Gynecologic diseases in childhood are common. This review is intended to enable careful and sound management of pediatric patients as the initial assessment is paramount to proper management.

1. By
Dr/ AHMED ALI M. NASRDr/ AHMED ALI M. NASR
Assistant professor of obstetrics & gynecology

3. Gynecologic diseases in childhoodGynecologic diseases in childhood
are common. This review isare common. This review is
intended to enable careful andintended to enable careful and
sound management of pediatricsound management of pediatric
patients as the initial assessmentpatients as the initial assessment
is paramount to properis paramount to proper
management.management.

4. The common conditions encounteredThe common conditions encountered
in clinical practice can bein clinical practice can be
classified into:classified into:
1.1. Problems in neonatal period.Problems in neonatal period.
2.2. Problems in early childhood.Problems in early childhood.
3.3. Problems at puberty.Problems at puberty.
4.4. Problems at adolescence.Problems at adolescence.

6. 1. Gyecomastia and galactorrhea: this
may develop in both girls and boys
and small amount of milk may be
expressed from breasts.
2.2. Vaginal bleeding:Vaginal bleeding: girls may dischargegirls may discharge
a mucous blug or little vaginala mucous blug or little vaginal
bleeding on the fourth day afterbleeding on the fourth day after
delivery.delivery.
Both of the above conditions areBoth of the above conditions are
physiologicphysiologic and are due toand are due to the effect ofthe effect of
withdrawal of maternal hormoneswithdrawal of maternal hormones
((estrogenestrogen andand progesteroneprogesterone)) after birth.after birth.
ManagementManagement::
Explanation and reassurance of theExplanation and reassurance of the
mother and follow up as bothmother and follow up as both
conditions are self limited.conditions are self limited.

8. 1.1. vulvovaginitis.vulvovaginitis.
2.2. Labial adhesion.Labial adhesion.
3.3. Lichen sclerosus.Lichen sclerosus.
4.4. Vulvar warts.Vulvar warts.

9. Vulvo-vaginitisVulvo-vaginitis
Predisposing factorPredisposing factor is the hypo-estrogenic state thatis the hypo-estrogenic state that
leads to:leads to:
Flattened vulval epithelium.
Attenuated labia minors.
Thin vaginal epithelium.
Alkaline vaginal secretion due to absence of
Dodrlein bacilli which secrete lactic acid
(bacteriostatic)
The above factors increase the susceptibility ofThe above factors increase the susceptibility of
vulvovginal infection.vulvovginal infection.

10. Causative organisms:Causative organisms:
 Non specific organisms:Non specific organisms:
1). H. influnza. 2). Staph. Aureus 3). E. COLI.1). H. influnza. 2). Staph. Aureus 3). E. COLI.
4). Group A streptococci. 5). Parasitic infestation by4). Group A streptococci. 5). Parasitic infestation by
Entrobius vermicularisEntrobius vermicularis
 Specific organisms:Specific organisms:
1.1. Candid species are rareCandid species are rare and may be found in girlsand may be found in girls
with certainwith certain predisposing factorspredisposing factors as prolongedas prolonged
antibiotic therapy (80%), D.M (0.3%), steroid therapyantibiotic therapy (80%), D.M (0.3%), steroid therapy
(0.2%), bad hygiene (5%) and diet rich in(0.2%), bad hygiene (5%) and diet rich in
carbohydrates (9%).carbohydrates (9%).
2.2. Sexually transmitted organisms asSexually transmitted organisms as trichomonastrichomonas
vaginalis and chlamydia trachomatisvaginalis and chlamydia trachomatis should prompt ashould prompt a
careful evaluation for sexual abuse.careful evaluation for sexual abuse.

11. Clinical picture:Clinical picture:
Symptoms range from
mild discomfort to severe
itching. Entrobius
vermicularis causes
mainly night itching.
On examination, the
vulva and introits are red
and inflamed associated
with serous/purulent
discharge.

12. treatment:treatment:
1.1. Symptomatic treatment in non specific vulvovaginitis.Symptomatic treatment in non specific vulvovaginitis.
2.2. Avoidance of tight clothes and irritant soap.Avoidance of tight clothes and irritant soap.
3.3. Front to back wiping after defecation.Front to back wiping after defecation.
4.4. Antibiotic treatment.Antibiotic treatment.
5.5. Estrogen cream for short course.Estrogen cream for short course.
6.6. Treatment of thread worm if present.Treatment of thread worm if present.
Recurrent vaginal discharge unresponsive to the aboveRecurrent vaginal discharge unresponsive to the above
treatment needs further evaluation to :treatment needs further evaluation to :
 exclude retained foreign body (by examination under
anesthetic and vaginoscopy).
 Vulvovaginities caused by specific organisms needs culture
and sensitivity tests..

