Paediatric Gynaecology - Session: 101

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  • Hypoestrogenic hormonal milieus causes the vaginal mucose to increased susceptibility to infection
    Mucosa is thin, lacks cornification, has an alkaline pH and therefore more susceptible to invasions from pathogens
    Microbiology of normal premanarchal vaginal flora and symptomatic vaginal discharge has been studied and has revealed mixed aerobes and anaerobes in both groups (Gerstner, 1982)
    Common sources for vaginal irritation or discharge includes fecal contamination from poor perineal hygiene, spread of respiratory bacteria from hand to perineal contact, local irritants (bubble baths, nylon underwear)
    Recommended treatments = improved hygeine, avoidance of irritants, oral antibiotics, estrogen cream
  • Remember though an adolescent may use dysmenorrhea as a pretext for contraception
    Think of obstructive anomalies if onset of dysmenorrhea within 6 months of menarche
    Questions to assess severity – school performance and absenteeism
    Ask also re discharge think PID in the sexually active adolescent with new onset dysmenorrhea
    Family hx – 6.9% incidence endo in family members
    Adolescent Prevalence Studies:
    Dysmenorrhea 43 – 93*%
    Severe 5*-23%
    Missing any activities:15 – 59%
    Missing school:10 – 40%
    Adolescent Prevalence Studies:
    Dysmenorrhea 43 – 93*%
    Severe 5*-23%
    Missing any activities:15 – 59%
    Missing school:10 – 40%
    Primary dysmenorrhea is highly prevalent among adolescent girls
    Most dysmenorrhea prevalence data come form convenience samples of varied populations
    Most representative and generalizable prevalence data come from 2 large cross sectional studies
    Klein conducted the only population based study of dysmenorrhea including younger adolescent girls using a national probability sample from the third cycle of the National Health Examination Survey
    Klein also reported the lowest prevalence of severe dysmenorrhea among the youngest adolescents
    This supports the widely held theory idea that dysmenorrhea is related to the establishment of ovulatory menstrual cycles
    Adolescent Prevalence Studies:
    Dysmenorrhea 43 – 93*%
    Severe 5*-23%
    Missing any activities:15 – 59%
    Missing school:10 – 40%
    Adolescent Prevalence Studies:
    Dysmenorrhea 43 – 93*%
    Severe 5*-23%
    Missing any activities:15 – 59%
    Missing school:10 – 40%
    Primary dysmenorrhea is highly prevalent among adolescent girls
    Most dysmenorrhea prevalence data come form convenience samples of varied populations
    Most representative and generalizable prevalence data come from 2 large cross sectional studies
    Klein conducted the only population based study of dysmenorrhea including younger adolescent girls using a national probability sample from the third cycle of the National Health Examination Survey
    Klein also reported the lowest prevalence of severe dysmenorrhea among the youngest adolescents
    This supports the widely held theory idea that dysmenorrhea is related to the establishment of ovulatory menstrual cycles
  • COX 2 withdrawn – Bextra, Vioxx from marker due to cardiovascular concerns and potentially life threatening skin reactions
    Metanalysis confirms 4 NSAIDs are effective in treatment of dysmenorrhea – 3 above, better than aspirin
    Less restriction in daily activities and absenteeism from work or school than women taking placebo
    Davis study – first RCT in adolescents, double blinded – showed reduction in worst pain and less pain medications than placebo groups – moderate to severe dysmenorrhea at onset – note very large placebo effect!, low dose 20 ug pill with effect other 5 trials > 35 ug! Questionnaires – Moos Menstrual Distress Questionnaire, form C – pain subscale
    (muscle stiffness, headache, cramps, backache,fatigue, general aches and pains)
