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.