Praca przeglądowa Review Paper Endokrynol. Ped. 2019.18.1.66:17-22 Pediatr. Endocrinol. 2019.18.1.66:17-22 DOI: 10.18544/EP-01.18.01.1712

Seksuologiczne i gineologiczne Sexuologic and gynecologic problemy u dzieci i dojrzewających problems in childhood and dziewcząt girls

1Jacek Boroch, 1Grażyna Jarząbek-Bielecka, 2Małgorzata Mizgier, 3Andrzej Kędzia

1Pracownia Ginekologii Wieku Rozwojowego i Seksuologii Kliniki 1Department of Perinatology and Gynecology, Division of Ginekologii Katedry Perinatologii i Ginekologii UMP, 2Zamiejscowy Developmental Gynecology and Sexology, Poznan University of Wydział Kultury Fizycznej AWF Poznań, 3Katedra Auksologii Klin- Medical Sciences, Poland, 2Department of Morphological and icznej i Pielęgniarstwa Pediatrycznego UMP Health Sciences, Dietetic Division, Faculty of Physical Culture in Gorzów Wlkp., University School of Physical Education in Poznań, 3Department of Clinical Auxology and Pediatric Nursing UMP

Słowa kluczowe Key words seksuologia, dziewczęta, masturbacja sexuology, girls, gynecology,

Streszczenie Abstract Seksuologia jako nauka bada ludzką seksualność Sexology, as a science, studies human sexuality ta- z uwzględnieniem rozwoju seksualnego, zachowań, king into account sexual development, behaviour, funkcji i preferencji. Problemy ginekologiczne są functions and preferences. Many gynecological pro- związane z rozwojem seksualnym , z rozwojem osi blems are connected with sexual development and podwzgórzowo-przysadkowo- jajnikowej. Rozwój developmnent hypothalamic-pituary-ovarian axis. i funkcje narządów płciowych są ściśle związane Development nad function of sexual organs is close- z czynnością osi podwzgórzowo-przysadkowo-jajni- ly connected with the hypothalamic-pituitary-ovarian kowej. Ginekologia wieku rozwojowego to interdysy- activity. Pediatric and adolescent gynecology is an in- plinarna specjalność, silnie związana z endokrynolo- terdysyplinary speciality strong connected with endo- gią. Problemy ginekologiczne u dziewcząt dotyczą crynology. The gynecological problems encountered zarówno medycznych jak i psychologicznych aspek- in children and adolescents are often both medically tów i wymagają specjalistycznego podejścia. jednym and psychologically complex and thus require a hi- z takich zagadnień jest problem masturbacji. ghly skilled and coherent approach. One between so problem is masturbation. Endokrynol. Ped. 2019.18.1.66.17-22. © Copyright by PTEiDD 2019 Pediatr. Endocrinol. 2019.18.1.66:17-22. © Copyright by PTEiDD 2019