    Scores 0 – 4
    Validated, reliable and has been used to measure dysmenorrhea in adolescents
    Main outcome measure
    Secondary outcome – depression, stress and self esteem as potential modifiers of effects
    Centre for Epidemiologic Studies Depression Scale, Rosenberg Self Esteem Scale and the Cohen Perceived Stress Scale
    All reliable, valid and extensively used in adolescent populations
    None of these results are included here At baseline 42% moderate, 58% severe dysmenorrhea
    Of those in school – 39% usually missed 1 day school per month, 14% missed 2+ days per month
    24% vomiting, 55% nausea, 5% syncope associated Worst pain, decreased in both groups over time (significantly)
    The decrease in the OC groups was greater than in placebo The number of analgesic pills decreased in both groups (used per cycle) but there was a larger decline in the OC than the placebo group
    The pills used: acetaminophen, naproxen, ibuprofen, ASA
    Narcotics were uncommon
    By cycle 3 OC group – mean of 1.3 vs. 3.7 pills of any type in placebo group (note fairly large SD in both groups which would lead to overlap) P 0.05
    61% of OC users no meds vs. 36% placebo group OR 0.37 (0.14-1.0)
    NSAID’s inhibit enzymes of the cyclooxygenase pathway, inhibiting conversion of aracidonic acid into prostaglandins along this pathway
  • SOGC Consensus Guideline JOGC 2005 Davis Obstet Gynecol 2005
    COX 2 withdrawn – Bextra, Vioxx from marker due to cardiovascular concerns and potentially life threatening skin reactions
    Metanalysis confirms 4 NSAIDs are effective in treatment of dysmenorrhea – 3 above, better than aspirin
    Less restriction in daily activities and absenteeism from work or school than women taking placebo
    Davis study – first RCT in adolescents, double blinded – showed reduction in worst pain and less pain medications than placebo groups – moderate to severe dysmenorrhea at onset – note very large placebo effect!, low dose 20 ug pill with effect other 5 trials > 35 ug! Questionnaires – Moos Menstrual Distress Questionnaire, form C – pain subscale
    (muscle stiffness, headache, cramps, backache,fatigue, general aches and pains)
    Scores 0 – 4
    Validated, reliable and has been used to measure dysmenorrhea in adolescents
    Main outcome measure
    Secondary outcome – depression, stress and self esteem as potential modifiers of effects
    Centre for Epidemiologic Studies Depression Scale, Rosenberg Self Esteem Scale and the Cohen Perceived Stress Scale
    All reliable, valid and extensively used in adolescent populations
    None of these results are included here At baseline 42% moderate, 58% severe dysmenorrhea
    Of those in school – 39% usually missed 1 day school per month, 14% missed 2+ days per month
    24% vomiting, 55% nausea, 5% syncope associated Worst pain, decreased in both groups over time (significantly)
    The decrease in the OC groups was greater than in placebo The number of analgesic pills decreased in both groups (used per cycle) but there was a larger decline in the OC than the placebo group
    The pills used: acetaminophen, naproxen, ibuprofen, ASA
    Narcotics were uncommon
    By cycle 3 OC group – mean of 1.3 vs. 3.7 pills of any type in placebo group (note fairly large SD in both groups which would lead to overlap) P 0.05
    61% of OC users no meds vs. 36% placebo group OR 0.37 (0.14-1.0)
    NSAID’s inhibit enzymes of the cyclooxygenase pathway, inhibiting conversion of aracidonic acid into prostaglandins along this pathway
  • J Pediatr Adolesc Gynecol 2001;14:3-8
    Important gaps in knowledge remain in the treatment of dysmenorrhea
    No randomized, placebo-controlled trials have examined the efficacy of modern, low-dose COC
    Small lab and observational data support a positive effect include data on few girls, even fewer minority girls
