Paediatric and Adult Gynae Flashcards
How does paediatric gynae differ?
- Usually a family consultation
- Sometimes just with father
- Often anxieties about confidentiality
- Consultation often directed at Parents
- Sometimes separate consultations
What is Gillick competence?
- Child <16 years can give/withhold consent if doctor feels she fully understands what is involved in an intervention
- In certain situations, parents can override girls wishes
What is Fraser competence?
Covers contraceptive advice for girls under 16.
- Mature enough to understand advice and implications of treatment
- Girl likely to begin or continue to have sex with or without treatment
- Doctor tried to persuade girl to inform her parents or to allow her/him to inform them
- Girl’s health would suffer without treatment/advice
- In girl’s best interests to give treatment or advice
What needs to be features in a gynaecological history?
Gynae:
- Age of menarche
- Pain
- Cycle
Sexual:
- Sexual activity
- Contraception
Weight gain/loss
Exercise
[sexual abuse]
What is involved with this examination?
General
- Intimite examination is never done on first vist…
- Must build rapport first
Breast examination
Gynae examination
What are the stages used to assess developement?
Tanner staging
What is amenorrhea?
What is primary and secondary amenorrhea?
The absense of menstruation.
Primary: fault in the cycle
Secondary: fault elsewhere
What are the causes of secondary amenorrhea?
- Weight changes
- PCOS
- Pregnancy
- Fluctuating LH/oestrogens
What are the features of PCOS?
- Present in 1-5 girls
- Rotterdam criteria
- Be careful with diagnosis - can’t be diagnosed until a few years after puberty
- Large spectrum
When do we need to investigate?
- Primary amenorrhoea and normal secondary sexual characteristics
- Investigate at age 16
- Primary amenorrhoea and absent secondary sexual characteristics
- Investigate at age 14
What investigations are needed prior to referall?
- Is there an outflow tract obstruction?
- Imperforated hymen/septum
- Present with cyclical abdominal pain and a big mass in the uterus (blood)
- Bleed is occurring – it is just not coming out
- They will have normal secondary sexual characteristics
- Progesterone withdrawal bleed
- If you don’t get blood on this challenge this means there is not enough oestrogen in the body
- Not enough oestrogen due to ovary pathology/pregnancy
- If you don’t get blood on this challenge this means there is not enough oestrogen in the body
- Full hormone profile
- FSH, LH, PRL, TSH, testosterone and oestrogen
- Pelvic USG
When do we induce puberty?
- When girls present at the age of 16/18 and have no secondary sexual characteristics
- Must induce puberty
How can we induce puberty?
- Gradual build up with oestrogen
- Effect on breast development
- Add progesterone
- Once maximum height potential is reached
- At least 20mg of oestrogen dose
What are the main bleeding disorders in paeds gynae?
- Anovulation – majority (normal for up to 2-4 years post-menarche)
- Be aware of other factors if they have irregular bleeding e.g. sexual abuse, bullying, trauma etc.
- Remember could be pregnancy complications
- Bleeding disorders – up to 10-20% of cases
- If history sounds like it, ask for clotting profile and clotting factors
- E.g. Von Willebrands, platelet defects
- Very very rarely = leukaemia
What is the treatment of menorrhagia? For how long?
- Firstly, reassure
- Talk to girl directly
- Progesterone only pill - works for most girls
- Tranexamic acid 1g
- Mefenamic acid
- Combined OCP
- Mirina: only use in those who have other medical conditions eg wheelchair bound and cannot deal with periods
Length of treatment: usually for months or years (not lifelong)
What is PCOS?
Polycystic ovary syndrome
- Syndrome of ovarian dysfunction along with cardinal features hyperandrogenism and polycystic ovary morphology
- No single diagnostic criterion is sufficient
What is needed to make a diagnosis of PCOS?
Made on 2 or 3 of the following:
- Anovulation
- CLinical/biochem signs of hyperandrogenism
- Polycystic ovaries on ultrasound or direct investigation
- Need to exclude other causes of hyperandrogenism
What are the most common vaginal cysts?
Where are they found?
What can happen to them?
- Small cysts are often functional or dermoids
- Gravity allows them to drop to lowest point in the pelvis
- Can then tort, turn gangrenous
What is a common history for cysts?
Subacute history
Usually tender to one side of pelvis or behind
Uterus and may feel a mass
What is vulvovaginitis? What ages are usually effected by vulvovaginitis? Causes?
- Inflammation or infection of the vulva and vagina
- 2 -7 years old
- Rule out any trauma/sexual abuse/foreign body
- Rule out urinary incontinence
Treatment of vulvovaganitis?
- Toilet training if urinary incontinent
What are labial adhesions (agglutinations)?
Fusion of the labia minora in the midline, usually asymptomatic and treated typically conservatively
How do we manage labial adhesions?
- As long as the girl can pee then it is fine
- No point trying to seperate it, as soon as the oestrogen levels rise it will sort it out itself
- If you carry out surgery you are killing eggs (apparently)
- If assymptomatic improved hygeine may be all that’s needed
- Treatment is indicated if there is a chronic vulvovaginitis or difficulty urinating
- Lubrication of the labia with a bland ointment
- Topical oestrogen
- Surgical separation is rarely necessary
What vaginal discharges are common in paeds?
- Mucoid discharge is common in infants for up to 2 weeks after birth – results from maternal oestrogen
- Common finding in prepubertal girls who experience increased oestrogen production by maturing ovaries
What are some pathological causes of discharge?
- Infections with organisms
- Haemolytic streptococcal vaginitis
- Monial vaginitis
- A foreign body
What is the management of vaginal discharge?
- Conservative
- Culture to identify causative organsims such as E. coli, proteus, pseudomonas
- Urinalysis to rule out cystitis
- Review proper hygiene
- Avoid nasty soaps
- Ensure correct underwear etc.
- Perianal examination with transparent tape to test for pinworms
- In cases of persistent discharge – examination under anaesthesia to rule out foreign body
At what age do we consider labial reduction?
- No intervention until the age of 18 years old
- Intervention only done if there is actually a problem from the labia
- Intervention done by plastics
