Adolescent gynaecology

Question 1

Gillick competence?

Answer 1

> 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

Question 2

Fraser competence?

Answer 2

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

Question 3

Gynaecological history in an adolescent female?

Answer 3

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

Question 4

Gynaecological examination in an adolescent female?

Answer 4

1) General
2) Breast
3) Gynaecological

Never in first visit though

Question 5

How can the sexual develop on an adolescent be staged?

Answer 5

Tanner staging

Question 6

At which age should primary amenorrhea and normal secondary sexual characteristics be investigated?

Answer 6

Investigate at the age of 16

Question 7

At which age should primary amenorrhea and absent secondary sexual characteristics be investigated?

Answer 7

Investigate at the age of 14

Question 8

Which investigations should be carried out before referral in primary amenorrhoea in an adolescent?

Answer 8

1) FSH, LH, PRL, TSH , testosterone and estrogen
2) Pelvic USG

3) Progesterone withdrawal bleed:
- Pregnancy
- Not enough oestrogen

Question 9

How can puberty be induced?

Answer 9

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

Question 10

Causes of secondary amenorrhoea within adolescent?

Answer 10

1) Weight
2) PCOS
3) Pregnancy
4) Fluctuating LH/ estrogens

Question 11

How can we diagnose polycystic ovarian syndrome?

Answer 11

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

Question 12

Although often normal what. other things should be considered in bleeding disorders within adolescents?

Answer 12

> 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

Question 13

Treatment of menorrhagia in adolescents?

Answer 13

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

Question 14

Which cysts are often functional?

Answer 14

Small cysts

Question 15

Where are cysts usually found in the pelvis and why?

Answer 15

Lowest point in the pelvis due to gravity

Question 16

What is the issue with cysts dropping to the lowest point in the pelvis?

Answer 16

Can tort, turn gangrenous or rupture

Question 17

How does an adolescent often present with cysts?

Answer 17

> Often subacute history

> Usually tender to one side of the pelvis or behind uterus and may feel a mass

Question 18

What is vulvovaginitis?

Answer 18

Vulvovaginitis is the inflammation of the vulva and vagina

Question 19

What are the symptoms of vulvovaginitis?

Answer 19

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

Question 20

How would someone usually present with yeast infection vulvovaginitis?

Answer 20

Discharge from a yeast infection is typically white, odorless, and clumpy, similar to cottage cheese. Itching is also a common complaint.

Question 21

What causes vulvovaginitis?

Answer 21

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.

Question 22

What are the types of vulvovaginitis?

Answer 22

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.

Question 23

How is vulvovaginitis diagnosed?

Answer 23

1) Thorough history
- New lubricant e.g. allergy
- Sexual history etc

2) Swab and microscopy

Question 24

How is vulvovaginitis treated?

Answer 24

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

Question 25

Long term implications of vulvovaginitis in the young?

Answer 25

No long term issues usually improve at puberty

Question 26

What are labial adhesions?

Answer 26

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.

Question 27

What causes labial adhesions?

Answer 27

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

Question 28

Aetiology of labial adhesions?

Answer 28

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.

Question 29

What are the symptoms of labial adhesions?

Answer 29

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

Question 30

Treatment of labial adhesions?

Answer 30

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

Question 31

What is is called when labial adhesions lead to complete adhesion of the labia minora within the midline?

Answer 31

Labial agglutination

Question 32

When is a mucoid discharge normal?

Answer 32

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

Question 33

Examples of some pathological discharge within adolescents?

Answer 33

1) Infections with organisms, such as E.coli, Proteus, Pseudomonas
2) Hemolytic streptococcal vaginitis
3) Monial vaginitis
4) A foreign body

Question 34

Management of abnormal discharge within an adolescent?

Answer 34

> 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.

Question 35

Common cause of absent uterus?

Answer 35

Müllerian agenesis, also known as Mayer–Rokitansky–Küster–Hauser syndrome (MRKH) or vaginal agenesis

Question 36

Type I Mayer–Rokitansky–Küster–Hauser syndrome (MRKH)?

Answer 36

Type I MRKH syndrome is characterized by variable underdevelopment of the vagina and uterus.

Question 37

Type II Mayer–Rokitansky–Küster–Hauser syndrome (MRKH)?

Answer 37

Type II MRKH also incorporates extragenital/extramüllerian malformations, including vertebral, cardiac, urologic (upper tract), and otologic anomalies.

Question 38

Signs and symptoms of Mayer–Rokitansky–Küster–Hauser syndrome (MRKH)?

Answer 38

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)