Paediatric And Adolescent Gynaecology

Question 1

Why do paediatric and adolescent gynaecological problems require a different approach to those affecting adults?

Answer 1

In adolescent may not just be the patient, may have family there
Need to remember gillicks competence with U16s, whereas with adults you do not
There may be language barriers
May need a separate consultation to examine or need to ask parents to leave in order to address privacy and sensitive information

Question 2

What are the key components of an adolescent history and exam?

Answer 2

Establish rapport first
History: gynaelogical eg age of menarche, cycle, pain, sexual history, weight gain/loss, exercise. Remember sexual abuse.
Examination: general, breast, gynaelogical

Question 3

What are the main causes of primary amenorrhea, what are the relevant investigations and how is it managed?

Answer 3

Primary amenorrhea and normal secondary sex characteristics investigate at age 16. Absent secondary sex characteristics investigate age 14.

Investigations:

• FSH, LH, PRL, TSH, testosterone, oestrogen
• Pelvic USS
• progesterone withdrawal bleeds

Management: induce puberty (gradual build up of oestrogen, then add progesterone

Question 4

How does the law affect management of a request for contraception by a minor?

Answer 4

Minors are subject to gillick competence: they can consent if they have sufficient understanding and intelligence to fully understand what is involved in a proposed treatment

Contraceptive advice (when minor does not wish parental input) is subject to the Fraser guideline:

• girl will understand advice given
• cannot be persuaded to inform parents/guardian
• very likely to continue intercourse
• physical and mental health are likely to suffer if she does not receive
• it is in her best interest

Question 5

How do common vulval, labial and vaginal conditions present in childhood?

Answer 5

Vulvovaginitis: persistent itch or discharge (3-7yo)

Foreign body: can cause genital symptoms w/o bleeding. Foul smell should raise suspicions.

Labial adhesions:usually asymptomatic

Adolescent menstrual dysfunction

• menorrrhagia: usually treated with contraceptives, transexamic acid, mefenamic acid
• dysmenorrhea: contraceptives and mefenamic acid
• amenorrhea: primary or secondary. Be aware of other possible factors eg abuse, bullying
• endometriosis

Remember to think of other causes for bleeding eg disorders such as von willebrands. Leukaemia.

Vaginal discharge: unusual discharge may be sign of infection, eg chlamydia, ecoli, or foreign body