© Copyright by PTEiDD 2019 Adres do korespondencji / Correspondence address: [email protected] Klinika Ginekologii Katedry Perinatologii i Ginekologiii UMP www.endokrynologiapediatryczna.pl tel .618419278; e-mail: [email protected] www.pteidd.pl Sexual life of a human is realised on three plat- Developmental endocrine and physiological forms: biological, psychological and social. changes during LATE CHILDHOOD & ADOLE- SEXUAL DEVELOPMENT = SOMATIC DEVE- SCENCE LOPMENT + PSYCHO-SEXUAL DEVELOPMENT *Hypothalamic-pituitary-ovarian axis, starting Paediatric and adolescent gynaecology, also of LH peaks at early nighttime. called paediatric and young girls gynaecology, is * (, axilarche), , a field that was separated out of general gynaeco- and occurs (average menarche logy because of the differences in physiology and is about 13 years). pathology of the female genital system during its Many sexuological and gynecological problems development. The reproductive tract in children are connected with processes during . Pu- and adolescents is somewhat different in structure, berty is the period of transition between childhood hormonal support, and function from that of and adulthood, a time of accelerated growth, sexual female, yet many of the same gynecologic disorder maturation, and profound psychological changes. occur in both grups [1–8]. When considering somatic sexual development, In sexual development of girls following stages the term “puberty” is used here, which refers to the can be distinguished: period of development when the ability to repro- 1. Neonatal stage – influence of maternal oestro- duce is obtained, while adolescence is a broader gens. term that covers psychosexual development as 2. Infantile stage – „hormonal silence” to the age well. The period of adolescence is related to soma- of 9-10 years. tic and sexual development, whose culmination is 3. Adolescence – influence of oestrogens by own the ability to reproduce, as well as psychosexual ovaries. development. Developmental endocrine and physiological It is difficult, however to determine a tangible changes during INFANCY culmination point in psychosexual development, *Neonatalfollicle-stimulation FSH and luteini- and it is even more challenging to measure it. This zing LH levels rise with the widrawal of is because the final sexual development is related maternal oestrogens. to psycho-emotional or social development, or the *Some stimulation from maternal placental development of one’s cognitive processes. oestrogen does occur, as a consequence the new- born female may exhibit estrogenic effects with During puberty very important is time of me- cervical mucos production, maturation of vaginal narche – epithelial cells, budding occasionally and the median age of menarche is 12.8 years, and rare estrogen withdrawal bleeding and follicular the normal is 21 to 35 days in cyst development. length. Bleeding normally lasts for 3 to 7 days and Developmental endocrine and physiological consists of 30 to 40 ml of blood. Cycles are abnor- changes during INFANCY mal if they are longer than 8 to 10 days or if more *Hymen may appear to be thickened and enlar- than 80 ml of blood loss occurs. Soaking more than ged because of oestrogen exposure. 25 pads or 30 tampons during a menstrual period *Uterus is palpable not for examination. is abnormal. *Lactobacilli populate the vaginal mucosa, le- Regular ovulatory menstrual cycles often do not ads to acidic pH. develop until 1 to 1.5 years after menarche, and 55- *Vaginal discharge or uterine bleeding may oc- 82% of cycles are anovulatory for the first 2 years cur in the first 2 weeks, because of exposure to and after menarche. Anovulatory cycles typically cause withdrawal from placental oestrogens. heavier and longer bleeding. Developmental endocrine and physiological Adolescents frequently experience irregular changes during EARLY CHILDHOOD menstrual bleeding patterns, which can include *Under age 1-7 years, changes in the hypothala- several consecutive months of amenorrhea. mus-pituitary-gonadal axis with the development During the , in the normal men- of an extremely sensitive feedback system as well strual cycle release of gonadotropin-releasing hor- as central inhibition of GnRH. mone (GnRH) from the hypothalamus stimulates *The pH of the vagina is alkaline, and vaginal the pituitary to secrete luteinizing hormone (LH) irritation is common. and follicle-stimulating hormone (FSH), which *Uterine corpus to cervix ratio is 2:1. then stimulate ovarian estrogen secretion, which

