Summary
This chapter discusses the history and examination of children and young people with gynaecological concerns. A child refers to a younger child who lacks the understanding or maturity to make important decisions for themselves. Older and more experienced children (generally adolescents) who can make these decisions are referred to as young people [1].
2.1 Introduction
This chapter discusses the history and examination of children and young people with gynaecological concerns. A child refers to a younger child who lacks the understanding or maturity to make important decisions for themselves. Older and more experienced children (generally adolescents) who can make these decisions are referred to as young people [1].
A Paediatric or Adolescent Gynaecology (PAG) consultation may be fraught with anxieties.
The transition through puberty is varied, and changes may be mistaken as signs of disease rather than a normal manifestation of pubertal development.
A parent’s or caregiver’s experience of gynaecological review will typically have included speculum examinations; many people assume an internal examination a standard part of a gynaecological review.
The gynaecologist may feel apprehension – they may have not seen many children and young people. They may have limited experience in the condition or co-morbidity that has prompted the PAG referral.
An unsatisfactory experience with a gynaecologist as a child or young person can impact on their long-term health. For instance they may be more reluctant to attend for sexual health advice or to engage with the cervical screening programme.
2.2 The Setting
Acute PAG reviews should be seen in the children’s emergency department. Outpatient PAG reviews should occur in designated clinics – ideally within the paediatric or adolescent outpatient department rather than within an adult gynaecology clinic.
Designated PAG clinics should be supported by appropriate nursing staff, i.e. specialists or paediatric trained nurses. The waiting rooms and clinical room for children should have an appropriate array of toys and seating area. The consultation room should provide a sense of privacy and not add to apprehension ahead of the consultation. For example, avoid an examination couch with stirrups and an array of speculums and swabs on display. The room seating set-up should allow a child or young person to feel comfortable being the focus of attention but without feeling a spotlight on them. A triangular configuration between the clinical team, the child or young person and their parent or caregiver is a helpful set-up for the consultation. With the move towards digitised notes care must be taken to demonstrably engage with receptive body language and eye contact. Since the COVID-19 pandemic more consultations are conducted remotely by telephone or video. It is important that the child or young person is present for a remote consultation.
2.3 History
Once confirming the patient’s details the team should introduce themselves by name and role to the child or young person and whoever accompanies them.
Ensure you identify who has attended with the child or young person and what relationship they are to them. This knowledge informs and helps direct enquiry when asking the child’s or young person’s social history.
The team should ask if the child or young person has a preferred name and consider asking for preferred pronouns (e.g. she/her, they/them, he/him).
The PAG team should avoid assumptions and aim to use neutral rather than gendered language. Pick up on cues from the child or young person and ask directly rather than assuming.
With adolescent consultations it’s helpful to establish at the start of the consultation that you will ask the parent or caregiver to step outside to allow time for the young person to be seen alone. This allows time for the young person to better explore their increasing autonomy and clinically it allows privacy for further psychosocial history and for the young person to raise concerns they feel more comfortable discussing away from their parent or caregiver. The opportunity for the young person to speak in private to their clinician should also be part of telephone or video consultations.
An adaptive and sensitive consultation model is necessary for PAG reviews with the approach primarily modulated to the child’s or young person’s age and developmental stage as shown in Table 2.1 [Reference Levene2]. Flexibility is required to navigate who relays the history. As a child develops they are increasingly able to contribute. Direct questions are helpful for younger children, with their parent or caregiver elaborating.
It’s important to involve a child or young person in taking their history as this allows for shared decision-making. The child’s perspective and the impact of the issue on them may differ from their parent or caregiver. Involving the child or young person will better identify other issues affecting the child including other physical symptoms, emotional or psychological or safeguarding concerns.
Children of one and under are naturally wary of new people and stranger anxiety is a normal stage in child development. Slowly increase your eye contact with them; they will be observing your interaction with their parent or caregiver and will engage with you partly based on their observations of this interaction.
Be mindful that some children will be more shy and prefer for their parent or caregiver to speak for them. Nonetheless it’s important to demonstrate you regard their involvement in the consultation as valuable. Occasionally ask them direct questions and allow them some time for reply. Do not be frustrated by a lack of engagement. Reassure the parent or caregiver as necessary that it’s OK for the child or young person to be shy.
Particular caution should be taken with consultations where the child’s or young person’s English is better than their parent’s or caregiver’s. Have a lower threshold for the use of a translation service to ensure a complete history and that management is explained well to both child or young person and their parent or caregiver.
2.4 Presenting Complaint
Unlike the traditionally taught medical model, PAG consultations are often best started asking general questions about the child or young person to establish a rapport before discussing gynaecological issues – which after all tend to affect their ‘privates’. An alternative strategy to this is to ask what the child or young person and parent or caregiver understand is the reason for referral. This will help establish their expectations for the consultation (and indeed worries of what this will entail). This may be an appropriate moment to explain that if examination is indicated what this will involve, with the caveat that you will only examine if they allow this.
