Adolescent gynecology ucaya

Adolescent Gynecology

Mike Guyton, MD

Assistant Clinical Professor/Academic Faculty in General Pediatrics

Objectives

• The Pelvic Exam and Vaginal Discharge– Indications and Technique

• Gynecologic Abdominal Pain– Acute vs Chronic

• Dysfunctional Uterine Bleeding– Causes, Eval, and Treatment

• Amenorrhea/Dysmenorrhea– Primary vs Secondary Amenorrhea

– Causes of Dysmenorrhea

• PCOS

• **This Material Represents ~ 4% of the material on the Boards**

The Menstrual Cycle

The Pelvic exam

• Valuable (and necessary) for many reasons• Begin with the Basics!!!

– Vitals, Height, Weight, and Symptoms!!

• Provide explanation of the procedure and devices early in the visit– Sometimes helps to have a diagram of the female anatomy

handy

• Give the adolescent a choice of who can stay in the room

• Position is key for an adequate exam• Your goal is to complete a exam tailored to the

complaint and provide comfort to the patient

External Anatomy

Indications for Exam

• Cervical Cancer Screening• STI Testing and evaluation• Pregnancy or postpartum• Pain• Discharge• Itching• Swelling• Bleeding• Menstrual Abnormalities• Less common (Trauma, abnormalities of development)

What to look for

• Presence/absence of pubic hair• Clitoral size

– Premenarchal is 3mm

• Configuration of the Hymen• Signs of Estrogenization

– Moist, thick, and dull pink

• Hygiene• Abnormalities from Normal

– Discharge– Discoloration– Trauma– Anatomical Defects

Vaginal Discharge

• Can be physiologic or Inflammatory Leukorrhea

– Physiologic tends to be more clear/slightly yellow and creamy in consistency 2

– Begins at onset of puberty and ends after menopause, due to estrogen influence

• Often, color and consistency are clues to diagnosis

• Important to be able to distinguish which discharge needs which treatment

Adapted from Zitelli Atlas of Pediatric Diagnosis

Physiologic Candida Chlamydia Gonorrhea Trichomonas Bacterial Vaginosis

HSV

Appearance White/Gray/Clear/ Mucoid

White, curdlike, plaques

Mucopus at cervix, clear/bloody discharge

Yellow/greenish discharge

Gray/yellow/green,malodorous, frothy

Gray/white/homogenous, thin

Serous

Vaginal Irritation

None, typically yes Not usual Not usual yes rare yes

pH <4.5 <4.5 variable <4.5 >4.5 >4.5 <4.5

Micro Epithelial cells, lactobacilli, few WBC

WBC’s, pseudohyp-hae with budding yeast

Increased WBC

Greatly increased WBC

Greatly increased WBC, motiletrichomonads

Few WBC, but clue cells present

Greatly increased WBC

Clinical Symptoms

none Itching, dysuria,dy-spareunia

Urethritis, PID, perihepatitis

Urethritis, PID, systemic illness, proctitis

Vulvar itching, prominent dysuria, pelvic discomfort

Fish-like odor LAN, pain

Vaginal Discharge: Treatments

• Candida:– Fluconazole 150mg po x 1

• Chlamydia:– Azithromycin 1g po x1– Doxycycline 100mg po BID x 7d– Levofloxacin 500mg po qd x 7d

• Gonorrhea:– Ceftriaxone 250mg IM x1 plus Azithromycin 1g po x1 or Doxycycline 100mg

po BID x 7 days

• Trichomonas:– Metronidazole/Tinidazole 2g po x1– Metronidazole 500mg po BID x 7d

• Bacterial Vaginosis:– Resolves spontaneously in up to 1/3 non-preg/ ½ preg women– Metronidazole 500mg po BID x 7d– Topical Clindamycin Cream (5g cream of 100mg Clinda) qhs x 7d– Clindamycin 300mg po BID x 7d

