Adolescent Gynaecology Flashcards
Define Gillick Competence?
Child <16yrs is able to give/withhold consent if the doctor feels theu fully understands an intervention and it’s risks
It can be overridden by parents in some circumstances
Define Fraser Competence?
Refers specficially to giving contraceptive advice/prescription to under 16s:
- Mature enough to understand advice and implications of treatment
- Likely to continue/begin sex regardless of treatment
- GP has tried to persuade to tell parents (or let you tell them)
- Health would suffer without treatment/advice
- In their best interest
At what age do you investigate Primary Amenorrhoea as abnormal?
Failure of menstruation by the age of 16 years in the presence of normal secondary sexual characteristics, or 14 years in the absence of other evidence of puberty
What tests can you do for primary amenorrhoea?
FSH, LH, PRL, TSH and oestrogen
Pelvic USS
Progesterone withdrawal bleed (confirms she has uterus, pregnancy or lack of oestrogen)
How do you induce puberty?
Gradually build up Oestrogen
Add progesterone once max height potential reached (and on atleast 20mg of oestrogen)
Causes for secondary amenorrhoea in adolescents?
- Weight (anorexia)
- PCOS
- Pregnancy
- Fluctuating LH/oestrogens (i.e. due to stress)
What bleeding disorders are common in adolescence?
Amenorrhoea (common periodically for first 2 years)
Pregnancy
Coagulation disorders e.g. Von Willebrands, leukaemia
Who gets vulvovaginitis and why?
Peak age 3-7yr olds
Often due to infection or labial agglutination (adhesion of labia minora in midline)
How do you manage labial agglutination?
- Hygiene
- Lubrication
- Topical Oestrogen
- Surgical separation (rarely)
How do you manage infection in vulvovaginitis?
- Culture (E. Coli, Proteus, Pseudomonas)
- Urinalysis (rules out cystitis)
- Hygiene
- Perianal exam with tape for pinworms
- Exam US if persistant discharge to rule out foreign body
Also always remember to test teens for!
Chlamydia!
What physical changes are seen during puberty?
- Growth accelerates
- Secondary sexual characteristics appear
- Initial increase in secretion of LH from pituitary gland (due to increase of GnRH from hypothalamus) –> rise in oestradiol levels
How do you determine where child is on Tanner stages?
DO NOT EXAMINE –> show patient cards and ask them where they think they are
How to take a history from an adolescent?
- Rapport!!!
- Ask about school
- Hobbies
- Tell them you aren’t necessarily going to have to examine them
- Gynaecological
- Age of menarche
- Cycle
- Pain
- Bleeding/how often they change sanitary product
- Sexual (In absence of parents)
- Sexual activity
- Contraceptive
- Weight gain/loss
- Exercise
Describe Examination
General
- Bone abnormality
- Weight
- Acne
Breast - Show them chart
Gynaecological - Rarely done, but if done has to be done under anaestetic
Define precocious puberty
The appearance of secondary sexual characteristics before the age of 8 years in girls and 9 years in boys
Common pathologies seen in clinic?
- Vulvovaginitis
- Foreign body
- Labial adhesions
- Amennorhea
- Bleeding disorders
- Vaginal discharge
What is vulvovaginitis (presentation and aetiology)?
Presentation:
- Yellow-green offensive discharge
- Vaginal soreness and itching
- On inspection the vulva has a typical appearance with a red ‘flush’ around the vulva and anus
Aetiology:
- Lack of oestrogen
- Chemical irritation
- Poor hygiene
Foreign body presentation and treatment?
Presentation:
- Vaginal bleeding
- Persistant foul smelling discharge
Treatment:
- Examination UNDER anaesthetic
- Removal
Presentation and treatment of labial adhesions?
- Thin membranous line in mid-line where tissue fuse
- Urethra is size of a pinhole
- Most children asymptomatic
Tx:
Surgical separation is rarely needed unless urinary symptoms are persistent and estrogen therapy has failed.
What is mennorragia?
HEAVY BLEEDING
- Anovulatory periods
- Irregular periods
- Considered normal for first 2 years whilst hypothalamic-pituitary-ovarian axis establishes regular cycles
Treatment for mennoragia?
- Reassure
- Talk to the girls directly
- Progesterone only pill – first line, less side effects and no withdrawal bleed
- Tranexamic Acid 1g qds
- Mefenamic Acid
- Combined Oral Contraceptive
- Mirena
What is dysmenorrhea?
PAINFUL PERIODS
What is the main cause of dysmenorrhoea? How to treat?
Pain due higher levels of prostaglandins and so anti-prostaglandin drugs such as mefenamic acid can be very helpful.
Suppression of ovulation with the combined oral contraceptive pill (COCP) is very effective in making periods less painful and lighter.
What is Amenorrhoea?
Absence of menstrual period
Classification of Amenorrhea?
Primary: failure of menstruation by 16 years with other normal secondary sexual characteristics
Secondary: Absent period for at least 6 months in a woman who has previously had regular periods or 12 months in previously has oligomenorrhoea (infrequent menstrual periods)
How to manage endometriosis?
NSAIDs and the oral contraceptive (POP)
Diagnostic laproscopy (if indicated or pain. not resolved)
Describe normal vaginal discharge
A mucoid discharge is common in infants for up 2 weeks after birth; it results from maternal estrogen.
It is also a common finding in prepubertal girls, who experience increased estrogen production by maturing ovaries.
What is the management of pahtological vaginal discharge?
- 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.
Define delayed puberty
- Boys have no signs of testicular development by 14yrs
- Girls have not started to develop breasts by 13yrs, or they have developed breasts but their periods have not started by 15yrs
When should vaginal examinations be carried out?
Should ONLY be performed on consenting adolescents who are sexually active and ONLY when it is likely to add value to the assessment
Performed under anaesthetic
Name causes of pathological vaginal discharge
- Infections with organisms such as E.coli, Proteus, Pseudomonas
- Hemolytic streptococcal vaginitis
- Monial vaginitis
- A foreign body
How are polycystic ovaries diagnosied in the adolescent?
Rotterdam Consensus Workshop:
PCOS is a syndrome of ovarian dysfunction along with the cardinal features hyperandrogenism and polycystic ovary morphology
- No single diagnostic criterion
- Diagnosis of PCOS made on the basis of two out of three;
- Oligo- or anovulation
- Clinical or biochemical sign of hyperandrogenism
- Polycystic ovaries on USS or direst inspection
- Other causes of hyperandrogenism should be excluded