  • TENS high frequency – 50 – 120 Hz more relief than placebo, less than ibuprofen, no difference with naproxen
    Accupuncture one study only, greater relief than placebo
    Heat – best heat and ibuprofen, heat and placebo better than no heat and placebo
    Topical heat as effective as ibuprofen
    In one study of adolescents – 98% used nonpharmacologic methods such as heat, rest or distraction to treat dysmenorrhea with a perceived effectiveness of <40%
    Other methods tried by the adolescents: avoiding alcohol, wear loose clothing, herbal drinks
    Mother, friend or media gave them the nonpharmacologic approaches – Campbell Nova Scotia 1999
    Eased discomfort 31%
    Convenient 28%
    Do not like drugs in body 27%
    Medication does not help 21%
    Do not like s-e meds 13%
    Nonpharmacologic works faster 11%
    Medical problem prevents meds 2%
    Other reasons (medication not available, easier than going to doctor) 27%
  • Laufer et al Pediatr Adolesc Gynecol 1997;10:199-202
    Ballweg et al Pediatr Adolesc Gynecol 2003, 16: s21 - 6
  • Laufer et al J Pediatr Adolesc Gynecol 1997 10:199-202
    Goldstein et al J Adolesc Health Care 1980;1(1):37-41
    Chatman DL et al J Reprod Med 1982;27(3):156-60
  • Obstet Gynecol 1999;93(1):51-58
    Consider the use of OCPs monthly or continuously- 80% of women with endo assoc dysmenorrhea satisfied with pain control with this method
    (Fertil Steril 1997;77”S23)
    Insufficient evidence comparing continuous vs. cyclic OCPS
    Danazol not recommended because androgenic properties promote weight gain,hirsutism, and acne
    OCPs diminish pain by creating pseudopregnancy
    DMPA shown to improve symptoms in 80-100% Vercillini Am J Obs Gynecol 1996
    Can consider oral treatment first so side effects can be identified
    “Continuous progestin treatment is effective in the treatment of chronic pelvic pain . For example, in one randomized study, 84 women with chronic pelvic pain were randomly assigned in a 2 X 2 design to receive medroxyprogesterone acetate 50 mg daily for 4 months with or without psychotherapy or placebo pills for 4 months with or w/o psychotherapy
    At 4 months of RX, 73% of women who took provera reported at least a 50% improvement in their pain scores compare to 31% of women who received placebo pills.
    Nine months after d/c TX, progestin therapy benefits disappeared
    (Farquhar CM, Rogers V, Franks S et al. A randomized controlled trial of medroxyprogesterone acetate and psychotherapy for the treatment of pelvic congestions Br Obstet Gynecol 1989;96:1153)
    Progestins are also effective for the treatment of pelvic pain due to endo
    (Vercellini P, Coartese I, Crosignani PG. Progestins for symptomatic endometriosis:a Critical analysis of the evidence. Fertil Steril 1997;68:393)
    Those available for Rx CPP:
    Provera 50mg daily
    Aygestin 5 mg daily(norethindrone acetate)
    Norgestrel (Ovrette 0.075mg daily)
    Norethindrone (9Micronor, Nor0QD 0.35mg daily)
    Consider empiric use of GnRH a – there is documented improvement in GnRHa groups
    Of whom 73% had LSC proven endometriosis after 12 weeks of Rx
    (Obstet Gynecol 1999;93:51)
  • Wright et al Fertil Steril 2005, 83: 1830 -6
  • Paediatric Gynaecology - Session: 101

    1. 1. 1 Paediatric Gynaecology Tarek Motan Division of Reproductive Endocrinology & Infertility Adolescent & Paediatric Gynaecology University of Alberta 25 September 2009
    2. 2. 2 ObjectivesObjectives • To discuss the following common conditions – Prepubertal girls • Vaginal discharges • Perineal trauma – Adolescents • Pelvic pain • Abnormal Bleeding
    3. 3. 3 Vaginal DischargeVaginal Discharge • Common prepubertal gynaecologic complaint • Lack of oestrogenic affect on vaginal mucosa increases susceptibility to infection – Thin mucosa with alkaline pH
    4. 4. 4 Vaginal DischargeVaginal Discharge • Non Infectious – Vulvovaginitis – Foreign body – Systemic disorders – Tumours – Anomalies • Infectious – Grp A Strep – Shigella – Pinworms – Gonococcus – Chlamydia – Trichomonas – Bacterial vaginosis
