Gynaecological disorders of childhood and adolescence Chapter Notes | Gynaecology and Obstetrics - NEET PG PDF Download

Introduction

• Gynaecological issues in prepubertal children and adolescents cause significant parental anxiety.
• These disorders are rare but require proper understanding for effective management.
• Disorders are divided into two groups: prepubertal and adolescent.

Prepubertal Child

Vulvovaginitis

• Most common gynaecological disorder in prepubertal children.
• Caused by opportunistic bacteria colonizing the lower vagina, leading to inflammation.
• At birth, the vulva and vagina are protected by maternal oestrogen, making the vaginal epithelium thick.
• Within 2–3 weeks after birth, a hypo-oestrogenic state thins the vulval skin and vaginal epithelium.
• Loss of vulval fat pad leaves the vaginal entrance unprotected.
• Vulval skin becomes sensitive, easily irritated, or infected due to thinness and lack of protection.
• Close proximity of anus increases risk of faecal bacterial contamination.
• Hypo-oestrogenic vagina has a pH of 7, ideal for low-virulence bacteria growth.
• Poor hygiene in children increases the risk of non-specific infections.
• Children exploring genitalia or masturbating may contribute to vulvovaginitis, which is hard to treat.
• Impaired local host defence (e.g., reduced neutrophil response) may increase susceptibility.

Causes of Vulvovaginitis in Children

• Non-specific bacterial infections are the most common cause.
• Candida infections are rare in children, usually linked to diabetes mellitus or immunodeficiency.
• Viral infections (e.g., herpes simplex, condyloma acuminata) may suggest sexual abuse.
• Vulval skin diseases like atopic dermatitis (common in children with eczema) or lichen sclerosis can cause itching, atrophy, fissuring, and secondary infections.
• Sexual abuse may present as vaginal discharge, especially recurrent cases.
• Bacterial infections like gonorrhoea are diagnostic of sexual abuse.
• Enuresis (urinary incontinence, especially at night) can cause a moist vulva, leading to bacterial irritation.

Diagnostic Procedures

• Inspect vulva and vagina with good illumination, especially if a foreign body is suspected.
• An otoscope can be used to examine the vagina through the hymen to detect foreign bodies.
• Bacteriological specimens are difficult to obtain due to child discomfort.
• Use a pipette with 1–2 ml of saline inserted through the hymenal orifice to collect vaginal fluid for bacteriology, as it is less irritating than a cotton swab.
• To diagnose pinworms, apply sticky tape over the anus in the morning before the child gets up to check for eggs under a microscope.
• Bacteriological results are hard to interpret; specific organisms are rarely identified.
• Most children do not have a pathological organism; treatment focuses on perineal hygiene.
• Parents should be reassured that vulvovaginitis does not cause long-term issues like sexual dysfunction or infertility.
• Management
  • Teach children to clean the vulva from front to back after defecation to avoid bacterial transfer.
  • After urination, ensure the vulva is cleaned and dried to prevent a damp environment.
  • Use gentle, unscented soap for daily vulval washing; avoid excessive washing to prevent dermatitis.
  • During acute episodes, burning during urination can be relieved with barrier creams.

Labial Adhesions

• Common but minor condition, often misdiagnosed as congenital absence of the vagina.
• Labia minora stick together in the midline, usually from posterior to anterior, leaving a small anterior opening for urine.
• Clitoris may also be bound by adhesions.
• Vulva appears flat with no normal tissues visible beyond the clitoris; a translucent midline line indicates adhesions.
• Usually asymptomatic, but older children may report spraying during urination.
• Caused by hypo-oestrogenic state in early childhood, not present at birth.
• Spontaneously resolves in late childhood as ovarian activity begins.
• Most cases require no treatment; reassure parents of normality.
• If symptomatic, apply local oestrogen cream for 2 weeks to resolve adhesions.
• If unresolved, gently separate labia with a probe after oestrogen therapy, followed by barrier cream to prevent re-adhesion.
• Rule out trauma or sexual abuse as a rare cause of adhesions.

Puberty

• Period when secondary sexual characteristics develop, menstruation begins, and psychological changes occur.
• Results in a physically and psychologically mature adult woman capable of reproduction.
• Physical changes include breast growth, pubic hair growth, axillary hair growth, growth spurt, and menarche.
• Tanner system classifies breast, pubic hair, and axillary hair development into five stages; stage 5 indicates maturity.
• Growth spurt in girls peaks at 8 cm/year around 11.5–12 years in the UK, earlier than in boys.
• Oestrogen production closes epiphyses, finalizing height around 14.5 years.
• Menarche occurs around 12.6 years in the UK, influenced by genetic and environmental factors.
• Gonadotrophin-releasing hormone (GnRH) release from the hypothalamus is controlled by genetic factors, neurotransmitters, endorphins, interleukins, leptin, and growth factors (e.g., transforming growth factor alpha, epidermal growth factor).
• Increased body fat percentage, influenced by nutrition, socio-economic status, or conditions like anorexia nervosa, triggers GnRH release.

