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Michelle M Fynes
MD MB BCh (Hons) BAO (Hons) MRCOG DU(RANZCOG) DipUS
Subspecialty Accredited Urogynaecologist RCOG RANZCOG
Specialist Complex Peri-partum Childbirth Injury
Adolescent and Paediatric Gynaecology
Consultant Urogynaecologist & Honorary Senior Lecturer
Quality care –
– Safe
– Effective
– Patient centred
– Timely
– Efficient
– Equitable
Adverse event/SUI/ Critical Incident reporting
Audit (measurement process and outcome)
CPD
Mandatory training/updates
Medical Ethics- Four Key Principles
• Beneficence – Provision of benefit whilst balancing this against risk. Also for individual
situation/procedure/treatment taking into account overall needs of the individual.
• Non-maleficence – ‘Primum non nocere’ - First of all do no harm. Do not attempt treatment
where there will be no benefit and likely risk of harm.
• Justice – Implies a duty to spread benefits and risks equally in a society. Treatment should be
available to all who may benefit from it. There should be no discrimination on the grounds of
factors such as age, disability or lifespan.
• Autonomy - Patients making their own informed decisions rather than healthcare (parents?)
providers making decisions for them. Autonomy requires that a person with capacity is
adequately informed, free from undue pressure and that there
is consistency in their preferences
Adolescent Gynaecology
Age of consent?
Capacity?
Rights of the parents?
Adolescent Gynaecology
Objectives
• Overview normal physiological development; skeletal growth, maturation of
the reproductive tract, development secondary sexual characteristics, CNS
maturation, personality and psychology of the female adolescent.
• Sex and the adolescent - STD’s, PID, cervical screening, HPV vaccination
• Teenage Contraception and Pregnancy
• Adolescent gynaecology and psychiatry - Body dysmorphic disorders
• Forensic and legal aspects to adolescent gynaecology
Female Development
• Embryology – Chromosomal and congenital fetal
development disorders
• Adolescent Neuro-psychology
– CNS development and maturation
– Adolescent female personality
– Sexuality and sexual identity
XX Embryology
The cranial end of the fused ducts the future uterus contains
mesoderm that forms uterine endometrium and myometrium.
Unfused cranial ends of the paramesonephric ducts (funnel
shaped) remain open as the fimbriale of the fallopian tubes.
Caudal end of fused ducts forms upper two-thirds of the vagina.
1. Gartner’s Duct
Gartner’s ducts are paired remnants of the
mesonephric duct . May give rise to Gartner’s
duct cysts normally in the broad ligament (BL).
3. Epoophoron ( XY epidydimis)
Most cranial part of the mesonephric duct
remnant in the lateral broad ligament. May
communicate with Gartner’s ducts (inferior BL)
Week 6- Urethral groove and anal pit form causing focal depressions on cloacal
Membrane (a). Primary urethral (urogenital) folds surround primary urethral groove.
Genital/labioscrotal swellings form lateral to the folds.
Puberty
At birth, females have a predetermined number
primordial follicles arrested during meiosis 1 at the
diplotene stage of prophase until stimulation at
puberty. Hypothalamus is in a quiescent state.
Stage I (Preadolescent) - Only papilla elevated above level of the chest wall.
At approximately 8 years, GnRH is synthesized in the Stage II - (Breast Budding) - Elevate breasts/ papillae (small mounds), wider areola
hypothalamus and released.
Stage III – breasts/areolae continue enlarging no separation of contour.
The adrenal cortex begins to produce DHEA initiating Stage IV – areola/papilla elevated, secondary mounds, increase overall breast tissue.
adrenarche (ie, the development of sexual hair). Stage V – Mature breasts, papillae extend above breast contour, areolar recession.
Update on precocious puberty: girls are showing signs of puberty earlier, but most do not
require treatment. Kaplowitz P. Adv Pediatr. 2011;58(1):243-58 Precocious Puberty: How Early
Puberty was considered precocious in girls < 8 years; recent studies indicate that signs of Is Early?
early puberty (breasts and pubic hair) are often present in girls (particularly black girls) aged Precocious puberty: The diagnosis depends on the
6-8 years. Early onset of puberty can cause several problems. The early growth spurt initially definition. Published on October 31, 2009
can cause tall stature, but rapid bone maturation can cause linear growth to cease too early by Jean Mercer, Ph.D.
and can result in short adult stature.
