menarche, with midline cramping, nausea, diarrhea, or headache on the first days of flow. The exam is normal. First-line: NSAIDs (ibuprofen or naproxen) started at onset or just before flow, scheduled for 1–2 days — not a single tablet after she is already in the school nurse's office. If NSAIDs fail, or if she also needs contraception, combined oral contraceptives (or another combined hormonal method) suppress ovulation and thin the lining. Heat and staying active help; they are not a substitute for a prostaglandin plan.

Secondary dysmenorrhea (endometriosis, outflow obstruction, PID) is pain from the first periods, pain that progresses, pain unresponsive to NSAIDs plus hormones, or pain with pelvic findings. Endometriosis occurs in adolescents. Do not tell a 15-year-old she is too young for it. Refer gynecology when first-line therapy fails.

Abnormal uterine bleeding (AUB) in adolescents is usually anovulatory in the early gynecologic years (unopposed estrogen, unpredictable heavy or prolonged flow). Always pregnancy-test. Soak times matter: a soaked pad or tampon every 1–2 hours, night flooding, clots, dizziness, or school absence is heavy. Check hemodynamics and hemoglobin. Von Willebrand disease and platelet disorders classically present as heavy bleeding from the very first menses — ask dental bleeding, epistaxis, and family history; do not iron-and-reassure without a coagulopathy thought. Infection, trauma, and foreign body remain on the list. Acute heavy bleeding with instability is an ED hormone-and-transfusion problem, not a "start a pill Monday" plan. Stable AUB: iron repletion, combined hormonal therapy per AAP/ACOG adolescent guidance, and a follow-up hemoglobin.

Prepubertal vulvovaginitis, labial adhesions, and when STI means abuse

The prepubertal vagina is thin, hypoestrogenic, and lacks lactobacillus-dominant flora. Nonspecific vulvovaginitis is the everyday diagnosis: hygiene, wiping back-to-front, tight synthetics, wet swimsuits, bubble baths, and irritants. Counseling is hygiene, loose cotton, no soap on mucosa, and clear-water soaks — not a 10-day azole. Candida is uncommon in toilet-trained prepubertal girls without antibiotics, diabetes, or diapers.

A genital exam in a child is external, with a chaperone, an explanation first, and no forced speculum. Frog-leg or knee-chest as needed. Trauma-informed: say what you will do before you do it.

Labial adhesions (agglutination) are fusion of the labia minora from low estrogen plus inflammation — a thin midline raphe, often found at a well visit. Asymptomatic adhesions that still allow urination: observe; they usually resolve with adrenarche or puberty. Symptomatic (recurrent UTI, post-void dribbling, coverage of the urethral meatus, recurrent vulvitis): topical estrogen cream on the raphe for a limited course, then petrolatum to prevent re-fusion. Do not manually lyse in the office as first-line — it hurts and they re-adhere. Surgery is rare and specialist-directed.

Gynecomastia you counsel versus gynecomastia you work up

Physiologic adolescent gynecomastia is common at Tanner 2–3, often slightly asymmetric, typically a tender disk under 4 cm. It usually involutes over 12–24 months. Counsel, avoid contributing drugs when relevant (spironolactone, some antipsychotics, anabolic steroids), mention marijuana when that history is on the table, and support shirt and self-image. Distinguish lipomastia (adipose, no glandular disk) from true gynecomastia by exam.

Red flags — not physiologic: prepubertal onset, rapid massive enlargement, a hard eccentric mass, small firm testes (Klinefelter), galactorrhea, or a feminizing systemic picture. Refer endocrine or surgery for red flags. Do not send every 13-year-old with a 2 cm tender disk to a plastic surgeon in month one.

Do not Pap average-risk adolescents under 21

USPSTF and ACOG: cervical cytology (Pap) for average-risk people with a cervix begins at age 21, independent of sexual activity, number of partners, or age at coitarche. HPV-related cytologic changes in teens usually regress. Early Pap produces false positives, unnecessary colposcopy, and harm. Sexual activity is an STI-screening indication, not a Pap indication. Use NAAT for chlamydia and gonorrhea (urine or self-/clinician-collected vaginal swab). A speculum exam is not routine in asymptomatic adolescents. Indicated exams: suspected PID, unresponsive discharge, foreign body, AUB needing visualization, or trauma — not a well-teen ritual. HPV vaccination is prevention (immunization chapter for schedules; Section 17.3 for the SRH connection). It does not move the Pap start age earlier.

Exam traps. Pap at 16 because she is sexually active. PCOS on month 4 of irregular cycles. Missing outflow obstruction in primary amenorrhea with cyclic pain. A single rescue NSAID tablet as the entire dysmenorrhea plan. Peeling labial adhesions. Calling physiologic gynecomastia cancer — or ignoring a hard eccentric mass. Treating prepubertal discharge as yeast or as a quiet STI.

Clinic close. Stage puberty. Time menarche about 2.5 years after thelarche. Define amenorrhea and pregnancy-test. Do not convert first-year anovulation into PCOS. NSAIDs, then hormones, for primary dysmenorrhea. Heavy from day one of menarche: think coagulopathy. Prepubertal vulva: hygiene, foreign body, pinworm, GAS; STI is maltreatment until proven otherwise. Observe or estrogen for adhesions. Reassure physiologic gynecomastia. No average-risk Pap before 21.