    5. 5. 5 Vaginal DischargeVaginal Discharge • Bloody – Grp A Strep – Shigella – Foreign body – Trauma – Scratching – Condyloma • Green – Staphylococcus – Streptococcus – Haemophilus – Gonococcus – Foreign body
    6. 6. 6 HistoryHistory • Onset, duration, colour, odour • Associated symptoms – Fever, pruritis, dysuria, anal sx • Improvement / worsening? • Bleeding? • Hygiene measures – Diapers, toilet trained, cleansing routine • Signs of puberty • Treatments tried
    7. 7. 7 ExaminationExamination • Systematic genital exam – Frog-leg (butterfly) position – Seated on parent – Knee chest position – Child can spread own labia • Cough or deep breath – May need an EUA • Specifics to note – Dermatological conditions • Psoriasis, eczema – Evidence of abuse • Bruising, trauma
    8. 8. 8 ExaminationExamination • Swab discharge – Prefer dacron male urethral swab – Avoid touching post hymen • Request – Aerobic culture – Gonorrhoea & chlamydia culture – Consider wet mount
    9. 9. 9 VulvovaginitisVulvovaginitis • Vulvovaginal inflam most common cause of discharge – Erythema, discomfort, itching, discharge & dysuria • Non specific (75%) • Specific (25%) – Respiratory pathogens – Enteric – STI’s – Pinworms – Foreign body – Systemic illness – Dermatologic disorders
    10. 10. 10 Vulvovaginitis - TherapyVulvovaginitis - Therapy • Vulvar hygiene – Front-to-back wiping with warm water after a bowel movement – Avoid deodorant soaps, bubble baths, or lotions – Keep vulvar area clean and dry – White cotton underwear or if in diapers, change soon after each urination or bowel movement – Use unscented toilet paper – Wash hands prior to & following use of toilet – Mild bath soap (e.g., Dove, Neutrogena, Basis, Cetaphil) – Remove wet bathing suits soon after exiting pool area – Sitz baths in lukewarm water with 2 tablespoons of baking soda or colloidal oatmeal
    11. 11. 11 Vulvovaginitis - TherapyVulvovaginitis - Therapy • Re-evaluate in 2 weeks • Review hygiene measures • If no improvement – Exclude pinworms & consider empiric treatment – Review results of culture • Amoxicillin for 10 days • Cephalexin for 10 days • Topical antibacterial cream – Oestrogen cream bid for 2w – Hydrocortisone cream bid until improved – Consider EUA to rule out foreign body
    12. 12. 12 VulvovaginitisVulvovaginitis • Infectious causes – Presents with vaginitis rather than vulvitis – Candida is rare in prepubertal age group – Respiratory organisms • Grp A Strep most common, Haemophilus, Staph • Itch, discharge, dysuria, pain, beefy red appearance • Treatment is systemic antibiotics & hand washing – Enteric organisms • Shigella • Mucopurulent bloody discharge, foul odour • Diagnosed on culture & treated with cotrimoxazole – Pinworms (helminth) • Itch & irritation, discharge in vagina infected • Diagnosed with tape test & treated with mebendazole
    13. 13. 13 Foreign BodyForeign Body • Daily, malodourous dark brown discharge • May also have pain or bleeding • Discharge is unresponsive to treatment • Toilet paper, safety pins, parts of toys • May be visible on examination – Vaginal irrigation with saline or EUA
    14. 14. 14 Perineal TraumaPerineal Trauma • Accidental injuries – Straddle • Aetiology - playground equipment, bicycle bar • Prominent surface, rarely hymen or vagina, usually anterior – Penetrating • Aetiology - falls on to pointed object, fence post, bed post • Hymeneal injuries may occur • If upper vagina is penetrated may extend to peritoneum – Non-penetrating • Crush or associated with pelvic fracture – Associated with multiple trauma, i.e. MVA – Urethral injuries • Insufflation injuries
    15. 15. 15 Perineal TraumaPerineal Trauma • History – Consistent history – Consider & rule out abuse – Ability to urinate or catheterise – Time since injury • Physical exam – Anterior injury common • Usually between 3 & 9 o’clock – Hymenal/vaginal injury rare – Peri-urethral injury – Visualise entire laceration
