Paediatric and Adolescent Gynaecology Flashcards
What do the Fraser guidelines state?
A doctor can give contraception to a girl under 16 provided the following:
- The girl will understand their advice
- They cannot persuade her to inform her parents or to allow them to inform the parents that she is seeking contraceptive advice.
- She is very likely to continue having sexual intercourse with or without contraceptive treatment
- Unless she receives contraceptive advice or treatment her physical or mental health or both are likely to suffer.
- Her best interests require them to give her contraceptive advice, treatment or both without the parental consent
How are the physical changes associated with puberty classified?
Tanner stages. Tanner stages rate breast development and growth of pubic hair on a scale of 1-5. In practice, the patient is usually given the chart and asked what stage they are at.
What changes are involved with the adolescent period?
- Psychological /Behavioural
- Hormonal changes
- Independence
- Peer Acceptance
- Decisions over future
What areas need explored in an adolescent gynaecological history?
- Age of menarche
- Cycle (heaviness of bleeding can be assessed either by asking how often they have to change sanitary products, size of clots or with a chart)
- Pain
- Sexual (in absence of parents)
- sexual activity
- contraception
- Weight gain/ loss
- Exercise
- REMEMBER SEXUAL ABUSE
How is precocious puberty defined?
The appearance of secondary sexual characteristics before the age of 8 years in girls and 9 years in boys
How is delayed puberty defined?
- Boys have no signs of testicular development by 14 years of age
- Girls have not started to develop breasts by 13 years of age, or they have developed breasts but their periods have not started by 15
What is the most common reason for gynaecological referral of a prepubertal girl?
Persistent vulval irritation or vaginal discharge
When is the peak incidence of vulvovaginitis in children?
3-7 years old
What are the symptoms of vulvovaginitis in children?
Yellow-green offensive discharge
Vaginal soreness
Itching
On inspection, the vulva has a typical appearance with a red flush appearance around the vulva and anus
What are the causes of vulvovaginitis in children?
- Poor perineal hygiene
- Lack of estrogen
- Chemical irritation- bubble baths and detergents
When should suspicion of a foreign body be raised?
Vaginal bleeding or persistent foul-smelling discharge resistant to treatment
Child may admit to insertion of foreign body
When is the peak incidence of labial adhesions?
In the first year of life
What is present with labial adhesions?
A clear, visible thin membranous line in the midline where the tissues fuse
What are the implications of a labial adhesion?
Most asymptomatic
Diagnosis on examination but can do ultrasound to check uterus
Oestrogen therapy mainstay with surgical options if this fails
What steps may be useful in management of menorrhagia?
- Reassure
- Talk to the girls directly
- Progesterone only pill
- Tranexamic Acid 1g qds- heavy periods
- Mefenamic Acid- pain
- Combined Oral Contraceptive- withdrawal bleed/side effects so less popular than POP
- Mirena
What conditions need to be excluded in cases of adolescent menorrhagia, and how is this done?
Acquired and congenital bleeding disorders relatively common causes
Severe bleeding disorders such as Von Willebrand disease and immune thrombocytopenic purpura need excluded, which can be done with ultrasound
What does dysmenorrhoea mean?
Pain during menstruation
When following menarche is dysmenorrhoea most common and how can it be treated?
Once regular periods are established (periods can be irregular for up to two years following menarche)
Pain related to increased prostaglandins so anti-prostaglandin treatment such as mefanemic acid can help
Combined pill can also help make periods lighter and less painful
How is primary amenorrhoea defined?
A 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.
How is secondary amenorrhoea defined?
Secondary amenorrhoea refers to absent periods for at least six months in a woman who has previously had regular periods, or 12 months if she has previously had oligomenorrhoea (bleeds less frequently than six-weekly).
What initial investigations can be done in primary amenorrhoea?
- Bloods- FSH, LH, PRL, TSH, testosterone and estrogen
- Pelvic ultrasound
How can puberty be induced in girls?
Gradual build-up of oestrogen (but this can impact breast development), with the addition of progesterone once the maximum height potential has been reached.
What are the possible causes of secondary amenorrhoea?
- Weight
- PCOS
- Pregnancy
- Fluctuating LH/estrogens
How is PCOS diagnosed in adolescents?
Difficult
FSH:LH ratio useful but not diagnostic
Ultrasound
Presence of two of following:
-Oligo or anovulation
-Clinical (loss of hair, voice changes) or biochemical signs of hyperandrogenism
-Polycystic ovaries on ultrasound or direct inspection
