Adolescent Gynaecology

Question 1

What is Gillick competency?

Answer 1

Child <16y can give/withhold consent if doctor feels she fully understands what is involved in an intervention without parental permission/knowledge

In certain situations, parents can overrule

Question 2

What is Fraser competence?

Answer 2

Child under 16yo who is considered to be sufficiently mature & has understanding to be competent to receive contraceptive advice without parental knowledge/consent

Question 3

What key things are encompassed by fraser competence?

Answer 3

Must be mature enough to understand advice/implications of Rx
Dr tried to persuade girl to tell parents/let her tell the parents
Girl’s health would suffer without Rx/advice
Is in girl’s best interest to give Rx/advice

Question 4

When do you investigate primary amenorrhoea

Answer 4

Primary amenorrhoea + normal secondary sexual characteristics - 16y

Primary amenorrhoea + absent secondary sexual characteristics - 14y

Question 5

What investigations should you do for primary amenorrhoea?

Answer 5

FSH, LH, prolactin, TSH, testosterone, oestrogen

Question 6

Why do you want to test prolactin in amenorrhoea?

Answer 6

Prolactinoma could grow into the pituitary and prevent FSH/LH production

Question 7

Why do you want to test TSH levels?

Answer 7

Hypothyroidism can cause amenorrhoea

Question 8

What tests/imaging should you do after the initial FSH etc. blood levels?

Answer 8

Pelvic USS
Progesterone withdrawal bleeding
ASK ABOUT CYCLICAL ABDOMINAL PAIN
Rule out pregnancy!!

Question 9

How does the progesterone withdrawal bleed work?

Answer 9

Give progesterone and if no withdraw bleeding occurs –> patient has v. low oestrogen/problem with outflow tract (e.g. adhesions/scarring)
If bleeds - oestrogen there but no ovulation is occurring

If lack oestrogen - investigate FSH/LH/TSH/prolactin

NB - low FSH/LH v. common in this age group (esp if v. thin)

Question 10

Why do you need to ask about cyclical pain in primary amenorrhoea?

Answer 10

May be imperforate hymen/septum - USS will show mass of blood collecting in uterus
Must make excision to let blood out

Question 11

What is puberty induction?

Answer 11

Mimicking normal puberty by gradually building up oestrogen (until they stop growing)
Add on progesterone once maximal height potential is reached (at go on low oestrogen pill at this point (at least 20mg)

Do if girl hasn’t gone through puberty at 16/18

Question 12

Why can’t you give high dose oestrogen straight away when inducing puberty?

Answer 12

Alters breast shape

Question 13

What is secondary amenorrhoea?

Answer 13

Absence of menses for more than 3 months in woman with previously regular cycles (or 6m in irreg. cycles)

Question 14

What can cause secondary amenorrhoea?

Answer 14

Weight
PCOS
Pregnancy
Fluctuating LH/oestrogens (e.g. fluctuating weight –> hypogonadoatrophic hypogonadism)

Question 15

What is PCOS?

Answer 15

Disorder characterised byb hyperandrogenism (xs androgen which leads to virulisation) oligoovulation/anovulation +/- polycystic ovaries

Question 16

What causes PCOS?

Answer 16

Individuals may be genetically predisposed, lifestyle, hyperinsulinaemia disrupts the HPO axis

Question 17

In PCOS what does hyperinsulinaemia result in?

Answer 17

Obesity
Epidermal hyperplasia/hyperpigmentation (acanthosis nigricans)
Increased androgen production in ovarian cells –> imbalance between androgen precursors & the resulting oestrogen produced in granulosa cells

Pituitary releases abnormally high LH –> disrupts FSH/LH balance –> impaired follicle maturation & oligo/anovulation
Immature follicles wont disappear properly & transform into fluid filled cysts

High LH and insulin –> testosterone production in ovaries –> abnormal hair growth, acne, male pattern baldness, clitoromegaly, voice deepening & increased oestrogen production by adipose tissue

Question 18

What are the clinical features of PCOS?

