5/13/2013 1 Wendy L. Jackson MD University of

5/13/2013
Wendy L. Jackson M.D.
University of Kentucky Department of
Obstetrics and Gynecology
5/16/13
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5/13/2013
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Identify common pediatric and adolescent
gynecologic medical issues pertinent to the
Pediatrician
Extrapolate on these medical conditions
Discuss the initial management of the
conditions
All lleave empowered
d and
d ready
d to
demonstrate our knowledge of PAG 101!!!
North American Society of Pediatric and
Adolescent Gynecology (NASPAG)
Journal of Pediatric and Adolescent
Gynecology (JPAG)
ME!!!! (859) 323-0005 or UKMD’s
(859) 323-5522
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Adolescent
Questionnaire
•
•
Published by
ACOG
Fill out at
every visit
separated
from guardian
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Systematic approach
T
t
llabia,
bi clitoris,
lit i urethra,
th h
Tanner
stage,
hymen,
anus
Reference abnormalities in relationship to a
clock face
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Rapport-without it the gyn exam is nearly
impossible
Approach: stirrups, frog leg, or knee chest
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Frog leg exam
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Stirrups or Dorsolithotomy position
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Dorsolithotomy and Frog leg view
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Knee Chest
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Knee chest view
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Thoroughly evaluate the hymen
D
t estrogenized
t
i d or nott
Document
Defects, bumps, lesions
Patent, imperforate, microperforate, cribiform,
annular, crescentic, cyst, tags, fimbriated,
redundant, septum, transections, bruising
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Imperforate
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Don’t forget to look for signs of abuse
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Usually incidental finding in
asymptomatic pt
13-23mo
Puberty=resolution
secondary to estrogen
No treatment unless
infection, persistence into
puberty
Estrogen cream bid x6wks
Monitor for breast buds
Once separated need to
continue estrogen v.
emollient temporarily
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Can be on various areas of the body with 1015% have onset in childhood
Tissue paper thin skin
Subepithelial hemorrhages
Pruritis
Loss of architecture
Figure of eight distribution
May have painful urination and constipation
Treatment: Temovate, Cutivate, and Aclovate
i t
t bid -2wks
2 k with
ith each
h potency
t
th
f/
ointment
then f/u
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The single most common complaints of the
prepubescent child
Presentation-Irritation, redness, pruritis,
discharge
Don’t treat like yeast unless it is yeast (this is
very uncommon in this age group
Because
the
patients
B
h vulva
l off these
h
i
iis thin,
hi
hairless, and sensitive they are prone to this
inflammatory process
In addition, neutral pH and poor hygiene
Etiology:
I f ti GAS shigella,
hi ll pinworms,
i
(
)
Infection-GAS,
yeastt (rare),
STDs (condyloma, gc/chl, trich)
Tumors-rhabdomyosarcoma, polyps
Foreign body-toilet paper=#1, crayons, charms,
Barbie doll shoes, etc.
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Collect a history:
A t
b iinfectious;
f ti
h
i
b
 Acute…prob
chronic…prob
nonspecific
 Color: bloody=shigella or GAS, foreign body,
condyloma; green=staph, strep, Haemophilus,
gonorrhea, foreign body
 Odor:
body
Od ? fforeign
i b
d
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If d/c seen…culture it
C l i swab
b avoiding
idi th
Calgi
the h
hymen
Send for aerobic cx, gonorrhea and chlamydia
(specific laboratory method)
KOH/wet prep
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If no d/c…then hygeine measures and magic
barrier cream
If no improvement at f/u then irrigate vagina
with pediatric feeding tube
Cx performed on initial fluid
If appreciate foreign body then…get it out via
flushing
her to the
OR.
fl hi or rectall or I can take
k h
h OR
Treat based on cx results
Mgmt:
wiping cotton panties
 Hygeine measures
measures…wiping,
panties,
positioning on toilet, hand washing, no soaps
to vulva, loose clothing
 Sitz baths
 Magic Barrier Cream
 Not better in 48hrs…empirically treat for
pinworms and abx (10d)
 If persists…month course abx, topical abx
ointment, qhs premarin, EUA
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DDX:
T
th
h examination
i ti and
d r/o
/ sexuall
Trauma-thorough
abuse; depending on extent of injury pt may need
EUA
2.Malignancy-i.e., rhabdomyosarcoma
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3. Foreign body
4. Condyloma
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5. Urethral prolapse
6.lichen sclerosus
7
i
b t
7.precocious
puberty
8.infection
9.exogenous estrogen
10.hemangioma,
yp y
11.hypothyroidism
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DO NOT perform unless the patient is :
1 21yo
21
1.