Gynecologic abdominal (Pelvic) pain

• Response to many conditions within the body– Distension, stretching, compression, irritation, ischemia,

neuritis, necrosis

• Best classified/discussed as Acute vs Chronic causes

• In pre-pubertal girls, most often involves the GI or Urinary tracts– Gynecologic causes more likely in late adolescence

• Adolescent female with abdominal/pelvic pain warrants a full evaluation and external genital exam, often including a pelvic exam– Indicated for sexually active females

Ovarian Cyst

• Very common between menarche and 18yo– Mature follicles that fail to

ovulate (follicular) or involute (CL)

• Classified as functional vsNon-functional– Functional = part of the

menstrual cycle

• Most asymptomatic and found incidentally– Could cause mentrual irreg.,

pain, urinary frequency, constipation, or pelvic heaviness

Ovarian Cyst Evaluation and Management

• Evaluation

– Detailed menstrual and sexual history• Dysmenorrhea? OCP’s?

– UPT +/- CBC (ie, worried about bleeding)

– Ultrasound• Calcification = think

teratoma

• Management

– Follicular• Usually resolve in 1-2

months

• <6cm = observe +/- OCP

• >6cm = observe vscystectomy (not aspiration!)

– Corpus Luteum• Observe 2wks-3mos (1st

Line) +/- OCP

• Persistent = cystectomy

Ovarian and Adnexal Torsion

• Ovarian torision = complete/partial rotation of ovary on its ligamentous supports– Adnexal when fallopian tube

also twisted

• Many causes– Spontaneous common in

premenarchal girls– Ovarian cyst or tumor– Strenuous exercise– Sudden increase abdominal

pressure

• MEDICAL EMERGENCY

Evaluation and Management of Torsion

• Clinical Presentation/Eval– Typical is ACUTE onset of

mod/severe pelvic pain with nausea +/- vomiting with an adnexal mass

– Fever and bleeding sometimes present

– Serum Hcg, CBC, and BMP

– Ultrasound is 1st line DI

• Management– Immediate surgical

intervention• Necrosis possible after

~36 hours

• Now prefer to save rather than remove the ovary

– Can reoccur• High dose OCP’s can help

suppress cyst formation

• Oophoropexy done in children without evidence of mass

Ectopic Pregnancy

• Developing blastocyst implants somewhere other than the uterus

• Incidence ranges from 6-16% and has increased and plateaued since the mid-20th century

• 876 maternal deaths associated with ectopic pregnancy between 1980 and 2007

• Sites of occurrence vary– Almost all occur in the fallopian tube (~98%, most in

the ampullary)– Other sites include: Cervix, Ovary,

Abdominal

Risk Factors for Ectopic Pregnancy

Low Moderate High

Previous pelvic/abdominal surgery

Infertility Previous ectopic pregnancy

Vaginal douching Previous Cervicitis (GC, Chlam)

Previous tubal surgery

Early age of intercourse (<18yo)

History of PID Tubal ligation

Multiple Sex Partners

Tubal pathology

Smoking In utero DES exposure

Current IUD use

Clinical Presentation

• Most common: 1st trimester vaginal bleeding and/or abdominal pain– Usually 6-8 weeks after LMP– Bleeding quality and quantity varies– Abdominal pain usually pelvic, but quality and timing can vary

• May be ruptured or unruptured at time of presentation, and may even be asymptomatic

• Must be considered in all women of reproductive age who present with vaginal bleeding and/or abdominal pain and:– Are pregnant but IUP not confirmed– Have unknown pregnancy status but amenorrhea >4 weeks

prior to episode– Present with HD instability and an acute abdomen

Evaluation

• Obtain complete history and preform complete physical– Detailed medical/menstrual history, sexual history, and past surgical

history– Complete pelvic exam with bi-manual

• Confirm pregnancy– Serum quantitative HcG level: measured serially every 48-72 hours,

usual doubling time is 1-2 days– HcG that does not rise appropriately can be indicative of an

ectopic/abnormal pregnancy– Transvaginal ultrasound (TVUS)

