Paediatric Gynecology

Question 1

Choose all correct answers:

a) In embryologic life, GNRH neurons are made in the olfactory placode
b) LH and FSH abruptly fall after birth
c) falling LH, FSH, E2 in childhood lead to oocyte atresia from 6 million at birth to 3-500,000 at puberty
d) adrenarche is the first stage of pubertal development in more than 50% of girls
e) number of oocytes peaks at birth

Answer 1

a) true
b) false -initially rise for the first 3/12 of life in response to fall in placental E2
c) true
d) false (minority will have adrenarche first, telarche usually first)
e) false peaks at 20 weeks GA

Question 2

Choose the correct answer:

a) pre-puberty, both LH and FSH are effectively zero
b) prior to puberty: FSH is usually higher than LH, after puberty: LH is usually higher than FSH
c) prior to puberty: LH is usually higher than FSH, after puberty: FSH is usually higher than LH
d) LH is always higher than FSH
e) FSH is always higher than LH

Answer 2

b

Question 3

Choose all correct answers:

a) a neonatal ovarian cyst measuring 4cm should be observed with serial u/s every 4-6 weeks
b) a neonatal ovarian cyst measuring 4cm should be surgically removed following birth
c) the most common ovarian mass in adolescence is a mature teratoma
d) ovarian masses in the adolescent population can be observed if < 5cm

Answer 3

a) correct, b) false -if less than 5cm observe, if >5cm can aspirate because of risk of torsion, surgery only if persistent
c) true
d) true

Question 4

Choose all correct answers:
a) the most common reason for pre-pubertal vaginal bleeding is exogenous estrogen
b)

Answer 4

a) false -most common reason is vulvovaginitis

Question 5

What is the ddx (5) for prepubertal vaginal bleeding?

Answer 5

precocious puberty, trauma, foreign body, vulvovaginitis, infection (shigella/strep), genital tumour (granulosa), adrenal tumour, lichen sclerosus, urethral prolapse, exogenous hormones, masses (cx/hymenal benign polyps), vaginal sarcoma botryoides (embryonal rhabdomyosarcoma)

Question 6

Which of the following regarding ambiguous genitalia are correct?

a) microphallus is defined as < 2.5cm
b) clitoromegaly is defined as > 1.5cm
c) 90% of cases are due to CAH
d) the most common enzyme deficiency is 17 hydroxyase

Answer 6

a) true
b) false > 9mm
c) true
d) false -21 hydroxylase absence –> build up of 17 hydroxyprogesterone in serum

Question 7

What investigations would you order in working up precocious puberty?

Answer 7

No virilization: FSH, LH, E2, TSH, bone age, pelvic u/s
brain imaging (secondary)
With virilization: add DHEAS, testosterone, androstenedione, 17OHP, cortisol stim test

Question 8

What is the “triad” of McCune Albright syndrome?

Answer 8

endocrinopathy (may present as precocious puberty)
cafe au lait spots
polyostotic fibrous dysplasia

Question 9

List a ddx for precocious puberty

Answer 9

Central (GnRH dependent): idiopathic (>80%), CNS lesions/tumours/infection/ischemia, head trauma
Peripheral (GnRH independent): primary hypothyroidism, E2 or T producing tumour (granulosa most common >60%), GnTRP or hCG producing tumour, CAH, exogenous exposure to E2/androgens, McCune Albright,

Question 10

What is the treatment method and rationale for precocious puberty? when would you stop this?

Answer 10

GnRH agonist -shut down HPO axis to prevent premature closing of ephyses and maximize growth potential (also reverses outward sx of PP), stop at age 11