Adolescent gynaecology Flashcards
Gillick competence?
> Child <16 years can give/withhold consent if doctor feels she fully understands what is involved in an intervention
> In certain situations, parents can override girls wishes
Fraser competence?
Contraceptive advice to under 16 yrs girl:
> Mature enough to understand advice and implications of treatment
> Girl likely to begin or continue to have sex with or without treatment
> Doctor tried to persuade girl to inform her parents or to allow her/him to inform them
> Girl’s health would suffer without treatment/advice
> In girl’s best interests to give treatment or advice
Gynaecological history in an adolescent female?
1) Gynaecological:
- Age of menarche
- Cycle
- Pain
2) Sexual (in absence of parents)
- Sexual activity
- Contraception
3) Weight gain/ loss
4) Exercise
5) REMEMBER SEXUAL ABUSE
Gynaecological examination in an adolescent female?
1) General
2) Breast
3) Gynaecological
Never in first visit though
How can the sexual develop on an adolescent be staged?
Tanner staging
At which age should primary amenorrhea and normal secondary sexual characteristics be investigated?
Investigate at the age of 16
At which age should primary amenorrhea and absent secondary sexual characteristics be investigated?
Investigate at the age of 14
Which investigations should be carried out before referral in primary amenorrhoea in an adolescent?
1) FSH, LH, PRL, TSH , testosterone and estrogen
2) Pelvic USG
3) Progesterone withdrawal bleed:
- Pregnancy
- Not enough oestrogen
How can puberty be induced?
1) Gradual build up with estrogen
2) Effect on breast development
3) Add progesterone
- Once maximum height potential is reached
- At least 20 mg of estrogen dose
Causes of secondary amenorrhoea within adolescent?
1) Weight
2) PCOS
3) Pregnancy
4) Fluctuating LH/ estrogens
How can we diagnose polycystic ovarian syndrome?
Two out of three:
1) Oligo- or anovulation
2) Clinical or biochemical signs of hyperandrogegism
3) Polycystic ovaries on ultrasound or direct inspection
Other causes of hyperandrogegism should be excluded
Although often normal what. other things should be considered in bleeding disorders within adolescents?
> Be aware of other factors eg. sexual abuse,
bullying, trauma etc.
> Pregnancy complications
> Bleeding Disorders ?up to 10-20%
eg. Von Willebrands, Platelet defects,
> Leukaemia
Treatment of menorrhagia in adolescents?
1) Reassure
2) Talk to the girls directly
3) Progesterone only pill
4) Tranexamic Acid 1g qds
5) Mefenamic Acid
6) Combined Oral Contraceptive
7) Mirena
Which cysts are often functional?
Small cysts
Where are cysts usually found in the pelvis and why?
Lowest point in the pelvis due to gravity
What is the issue with cysts dropping to the lowest point in the pelvis?
Can tort, turn gangrenous or rupture
How does an adolescent often present with cysts?
> Often subacute history
> Usually tender to one side of the pelvis or behind uterus and may feel a mass
What is vulvovaginitis?
Vulvovaginitis is the inflammation of the vulva and vagina
What are the symptoms of vulvovaginitis?
Symptoms of vaginitis include:
- Itching - Irritation - Burning - Redness - Swelling - Dryness - Rash, blisters or bumps
You may also notice:
- Discomfort when you urinate
- Pain during sex
- Light bleeding (spotting)
- Discharge and odor
How would someone usually present with yeast infection vulvovaginitis?
Discharge from a yeast infection is typically white, odorless, and clumpy, similar to cottage cheese. Itching is also a common complaint.
What causes vulvovaginitis?
You get vaginitis when the normal amount of yeast and bacteria in your vagina gets out of balance. This could happen for several reasons, including an infection, a change in hormones, or antibiotic use. It could also be because of a reaction you have to something that comes into contact with your vulva or vagina.
What are the types of vulvovaginitis?
1) Yeast infection = C.albicans, or any of several species of candida.
2) Bacterial vaginitis
3) Trichomoniasis = A one celled parasite Trichomonas vaginalis.
Others:
1) Sexually transmitted diseases (chlamydia and gonorrhea)
2) Viruses, including herpes and HPV (human papillomavirus)
3) A decrease in hormones, usually during menopause or after childbirth
4) Allergic reactions to lubricants, lotions, detergent, etc.
