PAG

Question 1

HEADS

Answer 1

Home
Education/Eating/Exercise
Activities/relationships
Drugs/ETOH.smoking
Sex/safety/sleep/suicide

Question 2

Precocious Puberty

Answer 2

<8 in girls
Order = growth, breast, pubic hair, menarche
Central = majority, but most idiopathic
Peripheral = tumours (adnreal/ovarian), exogenous steroids

Issues: growth, embarrassment, social interactions

MDT approach - PAG, psychosocial support

Invx - LH/FSH (elevated if central, suppressed if peripheral), oestradiol, androgens only if virilised, imaging brain, pelvic/abdominal

Slow growth velocity, with GnRH analogues

Question 3

MRKH

-mayer rokitansky kuster hauser

Answer 3

Structural condition, absent uterus/fallopian/upper 1/3 vagina

Associated with BONY and RENAL issues as well as hearing loss

Other organs - renal USS/MRI abdo/pelvis, skeletal xray
MDT approach
Will never menstruate
Sexual function - dilators (85% success), surgical vaginoplasty
Fertility - surrogacy, adoption

Question 4

Differentials primary ovarian insufficiencey

Answer 4

Chromosomal - turners, swyers, trisomy, deletion
Autoimmune - ovarian antibodies, thyroid, addisons, myasthenia gravis
Radiation - chemo/surgery/drugs
Primary -
Infection - mumps/TB, malaria, shigella, varicella
Genetic - fragile x/galactosemia
Metaboilc - 17OH def, galactosemia, myotonic dystrophy

Invx
-FSH (repeat) /progesterone/AMH/TFTs
-anti adrenal/coeliac/thyroid,
FMR1 gene (fragile x), vitamin D

Question 5

PRIMARY amenorrhea invx

Answer 5

Hx and exam dependent
FSH, LH, e2, TSH, PRL
Androgens: testosterone, androstenedione, DHEAS 17OH
Karyotype
Endometrial cultures - TB, schistomoniasis

Question 6

Swyer

Answer 6

XY, streak gonads, prepubertal uterus
–> defective SRY gene, therefore no AMH/testosterone

MDT
Puberty induction wiht estadiol
Long term HRT for bones (vit D/weight bearing), CVD
INfertility
Gonadectomy, 30% risk of germ cell tumour
Psychosocial support

Question 7

Hirsutism

Answer 7

GASED
Ferrimen Galway >8 is androgen excess >15 is severe

Gonadal - hormone secreting tumour
Adrenal - CAH, tumour, cushings
Systemic - PCOS, anorexia, thyroid
Ethnicity
Drugs - anabolic steroids, phenytoin

Question 8

PV bleeding in child

Answer 8

Vulvovaginitis
Foreign body 
Dermatitis
Abuse
Precocious puberty 
Hormone secreting tumour

Question 9

Differentials adolescent pelvic pain and management

Answer 9

Differentials

• primary
• structural
• endometriosis

MDY care, complex paediatric pain clinic, psychological support, pelvic floor physio, education + pelvic pain foundation resources

Meds - paracetamol, NSAID, TXA
Ovulation suppression: POP, depot, COCP, mirena

Question 10

Kallman Syndrome

Answer 10

Isolated gonadotrophin releasing deficiency
Anosmia

Treat with pulsatile GnRH