Causes of Precocious Puberty

• Early menstrual cycles are often anovulatory, with variable cycle lengths for 5–8 years post-menarche.

Causes of precocious puberty

• Primary dysmenorrhoea may appear later due to anovulatory cycles causing endometrial hyperplasia and heavy bleeding.

Precocious Puberty

• Defined as secondary sexual characteristics appearing before age 8.
• Idiopathic precocious puberty (95%) results from premature activation of normal puberty processes.
• Neurological conditions (e.g., cerebral tumours, hydrocephalus, postmeningitis) may trigger early hypothalamic activation.
• McCune-Albright syndrome involves cystic bone changes and hypothalamic-pituitary dysfunction, leading to precocious puberty.
• Ovarian or adrenal tumours may secrete hormones, causing reversible secondary sexual characteristics.
• Exogenous oestrogen ingestion can cause menstrual bleeding, not true precocious puberty.

Treatment

• Idiopathic cases are treated with GnRH analogues to suppress FSH production, restoring a prepubertal state until age 11.5–12.
• Breast or pubic hair development before treatment may regress in the hypo-oestrogenic state, especially if pre-Tanner stage 3.
• Post-Tanner stage 3 changes are less reversible.
• Neurological cases respond similarly to GnRH analogues.
• Tumours (ovarian, adrenal, gonadotrophin-secreting) are treated surgically, resolving symptoms.
• Social management is crucial due to the social undesirability of precocious puberty.
• Paediatric endocrinologists typically manage these cases, with gynaecologist involvement rare.

Adolescence

• Common issues include menstrual dysfunction, primary amenorrhoea, and hirsutism.

Menstrual Problems

• Menstrual cycles are often anovulatory initially, taking years to become regular.
• Management involves support and reassurance rather than active treatment.

Heavy Menstruation

• Accurate history from the child is essential, as maternal perception may exaggerate menstrual loss.
• Normal menstrual loss is up to 80 ml; 5% of girls have heavier loss without issues.
• Assess severity by measuring haemoglobin levels.
• If haemoglobin >12 g/l, reassure about normal physiology; no treatment needed, but follow up every 6 months.
• If haemoglobin is 10–12 g/l, indicate mild iron deficiency anaemia; treat with iron therapy and explain the cause.
• Use cyclic progestogens (21 days per 28-day cycle) or combined oral contraceptive pill to reduce menstrual loss.
• Stop therapy annually to assess if normal menstruation has established.
• If haemoglobin <10 g/l, treat urgently with oral contraceptive pill (continuous initially, then cyclic) and oral iron.
• Follow-up is essential for reassurance.
• If menstrual loss remains uncontrolled, perform an ultrasound to rule out rare uterine pathologies.

Primary Dysmenorrhoea

• Pain associated with menstrual bleeding, managed similarly to adults.
• Use non-steroidal anti-inflammatory drugs or oral contraceptive pills.
• If ineffective, perform ultrasound to check for uterine anomalies.

Premenstrual Syndrome

• Challenging in adolescents due to psychological and emotional changes during puberty.
• Stress-related disorder, often not medically treated.
• Provide reassurance and explanation; involve psychologists if needed.

Hirsutism

• Excessive hair growth on arms, legs, abdomen, breasts, or back, often with acne due to androgen effects.

Differential Diagnosis

Causes of hirsutism in adolescents

• Congenital adrenal hyperplasia (classic or late-onset) and androgen-secreting tumours are androgenic causes.
• Polycystic ovarian syndrome is the most common cause, though diagnosis in adolescents is challenging.
• XY gonadal dysgenesis should be considered.
• Idiopathic hirsutism is common; consider familial hair patterns as a constitutional cause.

Treatment

• Oral contraceptive pills are the primary treatment, suppressing ovarian androgen production.
• Effective for polycystic ovarian syndrome or undefined ovarian dysfunction.
• If insufficient, use cyproterone acetate or spironolactone to control hair growth.
• For non-medical hirsutism, cosmetic measures like shaving, waxing, electrolysis, or bleaching may be used.