    16. 16. 16 Perineal Trauma - TherapyPerineal Trauma - Therapy • Straddle injury – Superficial / haemostatic - observe – Repair under conscious sedation or EUA – Ability to urinate & need for catheter – Compression, ice packs & analgesia • Haematoma – Observe size & expansion – Expectant vs. evacuation with ligation of vessels – Catheterise, ice packs & analgesia
    17. 17. 17 Perineal Trauma - TherapyPerineal Trauma - Therapy • Vulvar Injury – Prophylactic pre-op antibiotics – Assess extent of laceration – Assure urethral / urinary tract intact – Anatomic repair – Fine absorbable suture – ? Post-op oestrogen cream
    18. 18. 18 Adolescent Pelvic PainAdolescent Pelvic Pain • Primary dysmenorrhoea • Secondary dysmenorrhoea – Painful menstruation in the presence of pelvic pathology – Endometriosis – Congenital obstructive Mullerian anomalies – Cervical stenosis – Pelvic inflammatory disease – Pelvic adhesions – Ovarian cysts
    19. 19. 19 Primary DysmenorrhoeaPrimary Dysmenorrhoea • Definition – Recurrent, crampy lower abdominal pain during menstruation in absence of pelvic pathology – pain 1 - 4 hours prior to menses & lasts 24 - 48 hours • Prevalence in adolescents – Very common (20 - 90%) – Only 15% adolescent females seek care – National Health Examination Survey • 12 to 17 year old girls • 50% of 2699 girls reported dysmenorrhoea • 25% of all excessive school absences due to pelvic pain or dysmenorrhoea
    20. 20. 20 • Pathogenesis – Prolonged uterine contractions – Decreased uterine blood flow to myometrium – Increased with ovulation • PGF2 alpha, PGE2, Leukotrienes • Therapeutic Options – NSAID’s first line treatment, unless contraindicated – OCP’s improve symptoms • Contraceptive advantages may make first line choice Primary DysmenorrhoeaPrimary Dysmenorrhoea
    21. 21. 21 • NSAID treatment – Ibuprofen 200 – 600 mg q6h – Naproxen sodium 550 mg initially • Followed by 275 in 8 hours – Mefenamic acid 500 mg initially • followed by 250 mg q6h – Take at onset cramps or menses – Take for 2 – 3 days (not to exceed 1 week) – Take with food Primary DysmenorrhoeaPrimary Dysmenorrhoea
    22. 22. 22 • Oral Contraceptive Pills – No randomized placebo-controlled trials – Improvement of dysmenorrhoea over time – But few adolescents enrolled in studies – Consideration should be given to extended use OCP’s – Depot MPA or Levonorgestrel IUS is effective • Both can be considered as treatment options Primary DysmenorrhoeaPrimary Dysmenorrhoea
    23. 23. 23 • Non Medicinal Therapeutic Options – High frequency TENS • Better than placebo • Less effective than Ibuprofen • Equivalent to naproxen – Acupuncture • 1 study benefit vs. placebo limited evidence – Topical heat therapy • Equivalent ibuprofen • Better than placebo • Faster relief in combination with ibuprofen – Spinal manipulation - No evidence – Exercise - Cochrane review pending Primary DysmenorrhoeaPrimary Dysmenorrhoea
    24. 24. 24 Adolescent EndometriosisAdolescent Endometriosis • Benign gynaecologic disorder • Characterized by growth of endometrial cells (glands and stroma) in an ectopic location – Most commonly found on pelvic structures and peritoneum – Bladder, rectum, vulva, vagina, cervix – Also found less commonly in extra-pelvic locations: Umbilicus, abdominal surgical scars, lungs
    25. 25. 25 • Most common cause of secondary dysmenorrhoea • Most common finding in chronic pelvic pain • Adolescents unresponsive to NSAID’s & OCP’s – Up to 73% diagnosed on laparoscopy • Delay to diagnosis – 4.2 MD’s consulted before diagnosis – 4.1 years from onset to diagnosis • Thelarche developmental threshold Adolescent EndometriosisAdolescent Endometriosis
    26. 26. 26 Adolescent EndometriosisAdolescent Endometriosis • Symptoms – Acyclic and cyclic pain 62.5% – Acyclic pain 28.1% – Cyclic pain 9.4% – Gastrointestinal pain 34.3% – Urinary Tract symptoms 5 – 12.5% – Irregular menses/abnormal bleeding 36%
