3.12 Gynaecology
Gynaecological problems in childhood are usually minor but not infrequent.
• Vaginal examination is inappropriate in paediatric patients. Ultrasonography or examination under anaesthesia (depending on the clinical problem) will provide the required information.
• For adolescent patients, vaginal examination is infrequently undertaken unless they are sexually active and have given consent for this examination.
• Transabdominal ultrasonography will almost always provide the necessary information in the adolescent population.
Gynaecological problems in neonates
• Vaginal bleeding – the decline in maternal oestrogens within the first week or 2 of birth – may result in a small vaginal bleed. No investigations are required.
• An imperforate hymen, may present as a perineal lump. The hydrocolpos can be drained and corrected with surgical incision of the hymen.
Common gynaecological problems in pre-pubescent girls
Labial fusion or adhesions
Labial fusion or labial adhesions are:
• not present at birth but may develop within a few months; the onset correlates with the decline in maternal oestrogen effects on the skin of the newborn and infant
• thought to occur secondary to skin irritation
• relatively common in childhood
Vulvovaginitis
• Occurs in the context of low oestrogens, with thin, atrophic vaginal and vulval skin.
• Is seen in girls from early childhood through to the establishment of puberty.
• The normal flora in the vagina of young girls is mixed bowel flora (candida is not found in the non-oestrogenized young girl).
• Overgrowth of the bowel flora in the vagina is thought to irritate the atrophic skin, causing a discharge which then irritates the vulval skin.
• The affected skin is primarily the contact surfaces between the labia.
Symptoms are usually intermittent and consist of:
The possibility of sexual abuse needs to be considered in a child with vulvovaginitis, but other symptoms or problems are usually present (see Chapter 3.9).
Investigations
• Swabs are rarely required as no specific organism is found, only mixed bowel flora.
• Take swabs when there is a profuse discharge or skin erythema extends beyond the contact surfaces of the labia majora. In these cases a single organism may be responsible for the problems and specific antibiotics may be required.
Management
• Application of a simple barrier cream (such as zinc–castor oil or Vaseline).
• Bathing – the addition of vinegar (half a cup to a shallow bath) is often advocated.
• Parents need reassurance that the natural history is intermittent recurrence until puberty.
• In the presence of this skin irritation it is advisable to avoid other potential irritants such as bubble baths and soaps.
• Faecal soiling as a consequence of poor toileting habits may also be an issue.
• When the skin irritation extends beyond the contact surfaces of the labia, additional irritants such as prolonged periods in wet bathers may have an aetiological role.
Blood-stained vaginal discharge
If itch is a significant component of the symptoms:
• pinworms need to be excluded
• eczema superimposed on the vulvovaginitis may be present. Look for evidence of generalized eczema. The approach to management is the same as for vulvovaginitis, with the addition of topical steroids to settle the eczematous component.
• lichen sclerosis, with whitened skin changes and superficial splitting of skin, may be present, secondary to the vulvovaginitis but can also be due to a relatively uncommon autoimmune skin problem. In the presence of vulvovaginitis symptoms and findings, the management of lichen sclerosis is as for vulvovaginitis, with the addition of topical steroid cream. A more potent steroid may be required for a short duration. Betamethasone (Diprosone) and methylprednisolone (Advantan) cream are often best tolerated, with others having irritant components in the cream or ointment base.
Adolescent gynaecology
Overview of puberty, adolescence and the menstrual cycle
• The average age of menarche is 12.5 years.
• Although breast bud development is usually the first sign of puberty, followed by pubic and axillary hair, variations to this can occur (see Chapter 19.1).
• Breast development may be asymmetrical initially and may be mistaken for a ‘breast lump’.
• In general, the time from commencement of breast development to first menses is less than 4 years.
• Absence of menses at age 16 years is suggestive of the need for further investigation.
• With the onset of puberty, multiple (15 to 20) follicles can be seen on ultrasonography; this is normal.
• An ovulation cyst or follicle can be 3–4 cm in diameter. On ultrasonography this will appear as a simple ‘cyst’, which can be expected to resolve and disappear during the next 2–6 weeks. It is important to reassure young women that this cyst is normal and demonstrates that the reproductive system is functioning normally.
• Ovulation can be associated with some pain (Mittelschmerz or mid-cycle pain). Occasionally, haemorrhage into an ovulation cyst can occur, giving rise to a more complex appearance of the cyst on ultrasonography (haemorrhagic corpus luteum).
• Irregular menses in the first 2–3 years is common and normal because of anovulation.
Consultation with young teenage girls needs to be undertaken with careful consideration for their developmental and cognitive stage, recognizing that consultation without a parent may be essential to explore relevant issues (see Chapter 3.11).
