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Adolescent gynecology ucaya

Adolescent Gynecology PowerPoint for UCAYA

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Adolescent gynecology ucaya

  1. 1. Adolescent Gynecology Mike Guyton, MD Assistant Clinical Professor/Academic Faculty in General Pediatrics
  2. 2. 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**
  3. 3. The Menstrual Cycle
  4. 4. 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
  5. 5. External Anatomy
  6. 6. 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)
  7. 7. 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
  8. 8. 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
  9. 9. Adapted from Zitelli Atlas of Pediatric Diagnosis Physiologic Candida Chlamydia Gonorrhea Trichomonas Bacterial Vaginosis HSV Appearance White/Gray/Cle ar/ Mucoid White, curdlike, plaques Mucopus at cervix, clear/bloody discharge Yellow/greenis h discharge Gray/yellow/gr een, 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, motile trichomonads 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
  10. 10. 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
  11. 11. 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
  12. 12. Ovarian Cyst • Very common between menarche and 18yo – Mature follicles that fail to ovulate (follicular) or involute (CL) • Classified as functional vs Non-functional – Functional = part of the menstrual cycle • Most asymptomatic and found incidentally – Could cause mentrual irreg., pain, urinary frequency, constipation, or pelvic heaviness
  13. 13. 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 vs cystectomy (not aspiration!) – Corpus Luteum • Observe 2wks-3mos (1st Line) +/- OCP • Persistent = cystectomy
  14. 14. 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
  15. 15. 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
  16. 16. 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
  17. 17. 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
  18. 18. 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
  19. 19. 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
  20. 20. 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
  21. 21. 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!!!
  22. 22. 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 Endometriosi s 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 Malformatio n 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
  23. 23. 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
  24. 24. 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.
  25. 25. 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)
  26. 26. Endometriosis: Treatment • Chronic condition = lifelong management plan • Expectant Management • Analgesia • Hormonal Therapy – Combo OCP – GnRH agonists – Progestins – Danazol – Aromatase inhibitors • Surgery • Combination
  27. 27. Abnormal Uterine Bleeding • Bleeding that is excessive or occurs outside the normal cyclic menstruation • Most common cause during initial ~2 years of menstruation is anovulatory cycles • 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. 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
  32. 32. 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
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. 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
  37. 37. 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
  38. 38. 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
  39. 39. 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
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. 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

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