This document discusses gynecological problems in pre-pubertal children and adolescents. It begins by outlining common issues seen in the neonatal period such as vaginal bleeding and breast development in female infants. Problems in early childhood include vulvovaginitis, labial adhesions, and urethral prolapse. At puberty, precocious puberty and its causes and treatment are discussed. The document provides clinical details on examining and managing various gynecological issues seen in female children and adolescents.

1. Presenter: Maryam A. yahya
Moderator: Dr. Mukhtar Yola
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2.  Gynecological problems in the pre pubertal child and at
adolescence create great levels of anxiety in parents
particularly, but fortunately very few of these disorders
could be considered common. However, when they do
present it is important that the clinician has an
understanding so that appropriate advice may be given
to the patient and management is frequently through
simple means.
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3.  1st few weeks of life, residual maternal sex hormone may
have physiologic effect on newborn
 Breast budding in majority of term female infants and
there maybe marked breast enlargement or even nipple
discharge but no treatment is required.
 Labor majora are bulbous
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4.  Labia minora are thick & protruding.
 Clitoris is relatively large ( normal is 0.6cm2 or less).
 Vaginal epithelium is dull pink initially and then as
maternal residual estrogen levels decline, genitalia fat
pad and the vaginal epithelium ( 1-3 cells thick)
becomes bright red.
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5.  Vaginal discharge. (usually composed cervical mucus
and exfoliated vaginal cells
 Vaginal bleeding is also common as the estrogen level
fall and stimulated endometrial lining sheds. Generally
stops in 7-10days.
 Hymen ( initially turgid).
 Vagina (4 cm long.)
 Utero-cervical ratio 3:1
 Ovaries are abdominal organs.
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6.  Little estrogen stimulation
 Labia majora flatten, minora and hymen become thin.
 Vagina has atrophic mucosa and is very susceptible to
trauma & infection.
 Uterus regresses in size until 6.
 By age 7-10 years, genitalia start to show signs of
estrogen stimulation with thickening of the mons pubis,
labia majora, hymen, & vaginal mucosa.
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7.  Labia minora become rounded & vagina elongates to
8cm.
 Ovaries begins to enlarge and descend.
 Uterus starts to grow and rapid endometrial
proliferation occurs as menarches becomes imminent.
 Ovarian follicles increases.
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8.  Give child opportunity to talk to you alone when
appropriate
 Give child as much control as possible over situation &
get them involved in the exam if possible.
 Be mindful of abuse and be aware of appropriate steps
in suspicious cases.
 Never restrain a child ( GA when required).
 Have parents sit on table with child.
 Positions appropaitely .
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9.  Inspect hymen carefully for signs of breaks or trauma as
minor external injuries may hide serious vaginal lesions.
 Inspect anal region but do vaginal/rectal exams only
when needed ( imaging often better option).
 Gynecologic care begins in the delivery room, the
delivering obstetrician should briefly examine the
external genitals of female infants to confirm the patency
of the vagina and assess the presence of any obvious
genital anomalies.
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10.  The pediatrician’s newborn examination should note
any abnormal findings such as ambiguous genitalia,
imperforate hymen, urogenital abnormalities,
abdominal mass, or inguinal hernia that might herald a
gynecologic problem.
 A complete gynecologic examination is indicated when
the child has symptoms or signs of a genital disorder.
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11.  Maybe needed to visualize 1/3-1/2 of the vagina.
 Office vaginascope of various sizes depending on child
age ( 0.5cm & 0.8cm) can be
 other instruments include urethroscope/laparascope.
 Anaesthetize the vulva where necessary ( Topical or
GA).
 Speculum examination with cultures may be necessary
in adolescent.
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12.  Common condition encountered can be classified into:
Problems in neonatal periods
Problems in early childhood
Problems at puberty
Problems at adolescence
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13. Problems in neonatal period
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14.  Gynecomastia and galactorrhea: can develop from both
male and female and small amount of milk maybe
expressed from breast.
 Vaginal bleeding: Girls may discharge a mucus plug or
little blood .( 2-10 day of life).
 Due to withdrawal effect of maternal hormones.
 Management is explanation and reassurance as both
conditions are self limiting.
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16.  Seen 1/14 000 newborn
 Need immediate identification and response as life
threating salt wasting congenital adrenal hyperplasia
maybe the cause.
 Ambiguity can be as a result from masculinization of
female child, exogenous hormone ingestion, maternal or
fetal overproduction of androgen, incomplete
virilization of male infant, hormonal insensitivity,
gonadal dysgenesis and chromosomal abnormalities.
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17.  Assessment should includes electrolytes, 17-
hydroxyprogestrone, cortisol, karyotyping, and any
other blood work.
 Genital examination and pelvic USS to detail the internal
anatomy.
 Multidisplinary approach is essential.
