1. The General Principles of Gynecologic Evaluation and
Management of Pediatric and Adolescent Patients
Dr.Süleyman Engin Akhan
Dept. Of Obst.&Gyn.

2. Gonadal Differantiation
 At approximately 5 th week of gestation the paired gonads are in the form
of gonadal ridges overlying the mesonephros.
 The migration of primordial cells to this gonadal ridge starts at around 4-6
th weeks of gestation.
 Gonads are “ bipotent” at the 6 th gestational week. It may be
differentiated to a ovary or a testes.
 The testes development is an active process and it depends on “SRY
region” which is found in the short arm of Y chromosome. In the absence
of “SRY” , gonads become differentiated as on ovary.

3.  The ovarian differentiation of a bipotent gonad in a XX embryo takes
place at around 8-9 gestational weeks.
 At this stage germ cells get proliferated by rapid mitotic multiplication and
reaching 5-7 millon oogonia by 20 weeks.
 After this stage follicle maturation and degeneration start. There are 1-2
million primordial follicle at birth.
 The development of anterior pituitary takes place 4-5 weeks of gestation.
 The hypothalamic-hyophyseal portal circulation becomes functional at 12
th gestational week.
 FSH levels peak at 20- 23 gestational week.

5. ♀Reproduktif Sistemin Embriyolojik Gelişimi
1. Development of pituitary gland
2. Migration of primordial germ
cells originate in the endoderm
of the yolk sac
3. Development of sex cords,
gonads and mullerian ducts
4. Sex determination
5. Development of ovaries and
genital ducts
6. Formation of broad
ligament
1.Trimester 2. Trimester 3. Trimester
2
1
3
4
5
6
72.Gün dişi farklılaşma

6. Genital Organ Farklılaşmasının Temeli
Sertoli Cells
AMH
Leading to regression
of mullerian ducts
Leydig Cells
Testosterone
Ensuring the continuity
of wolffian ducts
5--reductase
DHT
Development and virilization
of the external genitalia

7. The Uterus and Cervix During The Intrauterin and
Neonatal Period
 There are both wolfian ducts ( mesonephric canal) and mullerian ducts
(paramesonephric canal) in the embryo till the 8 th week of gestation and
this period is known as bipotent period. At the 12 th gestational week one
of these disappears.
 Differentiation is determined by the effect of antimullerian hormone (AMH)
secreted from Sertoli cells and testosteron secreted from Leydig cells.
 If there is no AMH, the uterus, fallopian tubes and upper 1/3 of vagina
develop from mullerian canal.

8.  Fusion of mullerian canal get
completed at 10 th gestational week,
canalization of uterine cavity and
development of cervical canal and
vagina is completed at 22 th week of
gestation.
 At 20 th gestational week uterine
cavity is lined with endometrium and
original squamocolumnar junction
occurs.

9.  In the neonatal period, breast tissue and uterus are under the effect of
placental oestrogen-progesteron and gonadotropins. Vaginal mucosa
and endometrium also proliferate under this effect.
 Cervix-corpus ratio is 1/3. Vaginal pH’s asidic. Physiologic eversion
can be seen at the cervix.
 Microscopic or macroscopic vaginal bleeding may be seen after birth
because of withdrawal of hormones and it may last 7- 10 days.
 The vaginal bleeding seen after 15th postpartum day is always
pathologic.
 Changes occuring because of placental and maternal origined
hormones encompass a period of 2 years.

10. Ovaries at the neonatal period
 FSH and LH levels are high during neonatal period. FSH level
further increases during infancy.
 FSH levels are high at 6 - l2 moths and at the same period
follicles respond to this elevated FSH-LH levels.
 That is why the MOST FREQUENT abdominal mass in girls is
ovarian cysts till the age of 1.

11. Genital Organs and Ovaries During the Childhood Period
 Childhood period is a period of
genital and hormonal silence.
 Gonadotroph cells controlling
hypothalamo-hypophyseal system
are sensitive to the negative feed-
back effect of oestrogen 10- 15
times more compared to adult
period.
 The mucosa of vaginal introitus is
pink and wet. Clitoris is small and
is about 5 cm in length. There are
a few rugae.