13. Labial adhesionsLabial adhesions
 Labial fusion is a common pediatric problem oftenLabial fusion is a common pediatric problem often
associated with low estrogen state and may complicateassociated with low estrogen state and may complicate
vulvovaginitisvulvovaginitis..
 The peak incidence (3.3% ) at 13-23 months of age.The peak incidence (3.3% ) at 13-23 months of age.
 The condition sometimes presents with a symptomaticThe condition sometimes presents with a symptomatic
bacteriuria , urinary tract infection, voiding difficulty andbacteriuria , urinary tract infection, voiding difficulty and
urinary incontinence.urinary incontinence.

14. Labial adhesionsLabial adhesions
Management:Management:
Topical estrogen cream, followed byTopical estrogen cream, followed by
manual separation on a regular basismanual separation on a regular basis
done by the mother. Surgical separationdone by the mother. Surgical separation
under anesthetics is done for casesunder anesthetics is done for cases
refractory to medical treatment followedrefractory to medical treatment followed
by estrogen cream to prevent readhesionby estrogen cream to prevent readhesion
at the cut surfaces.at the cut surfaces.

15. Lichen scelerosusLichen scelerosus
It is a chronic skin condition affecting the anogenitalIt is a chronic skin condition affecting the anogenital
area characterized by vulval itching, conistipation andarea characterized by vulval itching, conistipation and
sometimes skin changes as white papules, whitesometimes skin changes as white papules, white
plaques and hemorrhagic areas.plaques and hemorrhagic areas.
The exact cause is unknown, but there is a strongThe exact cause is unknown, but there is a strong
association with autoimmune disorders.association with autoimmune disorders.
Unlike the adult form of the disease the condition is selfUnlike the adult form of the disease the condition is self
limiting at or just after menarche with no risk oflimiting at or just after menarche with no risk of
malignancy.malignancy.
Management:Management:
Careful hygiene with the use of potent topicalCareful hygiene with the use of potent topical
corticosteroids as clobetasol propionate.corticosteroids as clobetasol propionate.

16. Vulvar wartsVulvar warts
Ano-genital warts may be due to HPV-2 induced
condylomata which can co-exist with cutaneous
common warts. It is important to exclude sexual
abuse.
The perinatal transmision is an important route of
infection through wart of the birth canal of the
mother.mother.

17. Treatment of vulvar wartsTreatment of vulvar warts
Podophylin 10-20% dependingPodophylin 10-20% depending
on the age of the child is usefulon the age of the child is useful
with maximum of threewith maximum of three
aplications to avoid damage ofaplications to avoid damage of
the normal surrounding skin.the normal surrounding skin.

19. definition: pubertaldefinition: pubertal
changes withchanges with
menarche before themenarche before the
age of 10 years andage of 10 years and
development of 2rydevelopment of 2ry
sexual charactersexual character
before the age of 8before the age of 8
yearsyears..
1)Precocious puberty1)Precocious puberty

20. causes:
1.1. GnRH- dependant(80%):GnRH- dependant(80%): due to prmaturedue to prmature
activation of the hypothalamo-pitutaryactivation of the hypothalamo-pitutary ––
ovarian axis which may be idiopathic in 10%ovarian axis which may be idiopathic in 10%
or due to organic lesion in CNS (meningities,or due to organic lesion in CNS (meningities,
hydrocephalus, skull injuries). CNShydrocephalus, skull injuries). CNS
Involvement may include MR, increased ICTInvolvement may include MR, increased ICT
and focal neurological deficit.and focal neurological deficit.
2.2. GnRh independent (20%):GnRh independent (20%): due to estrogenicdue to estrogenic
ovarian or adrenal tumor. Or drugs as COCsovarian or adrenal tumor. Or drugs as COCs
or anabolic steroids.or anabolic steroids.

21. Diagnosis:
 Detailed physical examination includingDetailed physical examination including
Tannar staging.Tannar staging.
 Determination of bone age.Determination of bone age.
 Hormonal assay for FSH, LH, thyroidHormonal assay for FSH, LH, thyroid
hormones and adrenal hormones.hormones and adrenal hormones.
 MRI and CT scan of the head.MRI and CT scan of the head.
 U/S examination of the abdomen andU/S examination of the abdomen and
pelvis for adrenal and ovarian tumor.pelvis for adrenal and ovarian tumor.