18 Endokrynol. Ped. 2019.18.1.66.17-22 Seksuologiczne i gineologiczne problemy u dzieci i dojrzewających dziewcząt induces endometrial proliferation. Ovulation oc- ner scale. Tanner scale considers development of curs 12 hours after the midcycle surge in LH. and and axillary hair growth and breast. The follows ovulation, and the The should be carefully inspected and corpus luteum secretes progesterone and estrogen. palpated. Progesterone inhibits endometrial proliferation The increasing diameter of the or uni- and induces glandular changes. Without fertiliza- lateral tender breast bud is often the first sign of tion, progesterone and estradiol levels decrease, puberty. and sloughing of the endometrium occurs 14 days 1. Infantile stage with no development whatso- after ovulation. ever. Rare, but difficult problem is teenage pregnan- 2. Development of breast bud as small mound cy. It is is defined as a teenaged or underaged girl beneath an anlarged areola. (usually within the ages of 13–18) becoming pre- 3. The breast and areola are enlarged still fur- gnant. It’s not only medical problem, but social ther to resemble a small adult breast with a conti- and psychological problem too. Therapeutic teams nuous rounded contour. should consider not only gynecologist, but educa- 4. The and areola are enlarged even tors, psychologists and psychiatrist too [4]. more to produce a secondary projection above the One between girls gynecological problems is contour of the remainder of the breast. amenorrhea and other menstrual disorders. 5. Normal adult breast with smooth rounded Primary amenorrhea is defined as the absence contours, the secondary mound of stage 4 having of menarche by age 16. Puberty is considered de- been assimilated into the whole breast form. layed and warrants evaluation if breast develop- Pediatric and adolescent gynecology is an emer- ment (the initial sign of puberty in girls) does not ging specialty, at the intersection of pediatrics, pe- begin by the age of 13. The mean time between diatric endocrinology, gynecology, genetics, pedia- the onset of and menarche is 2 tric surgery, dermatology, public health medicine, years. Absence of menses within 2 to 2.5 years of psychiatry and sexuology. It thus addresses a wide the onset of puberty should be evaluated. spectrum of diseases from the newborn period to Secondary amenorrhea is defined as the absen- adolescence. The adolescent, who is no longer ce of 3 consecutive menstrual cycles or 6 months a child but not quite an adult, poses a particular of amenorrhea in patients who have already esta- management problem to the traditional specialties blished regular menstrual periods. [1,2,7–9]. Early sexual maturation prior to age 8 in girls The gynecological problems encountered in and age 9 in boys. There are two types: children and adolescents are often both medical- – isosexual praecocity – characteristic are ap- ly and psychologically complex and thus require propriate for the child’s genetic and gonadal sex a highly skilled and coherent approach. One be- – heterosexual praeciocity – sexual characteri- tween so problem is masturbation [7–13]. stic inappropriate for the genetic sex (feminizing Masturbation refers to sexual stimulation, espe- syndrome in boys or virilizing syndrome in girls. cially of one’s own genitals and often to the point Delay of pubertal events beyond age 13 in girls of , which is performed manually, by other and age 14 in boy’s considered abnormal; bone age types of bodily contact (except for sexual interco- usually retarded: urse), by use of objects or tools, or by some combi- *hypothalamic tumors may result in pituary nation of these methods [7,12]. hormone deficienies by interfering with pulsatile Masturbation is self-stimulation of the genitals secretion of GnRH for pleasure and self-comfort. Children may rub *primary gonadal failure and the impaired se- themselves with a hand or other object. Mastur- cretion of gonadal steroids leads to decreased ne- bation is more than the normal inspection of the gative feedback and elevated LH and FSH levels genitals commonly observed in 2-year-olds during (hypergonadotrophic e.g.Turner baths. During masturbation, a child usually appe- syndrome ars dazed, flushed, and preoccupied. A child may Development of sexual organs is closely con- masturbate as often as several times each day or nected with the hypothalamic-pituitary-ovarian just once a week. Masturbation occurs more com- activity. monly when a child is sleepy, bored, watching te- In girls diagnostics very important is a scale for levision, or under stress. the assessment of sexual development – it is Tan-

