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Adolescent gynecology ucaya
This document provides guidance on evaluating and managing common adolescent gynecologic issues. It discusses indications and techniques for pelvic exams and evaluating vaginal discharge. It also reviews causes and treatments for gynecologic pain, abnormal uterine bleeding, amenorrhea, polycystic ovary syndrome, and more. Key topics include ovarian cysts, ectopic pregnancy, endometriosis, and approaches to chronic pelvic pain.
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Adolescent gynecology ucaya
- 1. Adolescent Gynecology Mike Guyton,MD Assistant Clinical Professor/Academic Faculty in General Pediatrics
- 2. Objectives • The PelvicExam 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.
- 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.
- 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 lookfor • 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 • Canbe 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 ZitelliAtlas 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 • Verycommon 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 Evaluationand 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 AdnexalTorsion • 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 Managementof 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 • Developingblastocyst 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 forEctopic 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 • Mostcommon: 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 completehistory 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 leftuntreated, 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 incidenceof 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 tissuelocated 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 • Historyand 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 • Chroniccondition = 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 BoardDifferential • 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 • ALWAYSstart 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 • Observationand 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 ofMenses • 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 • Startwith 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, crampylower 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 aname? • 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 PsychiatricDiagnosis 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 commoncause 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 • HormonalTherapy – 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
Editor's Notes
- #4 -Just as a reminder. Avg menstruation is 28-35 days -Most variability present in the first 5-7 years after menarche and the last 10 years of menstruation -Cycle length peaks at age 25-30
- #5 -Reasons Valuable: External exam to focus on dysmorphic changes, external infections (folliculitis, vulvar candidiasis, vulvar dermatoses), internal exam can yield several diagnostic studies (pap smears, STI testing) as well as visual clues (strawberry cervix with trich, discharge, cancers/warts)
- #8 -A: Fimbriated Hymen; B: Posterior Rim/Crescentic Hymen; C: Circumferential/Annular Hymen -Remember, 80-95% of girls who are victims of sexual abuse have a normal external genital exam
- #11 -Candida: 10-20% who harbor candida are asymptomatic. Fluconazole maintains therapeutic concentrations for 72 hours. Complicated infections, 150mg po q72h x 3 doses C. glabrata fails with azoles commonly (use flucytosine cream). C. krusei resistant to fluconazole, use clotrimazole cream/suppose -no general rec for treating partners -Gonorrhea: New guidelines in 2012 represent growing emergence of cephalosporin resistance patterns in GC. -Trich: allergy to flagyl = recommend desensitization; same treatment for male partners BV: treat if symptomatic, may also reduce the risk of acquiring other STD’s Tinidazole has a longer half life and fewer side effects, therefore it is an alternative, 1g po x 5days
- #15 -Ruptured cyst can lead to minor or severe bleeding Functional Cysts: Follicular cysts, Corpus Luteum Cysts, Thecal Cysts Non-Functional Cysts: Ovary with many cysts (PCOS), Chocolate Cysts (Endometriosis), Hemorrhagic Ovarian Cyst, Dermoid Cysts, Ovarian serous cystadenoma, Ovarian Mucinous Cystadenoma, Paraovarian cyst, Cystic Adenofibroma, Borderline Tumoral Cysts
- #17 Right ovary more common to twist than left (? Ligament longer, and left supported by sigmoid colon) Ligaments involved: infundibulopelvic ligament (fold of the broad ligament, holds vessels), utero-ovarian ligament, broad ligament
- #20 -Previous ectopic pregnancy (conservative treatment) carries risk as high as 15%! -In-utero DES expoure increases the rates of abnormal tubal morphology -Hormonal contraception can be protective (ironically, IUD use is included in this, but if conception occurs, the risk of ectopic pregnancy is high)
- #22 PE findings: abdominal exam range from unremarkable to exquisite tenderness, uterus may be slightly enlarged, and cervical motion/adnexal tenderness may/may not be present. May see HD variations or instability Other tests: CBC, blood type and screen, CMP (if going to be treated with methotrexate); may need to give Rhogam if Rh (d) negative
- #26 -In one study, was seen in 50% of teenagers undergoing laproscopy for evaluation of chronic pain or dysmenorrhea -Anatomic abnormalities may lead to retrograde menstruation, which could potentially increase the risk of endometriosis, also a familial tendency has been identified as well (as high as 7% in 1st degree relatives).
- #27 -Primary Dysmenorrhea tends to occur with menarche; dysmenorrhea with endometriosis often is after menarche.
