Paediatrics and adolescent gynaecology Flashcards
outline Gillick competence
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. If a child does not pass the Gillick test, then the consent of a person with parental responsibility (or sometimes the courts) is needed in order to proceed with treatment. In certain circumstance, parents wish can over rule.
Outline Fraser Guideline - contraceptive advice to under 16 girl
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.
changes during normal puberty in terms of hormones…
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
what is asked in hx?
Gynaecological: Age of menarche, Cycle, Pain, Sexual (in absence of parents), sexual activity, contraception, Weight gain/ loss, Exercise, remember to ask about sexual abuse in the history.
define Precocious puberty
Precocious puberty is defined as the appearance of secondary sexual characteristics before the age of 8 years in girls and 9 years in boys.
define delayed puberty
boys have no signs oftesticular 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 startedby 15
Vulvovaginitis
Vulvovaginitis - Persistent vulval irritation or vaginal discharge is the most common reason for the gynaecological referral of a prepubertal girl. Peak age - three and seven years. Presentation: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. causes : poor perineal hygiene, lack of estrogen, chemical irritation : bubble baths and detergents.
Labial Adhesions
Labial adhesions or fusion is estimated to occur in up to 3.3% of prepubertal girls. The peak incidence is in the first year of life. There is a clearly visible thin membranous line in the mid-line where the tissues fuse. The urethra may be just a pinhole opening in extensive fusion. The aetiology is unknown. Most children are asymptomatic. The appearance is typical and the diagnosis can be made on examination. 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 estrogen therapy has failed.
Menorrhagia
Troublesome periods may be too frequent, irregular and heavy.
A menstrual diary may be helpful and can also allow reassurance and explanation. In most girls, in the early months following menarche the most common cause is of anovulatory cycles. Irregular periods can be regarded as normal for the first two years whilst the hypothalamic–pituitary–ovarian axis establishes regular cycles. Acquired and congenital bleeding disorders are relatively common causes of menorrhagia and may occur in 10–15% of cases. Conditions such as von Willebrand disease and immune thromboyctopenic purpura should be excluded in any girl with severe menorrhagia refractory to simple treatments. An ultrasound scan is usually requested although rarely shows any pathology. The mainstay of treatment, however, is still the combined oral contraceptive pill. POP ,Depo-Provera or the Mirena® IUS can be considered in some cases. Tranexamic Acid 1g qds, Mefenamic Acid.
Dysmenorrhoea
Pain during menstruation may have a significant impact on schooling and examination performance.
Earlier periods may be pain free and painful menstruation usually occurs on establishing regular ovulatory cycles.
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.
Amennorrhoea
Primary 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.
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).
ix prior to referral
FSH, LH, PRL, TSH , testosterone and estrogen, Pelvic USS, Progesterone withdrawal bleed, Pregnancy, Not enough estrogen
how is puberty induced?
Gradual build up with estrogen, Effect on breast development, Add progesterone, Once maximum height potential is reached, At least 20 mg of estrogen dose
causes of secondary amennorrhoea
weight, PCOS, pregnancy, fluctuating LH/ Oestrogens
some info on PCOS
Switch between hypothalamic and PCOS picture, Diagnose on FSH: LH x, USS- TAS only, Weight reduction and lifestyle changes, Oral contraceptive pill. Syndrom eof ovariann dysfunnction along with cardinal features of hyperandrogenism and PCOmorphology, no single diagnostic cirteria is sufficient