Although there are clear social and psychological
Premature pubarche and premature thelarche are 2 common, benign, normal variant concerns about precocious puberty, the most
conditions , resemble precocious puberty but non/slow progressive . Premature thelarche serious reason for paying attention to early
isolated appearance breasts, usually in girls <3; premature pubarche pubic hair without other development is the possibility that this growth is
signs of puberty in girls/boys <7-8 years. History, examination, growth curve help distinguish driven by abnormalities in the child's central
normal variants from true sustained precocity. Must differentiate central precocious puberty nervous system.
(CPP) from precocious pseudopuberty (PSP). CPP is gonadotropin-dependent, early
maturation of the entire HPG axis, full spectrum physical/hormonal changes puberty. PSP However, Kaplowitz, the author mentioned earlier,
less common, refers to conditions where increased production sex steroids is gonadotropin- referred to a French study in which girls under 6
independent . Correct diagnosis aetiology sexual precocity critical, evaluation/treatment who showed signs of precocious puberty were
precocious pseudopuberty is different than that for central precocious puberty compared to girls between 6 and 8. About 6% of
the younger children did have some central nervous
Precocious puberty: a comprehensive review of literature. system problem, but only 2% of those over 6 had.
This suggests that girls showing precocious puberty
Cesario SK, Hughes LA. J Obstet Gynecol Neonatal Nurs. 2007;36(3):263-74
between 6 and 8 years of age probably do not need
Incidence – 1 in 7 Caucasian , 1 in 2 African American girls start to develop breasts or pubic further evaluation for nervous system problems.
hair by age of 8 years. Precocious puberty affects 1 in 5,000 . 10 times more common in girls.
Factors influence early sexual maturation female children are multi-factorial- Precocious puberty in boys, defined as
• Genetic, Ethnic, Paediatric obesity, Environmental toxins disrupt endocrine function development before age 9, is quite rare (1 in
(chemicals, toxins, plasticizers, infant feeding, skin/hair products, ART) 10,000 in the United States), but when it does occur
• Psychosocial stress, and early exposure to a sexualized society is much more often associated with central nervous
system problems that need treatment.
Paediatric and Adolescent Gynaecological (PAG) Service
PAG service Kettering General Hospital established 1993 Analysis referrals:
800 cases over 15 years (1999-2004)
Recurrent vulvovaginitis (relapsing/chronic) 18%
Dysmenorrhoea/menorrhagia 13%
Secondary amenorrhoea
Lichen sclerosus 3%
CAH
Definition - CAH masculinized external genitalia, excess adrenal androgen -in utero, or late
onsetin adolescence. Most e block in production cortisol . Enzyme defect 21-hydroxylase
(P450c21). Deficiency this enzyme 95% cases CAH.
Most severe form blocks aldosterone & cortisol- salt-wasting , shock , significant virilization.
Various mutations CYP21B gene responsible for 21-hydroxylase deficiency. Severity CAH Adrenal steroidogenesis
determined by specific gene mutation.
Onset - excess androgens occurs 60-80-mm stages fetus. Build-up of excess precursors
progesterone and 17-hydroxyprogesterone as unable to convert to aldosterone & cortisol.
Shunted to production androstenedione & testosterone. Excess androgens masculinize EG
in female. Degree masculinization depends on time onset CAH – clitoromegaly, psuedopenis.
The gonads are undescended ovaries. The disturbance of metabolic processes requires
prompt diagnosis and treatment.
CAH 5–8% due 11ß-hydroxylase deficiency, 11-deoxycortisol not converted to cortisol and
virilization will occur due to shunting of precursors into androgen biosynthesis, similar to
21-hydroxylase CAH. 11-deoxycorticosterone not converted corticosterone and
aldosterone, to a degree with this block .
True hermaphrodites possess both testicular and ovarian tissue. Both types may be
contained in one gonad, ovotestes, or one side may be an ovary other side testis. Internal
structures correlate to adjacent gonad. EG are ambiguous, may be sufficiently developed to
do XY gender assignment. 75% develop gynecomastia , > 50% menstruate puberty, perhaps
making female sex assignment easier.