• Determine location of pregnancy– TVUS

• Further assess stability of patient and consult with appropriate specialists

Management

• If left untreated, could progress to tubal abortion, tubal rupture, or spontaneous regression

• Conservative (hCG <5000, HD stable, willing to follow up, no fetal cardiac activity)– Methotrexate IV, IM, or orally– Single vs multidose protocols

(90% resolution for both)

• Surgical (ie HD unstable, CI to MTX, etc)– Salpingostomy vs

Salpingectomy

Chronic Pelvic Pain

• Usually defined as 3-6 months of pain• Prevalence as high as 3.8% in women 15-73yo• For adolescents, can potentially lead to missed school

days and inability to participate in social interactions• Investigation into non-gynecologic organ systems very

important• Often proceeds to laparoscopic investigation and

interventions• Key Point!!!!

– Offer support and empathy, be non-judgmental, and most of all be THOROUGH!!!

Age related incidence of laparoscopic findings in 129 adolescent patients with chronic pelvic pain (Children’s Hospital Boston, 1980-1983)

Number of patients (%)

Diagnosis Age 11-13 Age 14-15 Age 16-17 Age 18-19 Age 20-21

Endometriosis

2 (12) 9 (28) 21 (40) 17 (45) 7 (54)

Postop Adhesions

1 (6) 4 (13) 7 (13) 5 (13) 2 (15)

Serositis 5 (29) 4 (13) 0 (0) 2 (5) 0 (0)

Ovarian Cyst 2 (12) 2 (6) 3 (5) 2 (5) 0 (0)

Uterine Malformation

1 (6) 0 (0) 1 (2) 0 (0) 1 (8)

Other 0 (0) 1 (3) 2 (4) 1 (3) 0 (0)

No Path Found

6 (35) 12 (37) 19 (36) 11 (29) 3 (23)

Reproduced from Pediatric and Adolescent Gynecology 5th Edition, Emans et al

Endometriosis

• Endometrial tissue located at sites outside the uterus– Often discovered incidentally

• Chronic estrogen-dependent disorder, potentially debilitating symptoms– Pelvic pain, dysmenorrhea, dyspareunia, infertility

• Occurs in women of reproductive age (25-25 often)– Rare in pre-pubertal and post-menopausal girls and women

• Negative risk factors and protective factors exist– Negative: Nulliparity, early menarche/late menopause, short

cycles, prolonged menses, mullerian anormalities– Protective: Multiple births, extended intervals of lactation, late

menarche

Endometriosis: Clinical Presentation

• Classic symptoms are Dysmenorrhea (79%), Pelvic pain (69%), dyspareunia (45%), and/or infertility (26%)

• Pain is typically chronic, dull, crampy, and occuring 1-2 days prior to menses, then through menses

• Can occur in the urinary or lower GI tract, leading to bladder/bowel symptoms as well

• ~1/4 of women will present as infertility, 20% as an ovarian mass, or again found completely incidentially.

Endometriosis: Diagnosis

• History and PE– Often no abnormal

findings, but pelvic indicated

– Tenderness in posterior vaginal fornix

• Labs– None useful

• Diagnostics– Pelvic US

• Surgery– Laparoscopy (visual or

histologic diagnosis)

Endometriosis: Treatment

• Chronic condition = lifelong management plan• Expectant Management• Analgesia• Hormonal Therapy

– Combo OCP– GnRH agonists– Progestins– Danazol– Aromatase inhibitors

• Surgery• Combination

Abnormal Uterine Bleeding

• Bleeding that is excessive or occurs outside the normal cyclic menstruation

• Most common cause during initial ~2 years of menstruation is anovulatorycycles

• Specific definitions exist– Duration >8 days– Flow >80ml/cycle (or subjective impression of heavy flow)– Occur >every 24 days or <every 38 days– Intermenstrual bleeding/postcoital spotting– Absence of menses

• Terminology– Amenorrhea– Irregular bleeding– Heavy menstrual bleeding– Acute bleeding

