Paediatric and adolescent gynaecology

Question 1

What is the main difference between paediatric and adolescent gynaecology?

Answer 1

More people are involved in the consultation e.g. parents, grandparents, carers.

Question 2

What is meant by Gillicks competence

Answer 2

Children under 16 can consent if they have sufficient understanding and intelligence of what is involved in a proposed treatment

If a child does not pass the gillicks test then the consent of someone with parental responsibility is needed in order to progress with treatment

Question 3

What is Fraser’s competece?

Answer 3

Regarding specifically to contraception advice to girls under the age of 16 years old. A Dr can give advice on contraception to a girl under 16 years old provided he is satisfied on the following matters that:
A girl will understand his advice
He cannot persuade her to inform her parents
She is likely to keep having sex without contraception
Without contraception her physical and mental health will still suffer

Question 4

Describe the process of puberty in girls?

Answer 4

Endocrine change starts years before physical changes. Increase in pulsatile secretion of LH from the pituitary gland in response to an increase of GnRH from the hypothalamus
This precipitates a rise in estradiol levels

Question 5

What is Tanners scale of breast development?

Answer 5

A staging classification to determine stages of puberty

Stage 1: No glandular breast tissue palpable
Stage 2: Breast bud palpable under areola (1st pubertal sign in females)
Stage 3: Breast tissue palpable outside areola; no areolar development
Stage 4: Areola elevated above contour of the breast, forming “double scoop” appearance
Stage 5: Areolar mound recedes back into single breast contour with areolar hyperpigmentation, papillae development and nipple protrusion

Question 6

What is Tanners scale of pubic hair (male and female)

Answer 6

Pubic Hair Scale (both males and females)

Stage 1: No hair
Stage 2: Downy hair
Stage 3: Scant terminal hair
Stage 4: Terminal hair that fills the entire triangle overlying the pubic region
Stage 5: Terminal hair that extends beyond the inguinal crease onto the thigh

Question 7

What is Tanners scale of male external genitalia?

Answer 7

Stage 1: Testicular volume < 4 ml or long axis < 2.5 cm
Stage 2: 4 ml-8 ml (or 2.5-3.3 cm long), 1st pubertal sign in males
Stage 3: 9 ml-12 ml (or 3.4-4.0 cm long)
Stage 4: 15-20 ml (or 4.1-4.5 cm long)
Stage 5: > 20 ml (or > 4.5 cm long)

Can also use the Tanners testicle beads

Question 8

What changes occur during the adolescent stage o pubety?

Answer 8

psychological/behavioural
hormonal changes
Independence
Peer acceptance
Decisions over future

Question 9

What questions are important to ask when taking a gynae history from an adolescent?

Answer 9

Age of menarche
Cycle 
Pain?
Sexual activity
Contraception
Weight gain/loss
Exercise
Remember sexual abuse

Question 10

What are the important points about examination in adolescents

What examinations are carried out?

Answer 10

NEVER IN FIRST VISIT

General- ACNE= PCOS, Anorexia=ammenorrhea
Breast
Gynae examination

Question 11

What is precocious puberty?

Answer 11

The appearance of secondary sexual characteristics before the age of 8 in girls and 9 in boys

Question 12

What is delayed puberty?

Answer 12

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

Question 13

What is vulvovangitis?

What causes it?

Answer 13

The most common reason for a gynaecological referral of a prepubertal girl- peak age 3 and 7 years
yellow, green offensive discharge and vaginal soreness and itching
Red flush around vulva and anus

Caused by poor perinoeal hygiene
Lack of oestrogen
Chemical irritation (bubble baths and detergents)

Question 14

What is the typical presentation of a foreign body?

Answer 14

Vaginal bleeding of a persistent foul smelling discharge should raise suspicions of a foreign body
The child may also admit insertion of a foreign body and in this situation an examination under anaesthetic is necessary

Question 15

What is a labial adhesion?