Ovarian anomalies – Turners syndrome
• Genotype (sex) is determined at conception.
• Phenotype (morphologic) sex differentiation
shown in the ovaries week 7.
• Primordial germ cells found 24th day near
allantois. Germ cells proliferate, migrate to the
genital ridge, by week 5, become elevated and
thickened.
• Sex differentiation visible early week 8.
• Proliferation oogonia (germ cells) by mitosis
continues until 15th week at 16 weeks primary
follicles seen.
• Ovary is a discrete organ, “descends” to pelvic
brim and rotates laterally.
• Ovarian anomalies rare other than streak ovaries
(gonadal dysgenesis). Complete absence ovary is
extremely rare usually associated renal agenesis
absence ipsilateral fallopian tube.
• Gonadal dysgenesis usually streaks of CT tissue
called "streak gonads“. Dysgenetic ovaries
absence of follicular structures and oocytes. Most
common cause is Turner syndrome, 45X.
• Phenotypic females with streak gonads can also
have XX gonadal dysgenesis, XY gonadal
dysgenesis or mixed gonadal dysgenesis.
PAG - Suspected Precocious Puberty
Secondary amenorrhoea
Primary amenorrhoea Peak age 16 years (R12-18 years).
Peak age 16 years (R14-25 years)
Pathology:
18% discharged with no action needed 24% discharged at the first appointment/no further action
18% actively monitored over period of time. 6% primary ovarian failure
6% secondary regular medications (Na valproate, depot provera)
3% pituitary microadenoma
Treatment 3% hypogonadotrophic amenorrhoea
41% COCP 3% weight-related amenorrhoea
18% HRT
Treatment
12% multiple therapies 40% COCP
5% advice from a dietician 9% HRT
3% Bromocryptine
Outcomes Outcome:
76% constitutional/spontaneous menses 6% were actively monitored
15% review by a dietician
6% Turners syndrome 79% spontaneous return of menstruation without further tests
6% Primary ovarian failure
6% Prader–Willi syndrome A study of paediatric and adolescent gynaecology services in a British district
general hospital. S McGreal, PL Wood. BJOG 2010; 117(13):1643–1650
6% Weight-related amenorrhoea
PAG Service – Menstrual Dysfunction
Referral pattern:
13% Dysmenorrhoea and/or menorrhagia.
17% had been treated by the GP.
3% presented as an emergency admission
Median age: 14 years
Symptoms:
33% menorrhagia
25% dysmenorrhoea
17% dysmenorrhoea and menorrhagia
8% prolonged periods
6% frequent periods.
Treatment
34% COCP
14% tranexamic acid
14% depot provera Background
10% advice and education 25% of adolescents have marked menstrual disturbance
8% mefenamic acid Most of these cases are dealt with by GP
5% iron supplements More difficult cases are referred to the PAG service along
2% HRT with difficult contraception issues, especially in adolescents
1% Mirena IUS with developmental delay.
Concomitant haematological disorders multidisciplinary
46% combination of therapies
approach
5% laparoscopy +/-treatment for endometriosis.
A study of paediatric and adolescent gynaecology services in a British district general hospital
S McGreal, PL Wood. BJOG 2010; 117(13):1643–1650
Haematological Disorders –
Presenting with Gynaecological Symptoms
Haematological disorders
- von Willebrand disease;
- acquired haemophilia;
- carriers of haemophilia;
- Factor XI deficiency
Mennorrhagia
• Excessive haemorrhage is one of the commonest symptom when adolescents present to a gynaecologist.
• Less commonly, the bleeding is due to an undiagnosed underlying coagulation defect, the commonest of which is von
Willebrand (vWD) disease.
• Menorrhagia is a common, and may be the only, clinical manifestation of an inherited bleeding disorder. Screening 150
young women with menorrhagia, vWD was diagnosed in 13% and other hereditary haemorrhagic disorders in another 4%.
• Menorrhagia with onset at the menarche was predictive of an inherited bleeding disorder in 65% of vWD and 67% of FXI
deficiency. Testing for bleeding disorders should be considered in girls with early onset menorrhagia.