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18.  Normal clitoris is 1-1.5cm long and 0.5cm wide
 Abnormalities are uncommon
 Clitoromegally usually associated with androgens
exposure( often ass with labia fusion).
 Clitoral splitting is rare and caused by a midline fusion
defect.
 Bifid clitoris usually associated with bladder extrophy.
 More than 40% associated with some genital
abnormalities.
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19.  Neonates and peripubertal girls can present with a
white or clear or mucus discharge, which is a
physiologic effect of estrogen.
 Some girls may complain of the moisture and mucus.
 Hygiene measures including baths may help but an
explanation should reassure the patient and her mother.
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20. 9/23/2023 20

21. Vulvo vaginitis
Labia adhesion
Urethral prolapse
Foreign body
Imperforate hymen
Female genital mutilation (FGM).
Vulvar warts.
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22.  Vulvovaginitis is the most common gynecologic
problem in the prepubertal female child with a reported
incidence of 17–50%.
 It is estimated that 80% to 90% of outpatient visits of
children to gynecologists involve the classic symptoms
of vulvovaginitis.
 The age of presentation peaks at 4 and 8 years of age.
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23.  At birth the vulva and vagina are well oestrogenized
due to the intrauterine exposure of the fetus to placental
oestrogen.
 This oestrogenization causes thickening of the vaginal
epithelium.( protective against bac. Invasion).
 2–3 weeks of delivery the resultant hypo-oestrogenic
state leads to thinning of the vulva and vaginal
epithelium skin. ( Making it vulnerable to invasion,
chemical irritation or even allergic reaction).
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25.  Hypoestrogenic state- flattened vulval epith.
 Attenuated labia minor
 Thin vaginal epithelium
 Alkaline vaginal secretion due to absence of doderlein
bacilli which secretes lactic acid ( bacteriostatic).
 Other factors include poor hygiene, this results from the
anatomic proximity of the rectum and vagina.
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26.  Many children wipe their anus from posterior to
anterior and thus inoculate the vulvar skin with
intestinal flora.
 Children’s clothing is often tight fitting and non
absorbent, which keeps the vulvar skin irritated, warm,
moist, and prone to vulvovaginitis.
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27.  Causes of vulvovaginitis in children.
 Infectious vulvovaginitis. Can be
 Bacterial, viral or rarely candida spp.
 Dermatitis
 Atopic Lichen sclerosis
 Contact Sexual abuse
 Enuresis
 Foreign body
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28.  Vaginal discharge (quantity, color, odor and rashes).
 Mild discomfort to severe itching ( Enterobious
vermicularis associated with night itching).
 On examination the vulva and introits are red and
inflamed associated with serious/purulent discharge.
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30.  When the none pharmacological intervention fails, the
suspicion for bacterial colonization is greater and a
reasonable approach is the use of broad-spectrum oral
antibiotics such as amoxicillin or trimethoprim
sulfamethoxazole given for 10 to 14 days.
 Also anti fungal medication can be added.
.
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31.  Labial adhesions (adhesive vulvitis) literally means the
labia minora have adhered or agglutinated together at
the midline, creating a “flat appearance” of the vulvar
surface. ( due to hypoestrogenic state post delivery).
 This thin, narrow line in a vertical direction is
pathognomonic for labial adhesion.
 Labial adhesions are frequently misdiagnosed as
congenital absence of the vagina.
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34.  Treatment can be with:
 Topical estrogen (Premarin or Estrace cream 0.01%)
 Topical steroid (Betamethasone 0.05% ointment) applied
twice daily to the midline raphe under gentle traction.
 Surgical correction is rarely necessary, but recurrence is
common until the age of puberty.
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35.  Prolapse of the urethral mucosa is not a rare event in
children.
 Prolapse involves protrusion of urethral mucosa
through the external meatus, resulting in a friable
hemorrhagic mass that often obscures the adjacent
vaginal introitus.
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36.  This forms a red donut-like structure.
 The prolapse may be partial or incomplete, presenting as
a ridge of erythematous tissue.
 Occasionally the prolapse becomes necrotic and blue-
black in color
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39.  Predisposing factors include:
Hypoestrogenic state
Neuromuscular diseases
Urethral anomalies
Fascial defects
Trauma
Chronic increases in intraabdominal pressure
(e.g recurrent valsalva related to constipation or forceful
coughing).
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40.  The most common presentation is not urinary
symptomatology but prepubertal bleeding.
 On examination, the distal aspect of urethral mucosa
may be prolapsed along the entire 360 degrees of the
urethra.
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41.  The most common treatment is conservative, involves
twice-daily sitz baths
 Topical estrogen (e.g., Estrace 0.01%) at the affected area
for 2 week.
 If the prolapse remains, application should be continued
until complete resolution is achieved.
