Discussion
In this retrospective study of 97,252 patients visited at a PAG clinic
in a children’s hospital in eastern China over 23 years, we observed
that genital inflammation was the most common presentation followed by
early puberty, consultation of growth and development, gynecological
examination, and menstrual disorder. The number of PAG patients and the
percentage of genital inflammation increased substantially over the
13-year period. Furthermore, the disease pattern varied across age
groups, with the most common gynecological issues for each age group
being genital inflammation and early puberty for children (ages 0-6) and
teenagers (ages 7-9), and consultation of growth and development and
menstrual disorder for adolescents (ages 10-18).
Our findings are consistent with the very few long-term studies
conducted outside of China, which describe the overall pattern and
characteristics of PAG problems. For example, in a study conducted in a
district hospital in the U.K., 7recurrent
vulvovaginitis and labial adhesions, which were both categorized as
genital inflammation in our study, were the two most frequent reasons
for demanding professional PAG treatment among 800 patients over 15
years. The UK study also showed that aside from genital inflammation,
early puberty was the most common problem in patients aged 7-9, and
dysmenorrhea and/or menorrhagia were the most frequent issues for
patients at the age of 14. Moreover, it was also mentioned that genital
inflammation and menstrual complains were kind of the leading reasons
for a medical care and the most common complains of all
patients.8
Another study conducted in the U.K. based on a tertiary hospital
observed that patients of suspected genital tract anomalies and
disorders of sex development accounted for more than half of the 985
patients over 16 years. Other diseases like vulvovaginal conditions,
pelvic pain and cysts, labial dysmorphism, menstrual disorders, and
precocious puberty formed 6% - 8% of referrals .9 A
relatively different disease spectrum was observed in this study. In
Mugdha’s study anomalies of the genital tract was the most common
problems among the study patients, while this gynecological condition
took a relatively small proportion in our study. One potential reason
may be that patients with anomalies of the genital tract tended to seek
medical care at the tertiary clinic. Meanwhile, genital inflammation,
which was encountered frequently in our study, only accounted for less
than 15% in Mugdha’s study. The difference may be explained by the fact
patients with more serious diseases such as the anomalies of the genital
tract tended to be referred to the tertiary hospitals for further
treatment.
Regarding the PAG disease pattern in the Chinese population, our
systematic review included thirty-three studies conducted between
January 2005 and December 2018 among 26 cities from 14 provinces. The
studies were all published in Chinese journals. Due to differences in
age coverage, sampling area, sample size, clinical setting (20
outpatient and 13 inpatient settings) and other reasons, the proportion
of different PAG issues were highly heterogeneous across studies. After
standardized classification, the weighted percentage of the disease
spectrum was found to be similar to the findings in the current study.
In particular, genital inflammation and menstrual disorder were the top
two PAG issues in the meta-analysis. It is worth noting that genital
tumor and genital trauma ranked high in the meta-analysis, driven by 13
studies at inpatient settings which had very high proportions of these
patients. One reason could be that the conditions of inpatients is
generally more severe than that of outpatients. Consequently, the
proportion of genital tumor and genital trauma in inpatient-based
studies was relatively higher, which raised the proportion of genital
tumor and genital trauma in meta-analysis. What’s more, in the process
of meta-analysis, we found that the classification standards of
outpatient diseases in many PAG fields were widely different in China,
which may affect the accuracy of the research to a certain extent.
The most common PAG disease in this study was clinically nonspecific
gynecologic inflammation. This disease is closely related to improper
urination habits,10 personal
hygiene,11,12 and other factors including education,
economic status,13 nutrient deficiency (such as
vitamin A and β-carotene),14 and higher consumption of
energy-dense, high-glycemic index foods and parental awareness of the
reproductive health 11,15 The number of patients with
genital inflammation was particularly high during the summer, which
might be because the high temperature in summer increased the local
temperature and humidity of the female perineum, thus making bacteria or
candidiasis more prone to replication and causing
infection.16 The other reason of the more frequent
medical visits in summer may be that parents and children had more time
during the summer holiday to seek gynecological examination and
consultation at the PAG clinic. For genital inflammation among children
and adolescents, first-line management usually includes a review of
hygiene behavior and appropriate behavioral advice unless there are
concocters of other underlying pathology or sexual
abuse.17 Moreover, effective health promotion programs
are needed to prevent or reduce the occurrence of genital inflammation.
