Adolescent Gynaecology

Question 1

Define Gillick Competence?

Answer 1

Child <16yrs is able to give/withhold consent if the doctor feels she fully understands an intervention and it’s risks
It can be overridden by parents in some circumstances

Question 2

Define Fraser Competence?

Answer 2

Refers specficially to giving contraceptive advice/prescription to under 16s:

• Mature enough to understand advice & implications of treatment
• Likely to continue/begin sex regardless of treatment
• GP has tried to persuade to tell parents (or let you tell them)
• Health would suffer without treatment/advice
• In their best interest

Question 3

At what age do you investigate Primary Amenorrhoea as abnormal?

Answer 3

16 if normal 2* sex characteristics

14 if not

Question 4

What tests can you do for 1* amenorrhoea?

Answer 4

FSH, LH, PRL, TSH; oestrogen

Pelvic US

Progesterone withdrawal bleed

Question 5

How do you induce puberty?

Answer 5

Gradually build up Oestrogen

Add progesterone once max height potential reached (and on atleast 20mg of oestrogen)

Question 6

Causes for 2* amenorrhoea in adolescents?

Answer 6

• Weight (Anorexia)
• PCOS
• Pregnancy
• Fluctuating LH/oestrogens

Question 7

What bleeding disorders are common in adolescence?

Answer 7

Amenorrhoea (common periodically for 1st 2 years)

Pregnancy

Coagulation disorders e.g. vWs

Leukaemia

Question 8

Who gets vulvovaginitis and why?

Answer 8

2-7yr olds

Often due to infection or labial agglutination (adhesion of labia minora in midline)

Question 9

How do you manage labial agglutination?

Answer 9

• Hygiene
• Lubrication
• Topical Oestrogen
• Surgical separation (rarely)

Question 10

How do you manage infection in vulvovaginitis?

Answer 10

• Culture (E. Coli, Proteus, Pseudomonas)
• Urinalysis (rules out cystitis)
• Hygiene
• Perianal exam with tape for pinworms
• Exam UA if persistant discharge to rule out foreign body

Question 11

Also always remember to test teens for!

Answer 11

Chlamydia!

Question 12

What physical changes are seen during puberty?

Answer 12

• Growth accelerates
• Secondary sexual characteristics appear
• Initial increase in secretion of LH from pituitary gland- due to increase in estradiol

Question 13

Tanner stages

Answer 13

DO NOT EXAMINE- show cards

Question 14

How to take a history for teen?

Answer 14

1- Rapport!!!
o Ask about school
o Hobbies
o Tell them you aren’t necessarily going to have to examine them

2- Gynaecological
o Age of menarche
o Cycle
o Pain

3- Sexual

• In absence of parents
• sexual activity
• contraceptive

4- weight gain/loss
5- exercise

Question 15

Examination

Answer 15

General
o	 bone abnormality
o	Weight 
o	Acne 
Breast
o	Show them chart

Gynaecological
o Rarely done
o If done has to be done under anaestetic

Question 16

what are precocious and delayed puberty?

Answer 16

Precocius 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

Delayed puberty
• boys have no signs of testicular 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 started by 15

Question 17

Common pathologies seen in clinic?

Answer 17

• Vulvovaginitis
• Foreign body
• Labial adhesions
• Amennorhea
• Bleeding disorders
• Vaginal discharge

Question 18

What is vulvovaginitis?

Answer 18

Presentation:
•yellow-green offensive discharge
•vaginal soreness and itching.
•On inspection the vulva has a typical appearance with a red ‘flush’ around the vulva and anus

Aetiology:

• Lack of oestrogen
• chemical irritation
• Poor hygiene

Question 19

Foreign body presentation and treatment?

Answer 19

Presentation:

• Vaginal bleeding
• Persistant foul smelling discharge

Treatment:

• Examination UNDER anaestetic
• removal

Question 20

Presentation and treatment of labial adhesions?

Answer 20

• Thin membranous line in mid-line where tissue fuse

- Urethra is size of a pinhole

Question 21

What is mennorragia?

Answer 21

HEAVY BLEEDING

• Anovulatory periods
• Irregular periods- Normal for first 2 years whilst hypothalamic-pituitary-ovarian axis establishes regular cycles

Question 22

Treatment for mennoragia?

Answer 22

• Reassure
• Talk to the girls directly
• progesterone only pill- first line of treatment
• Tranexamic Acid 1g qds
• Mefenamic Acid
• Combined Oral Contraceptive
• Mirena
• Length of treatment???
• Usually for months or years? Stop and see!
• App

Question 23

What is dysmenorrhea?

Answer 23

PAINFUL PERIODS

Question 24

What is the main cause of dysmennhea?

How to treat?

Answer 24

• Higher levels of prostaglandins

- OCP and anti-prostaglandins

Question 25

What is Amenorrhoea?

Answer 25

Absence of menstrual period

Question 26

Classification of Amenorrhea?

Answer 26

Primary : failure of menstruation by 16 years with other normal secondary sexual characteristics
Secondary: Absent period for at least 6 months in a woman who has previously had regular periods or 12 months in previously has oligomenorrhoea

Question 27

How to manage endometriosis?

Answer 27

NSAIDs and the OCP

Laparoscopy

Question 28

Vaginal discharge

Answer 28

Mucoid discharge

• Common in under 2s
• From maternal oestrogen
• In pre-pubertal girls who have experience oestrogen production by maturation

Pathological discharge:

• Infections
• Hemolytic strep. vaginitis
• Monial vaginitis
• Foreign bodies

Question 29

How to deal with vaginal discharge?

Answer 29

• Culture to identify causative organisms.
• Urinanalysis to rule out cystitis.
• Review proper hygiene.
• Perianal examination with transparent tape to test for pinworms.
• In cases of persistent discharge, examination under anesthesia is indicated to rule out foreign body.