• Increased awareness among gynaecologists of these less common causes and close collaboration with the local
haemophilia centre and availability of management guidelines are essential for optimal outcome
Kadir, Aledort. Clinical & Laboratory Haematology 2000;22(s1):12-16
Known haematological disorders
• 116 women - 66 vWD, 30 carriers haemophilia, 20 factor XI (FXI) deficiency. Interview and gynaecological history obtained.
Menstrual loss objectively assessed by pictorial blood assessment chart (PBAC). Comparison with age-matched control
group (69 women). Menorrhagia (PBAC score> 100) confirmed in 74%, 57% and 59% of women with vWD, carriers of
haemophilia and FXI deficiency, respectively, in comparison with 29% of controls (P = 0.001). PBAC scores were higher in
vWD patients with a von Willebrand factor activity (vWF:Ac) of ≤ 30 IU dL−1 compared to those with higher levels.
• No relation between PBAC score and the severity of the disease in FXI deficient and carriers of haemophilia.
• Duration of menstruation significantly longer (P = 0.001), episodes of flooding significantly more common (P = 0.001) in
patients with inherited bleeding disorders compared to controls.
Kadir, Ecconomides, Sabin, Pollard, Lee. Haemophillia 1999;5(1):40–48.
Hirsutism - Causes -
Affects 5-15% XX 1.
2.
PCOS (70–80% hirsutism cases)
Endocrine: Hypothyroid , acromegaly, hyperprolactinemia,
cushings -cause hyper androgenism
3. Androgen tumours ovary (arrhenoblastomas; Leydig, hilar ,
thecal )/ adrenal ( 1in 300-1000) hirsutes/50% malignant)
4. Drugs – indep androgens, phenytoin, minoxidil, diazoxide,
streptomycin,high-dose steroids, psoralen, penicillamine.
5. Non-classic CAH (AR) -1.5–2.5% cases, 21-hydroxylase
deficient, >17-hydroxyprogesterone (androgenic)
6. Idiopathic (hyperandrogenism/hirsutism )6-7%
• Oligo or amenorrhoea
• Infertility and Miscarriage
• Acne
• Hirsutism, alopecia
• Weight gain and obesity
• High blood pressure
• Elevated insulin/insulin resistance (IR)/NIDDM
• PCO > 12 cysts 2-8mm diameter (20% XX PCO versus 5-10% XX PCOS)
Causes
6 (33%) Rokitansky Hauser Syndrome (RHS)
6 (28%) Uterine didelphys
5 - Imperforate hymen
3 - Transverse vaginal septum
2 - Septate hymen Mullerian agenesis, hypoplasia
1 - Pominent hymenal band Junqueira B L P et al. Radiographics 2009;29:1085-1103
Symptoms
Common Age presentation: Peaks 13-15 years (R 3-16)
Primary amenorrhoea
Abdominal pain RHS presented at younger age, 17% being as young as 7
Other years. 83% were treated conservatively with progressive
Urinary retention vaginal dilatation, surrogacy/infertility advice, ongoing
Vaginal discharge review, 17% referred/underwent vaginoplasty.
Pelvic mass
Difficulty using tampons Uterine didelphys older at median 13 years
Dysmenorrhoea 40% had a solitary kidney, 20% a non-functioning kidney.
Delayed puberty 3 cases presented with hemi-obstruction, making
Hirsutism. diagnosis more difficult and exemplifying the need for
good diagnostic imaging, paediatric radiologist.
A study of paediatric and adolescent gynaecology services
in a British district general hospital
S McGreal, PL Wood. BJOG 2010; 117(13):1643–1650
Embryology – Development Genital tract
Type No.
Double ureter, branched, unilateral or
15
bilateral
Hydronephrosis and/or hydroureter 10
Unilateral renal agenesis (all males) 3 Because of the close association of mesonephric and paramesonephric ducts,
urinary tract anomalies are frequently associated with malformations of the
Pelvic or “unascended” kidney 7 external genitalia and vagina.
Horseshoe kidney 3
Bilateral cystic kidneys (both males) 2 Thorough urologic studies must be performed on all cases müllerian
Bilateral renal agenesis (both males) 2 anomalies.