When the child or young person or parent or caregiver describes the presenting or referring issue, listen carefully to their words without interruption – clarify points afterwards. In particular check meaning when they use medical terms.
Take time to explore how the problem has affected the child or young person. For example are they missing time off school or hobbies? If so, how much time? How is it affecting their siblings, the rest of the household or family?
Establish a timeline and ask if there were any other changes that affected the child or young person or the household or family around that time. Encourage them to think laterally rather than obvious physical changes.
When a child or young person or their parent or caregiver is talking about an issue concerning genitals it’s crucial to clarify terminology. Most children will recognise ‘private parts’ as referring to their genital area – but this could encompass their entire anogenital area or just be referring to their vulva and or vagina. It’s important to use terms the child feels comfortable with – but that the child or young person, parent or caregiver, and clinical team understand these terms to mean the same thing [Reference Braun and Kitzinger3]. Table 2.2 gives examples of commonly used terms. Use of a diagram (or a mirror when examining) may be helpful. The child or young person may be concerned that their genitals are not normal; the PAG consultation is an important opportunity to reassure and explain vulval diversity [4].
2.5 Menstrual and Puberty History
The PAG consultation shouldn’t be limited to menarche – enquire about the development of secondary sexual characteristics – in particular breast budding. It’s often easiest to reference this to school year if the child or young person is unsure of timings.
An irregular menstrual history can be a muddle. Try to clarify the time spent bleeding (shortest and longest) compared to time spent not bleeding (shortest and longest). Many children and young people will have a menstrual diary app on their smartphones – ask if they can show you this if unclear.
Ask about the duration and nature of their bleeds – for instance a partial Müllerian obstruction may present with brown discharge persisting after every period and worsening cyclical pain.
Obtaining an accurate past medical and family history is important both for diagnosis and ongoing management options. Medical comorbidities can be a factor in their menstrual dysfunction or may limit treatment options.
A birth history isn’t essential for many PAG presentations but this is generally easily obtained from their parent or caregiver.
Ethnic profiling is inappropriate, but asking about female genital mutilation (FGM) should not be an extraordinary aspect of a gynae consultation. Explain that some communities traditionally practise cutting or circumcision. Ask if they are from such a community and if anyone in their family has been affected? Has the parent or caregiver considered FGM for their child? Or ask the child or young person themselves if they have been cut themselves?
2.6 Systematic Review
A selective approach can be refined with experience. Ask generally about their health – are they their normal self?
Particular focus for a systemic enquiry in a PAG consultation should be on any bladder or bowel dysfunction. This can be a brief question to check no problems – but a greater level of interrogation is required for other presenting complaints or pre-existing conditions such as pelvic or vulval pain.
When were they out of nappies and self-toileting? How often do they go to the toilet? Are they OK using toilet at school (i.e. a toilet away from home)? How do they sit on the toilet (sitting up, legs relaxed on a stool, or leaning forward, reading or on an iPad, with legs together)? Table 2.3 shows typical toileting development milestones.
| •By age 1: Most children have stopped opening bowels at night and will show distress if soiled. |
| •By age 2: Children start to show interest in potty training; a few children remain dry during the day. |
| •By age 2.5: Children are able to let a parent or caregiver know if they need to use the toilet; they require assistance to manage clothing and wiping. |
| •By age 3: Children will often toilet on their own; 9 out of 10 children are dry most days. |
| •By age 4: Most children are reliably dry during the day. |
| •By age 4.5: Children are able to toilet independently – pulling up and adjusting clothing. |
| •By age 5: Children will be washing hands after using the toilet. |
Note. From ‘How to Potty Train’, www.nhs.uk/conditions/pregnancy-and-baby/potty-training-tips/.
If they have a complex congenital urogenital anomaly and have had multiple reconstructions from an early age, how do they void? Are they still under urology or surgical follow-up?
Skin conditions can often manifest with vulval or vaginal symptoms and signs. Ask about their washing regime and any personal or family history of skin issues, allergies or atopy.
PAG clinicians are likely to see more young people with eating disorders than other specialties. Ask about their appetite? Is their weight stable? Consider using eating disorder screening questions (see Table 2.4) and where abnormal response take a further history – including diet history, binge or purging, exercise patterns, and their current mental state [Reference Sieke and Rome5].
Table 2.4 Eating disorder screen for primary care
| Eating Disorder Screen for Primary Care (ESP)Footnote a | SCOFFFootnote b |
|---|---|
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a From Cotton M-A, Ball C, Robinson P. Four simple questions can help screen for eating disorders. J Gen Intern Med. 2003;18:53–6.
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