- #29 -Often, there is therapeutic intervention at the time of diagnosis (during laparoscopy); helps to prevent/delay disease progression and avoid expense/SE of medical therapy -OCP’s vs GnRH agonists both equal for pain relief -GnRH agonists and Danazol induce “pseudomenopause; progestins alone mimic pregnancy (inhibit endometrial tissue growth and also inhibit pituitary gonadotropin secretion, ovarian hormone production) -Danazol has progestin-like effects, and helps to inhibit the growth and resolve implants (SE weight gain, muscle cramps, acne, hirsutism) -Aromatase inhibitors prevent estrogen production
- #30 -Annovulation is due to a immature hypothalamic-pituitary axis. Dysfunctional Uterine Bleeding: excessive (> every 21 days) non-cyclic endometrial bleeding unrelated to anatomic lesions or systemic disease; Anovulatory uterine bleeding is another term for this, and is a diagnosis of exclusion -Menometrohaggia: prolonged/excessive uterine bleeding that occurs irregulalrly or more frequently than normal (irregular menses with menorhhagia (causes include cancer, hormonal imbalance, progestin only contraception, endometriosis, and fibroids)
- #31 -Ovarian Failure, if the cause, can lead to osteoporosis
- #33 Medical History: Chronic medical illness Medicines: use of OCP FH: coagulation or gynecologic disorders Social: Stressors, exercise, sexual activity PE Pearls: Look for androgen excess, look at body distribution, palpate thyroid gland, look for evidence of brusing, general skin exam for possible acanthosis, examine abdomen for masses
- #34 Also, blood transfusion -Hemostatic agents are commonly seen in use for VWD
- #35 Secondary amenorrhea: cessation of menses after menarche for 6 months/length of time equal to 3 previous cycles -
- #36 -In eating disorders, amenorrhea may preceed the weight loss; menstrual irregularity not a diagnostic criterion for bulimia, and no longer for Anorexia -Idiopathic Hypogonadotropic Hypogonadism + Anosmia = Kallman’s Syndrome Secondary Amenorrhea: -Drugs: Phenothiazines, OCP, Glucocorticoids, Heroin -Endocrine: Hypo/Hyperthyroidism, cortisol excess -Chronic Illness: Cystic Fibrosis, DM1 -Hypothalamic Failure: Idiopathic, Lesions (Cranipharyngioma) -PCOS: ? Hypothalamic disorder according to researchers Pituitary: -Lesions: Sheehan Syndrome, empty sella syndrome, infiltration with hemochromatosis, Adenomas Ovarian: -Ovarian Failure: Menopause <35yo (autoantibodies) -Ashermann Syndrome: Uterine Synechiae accompianed by symptoms of infertility or amenorrhea -Pregnancy
- #37 Primary Amenorrhea: -Look at secondary characteristics (Breast development, Uterus Present/Absent); if both present, then look for cyclic pain which could be due to vaginal outlet obstruction; if no cyclic pain, pursue your secondary amenorrhea workup. -Serum Testosterone distinguishes between Testicular feminization (Male testosterone level, 46XY) and Congenital Absence of Uterus (Female test. Level, 46XX) -If high blood pressure, look for 17-alpha-hydroxylase deficiency.
- #45 Hirsutism: Seen in 2/3 of hyperandrogenic females, diagnosed based on grading scale (Ferriman-Gallway System, score of 8 or more, varies based on ethnicity) Hypertrichosis: Non-sexual/more generalized pattern, such as on forehead, shoulders Acne: in PCOS, moderate or more inflammatory (>10 facial lesions), harder to treat with traditional measures Balding: Male Pattern (fronto-temporal) or female pattern (Crown) Other hyperandrogenism: Hidradenitis suppurativa, hyperhidrosis, seborrhea Anovulation: Varied and often difficult to link with PCOS, chronic anovulation associated with endometrial hyperplasia and carcinoma Obesity: present in 50% of those with PCOS, central obesity is waist circumference of >88cm in adolescent and adult females Metabolic Syndrome: 25% have this, not well defined parameters in pediatrics, components are HyperTG, central obesity, hyperglycemia, low HDL, and HTN SDB: longer sleep latency, poorer sleep efficiency, and lower percentage of REM sleep NASH: Association with insulin resistance and dyslipidemia
- #46 -Cyclic progestin do not effectively help hirsutism (Avoid estrogen effects of thromboembolism [4X increased risk in 1st time users] and linear growth inhibition in perimenarchal girls with open growth plates) -Suspect adrenal hyperandrogenism if the levels of testosterone do not normalize with OCP administration -Metformin often used with or without evidence of glucose intolerance -Aldactone lowers hirsutism by 1/3