Adolescent Gynecology PowerPoint for UCAYA

1. Adolescent Gynecology
Mike Guyton, MD
Assistant Clinical Professor/Academic
Faculty in General Pediatrics

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. The Menstrual Cycle

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. External Anatomy

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. 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. 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. 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. 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

12. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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!!!

24. 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

25. 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

26. 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.

27. 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)

28. Endometriosis: Treatment
• Chronic condition = lifelong management plan
• Expectant Management
• Analgesia
• Hormonal Therapy
– Combo OCP
– GnRH agonists
– Progestins
– Danazol
– Aromatase inhibitors
• Surgery
• Combination

29. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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