Pediatric and Adolescent Gynecology

Children

Hormonal state

Newborn: estrogen present – may have "withdrawal bleed" after birth (metabolizing maternal hormones)
Young child: low estrogen state – many vulvovaginal problems related to this

Anatomy

Newborn anatomy
Child anatomy: vulva (fat bads and hymen protect vagina), hymen (annular, crescentic), vagina (atrophic, alkaline pH NOT acidic), uterus (small, cervix bigger than fundus), ovaries (small, ovarian cysts present- normal)

Common problems: vulvovaginal pathology

Vulvitis:

irritant (soaps, detergents, etc.),

bacterial – vaginal flora present is normal gastrointestinal flora because no environment in vagina protective (ß pH) as adult (group a strep, E.coli, shigella, chlamydia, and gonorrhea – contrast to adult where vaginal infection is rare with these agents)

Labial adhesions (agglutination) – labia minora adherent in midline, caused by chronic inflammation and lack of estrogen, usually resolve spontaneously

Red flags

STD

Bleeding:

secondary sexual development present = precocious puberty or estrogen source
secondary sexual development absent = lesion of vagina or cervix/uterus (urethral prolapse, foreign body, sarcoma, trauma)

Approach to the child with gynecological problem

History – screening for sexual abuse, parent-child "dyad"
Physical examination – desensitizing (and screening) at routine exams, positioning for examination,

Adolescents

Hormonal state - Normal cycles for adolescents:

Signs of puberty by age 13
Menses by age 16 or about 2 years after breast development

Cycles q21-40 days, 2-8 day (manageable) flow

50% anovulatory first 2 years after menarche, 80% ovulatory by 5 yrs

Why? + feedback system matures last (cyclic changes in serum estrogens lead to episodic E withdrawal bleed (no ovulation) – not an E breakthrough bleed as seen in adults (who do ovulate, obviously)

Anatomy – different Hymen findings (septate, cribiform, parous)

Common problems

Abnormal bleeding – possible pregnancy, If pregnancy test negative –

Anovulation – estrogen breakthrough

Coagulopathy – more likely when found when bleeding is severe, hemorrhage is at menarche (von Willebrand’s)

Primary amenorrhea: no puberty by age 13 or mensus by age 16. Causes:

(1) Absence of hormones

primary hypogonadism – hypergonadotropic hyogonadism - Ý FSH (gonadal dysgenesis – Turner syndrome)

secondary hypgonadism – hypothalamic/pituitary dysfunction, eating disorder

(2) Absence of uterus: an embryological problem:

Mullerian agenesis – congenital absence of mullerian system, associated with bony abnormalities

Androgen insensitivity syndrome – complete absence of androgen receptors. When testis develop Þ androgen ineffective (female apperance) but mullerian inhibiting substance still produced (no female organs) Þ gonads still exist (testosterone levels give symptoms)

complete (female appearance but no uterus), partial

(3) Obstruction of outflow tract: transverse vaginal septum, imperforate hymen