 Surgical excision is rarely necessary and reserved
primarily for management of necrotic tissue
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42.  Foreign bodies are occasionally found in the vagina and
may lead to vaginal discharge.
 In patients who have persistent vaginal discharge
despite treatment, an ultrasound scan may detect a
foreign body or, if a history of a foreign body is
forthcoming, it is probably best to carry out an
examination under anaesthesia and remove any foreign
body at that time.
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43.  Represents a persistent portion of the urogenital
membrane
 One of the most common obstructive lesions in the
female genital tract
 Incidence 1 /1000 live born female.
 Often not diagnose until puberty with c/o of cyclical
abdominal pain and primary amenorrhea.
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44.  Classic is bluish bulge at introitus.
 Mucucolpus/ hematocalpus May cause pain, difficulty
voiding/ defecating
 Variations include micro perforate, cribriform and
separate.
 Treatment is by surgical resection is clinical of clinical
significance evident.
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45.  FGM is internationally recognized as a violation of the
human rights of girls and women, reflecting deep-
rooted inequality between the sexes.
 FGM is almost always carried out on minors, it is also a
violation of the rights of children.
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46. 9/23/2023 46

47.  Change traditions with the support of older generations
 Educate girls on their right to decide what happens to
their body
 Speak out about the risks and realities of FGM
 Keep pushing for FGM to be banned
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48.  Human papillomavirus (HPV), the causative agent of
genital warts, may be transmitted to children from the
maternal genital tract at delivery or by sexual or
nonsexual transmission after birth.
 however, it appears likely that most warts appearing
prior to 3 years of age are from maternal-child
transmission .If the child is 3 years of age or older,
serious consideration should be given to the possibility
of sexual transmission.
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50.  Approximately half of lesions will regress over 5 years.
 Expectant management is reasonable.
 Treatment in children is difficult.
 Caustic treatments such as trichloroacetic acid are
painful even if children are pretreated with local
anesthesia.
 Topical imiquimod cream, ( 12Y),
 Topical Podophylin 10-20% Max. 3 application.
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51. problems at puberty
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52.  Pubertal changes with menarche before the age of
10years and development of sexual secondary
characteristics before the age of 8.
 Causes can be:
GnRH dependent (80%). Due to premature activation
HPO axis. Can be idiopathic in 10% cases or due to
organic lesion in CNS ( meningitis, hydrocephalus, skull
injuries).
GnRH independent (20%). Due to estrogenic ovarian
or adrenal tumor. Or drugs as COCs or anabolic steroids.
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53.  Detailed physical examination including tanner staging.
 Determination of bone age
 Hormonal assay for FSH,LH,TFT and adrenal hormones.
 MRI and CT scan of the head.
 US examination of the abdomen and pelvis for adrenal
and ovarian tumor.
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54.  Includes treatment of the cause which include
Thyroxin treatment
Surgical removal of adrenal and ovarian tumor
Stoppage of drugs containing sexual hormones.
Neurosurgery or radiotherapy for brain tumors
Idiopathic precocious puberty is treated by GnRh
analogue to produce suppression of HPO axis.
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55.  Primary amenorrhea : failure of menses to occur after 16
years of age irrespective of presence or absence of
secondary sexual characteristics.
 Oligomenorrhea : infrequent menses, very common in
young girls due to starting function of the HPO axis.
 Managements of the above requires both proper
evaluation and gynecologic consultation
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56.  Primary endodermal sinus (i.e., yolk sac) tumors, but
early diagnosis is imperative given the malignancy’s
aggressive nature and poor prognosis.
 Rhabdomyosarcoma is the most common soft tissue
sarcoma of childhood, 3% arise from the uterus or
vagina.
 The embryonal variant is responsible for uterine
sarcomas, whereas the embryonal subvariant sarcoma
botyroides is found in the vagina.
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57.  Both endodermal sinus and sarcomatous tumors arise
primarily in the first 3 yrs of life.
 Presenting on examination with a cystic or polypoid
mass, bloody discharge, and occasionally urinary
retention.
 Treatment consists of a multimodal approach, including
surgery, radiation, and chemotherapy
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58.  It is estimated that 80% to 90% of outpatient visits of
children to gynecologists involve the classic symptoms
of vulvovaginitis, introital irritation and discharge.
 A vaginal discharge that is both bloody and foul
smelling strongly suggests the presence of a foreign
body.
 The foundation of treating childhood vulvovaginitis is
the improvement of local perineal hygiene.
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59.  Dewhurst CJ, Spence JEH. The XY female. Br J
Hosp Med 1977;17:498.
 Kathryn C. Stambough and Diane F. Merritt
nelson text book.
 Comprehensive obstetrics in tropics.
 http://www.who.int/gender/violence/who_mul
ticountry_study/en/.
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60. THANK YOU ALL FOR LISTENING
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