Malrotation of kidney (all females) 3 Ectopic kidneys and ureters, particularly solitary pelvic kidney, real hazard for
Crossed renal ectopia 1 the gynecologist. Renal ectopia per se is not a problem, but if the kidney has
Urachal cyst 1 failed to ascend to the normal level, complications can arise.
Bicornuate uterus (all types) 1
The short ureter and short blood vessels preclude an attempt to "replace" the
Unicornuate uterus 2 kidney at the normal level.
Clitoral hypertrophy 2
Fused labia 1 Incidence solitary kidneys is 1 in 22,000 patients. Associated anomalies of the
Absence of external genitalia (sirenomelia) 2 reproductive tract are present in nearly all women with a single kidney.
Imperforate urogenital sinus 2
Careful and thorough diagnosis is essential to avoid complications. There are at
Persistent urogenital sinus 1 least two recorded cases in which solitary kidneys have been removed.
Urethra atresia (male) 1
Renal hyperplasia 1 Double ureters may come from solitary kidney does not prove two kidneys .
Penile chordee 2
Classification - Mullerian/Uterine Malformations
Incidence: 1 in 200-1 in 600
American Fertility Society classification 1988 - Müllerian duct anomalies or DES,
∗=uterus may be normal or take variety abnormal forms, ∗∗=may be two cervices.
AFS classification system framework for description anomalies, communication
among physicians, comparison of therapeutic modalities, often confusion about
reporting of certain anomalies, particularly those with features >one class. MRI
gold standard-accuracy, detailed outline uterovaginal anatomy. Laparoscopy and
hysteroscopy reserved for those where interventional therapy may be undertaken.
Incidence Type 111 -Didelphus – 0.1-0.5%
Transverse vaginal septum (pelvic pain/amenorrhea-13 yrs) MRI - (A) Longitudinal US distended uterus (U)/ vagina (V)
haematocolpos (HC); caudal portion of the dilated vagina (arrowheads) not as low as caudal aspect (B) ? transverse vaginal
septum (VS). (B) Coronal T2-weighted fat-suppressed (C) sagittal T1-weighted MRI evaluate for uterine anomalies, normal (U).
(V) and (U) HC. Arrow thick transverse (VS) lower part (V)(*) collapsed. Ovaries noted contain normal follicles (arrows).
Transverse septums –
varies occlusion to mild constriction. Frequently, small opening allows
secretions/ blood to drain. Unlike bulging membrane associated with
imperforate hymen, no external sign of blockage. In nearly all internal
organs are normal and pregnancy not infrequent. Transverse septums
represent failure of complete canalization of the vaginal epithelial mass.
Stenosis may be caused by a constricting fibromuscular band. Menstruation
and coitus occur without trouble, condition may not be detected until pelvic
examination reveals its presence.
Symptoms -
Depends on the presence of adequate uterine drainage. Complete vaginal
atresia, lower abdomen mass (hematometrocolpos ), pelvic abscesses, may
cause dystocia and cesarean section the safest method of delivery.
Treatment-
Depends on degree stenosis and rigidity of constricting band. No treatment
or 2/3 longitudinal incisions may suffice. Complete excision of annular
segment of vaginal wall may result in scarring or fistula .
Treatment:
Septal defects: Usually require surgical excision
Creating a neo- vagina:
For vaginal agenesis you need to create a vagina to have normal sexual
function. Length, capacity, lubrication.
Options:
Vaginal dilators (VD): VD pushed against area where vagina should be
located; constant pressure on a daily basis, can create a functional
vagina. Those with vaginal agenesis can have normal orgasms as
clitoris, external genitalia normal. VD takes 6 months-2 years.
Skin grafts: McIndoe procedure, split thickness skin graft (buttock),
space created for the placement vaginal mold with skin graft attached
to it. After seven-days, remove the mold used to create the vagina and
then VD. This can result in a normal, functional vagina. May be dry use
lubricants.
Bowel use: the bowel is used to create a neo vagina. May have chronic
vaginal discharge GI mucosa constantly produces. Concerns exist
about risk STI’s. Prolapse.
Vechietti procedure: Laparoscopic/laparotomy, dissection plane to
hymen, use weighted olive device, placed on traction (see images)
Vaginal reconstruction
Ethics - Risks of surgery ?