AUB: Specific Board Differential

• Pregnancy Related Bleeding– Threatened abortion (or spontaneous, incomplete, or missed)– Iatrogenic (problems with termination procedures)– Tubal pregnancy

• Pelvic Inflammatory Disease• Endocrinopathies

– Anovulatory Uterine Bleeding– Hyperthyroidism– Adrenal Disorders– Hyperprolactinemia– PCOS– Ovarian Failure

• Coagulopathies– Von Willebrand Disease

AUB: Evaluation

• ALWAYS start with the history and PE– History with and without parent; detailed menstrual history with focus

on symptoms, medical history, medicines, FH, and social factors– External Genital and Pelvic exam, in addition to tanner staging general

PE parameters

• Pelvic Ultrasound– Indicated if PE limited or to evaluate internal structures

(present/absent)

• Laboratory evaluation– UPT– CBC– TSH– Other: Prolactin, type and cross

AUB: Treatment

• Observation and reassurance (mild)• OCP’s

– Combination or Progestin Only– Can be taken as much as TID x 48 hours if moderate-severe bleeding

• Iron Supplements– Often can lead to iron deficiency

• Hemostatic Agents– Desmopressin and Amicar

• Surgery– D&C

• Hospitalization– Hgb<10 + Heavy Bleeding, Initial Hgb <7, or Orthostatic Hypotension

Amenorrhea

• Absence of Menses

• Primary vs Secondary– Primary amenorrhea defined

as the lack of menses by age 15 or 2 years after sexual maturation has occurred

– If no sexual characteristics by age 13, then begin workup

– Short Stature + Amenorrhea (primary or secondary) = THINK TURNER SYNDROME

Causes of Amenorrhea

Primary• Hypothalamic/Pituitary Disease

– Functional Hypothalamic Amenorrhea

• Congenital GnRH Deficiency– Idio. Hypogonadotropic Hypogonadism

• Constitutional Delay of Puberty– Later occurring menses

• Hyperprolactinemia (Rare)• Ovarian etiologies

– Gonadal Dysgenesis– Turner Syndrome– PCOS

• Congenital Anatomic Lesions– Imperforate Hymen– Transverse Vaginal Septum– Vaginal Agenesis

Secondary• PREGNANT UNTIL PROVEN

OTHERWISE!!!!!• Hypothalamic Causes

– Idiopathic/Meds– Endocrinopathies– Stress/Exercise/Eating Disorders– Weight Loss– Chronic Illness– Hypothalmic Failure– PCOS

• Pituitary Causes– Lesions

• Ovarian Causes– Premature Ovarian Failure– Asherman Syndrome

Amenorrhea Work-Up

Primary• Start with Physical Exam

• Uterus Absent:– Karyotype

– Serum Testosterone

• Uterus Present:– Serum hCG

– Serum FSH

• Other– Prolactin

– TSH

– DHEA-S

– 17-alpha-hydroxylase

Secondary

• RULE OUT PREGNANCY– Urine/serum hCG

• Minimal Testing– Prolactin

– FSH

– TSH

• Hyperandrogenism– Morning 17-OH Progesterone

– DHEA-S

Amenorrhea Treatment

Primary

• Education/Counseling

• Cause Specific– Anatomic Lesion/Y

chromosome Material = Surgery

– Primary OF = HRT

– PCOS = TBA/Goal Oriented

– Hypothalamic Amenorrhea = weight gain, stress/exercise modification, GnRH (help infertility issues)

Secondary• Directed at the underlying

pathology• Hypothalamic

– Lifestyle Change– CBT– Leptin Administration (experimental)

• Hyperprolactinemia– Depends on cause and goals

• Premature OF– Estrogen therapy (OCP or HRT)

• PCOS– TBA/Goal Oriented

• Asherman Syndrome– Hysteroscopic lysis of adhesions, long

term estrogen therapy

Dysmenorrhea

• Recurrent, crampy lower abdominal pain during menstruation– Responsible for episodic school absence in girls/young women– Prevalence 60-93% in adolescent females, only 15% seek medical

advice– Does not occur until menstrual cycles are established

• Primary vs Secondary– Primary = no obvious organic disease– Secondary = IUD, PID, Endometriosis, other organic disease