12. Genital Organs and Ovaries During the Childhood Period
 Genital organs are susceptible to traumas and infections because of low
oestrogen levels.
 Vaginal pH is notr or slightly alkaline and it has a mixed bacterial flora.
 There are multipl follicles during childhood period. Number of follicle
decreases gradually. Ovaries expand their volumes with increasing age and
descent into minor pelvis.
 İt is possible to see big follicles at this stage and it does not need any surgical
intervention or biopsy.

13. Stages Of a Women Life
1. Neonatal period (postpartum first
28 days)
2. Childhood period (till at the age
of 8)
3. Prepuberty and puberty period
(between the ages of 8 – l2)
4. Adolescence period (between the
ages 12 - 20)
5. Sexual maturity period(between
the ages of 18-50)
6. Climacterium and senium (after
the age of 50)

14. Gynecologic examination in pediatric patients
 Basically, pediatric gynecological examination is very
simple,
Key points before the gynecological history and
examination :
Ensure that the child calm and cooperative
Gynecologist with confidence
Give confidence to the family
 Parents or someone who they trust should support
children during examination

15. Gyneacologic Examination and Evaluation
 Basic conditions for physical examination of the pediatric patient:
1. Time
2. Patience
3. Communication ability
4. Communication with family
5. Assistance (Educated nurse. staff )
6. Equipment
7. Good team work (Pediatry, Microbiology, Pediatric
surgery,Urology)

16. The history
 The most important thing is to achieve incorporation of the
child. The history should be taken first from the child,
thenafter, you can talk to the parents.
 İnterviewing with just parents may cause serious
incofidentiality problems.
 History should be specifically focused on the main complain.

17.  In the case of vulvovaginitis, it should be asked when the the symptoms
have begun and if there is any antibiotic use or urinary system anomaly
(such as VUR).
 In the presence of vaginal bleeding, signs of puberty, growth curve of the
child, hormonal medication use history should be questioned thoroughly. In
both vulvovaginitis and vaginal bleeding conditions, doctor should ask
whether she is masturbating.
 The possibility of foreign body should be remembered in the presence of
both vaginal discharge and bleeding.

18. Gyneacologic Examination
 Those must be certainly evaluated in a girl’s gyneacologic
examination: Height- weight, head- neck, thoraks, heart,
abdomen, breast
 An exact gyneacologic examination:
1.Inspection of external genital organs
2. Visualization of the vagina and cervix
3.Rectoabdominal palpation

19. Gynecologic examination of the newborn
 Labia minora can be thick, protruding and stick out beyond labia
majora according tomaternal estrogenization.
 Labia majora is pink and covered by physiological vaginal
discharge
 Apparent estrogenization findings are present in the first 6-8 weeks
after birth
 It can be hard to see vaginal
orifice and a urethral catheter
can be needed.
 Vaginal length is approximately
4 cm.

20. Gynecologic examination of the child
 What should be evaluated : Height-weight , head-neck, chest-
heart-abdomen-breast
 Inspection of breasts is very important. Especially, color of the
areola should be carefully checked.
 When there is Tanner stage I or II breast development with
dark brown areola, hormone use should be questioned.

21. The instruments and position used
 Mother’s help is important, the
child should be kept in the frog
position.
 Otoscope and lenses can also
used during inspection.
 Another important inspection
instrument is mirror
 The child should discover the
instruments to feel safe.

22.  Inspection of external genital organs:
1. Pubic hair
2. Size of the clitoris
3. Anatomy of hymen
4. Signs of oestrogenisation in vagina and hymen
5. Perineal hygene .
 In a prepubertal girl, clitoris is 3-4 mm in length and 2-3 mm in width.
Shape of hymen should be noted.

23. To inspect hymen and vagina:
Hands are placed to the perineum and
labium drawn up and sideways.
Labium majora is moved forward.
When the child coughs, a significant
part of vagina can be seen.
Labium should not move laterally
since it causes pain

24. Physical examination of vagina and cervix in Child
 Above 2 year-age,vagina and
cervix are perfectly visualised in
knee-elbow position.
 In the same position, otoscope
can be easily used.
 Other visualisation merthods of
mentioned organs are
vaginoscope and hysteroscope.