22. Treatment:
 It is the treatment of the cause and canIt is the treatment of the cause and can
involve the following:involve the following:
 Thyroxin treatment,Thyroxin treatment,
 Neurosurgery or radiotherapy for CNS tumor.Neurosurgery or radiotherapy for CNS tumor.
 Surgical removal of adrenal or ovarian tumor.Surgical removal of adrenal or ovarian tumor.
 Stoppage of drugs containing sex hormones asStoppage of drugs containing sex hormones as
COCs or androgens.COCs or androgens.
 Idiopathic precocious puberty is treated byIdiopathic precocious puberty is treated by
GnRh analogue to produce suppression ofGnRh analogue to produce suppression of
HPO axis until epiphyseal fusion occur orHPO axis until epiphyseal fusion occur or
until appropriate pubertal/chronological agesuntil appropriate pubertal/chronological ages
are matched.are matched.

23. Primary amenorrhea:Primary amenorrhea: failure offailure of
menstruation to occur by the age of 16menstruation to occur by the age of 16
irrespective of the presence or absence ofirrespective of the presence or absence of
2ry sexual character. This condition2ry sexual character. This condition
needs proper evaluation and gynecologicneeds proper evaluation and gynecologic
consultation.consultation.
Oligomenorrhea:Oligomenorrhea: it means infrequentit means infrequent
menstruation. It is a very commonmenstruation. It is a very common
condition among young female and is duecondition among young female and is due
to starting function of the HPO axis.to starting function of the HPO axis.
Management of this condition requiresManagement of this condition requires
cyclic hormonal regulation.cyclic hormonal regulation.
2)Delayed puberty and primary2)Delayed puberty and primary
amenorrheaamenorrhea

25. 1.1. Dysfunctional uterine bleeding.Dysfunctional uterine bleeding.
2.2. Dysmenorrhea.Dysmenorrhea.
3.3. Secondary ammenorrheaSecondary ammenorrhea..

26. 1) Dysfunctional uterine bleeding1) Dysfunctional uterine bleeding
It means abnormal uterine bleeding in absence ofIt means abnormal uterine bleeding in absence of
an organic cause.an organic cause.
It is a common problem in the adolescence.It is a common problem in the adolescence.
It is due to delayed maturation of HPO axis inIt is due to delayed maturation of HPO axis in
95% of cases leading to anovulation with over95% of cases leading to anovulation with over
proliferation of endometrium caused byproliferation of endometrium caused by
unopposed estrogen and absence ofunopposed estrogen and absence of
progesterone. The hyperplastic endometriumprogesterone. The hyperplastic endometrium
is break down results in heavy irregularis break down results in heavy irregular
bleeding.bleeding.

27. Management:
 Exclude pregnancy at first.Exclude pregnancy at first.
 Exclude thyroid , adrenal disorders, hyperExclude thyroid , adrenal disorders, hyper
prolactinemia and acromegaly.prolactinemia and acromegaly.
 Exclude coagulation defects as VonExclude coagulation defects as Von
willebrand's disease.willebrand's disease.
 Antiprostaglandins as mefenamic acid willAntiprostaglandins as mefenamic acid will
decreases the ammount of beeding by 50%.decreases the ammount of beeding by 50%.
 Hormonal treatment by progestin therapyHormonal treatment by progestin therapy
(norethisteron 5mg tds from day 15-25 of the(norethisteron 5mg tds from day 15-25 of the
cycle).cycle).

28. 2)Dysmenorrhea2)Dysmenorrhea
It means painful menstruation. Pain is colickyIt means painful menstruation. Pain is colicky
intermittent felt in the suprspubic region at the onsetintermittent felt in the suprspubic region at the onset
of bleeding and persists for 2-3 days.of bleeding and persists for 2-3 days.
It is a very common problem in adolescenceIt is a very common problem in adolescence..
Management:Management:
 Explanation and reassurance.Explanation and reassurance.
 Anti prostaglandin as mefenamic acid shouldAnti prostaglandin as mefenamic acid should
starts premenstrually and continue during thestarts premenstrually and continue during the
days affected.days affected.
 In severe cases oral contraceptive pills can beIn severe cases oral contraceptive pills can be
prescribedprescribed (socially unaccepted in virgins)(socially unaccepted in virgins).

29. 33((Secondary amenorrheaSecondary amenorrhea
It means absence of menstruation for 6 months orIt means absence of menstruation for 6 months or
more after it has been present.more after it has been present.
 The commonest cause in adolescent that fistThe commonest cause in adolescent that fist
needs exclusion is pregnancy.needs exclusion is pregnancy.
 Low BMI in this age also leads to amenorrhea.Low BMI in this age also leads to amenorrhea.
 Endocrinal disorders must also be ruled out.Endocrinal disorders must also be ruled out.
 Abnormalities in genital tact as PCOS should beAbnormalities in genital tact as PCOS should be
excluded.excluded.
Management:Management:
Gynecologic consultation is essential with properGynecologic consultation is essential with proper
treatment of the cause after propertreatment of the cause after proper
investigationinvestigation