Jacek Boroch, Grażyna Jarząbek-Bielecka, Endokrynol. Ped. 2019.18.1.66.17-22 19 Małgorzata Mizgier, Andrzej Kędzia Occasional masturbation is a normal behavior use or when other people are around”. By the time of many toddlers and preschoolers. Up to a third of children are 4 or 5 years old, they become sensiti- children in this age group discover masturbation ve to other people’s feelings and understand that while exploring their bodies. Often they continue they should masturbate only when they are alone. to masturbate simply because it feels good. Some Younger children may have to be sent to their ro- children masturbate frequently because they are oms to masturbate. unhappy about something, such as having their pacifier taken away. Others are reacting to punish- ment or pressure to stop masturbation completely Discuss this approach with your child’s day care [10]. or preschool staff Masturbation has rare medical causes, maybe after vulovaginitis and in rare situation after sexual Ask your child’s caregiver or teacher to respond abuse – children respond to sexual assault in many to your child’s masturbation by first trying to di- different ways [6–8,13]. stract the child. If this doesn’t work, they should Attention is paid to the problem of early chil- catch the child’s attention with comments such as, dhood masturbation, which has specific medical “We need to have you join us now.” Masturbation and psychological significance. There is a need for should be tolerated at school only at naptime. proper sexual education of children, adolescents and parents [6–8,12]. Information for parents: „How can I help my Increase physical contact with your child child”? and „When should I call my child’s health- care provider? ” Some children will masturbate less if they re- ceive extra hugging and cuddling throughout the day. Try to be sure that your child receives at least Have realistic goals 1 hour every day of special time together and phy- sical affection from you. It is impossible to eliminate masturbation. Ac- cept the fact that your child has learned about it and enjoys it. The only thing you can control is Common mistakes where he or she does it. A reasonable goal is to permit it in the bedroom and bathroom only. You The most common mistake that parents make is might say to your child: ‟It’s OK to do that in your to try to eliminate masturbation completely. This bedroom when you’re tired”. If you completely leads to a power struggle which the parents inevi- ignore the masturbation, no matter where it’s done, tably lose. Children should not be physically pu- your child will think he or she can do it freely in nished for masturbation, nor yelled at or lectured any setting. about it. Do not label masturbation as bad, dirty, evil, or sinful, and do not tie your child’s hands or use any kind of restraints. All of these approaches Ignore masturbation at naptime and bedtime lead only to resistance and possibly later to sexual inhibitions. Leave your child alone at these times and do When should I call my child’s healthcare pro- not keep checking on him or her. Do not forbid vider? your child from lying on the abdomen and do not Call during office hours if: ask if his or her hands are between the legs. • Your child continues to masturbate when other people are around. • You suspect that your child has been taught to Distract or discipline your child for masturbation masturbate by someone. at other times • Your child tries to masturbate others. • You feel your child is unhappy. First try to distract your child with a toy or acti- • You cannot accept any masturbation by your vity. If this fails, explain to your child: “I know that child. feels good, and it’s okay to do it in your room or • This approach does not bring improvement wi- the bathroom, but do not do it in the rest of the ho- thin 1 month.

20 Endokrynol. Ped. 2019.18.1.66.17-22 Seksuologiczne i gineologiczne problemy u dzieci i dojrzewających dziewcząt • You have other questions or concerns [12]. well as the isolated or associated character of the In rare situation masturbation can be connected lesions [6,10,11]. with vulvovaginitis. It is important to get a good Medical, psychological and social aspects of pe- history, including the time of appearance of the diatric and adolescent gynecology and sexuology lesions, whether they are congenital or not, and is the subject of many papers [1,9–14]. their evolution. Any cutaneous perineal lesion in a child should trigger a careful mucosal, cutaneous and systemic examination, in the presence of the Conclusion parents if the child is young or in private according to a teenager’s preferences [6,10,11]. This study of sexuological and gynecological In so situation, it is bacterioscopic examination girl problems confirms the need for creating cen- of stained sample, clinical evaluation and occa- ters for children and adolescent gynecology and sionally precise bacterial identification are useful sexuology which can provide medical, psycholo- in diagnostic procedures. For etiological purpo- gical and social information and a comprehensive ses, one should consider the child’s age and the aid to teenagers, children and parents. circumstances in which the disease occurred, as

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Jacek Boroch, Grażyna Jarząbek-Bielecka, Endokrynol. Ped. 2019.18.1.66.17-22 21 Małgorzata Mizgier, Andrzej Kędzia