25. Taking Vaginal Culture from Child
 One of the most important points in vaginal examination is
sampling discharge, especially vaginal culture in the case of
sexual abuse.
 Vaginal sample can be obtained by culture swabs. Swab is
inserted into the vagina witout touching hymen while the
child is coughing.
 Anterior labial foldlarda kalın beyaz bir madde bulunur.
Buna smegma adı verilir ve lökore ile karıştırılmaması
gerekir.

26.  In case of sexual assault, sampling is made by vaginal
washing with the help of an injector and serum set or
feeding tube.
 Pokorny is a sampling made with 1 ml of SF through a 4
inch iv catheter placed in to no:12 bladdder catheter.

27.  Understanding the
problem of incest in
Turkey

28.  Obtaining material is followed by rectoabdominal examination.
Bimanual examination is performed by placing thumb on abdomen
and other finger in rectum.
 Only cervix and vagina are palpable in rectovaginal examination. In
newborn period,uterus, under oestrogen effect, may be palpated as a
large mass.
 Varies are located higher than in adulthood, therefore, palpation is
pathological.
 Finally, as little finger is taken out of rectum, vagina is squeezed so
that a polypoid tumor can be detected.
Rektoabdominal Examination

29. What is Adolescence?
Adolescence is the time period of physical,
cognitive and social development between
childhood and adulthood.

30. The stages of adolescence
 Early period: 12-14 years
Period of pubertal growth and menstruation.
They start separating from the family and interpret the family
according to their own values
 Middle period: 15-17 years
They start creating their moral values and begin to make choices.
They interpret the rights and wrongs in their own again.
They begin to take risks in their relationship.
They care about their appearance and health more than before.
They argue with their parents.
 Late period: 18-21 years
Formal thought is developed. They begin to consider possible
outcomes and consequences of actions.
They accept the parent's value and can even become a parent.

31. Development of the adolescent brain
 The brain's remote control is the
prefrontal cortex, a section of the
brain that weighs outcomes, forms
judgments and controls impulses and
emotions. This section of the brain
also helps people understand one
another.
 The prefrontal cortex is immature in
teenagers when compared to adults; it
may not fully develop until mid-20s.
(Kotulak, Randal 2004)

32.  An area of the teenager's brain
that is fairly well-developed
early on is the nucleus
accumbens, or the area of
the brain that seeks pleasure and
reward.
 In imaging results that
compared brain activity when
the subject received a small,
medium or large reward,
teenagers exhibited exaggerated
responses to medium and large
rewards compared to children
and adults. (Nature 442, 865-867, 2006)

34.  During adolescence,
 The reward system is over reactive.
 Nucleus accumbens is well developed and
dopaminergic activity is extremely high.
 The neurobiologic system does not need to de-
activate the frontal cortex and the prefrontal
cortex, because they are already immature.

35. Psychologic State of Adolescence
 Not a child anymore, but a sexual object. Potential sexual
partner for the opposite sex.
 Reproductive functions are possible.
 Body is fully developed, however psychologic state is not
mature yet.
 The most important thing is that he/she does not have
control mechanisms for the instinctual behavior
The body is ready for reproduction and sexuality;
however the mind is not.

36. Paradox: Overemphasized sexuality on one
hand. On the other hand romanticism that
interferes with sexuality.

37. Transition from childhood to adulthood involves
becoming ‘Me’ instead of ‘Us’
It is important to emphasize the differences with
parents. The situation of the parents changes.
Has own opinions, interests, and moral values. From
US to ME: becoming a female or male

38. Gynecoogic examnination for
adolecents
 Gynecologic examination of an adolescent cannot be
routine examination.
 Three main objectives of the examination:
We ensure the right ambience and establish a
relationship based on trust with young girl who can
have deep emotional problems about sex, fertility or
puberty.
Clinically evaluate
 Diagnosis and treatment

39. The clinician should spare enough time and take a
careful history, preferably also from parents. It is
important to listen and observe the patient
carefully.
Cultural values of the patient and the parents need
to be taken into account but treatment regulation
cannot be made carelessly without examination.