• Pathophysiology– Believed to be caused by excess production of endometrial

prostaglandin F2 alpha– Leads to dysrhythmic uterine contractions and increased muscle tone uterine ischemia

– Also see nausea, vomiting, and diarrhea due to GI tract stimulation

Dysmenorrhea

• Clinical Symptoms– Abdominal Pain (lower quadrant) several hours prior to

menses, lasting for several days

– Nausea, Vomiting, Diarrhea, HA, dizziness, or back pain

– Can impact daily activities

• Treatment– 1st line: NSAID’s

• Ibuprofen, Naproxen

– 2nd line: Birth Control (can combine with NSAID’s)

– Exercise, APAP, healthy diet, and rest are overly ineffective

What’s in a name?

• Pre-Menstrual Syndrome– The occurrence of at least one affective (emotional

labiality, depression) or physical (breast pain, bloating) symptom associated with economic or social dysfunction during the 5 days preceding a menstrual cycle and present in at least 3 cycles

• Pre-Menstrual Dysphoric Syndrome– Symptoms present for most of the preceding year, and 5 or

more of the symptoms being present during the week prior to menses and resolving shortly after menses• Must have significant distress or impairment of daily activities

PMDD: A Psychiatric Diagnosis

1+ must be present

• Mood swings, sudden sadness, increased sensitivity to rejection

• Anger, irritability

• Sense of hopelessness, depressed mood, self-critical thoughts

• Tension, anxiety, feeling on edge

1+ must be present to reach total of 5 symptoms• Difficulty concentrating• Change in appetite, food cravings,

overeating• Diminished interest in usual

activities• Easy fatigability, decreased

energy• Feeling overwhelmed, or out of

control• Breast tenderness, bloating,

weight gain, or joint/muscles aches

• Sleeping too much or not sleeping enough

Polycystic Ovarian Syndrome

• Disorder of the H-P-O System temporary/persistent anovulation and androgen excess

• Requires 2/3 Criterion (2003 Rotterdam Consensus)– Oligo and/or anovulation

– Clinical and/or biochemical signs of hyperandrogenism

– Polycystic Ovaries by US

PCOS

• Very common cause of amenorrhea (Primary and Secondary)• Most common cause of hyperandrogenism in women and girls

– Affects 5-10% of premenopausal girls

• Close association with diabetes– Insulin resistance increased metabolic and cardiovascular risks

• Pathophysiology is unclear– Abnormal H-P function– Abnormal Ovarian function– Abnormal adrenal androgen metabolism– Insulin resistance hyper insulinemic state excessive ovarian

androgen production by theca cells

PCOS: Clinical Symptoms/Diagnosis

• Cutaneous Findings– Hirsutism

• Vs Hypertrichosis

– Acne– Balding

• Ovarian Findings– Anovulation

• Primary/Secondary Amenorrhea, Oligomenorrhea, DUB

– Polycystic Ovaries with pelvic pain

• Metabolic Associations– Obesity– Manifestations of Insulin Resistance

• Acanthosis Nigricans, Metabolic Syndrome, Sleep Disordered Breathing, Nonalcoholic Fatty Liver Disease

PCOS: Treatment

• Hormonal Therapy– Combined OCP or cyclic progestin– GnRH agonist therapy (if unresponsive to above)– Glucocorticoid therapy (non-obese, solely adrenal

hyperandrogenism)

• Metformin– Indication: abnormal glucose tolerance– Reduces insulin concentrations– Promotes ovulation– Lowers androgen levels

• Antiandrogens– Spironolactone (Aldactone), Finasteride (Propecia)

• Weight Loss

Take Home Messages

• Don’t be afraid of the pelvic exam

• More information is better than no information for our patients

• Consider pregnancy in any reproductive age female with abdominal pain or odd presenting symptoms

• Do not underestimate the social or psychological impairments of gynecologic disease