14. In the premenarchal girls Flashcards
What does vaginal bleeding in early childhood indicate?
Vaginal bleeding in early childhood, regardless of duration or quantity, always indicates pathology.
What are the two main sources of abnormal vaginal bleeding in premenarchal girls?
- Local vulvar, vaginal, or cervical lesions.
- Endometrial shedding as a manifestation of precocious puberty.
How is precocious puberty defined?
- The appearance of secondary sexual characteristics before 8 years of age.
- Onset of menarche before 9 years of age.
What are the local causes of vaginal bleeding in premenarchal girls?
- Vulvovaginitis / infection (bacterial, parasite)
- Foreign body
- Trauma (including sexual abuse)
- Urethral prolapse
- Hymenal tags
- Vulval skin disorders (lichen sclerosis, warts, haemangioma)
- Sarcoma Botryoides
- Other rare malignancies of the genital tract
What are the causes of endometrial shedding in premenarchal girls
- Physiological (neonatal withdrawal bleeding due to the circulating oestrogen left over from the mother’s circulation)
- Premature menarche
- Exogenous oestrogens (pills, food)
- Endogenous oestrogen (functional cyst, an oestrogen-producing tumour)
- Precocious puberty (a) idiopathic (b) central nervous system lesion
What are the key components of history-taking in a premenarchal girl with vaginal bleeding?
- Medical and surgical history, especially CNS problems
- Associated trauma (including sexual abuse)
- Duration
- Offensive or not
- Other relevant systemic symtoms: weight loss etc
What is the main indication for an examination under anesthesia (EUA) in a premenarchal girl?
Vaginal bleeding, to allow thorough inspection of the lower genital tract.
Why is it important to check for secondary sexual characteristics in a premenarchal girl with vaginal bleeding?
If present → suspect precocious puberty.
If absent → Perform a genital examination to identify trauma or lesions.
If no signs of secondary sexual characteristics are present, what should be examined next?
A thorough genital examination for:
- Trauma.
- Lesions (warts, polyps, urethral prolapse, skin lesions, lichen sclerosis, tumors).
If there are no lesions or signs of trauma, what should be assessed next?
Determine if the bleeding is offensive in odor.
What does offensive vaginal bleeding in a premenarchal girl suggest?
A foreign body should be suspected.
What does non-offensive vaginal bleeding in a premenarchal girl suggest?
Vulvovaginitis or rarer tumors should be considered.
Why is it important to suppress GnRH in idiopathic precocious puberty?
To prevent premature closure of long bones, which would stop further growth.
What is the treatment for lichen sclerosis in premenarchal girls?
Potent steroid cream.
What are the treatment options for warts in premenarchal girls?
Cautery, excision, or laser.
How is urethral prolapse treated in premenarchal girls?
Estrogen cream (Premarin) or excision.
What is the management of other vulval lesions in premenarchal girls?
Excision biopsy and/or additional biopsies.
How is a foreign body managed in a premenarchal girl with vaginal bleeding?
Examination under anesthesia (EUA) and removal of the foreign body if present.
What are the steps in treating vulvovaginitis in premenarchal girls?
- Take pus swab for microscopy, culture, and sensitivity.
- Use Premarin cream (to change vaginal pH) for 2 weeks.
- Treat based on microscopy and sensitivity results.
Why should sexual abuse always be considered in premenarchal girls with vaginal bleeding?
Because trauma from abuse is a possible cause and must be ruled out.
Why is candidiasis rarely seen in premenarchal girls?
Because estrogen is necessary for Candida growth, and premenarchal girls have low estrogen levels
How can parasitic infestations contribute to vaginal bleeding?
Worms can cause irritation and bleeding, so if suspected, empirical treatment for worms should be considered.
What should be done if an abnormal mass or tumor is seen on EUA (examination under anesthesia) ?
A biopsy should be taken. If malignancy is confirmed, refer to an appropriate referral center.