40. İmportant points
 According to western literature: Adolescents should be
examined alone after 13 years old.
 Istanbul University Faculty of Medicine Adolescent
Outpatient Service : We usually get history and examine
alone after 15-16 years old.
 We should ask the adolescent whether she is sexually active
alone ve define the meaning of being sexually active.

41.  What should be evaluated : Height-weight , head-neck, chest-
heart-abdomen-breast
 Inspection of breasts is very important. It’s especially important
for the patients with primary or secondary amenorrhea.

42.  Inspection of vulva and vagina
(Plast. Reconstr. Surg. 122: 1780, 2008.)

43. Our patient MK;
17 years old, height:1.62, weight: 43.
Reason for admission: oligomenorrhea. Age at menarche:13
She had used oral contraceptives for 1 year and she stopped
taking it 2 months ago. She hasn't had menstruation for 2
months.
Hormone profile: LH slightly ↓; FSH ↓; E2 ↓; P ↓. There is no
another feature.
Mild hirsutism, especially around neck; PCO like appearance
on ultrasound but do not meet Rotterdam Criteria.
Diagnosis: Anorexia nervosa

44.  There is no significant difference between gynecological
examination of children and adolescents who are virgin. We
can use very small and thin speculums if necessary. After
examination, we should discuss the findings and treatment
options with the parents.
 Pap smears are required for the patients who are sexually
active and talk the patient first about findings then you can
give the family the information with the patient's permission
and make a plan of treatment.
 It is also absolutely necessary to give the patient some
information about birth control methods.

45. Diagnostic imaging methods -I-
ULTRASONOGRAPHY
 Abdominal ultrasound is very efficient for
the pediatric patients. A good image can
be obtained by reason of thin
subcutaneous fat tissue before puberty.
 When there is a suspicion of early puberty
abdominal ultrasound is also efficient to
rule out ovarian pathology.
 Transrectal ultrasound is also performed
to follow-up of patients who were
diagnosed with cancer and operated or in
the presence of suspicion of malignancy
after 12 years old.

46. Diagnostic imaging methods -II-
MR
MR can be performed in
the presence of suggestive
symptoms of sarcoma
botryoides or suspicion of
adnexal mass for the
pediatric patients.
In the presence of
suggestive symptoms of
Mullerian anomaly for the

47. Diagnostic imaging methods
TA USG
TR USG
Magnetic Resonance

48. Vaginoscopy in Pediatric Patients
 The main indication for
vaginoscopy in pediatric patients is
bloody vaginal discharge.
 We are using office hysteroscopy
for this purpose.
 I always prefere to take the mother
in the operating room !!
 The procedure is so simple.

49.  The most common pathology in
pediatric patient with vaginal
discharge or bleeding is foreign
body.
 8 years old girl with vaginal
bleeding and examine by pediatric
endocrinology because of puberty
precox.
 There is no stigmata for the
puberty precox
 Hormonal profile is normal

50.  Vaginoscopy should not be postponed in pediatric patients with
bloody vaginal discharge.
9 years old girl with real
puberty precox
She was using GnRH analogue
and aromatase inhibitor.
She have a unstoppable vaginal
bleeding! With vaginal heavy
discharge
Primary Clear Cell Vaginal Ca

51. Hysteroscopy in Adolescent Patients
 Main indication for hyteroscopic surgery in adolescent patient is
dysfunctional uterine bleeding (DUB)
15 years old girl, with vaginal heavy
bleeding and anemia.
She used different medication
including GnRH analogues
BMI= 46.2 !!

52. Common Problems in Pediatric
Gynecology
Vulvovaginitis
Vaginal bleeding
Genital trauma
Labial fusion
Early puberty - cliteromegaly

53. Common Problems in Adolescent
Gynecology
Gynecologic Endocrinology
 Dysfunctional uterine
bleeding
 Vaginal discharge
 Dysmenorrhea
 PCOS
 Primary amenorrhea
Premature ovarian failure
Gynecologic Surgery
 Intersex disorders and
surgİcal treatment
Clitoral surgery
Gonadectomy
 Mullarian system
abnormalities
 Management of adnexal
mass