Answer 15

Estimated to occur in up to 3% of prepubertal girls
Peak incidence is in the first year of life
Clearly visible thin membranous line in the mid line where the tissues fuse
The urethra may just be a pinhole opening in extensive fusion
If parents are worried about ambiguous genitalia (google) then a pelvic ultrasound will establish this
Surgery is rarely needed unless urinary symptoms are persistent and oestrogen therapy has failed

Question 16

What is some good information about menorrhagia

Answer 16

may be too heavy, too frequent or irregular periods
Main cause in the early months following menarche is anovulatory cycles
Irregular periods can be regarded as normal for the first two years while the HPO acquires a regular cycle

Question 17

What investigations/differentials are in mind with menorrhagia?

Answer 17

Bleeding disorders such as vWF deficiency and immune thrombocytopenia purpura
Ultrasound can be requested to look for abnormal patholgies but does not typically show anything

Question 18

What is the mainstay of treatment for menorrhagia?

Answer 18

Combined oral contraceptive pill
POP, depo-provera or the mirena IUS can be considered in some cases

POP is first line in Aberdeen as there are less side effects and a higher compliance

Question 19

What is dysmenorrhea

Answer 19

Pain during menstruation. May have a significant impact on schooling and examination performances

Question 20

What causes dysmenorrhoea and how can it be treated?

Answer 20

Painful menstruation is thought to occur when regular cycles are established

Painful menstruation is attributed to higher levels of prostaglandins and so anti-prostaglandin drugs such as mfenamic acid can be very helpful

Suppression of ovualtion with the combined oral contraceptive pill can be very effective at making periods painful and lighter

Question 21

What is primary amenorrhoea?

Answer 21

The failure of menstruation by age 16 in the presence of normal sexual characteristics or 14 years in the absence of another evidence of puberty

Question 22

What is secondary amenorhoea

What are the most common causes?

Answer 22

Absent periods for at least 6 months in a woman who has previously had regular periods or

12 months if she has previously had oligomennorhea (bleeds less frequently than 6 weekly)

Most common causes are PCOS, Anorexia, too much sport and pregnancy

Question 23

What investigations should be carried out when amenorhea occurs?

Answer 23

FSh, LH, PRL, TSH, testosterone levels, oestrogen levels, TFT’s

Pelvic USS

Progesterone withdrawl bleed

Question 24

How do you induce puberty?

Answer 24

Gradually build up oestrogen
Add progesterone once maximum height potential is reached
At last 20mg of oestrogen dose

Question 25

What are the criteria for diagnosing PCOS?

Answer 25

Two out of the three of the following:
Oligo or anovulation
Clinical or biochemical hyperandrogenism
polycysitc ovaries on ultrasound or direct inspection

Question 26

What is endometriosis

Answer 26

Endometriosis is a medical condition that occurs when the lining of the uterus, called the endometrium, grows in other places, such as the fallopian tubes, ovaries or along the pelvis
38% of adolescents presenting with chronic pelvic pain have endometriosis

Question 27

How is endometriosis managed?

Answer 27

NSAIDS
Oral contraceptive pill
Diagnstic laparoscopy

Question 28

Describe the pathology of pelvic cysts

Answer 28

usually benign, gravity allows them to drop to the lowest point
Can tort, turn gangrenous or rupture
Often subacute history
Usually tender to one side of the pelvis or behind uterus, may feel a mass

Question 29

When is vaginal discharge common in the paediatric and adolescent population?

Answer 29

In infants up to 2 weeks after birth

Prepubertal girls experiencing increased oestrogen production by maturing ovaries

Question 30

What pathological conditions may cause vaginal discharge?

Answer 30

Infections (gonorrhoea, chlamydia)
Heamolytic streptococcal vaginitis
Monial vaginits
Vaginal yeast infection (most common cause)
Foreign body

Question 31

What is the management of vaginal discharge?

Answer 31

Culture to identify a causative organism
Urinalysis to rule out cystitis
Review proper hygiene
Perineal examination looking for pinworms
Examination under anaesthesia to rule out foreign body