    27. 27. 27 • Medical Management – NSAIDS therapy • Use upper end of dose range • Ibuprofen 600mg every 6 hours – OCP’s or vaginal ring monthly or extended • Create “pseudopregancy” – Continuous progestin treatment • DMPA – GnRH agonists • Usually withheld until 16 years to allow full growth & development • Needs addback oestrogen Adolescent EndometriosisAdolescent Endometriosis
    28. 28. 28 • Surgical Management – Consider laparoscopy within 3 - 6 mths if pain persists – May proceed prior to 3 mths if interfering with school or social activities – Resection or ablation are equally effective • Laser, scissors, harmonic scalpel, electrocautery • 24 patient RCT for chronic pain with stage I or II • No difference in pain over 6 months Adolescent EndometriosisAdolescent Endometriosis
    29. 29. 29 Abnormal BleedingAbnormal Bleeding • 50% of all adolescent gynae visits – Minimal to profuse bleeding – 80% manageable in clinic – Hospitalisation mainly for hypovolaemia – 80% due to anovulatory bleeding • Normal menstrual pattern – Ovulatory cycle length ranges 28 ± 7d – Flow 4 ± 2 days while excessive > 8 - 10d – Blood loss ~ 40 ± 20 ml while excessive > 80ml/cycle
    30. 30. 30 Aetiology of Abnormal BleedingAetiology of Abnormal Bleeding • Endocrine – Hypothyroidism – Hyperprolactinaemia • Vulva/vagina – Vaginitis – Trauma – Infection – Malignancies – Sarcoma botryoides – Clear-cell adenocarcinoma • Cervix – Cervicitis – Condyloma – Polyps – Malignancies – Sarcoma botryoides • Uterus – Pregnancy – Endometritis – Hyperplasia – Malignancy – Polyps – Leiomyomata • Ovaries – Immature hypothalamic-pituitary axis – Polycystic ovarian disease – Oestrogen-producing tumours • Other – Exercise – Dieting/anorexia nervosa
    31. 31. 31 • Exclude pregnancy & related conditions (ectopics, etc) – Dx: Β-hCG & endovaginal ultrasound • Immature H-P-O axis – Ovulatory by 1y - 18%, 5y - 80%, 6y - 100% post menarche – LH & FSH for follicles development but not for ovulation – Endometrium outgrows blood supply & sheds irregularly – Therapy • Mild bleeding - reassurance & Fe • Hb 90 - 120: OCP’s & Fe for 3-6m • Hb < 90: if stable OCP’s & Fe for 6-12m • Severe: hosp, transfusion, D & C, OCP’s 3/2/1 & a further 28d Abnormal BleedingAbnormal Bleeding
    32. 32. 32 • Endocrine abnormalities – Hyperprolactinaemia • Prolactinomas, stalk lesions, meds, hypothyroidism • Affects H-P-O function, CL dysfunction • Rx: dopamine agonists regulate menses in 4m – Hypothyroidism • ↑ TRH affects PRL & dopamine action • Rx: thyroid replacement Abnormal BleedingAbnormal Bleeding
    33. 33. 33 • Blood dyscrasia – Affects 5 - 19% of adolescents hospitalised with menorrhagia – ITP, von Willebrand’s disease, leukaemia, platelet dysfunction – Dx: CBC, PTT, INR, bleeding time, vWF:Ag, ristocetin cofactor • Müllerian anomalies – Incidence 1:3000 births – Dx: U/S & MRI – Rx: formal surgical correction Abnormal BleedingAbnormal Bleeding
    34. 34. 34 • Infections – Cervicitis • Chlamydia or gonorrhoea • Non-infectious causes if swabs negative – Vaginitis • Trichomonas, Candidiasis, bacterial vaginosis – Endometritis • Acute & chronic forms • Menometrorrhagia, mucopurulent PVD, uterine tenderness • Dx: endometrial biopsy, ↑ ESR, ↑ WCC – Treatment is aerobic & anaerobic antibiotics Abnormal BleedingAbnormal Bleeding
    35. 35. 35 • Condyloma accuminata – 15% of adolescents HPV +ve (types 6 & 11) – Rx: cryotherapy, podophyllin, TCA, CO2 laser, imiquimod • Recurrence: chemical - 27-65%, laser - 35%, imiquimod - 20% • Uterine fibroids & polyps – Low incidence in adolescents • Haemangiomas – Dx: physical exam & MRI – Rx: laser, sclerosing, embolisation, cauterisation, steroids Abnormal BleedingAbnormal Bleeding
    36. 36. 36 Questions Please

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