McIndoe procedure:
Neovaginal space between bladder/rectum lined with split-
thickness skin graft over a mould, inserted into the
neovagina. The woman has to wear the mould for 3 months Ethics - If, in the future ??
and is advised to use a dilator regularly. Disadvantages
vaginal stenosis, perforation bladder/rectum, graft failure, Uterine transplantation becomes safe and effective, will it be
unsightly scarring the graft site ethical for a woman to donate her uterus to her daughter?
Sigmoid vaginoplasty: With many children awaiting adoption, should women with
Disadvantages chronic vaginal discharge, foul odour, stenosis Mayer–Rokitansky–Küster–Hauser syndrome be encouraged to
anastomotic site, risk adenocarcinoma graft adopt rather than undergo surrogacy?
Williams vulvovaginoplasty:
Horseshoe-shaped incision perineum, skin flaps labia majora Who should pay for assisted reproduction treatment, given the
create a pouch horizontal to perineum. Technically simpler constraints of health service budgets?
than other 2 methods, short length, unusual angle coitus
Should women with Mayer–Rokitansky–Küster–Hauser
syndrome be managed in selected centres of excellence?
Most popular techniques:
Vecchietti procedure:
Disadvantages visceral injury laparoscopy, stress incontinence.
Davydov procedure:
Neovagina created peritoneal lining. Dissection rectovesical Mayer–Rokitansky–Küster–Hauser syndrome: diagnosis
space, abdominal mobilised peritoneum, create vaginal and management.
Fornices, attach peritoneum to introitus. Mould worn 6 S Valappil, U Chetan, N Wood, A Garden
The Obstetrician & Gynaecologist. 2012;14(2):93-98
weeks/regular vaginal dilators
PAG Emergencies
• Ovarian cysts – simple (follicular), complex (teratoma)– rupture,
haemorrhage, torsion, acute pain enlarging mass, painful endometrioma.
• Ovarian and or tubal torsion
• Haematocolpos
• Appendicitis (tubo-ovarian abscess)
• Foreign body vaginal/urethra
• Severe menorrhagia (menarche, haematological disorder)
• Acute vulvitis, vaginitis, STI, PID (discharge, systemic unwell, abscess)
• Early pregnancy -ectopic pregnancy, miscarriage, abortion sepsis
• Bartholins cyst/abscess
• Acute congenital anomaly (urinary retention, haematocolpos)
• Labial fusion
PAG - Emergencies
Isolated tubal torsion. (A) Color Doppler image shows a swirling appearance
of the vascular pedicle (arrows) and a dilated right Fallopian tube
(arrowheads) with findings concerning for tubal torsion. (B) Corresponding
laparoscopic intraoperative image demonstrates the torsed Fallopian tube.
Detorsion of the Fallopian tube with fenestration of the dilated end
(fimbriaplasty) was performed as the tube and ovary appeared viable
Paraovarian cyst with torsion. Midsagittal US scan through the bladder (B)
shows an enlarged, heterogeneous ovary (arrowheads) and an adjacent cyst
(C). No flow could be elicited on color Doppler interrogation. On surgery it
proved to be adnexal torsion related to a paraovarian cyst leading to
ipsilateral salpingo-oophorectomy.
PAG - Emergencies
Ovarian teratoma with torsion. (A) Enhanced axial CT adolescent XX sudden
onset pelvic pain reveals teratoma (arrows) containing fat/calcification.
Adjacent ovary prominent peripheral follicles (arrowheads). Thickened
teratoma wall, surrounding fat is stranded, free pelvic fluid (*). B, bladder; U,
uterus. (B) pathologic specimen; torsion confirmed at surgery.
Symptoms
44% Vaginal discharge
16% Vaginal soreness
10% Malodour
Organisms –
41% mixed anaerobes - recurrent vulvovaginitis, no FB
13 % group-B streptococcus
8% candida
7% Haemophilus influenza
3% chlamydia trachomatis
0.5% neisseria gonorrhoea
Other conditions
Streptococcal vulvovaginitis – (Grp A haem strep) acute
vulvitis in a child. Sudden onset erythema, swollen,
painful vulva/vagina, thin mucoid discharge. Preceding
throat infection, or dermatitis. Diagnosed by introital or
perianal swabs. Oral penicillin/cephalexin (10 days to Treatment
prevent recurrence).
