Journal Archives - Volume 11
Co-Editor:
Dr. Lisa M. Allen, MD, FRCSC
Section Head Pediatric Gynecology,
Hospital for Sick Children, Head Gynecology
Mt. Sinai Hospital, Department of Obstetrics and
Gynecology and Pediatrics, University of Toronto
Dr. Allen obtained her MD from the University of Western Ontario, London. She completed a fellowship at the Women’s College Hospital, which was directed to developing surgical skills in pelvic floor surgery, laparoscopic urogynecologic surgery, and laser endometriosis surgery.
Dr. Allen is the Head of the Section of Pediatric & Gynecology at the Hospital for Sick Children and Head of Gynecology at Mr. Sinai Hospital. She has a primary appointment as Assistant Professor in the Department of Obstetrics and Gynecology and in the Department of Pediatrics at the University of Toronto. She is the fellowship director for Pediatric and Adolescent Gynecology at the Hospital for Sick Children in addition to be actively involved in undergraduate, residency and continuing medical education.
Vulvovaginal symptoms that are encountered in children such as vaginal discharge, bleeding and pain may be as a result of common diagnoses such as vulvovaginitis or reflect infrequent pathology for example a dermatologic or ulcerative condition. An understanding of the normal pediatric external genital anatomy is important to then be able to determine on examination the abnormal. Many vulvovaginal disorders can be diagnosed with an appropriate external genital examination. A careful history and examination of the external genital will allow the practitioner to diagnose the majority of vulvovaginal disorders. With experience, an examination under anaesthetic, cultures or further investigations are rarely required to provide a conclusive diagnosis.
In pediatrics, genital trauma is a common presentation of accidental injury or can be related to intentional trauma and sexual assault. The most common mechanism of accidental female genital injuries are “straddle injuries”. Adolescents can experience genital trauma as a consequence of consensual sexual activity. The history is the most important component of the evaluation as it is key to determining whether the injury is accidental or whether there is concern of abuse. While many injuries may be minor, genital trauma in pediatrics causes parental anxiety due to the location of the injury, raising concern over the young girl’s future gynecologic and psychosexual development. The sensitive, calm, objective, thorough and knowledgeable evaluation of the child can be reassuring to the family. Many wounds will require no more than debridement and cleansing. Injuries that are larger, involve other structures or that may heal with nonanatomical results should be considered for surgical repair. Female Genital Cutting contravenes the UN’s Universal Declaration of Human Rights and the 1995 Commission on Human Rights called for elimination of the practice.
Ovarian masses may be cystic, solid or both. The actual incidence of an ovarian neoplasm is rare and is estimated to occur at a rate of approximately 2.6 cases per 100,000 girls per year with malignancy making up 1% of all childhood cancers. Ovarian masses often are picked up incidentally at ultrasound. More frequently they come to attention when the patient presents with acute or chronic pain. Some patients may have a mass effect, more rarely patients present with endocrine disturbances. Ovarian disorders must be considered in the differential diagnosis in any pediatric or adolescent patient that presents with these symptoms. Normal ultrasound findings vary significantly in the neonate, child and adolescent. Functional ovarian cysts occur at two peaks, during the first year of life and around menarche. The development of an ovarian cyst at any other time should arouse the suspicion of possible neoplasm. The management of masses regardless of age is initial close observation and conservative treatment. Preservation of the ovary is paramount and should be considered unless the suspicion for malignancy is exceedingly high.
The prevalence of anomalies of the female genital tract varies depending on the population that is referenced and the sensitivity of the method used for diagnosis. In the general population 0.4 to 5.3% of young women may be diagnosed with a genital malformation. Anomalies may present in a variety of ways, ranging from an incidental diagnosis in an asymptomatic patient to symptoms of abdominal or pelvic pain, amenorrhea, menstrual irregularity, a palpable mass or history of infertility or pregnancy losses. The majority of Mullerian anomalies are diagnosed in the adolescent age group, where the most common presentation is pelvic pain. Given the high association of renal anomalies and mullerian duct abnormalities if a newborn or child is diagnosed with an abnormality of the mesonephric duct preemptive counseling and early imaging postpuberty may aid in the timely diagnosis of the associated mullerian abnormality. Once the diagnosis is contemplated, ultrasonography is often the first step in imaging as it is readily available. Magnetic resonance imaging is generally considered the gold standard for diagnosis of congenital genital anomalies. The presentation, diagnosis and management of each Mullerian anomaly will be addressed in this chapter.
The pubertal transition to a woman capable of reproduction can present many difficulties to the adolescent female. Menstrual disorders are one of the most common reasons for this population to seek the attention of healthcare professionals. The development of normal menstrual cycles is dependent on the coordinated function of the hypothalamic-pituitary-ovarian axis. While a significant proportion of menstrual disorders may be due to immaturity of the hypothalamic-pituitary-ovarian axis, abnormal menses may be the first presentation of underlying pathology such as a coagulation disorder or endocrinopathy, and a high index of suspicion is needed to ensure proper diagnosis and treatment. While oral contraceptive therapy remains the mainstay of treatment there are new hormonal delivery methods and non-hormonal treatments that can be equally, if not more effective, and more palatable to adolescents and their families. Involvement of adolescents by means of education and menstrual charting not only aids in diagnosis and assessment of treatment, but aids in patient satisfaction and compliance.