How is vulvovaginitis diagnosed?
1) Thorough history
- New lubricant e.g. allergy
- Sexual history etc
2) Swab and microscopy
How is vulvovaginitis treated?
This is based on the cause:
1) Allergy may require removing allergen
2) Yeast = Anti-fungals:
- Fluconazole (Pill)
- Clotrimazole (Cream)
- Miconazole (Cream)
- Tioconazole (Cream)
3) Bacterial:
- Clindamycin (topical)
- Metronidazole (Pill or topical)
4) Trichomoniasis:
- Metronidazole (Pill)
5) Prevention:
- Condom
- Avoid tight fitting clothes
- Avoid douching
- Avoid perfumed soaps
Long term implications of vulvovaginitis in the young?
No long term issues usually improve at puberty
What are labial adhesions?
Labial adhesions occur when the labia minora adhere together forming a shiny membrane of inflammatory tissue.
Labial adhesions range in severity from near complete fusion to milder cases with 30-50 percent of the length of the labia minora fused.
What causes labial adhesions?
Unknown cause theories include:
1) Adhesions are generally seen in girls between the ages of 3 months to 6 years when estrogen levels are low. Once girls begin puberty and estrogen levels increase, the adhesions are less common or may separate on their own.
2) A chronic inflammatory process as the result of fecal soiling, vulvovaginitis, eczema or dermatitis can also play a role in the development of the adhesion.
3) Sexual abuse
Aetiology of labial adhesions?
Labial adhesions are, by definition, a disorder of females and occur most often in infants and girls aged 3 months to 6 years, with a peak incidence around the age of 13-23 months.
What are the symptoms of labial adhesions?
1) Often asymptomatic
2) Urine pooling in the vagina with voiding and subsequent urine leakage from the vagina upon standing after voiding (postvoid dribbling or vaginal voiding)
3) Associated urinary tract infection (UTI) or vulvo-vaginitis
4) Discomfort with voiding
Treatment of labial adhesions?
1) Observation - 80% will spontaneously resolve within a year
2) Topical oestrogen creams
3) Lubrication of the labia with a bland ointment.
4) Manual or surgical seperation
5) Avoid irritants
What is is called when labial adhesions lead to complete adhesion of the labia minora within the midline?
Labial agglutination
When is a mucoid discharge normal?
1) In infants for up to 2 weeks after birth as a result of maternal oestrogen
2) Prepubertal girls, who experience increased oestrogen production by maturing ovaries
Examples of some pathological discharge within adolescents?
1) Infections with organisms, such as E.coli, Proteus, Pseudomonas
2) Hemolytic streptococcal vaginitis
3) Monial vaginitis
4) A foreign body
Management of abnormal discharge within an adolescent?
> Culture to identify causative organisms.
> Urinanalysis to rule out cystitis.
> Review proper hygiene.
> Perianal examination with transparent tape to test for pinworms.
> In cases, of persistent discharge, examination under anesthesia is indicated to rule out foreign body.
Common cause of absent uterus?
Müllerian agenesis, also known as Mayer–Rokitansky–Küster–Hauser syndrome (MRKH) or vaginal agenesis
Type I Mayer–Rokitansky–Küster–Hauser syndrome (MRKH)?
Type I MRKH syndrome is characterized by variable underdevelopment of the vagina and uterus.
Type II Mayer–Rokitansky–Küster–Hauser syndrome (MRKH)?
Type II MRKH also incorporates extragenital/extramüllerian malformations, including vertebral, cardiac, urologic (upper tract), and otologic anomalies.
Signs and symptoms of Mayer–Rokitansky–Küster–Hauser syndrome (MRKH)?
The following may be observed in patients with MRKH syndrome:
- The patient undergoes puberty with normal thelarche and adrenarche; however, menses do not begin (ie, primary amenorrhea)
- Patients may report cyclic abdominal pain due to cyclic endometrial shedding without a patent drainage pathway
- Because ovarian function is normal, patients experience all bodily changes associated with menstruation
- Infertility
- Difficulty with intercourse
- Voiding difficulties, urinary incontinence, or recurrent urinary tract infections (UTIs)
- Vertebral anomalies (most commonly scoliosis)
