Adolescent Gynaecology Flashcards
What is Gillick competency?
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
What is Fraser competence?
Child under 16yo who is considered to be sufficiently mature & has understanding to be competent to receive contraceptive advice without parental knowledge/consent
What key things are encompassed by fraser competence?
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
When do you investigate primary amenorrhoea
Primary amenorrhoea + normal secondary sexual characteristics - 16y
Primary amenorrhoea + absent secondary sexual characteristics - 14y
What investigations should you do for primary amenorrhoea?
FSH, LH, prolactin, TSH, testosterone, oestrogen
Why do you want to test prolactin in amenorrhoea?
Prolactinoma could grow into the pituitary and prevent FSH/LH production
Why do you want to test TSH levels?
Hypothyroidism can cause amenorrhoea
What tests/imaging should you do after the initial FSH etc. blood levels?
Pelvic USS
Progesterone withdrawal bleeding
ASK ABOUT CYCLICAL ABDOMINAL PAIN
Rule out pregnancy!!
How does the progesterone withdrawal bleed work?
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)
Why do you need to ask about cyclical pain in primary amenorrhoea?
May be imperforate hymen/septum - USS will show mass of blood collecting in uterus
Must make excision to let blood out
What is puberty induction?
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
Why can’t you give high dose oestrogen straight away when inducing puberty?
Alters breast shape
What is secondary amenorrhoea?
Absence of menses for more than 3 months in woman with previously regular cycles (or 6m in irreg. cycles)
What can cause secondary amenorrhoea?
Weight
PCOS
Pregnancy
Fluctuating LH/oestrogens (e.g. fluctuating weight –> hypogonadoatrophic hypogonadism)
What is PCOS?
Disorder characterised byb hyperandrogenism (xs androgen which leads to virulisation) oligoovulation/anovulation +/- polycystic ovaries
What causes PCOS?
Individuals may be genetically predisposed, lifestyle, hyperinsulinaemia disrupts the HPO axis
In PCOS what does hyperinsulinaemia result in?
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
What are the clinical features of PCOS?
Menstrual irregularities - amenorrhoea/oligomenorrhoea
Infertility
Obesity/other sx of metabolic syndrome (insulin resistance, HTN, hypertriglycermidaemia etc.)
Hirsutism
Androgenic alopecia
Acne vulgaris
Acanthosis nigricans
What is the Rotterdam Criteria?
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!)
What would you expect the blood levels of testosterone, LH, progesterone & oestrogen to be with something with PCOS?
High testosterone
High LH
Low progesterone
Normal/high oestrogen
How do you Rx PCOS?
Weight reduction & lifestyle changes
OCP to regulate menses
When is anovulation normal?
2-4y post-menarche as HPO is just being set up
Very very heavy bleeding in a young girl may be suggestive of what?
Bleeding disorder, e.g. vWF dx
How do you Rx menorrhagia?
Reassure POP COCP Mirena Tranexamic acid Mefenamic acid
What accidents can occur to cysts?
Small cysts are often functional/dermoid
Gravity allows the to drop to lowest point in pelvis
Can tort/turn gangrenous/rupture
What is the typical presentation of accidents to cysts?
Subacute hx
Tenderness to one side of pelvis
May feel mass
How do you manage accidents to cysts?
Reassure & follow up USS
Don’t want to operate on ovaries as you damage eggs
What is vulvovaginitis?
Inflammation of the vulva/vagina due to either infection/non-infectious aetiologies
What age is vulvovaginitis most common?
2-7 year old girls
What are your differentials for vulvovaginitis?
Trauma, sexual abuse, FB, urinary incontinence (–> irritation)
What characterises vulvovaginitis?
Bloody, purulent, foul smelling discharge, dysuria
What are labial adhesions?
Adhesions of the labia minora
Usually affects >4y
Results from superficial labial injuries caused by perineal inflammation (e.g. UTI, diaper dermatitis, diarrhoea)
How do you Rx labial adhesions?
Resolves spontaneously at puberty once oestrogen levels rise
What is the usual presentation of labial agglutination?
Adhesion of labia minor in midline
Vertical line of fusion distinguishes from imperforated hymen/vaginal atresia
What can agglutination lead to?
Retention of uterine/vaginal secretions –> vulvovaginitis/UTI
When should you Rx labial agglutination?
If chronic vulvovaginitis/UTI
How do you Rx labial agglutination?
If asymptomatic - improved hygiene
Lubrication of labia with bland ointment
Topical oestrogen
Surgical separation only rarely req.
What constitutes abnormal discharge and what may cause abnormal discharge?
Smelly, purulent, change in colour
Infection (e.g. yeast infection)
Rule out sexual abuse and FB
When is a mucoid discharge normal?
In infants up to 2m after birth (due to maternal oestrogen)
& prepubertal girls who experienced increased oestrogen production by maturing ovaries
What is the Rx for abnormal vaginal discharge?
Advise to avoid soap, good hygiene, cotton underwear
How might you investigate abnormal discharge?
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
When might you do labial reduction?
Asymmetric labia/large labia affecting QoL
Only after 18yo & reassurance of normality