Dermatitis- Avoid contact with soap, bubble bath/shampoo
Foreign bodies - not common (bits toilet paper or fluff), (use bath oil), tight lycra clothes (wear cotton underwear), no
persistent purulent discharge, may cause maceration perfume (toilet paper, wet wipes), avoid OTC medication,
vulval skin. Swabs recurrent bacterial infection, responds chlorinated water. Apply vaseline or zinc cream before
to antibiotics but rapidly recurs, requires EUA and saline swimming.
lavage. Most respond to 1% hydrocortisone, ointment preferable to
creams (stinging). If resistant consider non-compliance,
Sexual abuse - If concerns about sexual abuse referral to infection and psoriasis.
a paediatrician/child protection unit. Not sure whether a
skin condition or a sign of trauma, refer the child to a Psoriasis- rash erythematous, well defined, perianal
dermatologist. involvement, look signs of psoriasis, family history.
Management
Investigations:
Urodynamic studies (3%)
Cystoscopy (3%)
Management:
Antimuscarinic medication (39%), Potassium citrate
(3%)
Prophylactic antibiotics (3%).
Conservative measures:
Caffeine restriction (coca cola)
Bladder training
Urinary input/output charts
A study of paediatric and adolescent gynaecology
services in a British district general hospital
Referral: S McGreal, PL Wood. BJOG 2010; 117(13):1643–1650
This group greatest referral rate to other specialities
(17%), included urology, neurology, enuresis clinic,
community/ hospital-based paediatric referrals.
Sex and the Adolescent
What are the rules?
• In England, Scotland, Northern Ireland and Wales we have to
be 16 or older to have homosexual (gay) or heterosexual
(straight) sex.
• 'Sex' means penetrative sex, oral sex or masturbating
together.
What happens if you have underage sex?
• The law sees it as sexual assault - it's a criminal offence. This
is because in the eyes of the law we are unable to give
informed consent to sex when still a child.
• A boy who has sex with a girl under 16 (17 in NI) is breaking
the law. Even if she agrees.
• If she is 13-15, the boy could go to prison for two years.
• If she is under 13 he could be sentenced to life
imprisonment.
• A girl aged 16 or over who has sex with a boy under 16 can
be prosecuted for indecent assault
What is allowed ?
• There is no law against asking questions. Or finding out
about sex. What it means, how to do it, how to protect
ourselves from the consequences: pregnancy, STIs. And
broken heart.
Adolescent Gynaecology – Sex and the Teenager
Sexual Behaviour
The second National Survey of Sexual Attitudes and
Lifestyles (Natsal 2000), which included over 11,000
men and women aged 16–44 in Great Britain: Use of contraception
• Among 16–19 year olds in 2008–09: 57%
Median age at first heterosexual intercourse was 16 for used contraception.
both men and women • Of these 65% used condoms and 54% COCP,
One third of men and a quarter of women aged 16–19 86% had heard of EHC
had heterosexual intercourse before they were 16 • 17% used EHC at least once in the previous
12 months.
80 per cent of young people aged 16–24 said that they • Use of contraceptive clinic services
had used a condom when they first had sex. Less than 1 • 71,000 women < 16 attended FPC in UK in
in 10 had used no contraception when they first had sex 2009–10. 7.9% of the resident population, a
slight decrease from 2008–9.
20% men and almost 50% women aged 16–24 said they • 281,000 or 21.5% resident female population
wished they had waited longer to start having sex. They in UK aged 16–19 years of age visited a FPC in
were twice as likely to say this if they had been under 15 2009–10, a slight increase from 2008–09
when they first had sex.
Both young men and women aged 16–24 had had an
average of 3 heterosexual partners in their lifetime
0.9% men and 1.6% women aged 16–24-year had had
one or more new same sex partners in the previous year
Lader D, Contraception and Sexual Health, 2008/09 (London: Office for National Statistics, 2009).
Information Centre, NHS contraceptive services, England: 2009–10 (London: IC, 2010).