There are numerous hyperandrogenic disorders that can affect young women. The most classic and common is Polycystic Ovary Syndrome (PCOS). Other disorders include idiopathic hyperandrogenism, idiopathic hirsutism, and other entities such as Congenital Adrenal Hyperplasia, Cushing’s syndrome and androgen secreting tumors. The presentations can vary widely from mild androgen phenotypes to severe virilizing disorders. Differentiation between these disorders, especially the more subtle variations, can sometimes be difficult. PCOS is a clinical diagnosis based on clinical presentation, laboratory parameters, and possibly ovarian morphology. There is no one defined test to make the diagnosis. Therapeutic interventions are aimed at addressing the patient’s present concerns and at preventing long-term complications of these androgen excess disorders. The goals of treatment are to improve hirsutism and acne, protect the endometrium, optimize reproductive function when fertility is desired, and reduce the long-term sequelae of insulin resistance PCOS and other androgen excess disorders are chronic, lifelong, metabolic syndromes requiring management throughout the lifespan.
Adolescent females may present with acute, chronic, or recurrent pelvic pain. There are many possible gynecologic and non-gynecologic etiologies of pelvic pain that should be considered in the differential diagnosis in this age group. Although medical details are important in the assessment of pelvic pain, a broader psychosocial history may be required in order to help understand the impact and potential etiology. Primary dysmenorrhea, defined as recurrent menstrual cramps in the absence of pelvic pathology, may affect up to 93% of adolescent girls. Secondary dysmenorrhea is menstrual pain associated with underlying pelvic pathology, such as endometriosis, congenital malformations and pelvic infections. Acute pelvic pain in adolescent females should be aggressively investigated. Chronic pelvic pain may lead to frequent or prolonged school absences and an inability to take part in social activities. Pelvic pain in the pediatric and adolescent females can pose significant diagnostic and management challenges to health care providers. A broad range of differential diagnoses should be considered when presented with this clinical problem.
In many countries around the world, the vast majority of adolescents have engaged in sexual activity, and in particular, intercourse by the time they are nineteen. Health care providers who care for adolescents must offer the opportunity to discuss sexuality and contraception and preferably be able to help the teen in need of birth control make informed personalized choices. Sexually transmitted infections are quite common among sexually active adolescents and young adults. When caring for an adolescent the health care provider should avoid making assumptions about sexual activity, sexual orientation, substance use, depression, self-harm and risk-taking. Having routine private time will often be very fruitful in terms of identifying areas where education and preventative measures may be indicated. Most adolescents seeking contraception will choose a combined hormonal method but for some, long-acting progestins, barriers/spermicides, Plan B® and even intrauterine devices can (and should) be offered.
Adolescent pregnancy represents an important societal concern. It is associated with high costs, on the monetary, medical and social aspects. Adolescent pregnancy rates in several countries have declined in recent years. At the same time, the abortion rate for adolescents has stabilized. As a result, the proportion of adolescent pregnancies that end in abortion has increased exceeding live births for the first time. The reasons adolescent get pregnant are multifactorial in origin. We must consider individual characteristics of the adolescent, socio-economic factors, social influences and access to health services. Adolescent prevention strategies need to be comprehensive while being supportive. Pregnancy in an adolescent is considered higher risk than in the general population. Adverse pregnancy outcomes are associated with lower socio-economic status, inadequate prenatal care and poor weight gain in pregnancy. Recently it has been determined that young maternal age increases the risk of adverse birth outcomes independent of other confounders Multidisciplinary prenatal care adapted for pregnant adolescents lowers maternal and fetal complications.
The prevalence of anomalies of the female genital tract varies depending on the population that is referenced and the sensitivity of the method used for diagnosis. In the general population 0.4 to 5.3% of young women may be diagnosed with a genital malformation. Anomalies may present in a variety of ways, ranging from an incidental diagnosis in an asymptomatic patient to symptoms of abdominal or pelvic pain, amenorrhea, menstrual irregularity, a palpable mass or history of infertility or pregnancy losses. The majority of Mullerian anomalies are diagnosed in the adolescent age group, where the most common presentation is pelvic pain. Given the high association of renal anomalies and mullerian duct abnormalities if a newborn or child is diagnosed with an abnormality of the mesonephric duct preemptive counseling and early imaging postpuberty may aid in the timely diagnosis of the associated mullerian abnormality. Once the diagnosis is contemplated, ultrasonography is often the first step in imaging as it is readily available. Magnetic resonance imaging is generally considered the gold standard for diagnosis of congenital genital anomalies. The presentation, diagnosis and management of each Mullerian anomaly will be addressed in this chapter.
When managing the pediatric and adolescent gynecologic patient it is important to stay cognizant of the impact that disease or treatment of disease might have on future fertility. It is also ideal to be able to provide a patient and her family with some general comments about fertility as part of patient counseling. While the advent of assisted reproductive technologies have provided patients with greater reproductive choices, the accessibility to these therapies is frequently limited due to issues of cost and restrictive legislation. It is logical to separate disorders that may affect future fertility into those that are primarily ovulatory in nature versus those that are structural and related to the function of the uterus or Fallopian tubes. This chapter is intended to provide a general overview of treatment options available to patients who have had gynecologic disease diagnosed during childhood or adolescence.