Paediatric And Adult Gynacology

Question 1

Gillick competence

Answer 1

Children under 16 can consent if they have:

• sufficient understanding and intelligence to fully understand what is involved in a proposed treatment
• including its purpose, nature, likely effects and risks, chances of success and the availability of other options

Question 2

Fraser Guideline

Answer 2

A doctor could proceed to give contraceptive advice and treatment to a girl under 16: provided he is satisfied on the following matters that:

• The girl will understand his advice
• He cannot persuade her to inform her parents or to allow him 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 him to give her contraceptive advice, treatment or both without the parental consent

Question 3

Changes during normal puberty

Answer 3

• Growth accelerates and secondary sexual characteristics appear.
• The endocrine onset of puberty begins several years before physical changes are visible.

Question 4

Endocrine changes during puberty

Answer 4

• Initially, there is an increase in the pulsatile secretion of LH from the pituitary gland in response to an increase of pulsatile GnRH from the hypothalamus at night.
• These pulses then stimulate a rise in estradiol levels.
• The physical changes are progressive and are described as ‘Tanner’ stages

Question 5

Precocious Puberty

Answer 5

Precocious puberty is defined as the appearance of secondary sexual characteristics before the age of 8 years in girls and 9 years in boys.

Question 6

Delayed puberty

Answer 6

• 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 7

Vulvovaginitis presentation

Answer 7

• yellow-green offensive discharge and vaginal soreness and itching
• on inspection the vulva has a typical appearance with a red ‘flush’ around the vulva and anus

Question 8

Vulvovaginitis causes

Answer 8

• poor perineal hygiene
• lack of estrogen
• chemical irritation : bubble baths and detergents

Question 9

Vulvovaginitis peak age

Answer 9

3-7 years

Question 10

Foreign body presentation

Answer 10

• Vaginal bleeding or a persistent foul smelling discharge refractory to treatment 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 11

Labial adhesions diagnosis

Answer 11

• Most children are asymptomatic
• The appearance is typical and the diagnosis can be made on examination

Question 12

Labial adhesions management

Answer 12

• topical oestrogen
• if the parents have been concerned about the presence of a uterus, a pelvic ultrasound will establish this
• surgical separation is rarely needed unless urinary symptoms are persistent and oestrogen therapy has failed

Question 13

When should vaginal exams be performed on adolescents?

Answer 13

Vaginal examinations should ONLY be performed on consenting adolescents who are sexually active and ONLY when it is likely to add value to the assessment.

Question 14

Menorrhagia

Answer 14

Abnormally heavy bleeding at menstruation.

Question 15

Menorrhagia Investigations

Answer 15

An ultrasound scan is usually requested although rarely shows any pathology

Question 16

Menorrhagia management

Answer 16

• the mainstay of treatment is the combined oral contraceptive pill
• POP, progesterone injection or an IUS can be considered in some cases

Question 17

Dysmenorrhoea

Answer 17

Painful menstruation

Question 18

When is dysmenorrhoea likely to start?

Answer 18

Earlier periods may be pain free and painful menstruation usually occurs on establishing regular ovulatory cycles.

Question 19

Dysmenorrhea management

Answer 19

• Pain is attributed to 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 is very effective in making periods less painful and lighter.

Question 20

Primary Amenorrhoea

Answer 20

Primary amenorrhoea refers to 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.

Question 21

Secondary Amenorrhoea

Answer 21

Secondary amenorrhoea is defined as 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).

Question 22

Investigations prior to referral for amenorrhoea

Answer 22

• FSH, LH, PRL, TSH, testosterone and estrogen
• Pelvic USS
• Progesterone withdrawal bleed

Question 23

Puberty induction

Answer 23

• Gradual build up of oestrogen
• Add progesterone
  
  • Once maximum height potential is reached

Question 24

Secondary amenorrhea causes

Answer 24

• Weight
• PCOS
• Pregnancy
• Fluctuating LH/ oestrogens

Question 25

Polycystic ovary syndrome (PCOS)

Answer 25

PCOS is a syndrome of ovarian dysfunction along with the cardinal features of hyperandrogenism and polycycstic ovary morphology.

Question 26

PCOS diagnosis

Answer 26

The Rotterdam criteria

The diagnosis of PCOS can be made on the basis of two out of three of the following:

• oligo or anovulation
• clinical or biochemical signs of hyperandrogenism
• Polycystic ovaries on ultrasound or direct inspection (12 or more follicles or greater than 10cm²)

Question 27

Endometriosis in adolescent girls

Answer 27

• Up to 38% of adolescents presenting with chronic pelvic pain have endometriosis.
• If pelvic pain is refractory then usual treatments such as non-steroidal anti-inflammatory drugs and the oral contraceptive should be administered.
• A diagnostic laparoscopy is then indicated.

Question 28

Causes of vaginal discharge in preadolescent girls

Answer 28

• A mucoid discharge is common in infants for up 2 weeks after birth; it result from maternal estrogen. It is also a common finding in prepubertal girls, who experience increased estrogen production by maturing ovaries.
• Pathologic discharge may result from any of the following conditions:
  
  • Infections with organisms, such as E.coli, Proteus, Pseudomonas
  • Haemolytic streptococcal vaginitis
  • Monial vaginitis
  • A foreign body.

Question 29

Management of vaginal discharge in preadolescent girls

Answer 29

• 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