Teenage Pregnancies, STI’s and Emergency Contraception
Claim
• Sex education & emergency contraception
causing increase in pregnancy, abortion
and STI’s, in teenagers
Facts
• Teenage pregnancy rates falling
• STI rates increasing (chlamydia & syphilis)
• Syphilis rise due to increase men/men sex
• Only an apparent rise in Chlamydia
• Chlamydia screening programme from 2005
Sexually Transmitted Infections
PID Treatment
OPD treatment based one following regimes:
▪ Ofloxacin 400 BD + PO Flagyl 400 BD x 14/7
▪ IM ceftriaxone 250 stat, PO doxycycline 100
BD + Flagyl 400 BD x 14/7.
Wandsworth Guardian
Teenage pregnancies fall across south west London
2:50pm Sunday 11th March 2012 in News
The number of teenage pregnancies has fallen significantly new figures show.
NHS South West London say figures released by the Office for National Statistics indicate
that between 1998 and 2010, most boroughs in the cluster achieved a reduction equally or
surpassing the country's reduction of 24 per cent.
Merton achieved a reduction of 40.4 percent, with both Sutton and Wandsworth achieving
reductions of over 35 percent. These reductions put Merton and Sutton 2nd and 3rd
respectively in a table of the highest reductions in outer London, while Wandsworth is
ranked sixth.
Croydon saw a reduction of 29.3 percent placing them in fourth. Richmond and Kingston also
saw a reduction in line with the national trend. Jonathan Hildebrand, Director of Public
Health for NHS South West London said: "One of the reasons we may be seeing this dramatic
reduction in teenage pregnancy is because of the dedicated work of the Public Health teams
to improve sex and relationship education and access to contraceptive and local sexual
health services.
"There have been a variety of initiatives conducted across the boroughs, for example, Sutton
and Merton commissioned a sexual health service specifically for under 20’s called 'Check it
Out' which offers contraceptive advice and treatment in schools and youth venues. The
boroughs also came together to provide a NHS South West London sexual health website for
under 19s.
Teenage Contraception and Abortion
Cervical Screening
Between 25-60 years the NHS cervical screening
programme contacts you every 3-5 years for a
smear test. 3 yearly screens prevent 84/100 cancers
that would develop with no screening.
Diagnostic screening of symptomatic young
women still indicated (risk assess)
Adolescent Gynaecology and Psychiatry
BDD symptoms include depression, social phobia, and OCD. Affected individual may
become hostile towards family members for no reason.
Diminished QoL, can be co-morbid with major depressive disorder and social phobia
(chronic social anxiety); suicidal ideation 80%, extreme cases linked to dissociation
Treatment successful with CBT and SSRIs
Adolescents and the Designer Vagina
Types surgery ?
• Labia reduction surgery or labioplasty
• Hymenoplasty or hymenorrhaphy
• Other forms of female cosmetic genital surgery
– Revirgination refers to surgery for vaginal ‘laxity’,
believed to result from childbirth and/or ageing.
– G-spot amplification consists of injections in the
area G-spot is purported to be to enhance sexual
arousal/pleasure during sex Female genital cosmetic surgery: how can clinicians act
in women’s best interests?
Michala L, Liao LM, Creighton SM. TOG 2012;14:203–206.
Duty of care
• Requirement for parental/guardian consent
• Contraception/sexual health issues/termination of pregnancy
• Suspected sexual abuse/assault
• Age of consent sexual intercourse
• Who to inform and when to inform – social work, police, forensic team ?
Trust and confidence in the Panic Decisions have consequences Appreciate importance
doctor-patient relationship
• Suggested reading
• Further training
• Careers
www.britspag.org/
Adolescent Gynaecology
Review objectives
✓the
Overview normal physiological development; skeletal growth, maturation of
reproductive tract, development secondary sexual characteristics, CNS
maturation, personality and psychology of the female adolescent.
✓Adolescents
✓
presenting with Specific Gynaecology issues:
Menarche and physiological changes
✓ Congenital disorders
✓ Adolescent gynaecological disorders
✓ Problems unique to adolescents,
✓ General gynaecological disorders presenting in adolescents
✓ Adolescent urogynaecology
✓ Haematological disorders presenting with secondary gynaecological symptoms
✓ Dermatological conditions presenting with gynaecological symptoms
✓Sex and the adolescent -
✓Teenage Contraception and Pregnancy
STD’s, PID, cervical screening, HPV vaccination