Dr. Shirin Venkatramani, MD (Bom), FRCOG (Lon), Consultant Obstetrician and Gynaecologist, based in Dubai, is an authority on women's medical problems and is well-known for her work in the areas of High Risk Pregnancy, Menstrual disorders and ovarian cancer. Discuss with Dr. Shirin your personal medical problems or any other issue that would help you understand your body better. This is your forum.

In this series of articles, I would like to trace female problems right from birth to oldage. Briefly, I will outline the causes of commonly seen conditions and indicate where expert opinion must be sought.

In Utero(womb): Sometimes one gets a scan report saying the female foetus is having a cyst in the ovary - this is generally speaking not an alarming find unless of an unusual size.

At Birth: The newborn may present with ambiguous genitalia. This can happen if certain hormones are given in the first 3 months of pregnancy, hence it is always wise to avoid any drugs unless absolutely necessary during this period of pregnancy. Other causes like chromosomal defects, improper gonadal development are best left to the expert.

Neonatal Life : (i.e. first month of life) : 10/15% of female babies may have a vaginal discharge, which may be white or even blood stained. This is due to an excess of maternal hormones circulating in the baby's blood and will settle down in a few weeks - does not require treatment.

'Witches milk' is the name given to a milk discharge from the baby's nipple and is also due to the circulating maternal hormones. The newborn's nipple should never be squeezed as some of the dais' (maids) are prone to do. This will result in infection and damage the delicate tissue. Breast enlargement may be similarly present and will subside in a few weeks time.

On rare occasions the hymen has no opening and the secretions collect causing a swelling to appear in the abdomen - this requires surgical correction.

Still more rarely, the anus may open into the vagina - this too will require expert attention.

As the infant grows the maternal hormones wane and the baby now has the skin and high PH similar to that of an old lady whose ovaries have failed. This makes the baby easily susceptible to infection.

A female child may therefore get infection of the external and lower genital tract called - Vulvovaginitis : presents as a sore vulva, with discharge which could be blood stained, purulent &/or foul smelling. The child may complain of itching and burning during urination. There are several causes for this:-

• Bacteria of low virulence due to lowered local resistance.
• Pinworms which infect the lower bowel and peri-anal region giving rise to intense itching.
• Foreign bodies inserted up the vagina out of curiosity (discharge is bloodstained and foul smelling)
• Gonorrhea (sexually transmitted disease ) in cases of child abuse.
• Secondary infection due to lesions elsewhere in the body.
• As a feature of other general skin diseases such as lichen schlerosus or eczema.

The doctor only has to separate the two lips of the vulva to examine the child and take a swab for testing. Rectal examination is done to exclude a foreign-body.

The treatment consists in:

• Local hygiene - always use luke warm water to wash, swab the baby front to back not the other way around. No bubble baths as it is difficult to cleanse the residue of soap or detergent which can cause chemical irritation. Same holds true about the under clothing - which should be thoroughly clear of any soap or detergent. Antiseptic solutions should not be used.

• Oral or local antibiotics if indicated. Estrogen cream locally to increase the resistance to infection.

Labial fusion : This means the two lips of the labia adhere to each other and close the opening, this alarms the mother unduly. All that is required is gentle separation, followed by application of an estrogen cream for 2 weeks.

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Puberty refers to the whole period of time during which the secondary sexual characteristics are being developed. Menstruation (periods) begins and the entire psychosexual outlook of the girl changes. Thus, at this age the attitude the mother has towards menses, sex, reproduction and the woman's role as a whole will have a profound effect on the girl. There are five physical changes of puberty :

• Breast development (thelarche)
• Pubic hair }
• Axillary (armpit) hair }adrenarche
• Growth spurt
• Menstruation (menarche age of first menses)

The average age of the onset of periods in the UK is 13 years. 95% of the female population will have reached menarche between the ages of 11 and 15 years.

Disorders related to puberty are :

• Precocious Puberty
• Delayed Puberty
• Excessive Menstrual loss
• Irregular and infrequent periods
• Genital Tract Tumors

Precocious Puberty : is considered if there is breast and pubic hair growth prior to age 8 years or onset of periods before the age of 10 years. This may be due to

• Constitutional early development
• Meningitis
• Cerebral or ovarian tumor

Diagnosis and treatment are best left to the expert.

Puberty is considered as delayed if no sign of secondary sexual development occurs by age 14 years or periods don't start by 16 years.

Excessive menstrual bleeding :
Early menstrual cycles seldom occur as regularly as in later life. The interval between periods, their duration and the amount of loss are often variable for some months or longer. It is always helpful to keep a menstrual calendar i.e. note the number of days of blood loss, interval during periods and pads soaked per day. Occasionally, periods are more frequent and heavier in which case a doctor should be consulted to rule out any pathology. With the advent of the ultrasound it is very easy now to examine unmarried young girls. Treatment generally consists of improved diet in terms of iron and calcium content that means more green vegetables and low fat milk, oral iron supplements if the patient is anemic, sometimes hormonal treatment may become necessary. Rarely this may be due to blood disorders which the doctor will rule out.

Dysmenorrhea : painful periods are more often a result of phobias and tabboos associated with menstruation rather than a physiological cause. It is true however, that "eggless" periods i.e when the egg is not formed are usually painless. A little reassurance and reorientation of the girl and her mother towards this normal process goes a long way to relieve the pain. Occasionally analgesics are prescribed.

Irregular or infrequent periods when associated with obesity, abnormal hair growth and acne fall into a syndrome often associated with ovarian dysfunction due to polycystic changes in the ovary. General instructions for such girls include:

• Regular exercise to lose weight as body fat stores estrogen (female hormone) which is released erratically and disrupts the cycle.
• Diet should be rich in fruits and vegetables while avoiding chicken, red meat and chocolates.
• Hormones if required for regularizing the periods.
• Drugs such as cyproterone acetate, diane, spiranolactone for excessive hair growth best left to the expert.
• Cosmetic management.