Adolescent Gynae Flashcards
Workup of primary amenorrhea
Scenario 1/2 - 16yo primary amenorrhea
- Thelarche (breast budding, E)
- Adrenarche/Pubarche (pubic hair then axillary - androgen dependent)
- Menarche (within 2-3 years of Thelarche - menstruation)
- Stage 2 tanner = Thelarche
- Growth spurt peak from Stage 2 Tanner
Definition of primary amenorrhea
- no menses by 16yo
- no menses 2yr after breast develop
Definition of delayed puberty
- no 2ndary sexual characteristics by 13 - no menses by 15
DDx (from head to ut)
- Constitutional delay
- Congenital - Kallman/Turner/Swyers
- Hypothal - eating/exercise
- Pituitary tumor/Prolactinoma
- CAIS/MRKH
- Preg/PCOS
- T-Septum/imperforate hymen
Hx
- menses - never or stalled (CNS)
- growth spurt/breast devlop/pubic hair
- anosmia/HA/visual sx/galactor
- LOW/heat intolerance
- cyclical pain w/o menses
- PHx/Med/FHx…
HEADS
- home/ed/employ/exercise/eat
- drug/depression/sex (in private)
Exam
- BMI/vitals
- Turner’s (webbed neck/facies/short)
- Hyperandrogenism (hirsutism/acne)
- Tanner staging/pubic/axillary hair
- Genital - external only - clitoromegaly
Ix
Tanner staging + Pelvic USS + Karyotype
- brst+ ut+ = obstruct/POI/2nd ameno
- brst- ut+ = Turner’s (45XO)
- brst+ ut- =MRKH (46XX) CAIS (46XY)
Gonadotrophins
- bHCG/FSH/LH/E2/TSH/Prl
- free T/SBHG/FAI/DHEAS/17-OH
Counselling/Mx of 45XO
Scenario 1 - 19yo no puberty, dx/mx
Puberty and development
- Tertiary care
- MDI - PAG or Gyn/Endo/Psych
- GH if juvenile bone age
- Puberty induction with low dose E2
- once breast/ut developed
- change to low E2 OCP ongoing
- 2yrly pelvic USS -> uterine growth
General Risks
- hypothyroid (usually Hashi)
- cardiac (bicuspid/aortic root dilation)
- renal (duplex/horshoe kidney)
- coeliacs/IBD
- deafness (recurrent OM)
- hypertension
Investigation
Bloods
- FBE/UEC/LFT/TFT
- Coeliac serology, B12, IF abs
Imaging
- Audiology
- ECG +/- TTE +/- Cardiac MRI if abn
- Renal tract USS
- DEXA scan
Fertility/Preg
- spont conception rare
- adoption v surrog v IVF w donor ovum
- 2% maternal mortality
- 30% if abn echo -> aortic dissection
- high risk for GDM/PET/IUGR/CS del
If planning fertility
- refer to fertility service
- if plan to carry preg with donor egg
- MDI pre-preg counselling
- Screen/Optimize co-morbid (above)
- Medication rv
- Precon bloods/vaccinations..
Mx/Counselling for
45X/46XX mosaic vs 45X/46XY mosaic
45X/46XX mosaic
more likely to have spontaneous puberty pregnancy, with longer preservation of ovarian function
45X/46XY mosaic
5-30% risk of dysgerminoma if leave gonads in, so need to excise them laparoscopically
Counselling/Mx of MRKH
- Mayer-Rokitansky-Kuster-Hauser syndrome (MRKH)
- congen abno - no FRT = no ute/cervix/vag
Mx
- Ref tertiary
- MDI - PAG/Paed/Psych
+/- renal tract USS
- sexual = vaginal dilator +/- McIndoe vaginoplasty
- fertility = adoption/surrogacy
- written info
- support group
Counselling/Mx of CAIS
Explanation
- Congenital androgen insensitivity syndrome
- X-linked recessive disorder with androgen receptor mutation
- Male genotype and female phenotype
- No male 2ndary sexual characteristic due to lack of receptor response to T
- female sexual characteristic due to conversion of peripheral T to E
Mx
- Ref tertiary
- MDI - PAG/Endo/Paed/Psych
- Gonadectomy at end of puberty, 15% risk of ca
- HRT (E2 only) - breast/cardio/osteo
- dilator therapy for short vagina
- fertility = adoption
- written information
- support grp
Counselling/Mx of Gonadal dysgenesis XY (Swyer’s syndrome)
- male genotype, female phenotype
- abn/absence in SRY gene -> lack AMH/testosterone production
- clinical - rudimentary breast, no pubic hair, amenorrhea, tall, no puberty
- streak gonads -> 30% risk of dysgerminoma
Mx
- Ref tertiary
- MDI - PAG/Endo/Ped/Psych/SW/Geneti
- Gonadectomy - at diagnosis
- Gender assignment
- Delay (GnRH) or induce puberty (E2)
- HRT (combined) - CVD/osteo risk induction
- Fertility - donor/surrogate/adopt
- written information
- support group
Initial mx of DUB in adolescent
DDx
- anovulatory
- PCOS
- coagulopathy
- thyroid
- STI
- preg
- HEADS screen (parents outside part)
- External exam only if not SA
- FBE/Ferritin/TSH/Coag/PCOS/bHCG
+/- STI screen - Pelvic USS
- risk of anemia/social impact
- expectant vs medical
- expectant = observe, await HPO
- medical = non-hormonal vs hormonal
- non-hormonal - NSAID+Txa
- hormonal - cyclical P eg provera
- doesn’t interfere w HPO, SE-mood/wt
- contraception/safe sex advice if SA
- written information
- follow-up review
Underage UPSI + EC advice
(same for adult)
- risk of preg & STI
- confirm Gillick’s competence (<16)
- confirm age of consent/partner
- confirm no coercion
- exclude STI (include serology) & preg
- chlam/gon/mg/trich/HIV/HCV…
- HEADS screen
- 3 EC options - IUD vs 2 oral options
- Cu IUD/LNG/Ulipristal
- Cu IUD - 5d, 99%/ongoin/PID/STI/abx
- Ulipristal - 5d, 1 dose, ovulate
- LNG - 3d, 1 dose, SE-N&V, ovulate
- F/U - 3-4/52, menses, GP, bHCG
- advice on safe sex/barrier
- advice on contraception
- COCP/POP/Depo/implant/IUD
risk of failed EC on bkg of UPSI - don’t forget ectopic!!!
Advice on how to take the pill
- risk of incorrect dosing = preg
- start within 5d of menses
- start outside of 5d of menses - 7d barri
- daily pill, placebo for withdrawal
- if forget, take when rememb & contin
- if vomit within 2hr, retake & continue
- if abx/diarrhea-barrier during/7d post
- miss >=3 week 1 - EC if UPSI + 7d barri
- miss >=3 week 2 - 7d barri
- miss >=3 week 3 - 7d barri + next pack