Answer 18

Menstrual irregularities - amenorrhoea/oligomenorrhoea
Infertility
Obesity/other sx of metabolic syndrome (insulin resistance, HTN, hypertriglycermidaemia etc.)
Hirsutism
Androgenic alopecia
Acne vulgaris
Acanthosis nigricans

Question 19

What is the Rotterdam Criteria?

Answer 19

Diagnose PCOS if 2+ of following & have ruled out other causes of irregular bleeding & elevated androgens:
Hyperandrogenism
Oligo/anovulation
PCOS on USS (don’t do TVUS on virigins!)

Question 20

What would you expect the blood levels of testosterone, LH, progesterone & oestrogen to be with something with PCOS?

Answer 20

High testosterone
High LH
Low progesterone
Normal/high oestrogen

Question 21

How do you Rx PCOS?

Answer 21

Weight reduction & lifestyle changes

OCP to regulate menses

Question 22

When is anovulation normal?

Answer 22

2-4y post-menarche as HPO is just being set up

Question 23

Very very heavy bleeding in a young girl may be suggestive of what?

Answer 23

Bleeding disorder, e.g. vWF dx

Question 24

How do you Rx menorrhagia?

Answer 24

Reassure 
POP
COCP
Mirena 
Tranexamic acid 
Mefenamic acid

Question 25

What accidents can occur to cysts?

Answer 25

Small cysts are often functional/dermoid
Gravity allows the to drop to lowest point in pelvis
Can tort/turn gangrenous/rupture

Question 26

What is the typical presentation of accidents to cysts?

Answer 26

Subacute hx
Tenderness to one side of pelvis
May feel mass

Question 27

How do you manage accidents to cysts?

Answer 27

Reassure & follow up USS

Don’t want to operate on ovaries as you damage eggs

Question 28

What is vulvovaginitis?

Answer 28

Inflammation of the vulva/vagina due to either infection/non-infectious aetiologies

Question 29

What age is vulvovaginitis most common?

Answer 29

2-7 year old girls

Question 30

What are your differentials for vulvovaginitis?

Answer 30

Trauma, sexual abuse, FB, urinary incontinence (–> irritation)

Question 31

What characterises vulvovaginitis?

Answer 31

Bloody, purulent, foul smelling discharge, dysuria

Question 32

What are labial adhesions?

Answer 32

Adhesions of the labia minora
Usually affects >4y
Results from superficial labial injuries caused by perineal inflammation (e.g. UTI, diaper dermatitis, diarrhoea)

Question 33

How do you Rx labial adhesions?

Answer 33

Resolves spontaneously at puberty once oestrogen levels rise

Question 34

What is the usual presentation of labial agglutination?

Answer 34

Adhesion of labia minor in midline

Vertical line of fusion distinguishes from imperforated hymen/vaginal atresia

Question 35

What can agglutination lead to?

Answer 35

Retention of uterine/vaginal secretions –> vulvovaginitis/UTI

Question 36

When should you Rx labial agglutination?

Answer 36

If chronic vulvovaginitis/UTI

Question 37

How do you Rx labial agglutination?

Answer 37

If asymptomatic - improved hygiene
Lubrication of labia with bland ointment
Topical oestrogen
Surgical separation only rarely req.

Question 38

What constitutes abnormal discharge and what may cause abnormal discharge?

Answer 38

Smelly, purulent, change in colour
Infection (e.g. yeast infection)

Rule out sexual abuse and FB

Question 39

When is a mucoid discharge normal?

Answer 39

In infants up to 2m after birth (due to maternal oestrogen)

& prepubertal girls who experienced increased oestrogen production by maturing ovaries

Question 40

What is the Rx for abnormal vaginal discharge?

Answer 40

Advise to avoid soap, good hygiene, cotton underwear

Question 41

How might you investigate abnormal discharge?

Answer 41

Culture to identify causative organisms
Urinalysis to rule out cystitis
Perianal Ex with transparent tape to test for pinworms

Persistent discharge may req. Ex under GA to rule out FB

Question 42

When might you do labial reduction?

Answer 42

Asymmetric labia/large labia affecting QoL

Only after 18yo & reassurance of normality