Early puberty was mainly concentrated at ages 7-9, while the average age
of menstruation among Chinese girl was 13 years old
.18 The physical condition of 7-9 age may be
influenced by a variety of factors, including emotional fluctuations,
stress from entering school and taking examinations, environmental
changes and malnutrition. Ovarian function can be very unstable at this
stage, which may lead to early puberty. Consultation of growth and
development and menstrual disorders were the main complaints of the
10-18 age group. After the age of 10, girls begin to experience
menarche, which is often thought of as a sign of starting to maturity.19 If teenagers are growing and developing behind or
overstepping their peers at this time, many parents may feel anxious and
take them to the hospital for help. However, as the regulatory functions
of the hypothalamus and pituitary are not fully mature, stable periodic
regulation with the ovary has not yet been
established.19,20 During this process, physiological
and psychological disorders might lead to the occurrence of various
menstrual diseases such as dysfunctional uterine bleeding, dysmenorrhea
and amenorrhea.21 Other PAG issues including genital
trauma, masturbation syndrome, anomalies of the genital tract, and
genital tumor were less common in our study population. However, these
diseases were relatively severe. They were sent to inpatient ward for
further treatment which imposed a heavy burden on individuals and
families, suggesting the need for more attention and support
.2
Utilizing clinical medical record data collected over one decade based
on the first PAG clinic visit, this study represents the first
large-scale study with the longest time-span describing the spectrum of
gynecological issues in both pediatric and adolescent patients in China.
The large sample size, long time span and wide range of conditions
provides a better understanding of PAG problems, a highly neglected
issue in China and worldwide. However, there were several limitations to
this study. Firstly, the patient’s diagnosis at first clinical visit may
not be the final diagnosis. There may have been additional tests
conducted after the initial visit, which may have altered the diagnosis.
Nevertheless, the diagnosis at first clinical visit was easy to use for
describing the overall patterns of PAG issues in this large study base.
Secondly, the results of this study are based on medical records from a
single center, which may not represent the PAG disease spectrum in other
regions of China.
Children and adolescents with PAG issues have received increasing
attention from the global community. For example, an International
Fellowship of Pediatric and Adolescent Gynecology
(IFEPAG),
an international diploma of recognition, has been founded facilitated by
the International Federation of Pediatric and Adolescent gynecology
(FIGIJ).1 North American Society for Pediatric and
Adolescent Gynecology (NASPAG) have designed short and long curriculums
and develop them continuously to provide professional knowledge for the
postgraduate trainees in obstetrics and gynecology in residency
programs.22 However, there remains a major shortage of
PAG clinics all over the world, especially in underdeveloped countries
and regions.23-24 The high costs, insurance issues,
stigma, absence of PAG education to community health service providers
led to the residents’ difficulties in access to specialists and the lack
of place for better care by someone closer to the family’s home. These
barriers put a huge workload on doctors and increased the cost of
medical care for patients, which also led to lengthy diagnostic delays.
Therefore, it is imperative to establish a PAG service network to
provide standardized clinical, educational and referral pathways and to
secure the gynecological and reproductive health of children and
adolescents in China.
Our study aimed to establish a spectrum of PAG diseases to advocate for
and alongside young females to achieve specialized and expertized
gynecological care and support. In China, embarrassment, privacy
concerns, or other cultural factors are usually barriers to women
visiting gynecologists, and this may be exacerbated among children and
adolescent girls. Professional gynecology research and guidance can play
an important role in popularizing gynecology education, removing public
stigma, and reducing health and social inequality in this field.
Therefore, our findings could help health care providers and
investigators gain insight into the specific medical needs of this
particular population group, which could inform future targeted clinical
investigations and healthcare quality improvement programs.