2. immunocompromised
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May be simple or complex
Incidental or Symptomatic
(pain bleeding
(pain,
bleeding, n/v
n/v, torsion
torsion,
urinary sx, constipation,
pelvic pain)
DDX: GI pathology,
reproductive anomaly,
paratubal cyst, ovarian
tumor, ectopic, abscess,
cancer
Mgmt: u/s pelvis in 3mo if
simple
<6cm; >6
>6cm or
i l and
d <6
symptomatic then
laparoscopic cystectomy;
concern for malignancy then
tumor markers and plan for
removal
Oral contraceptive pills may aid in prevention
of other cysts,
cysts but will not resolve the existing
one
When ordering the u/s unless sexually active it
should be ordered transabdominal u/s of
pelvis
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Human Papillomvirus –sexually transmitted
virus responsible for cervical cancer,
cancer some
vaginal and vulvar cancers, genital warts, anal
cancers, and some oropharyngeal cancers
Gardasil approved in 2006 by FDA
Ceravix approved in 2009
HPV types 16 and
d 18 are responsible
ibl for
f 70%of
70% f
cervical cancer (third leading female cancer in
the world) and 70% of anal cancers
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HPV types 6 and 11 are responsible for 90% of
genital warts
The available vaccines are for females and males
The are most efficacious in those HPV naïve
patients hence the reason behind earlier
vaccination (11-12yo but as early as 9yo and catch
p 13-26))
up
If for some reason the teen has prematurely had a
pap smear and is found to HPV+ she should still
have the vaccine b/c she is still at risk for other
subtypes
Side effects: pain at injection site, bruising,
syncope
VTE the
syncope, VAERS has documented VTE-the
majority of the patients also had other risk
factors for VTE; anaphylaxis has also been
noted though rare
Not to be administered during pregnancy
despite it not containing live virus
Efficacy data is not available for
immunocompromised hosts however, the
recommendations say to administer
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If a patient starts the series and the
interrupted pick up where
administration is interrupted…pick
you left off
Gardasil
 Quadrivalent
 Zero, two, and six mo
 Prevention of CIN2 in
HPV naive=97-100%
 Prevention in HPV
exposed=44%
 2010 approvall by
b FDA
for prevention of AIN
and anal cancer in
females
Ceravix
 Bivalent
 Zero, one, and six mo
 Prevention of CIN2 in
HPV naive=93%
 Prevention in HPV
exposed=53%
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Periods lasting greater than 7d
M
th 6 toiletries
t il t i per day
d
More
than
Missing school secondary to soiling clothing
Epistaxis, gingival bleeding, or post op
bleeding
If she is experiencing these things and is being
evaluated for pubertal menorrhagia…she
needs more than just ocp’s
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5/13/2013
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PBAC score greater than 100 warrants futher
evaluation
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U/S of pelvis-r/o granulosa cell tumor
L b ttype and
d screen, tsh,
t h coags, cbc,
b ffactor
t
Labs:
VIII level, von Willebrand factor antigen and
level, PFA
If bleeding heavy and no contraindications to
ocp’s then start a taper
Start
S
iiron if anemic
i
If no success with ocp’s then consider mirena
iud
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Pain with menses…what to do???
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Primary-no with menarche…occurs later-no
pathology
Secondary-associated with pelvic pathology
(reproductive tract anomalies, endometriosis,
adhesive disease)
This cramping is initiated when the body
releases prostaglandins that result in uterine
contractions;
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Peform H&P
Initiate treatment with NSAIDs if no
contraindications 24-48hrs prior to menses
Provide heat in the way of heating pad or
Thermacare
Consider Mefenamic acid
Hormonal mgmt is another option if
conservative mgmt is failing
Last resort-gyn will consider dx lap
Oral contraceptive pills:
 Contraindications p
pertaining
g to adolescentmigraine with aura, stroke, VTE, MI, liver disease,
thrombophilia
 Start cycle d#1 or Sunday after the bleeding starts
 Taken same time everyday; miss one pill take as
soon as remember then take the one for that day;
do that more than twice then have a period and
start new pkg
 RTC in 3mo to ensure working well;
 If contraindication to combined pill then start
micronor but remember no placebo pills and less
efficacious
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Contraceptive patch:
Ch
t h weekly
kl ffor 3 wks
k th
t h
 Change
patch
then one patch
free wk
 Max wt=198lbs
Vaginal ring:
Pl
iin vaginal
i l ffor 33wks
k th
 Place
then remove ffor one
ring free week
 Effective 7d after insertion
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Depo Provera:
P
ti only
l
 Progestin
 One injection every 3mo
 Monitor for wt gain, irregular bleeding, mood
changes
 Counsel on effects of depo on bone; need ca2+
supplement
IUD’s
Sk l
ti only;
l good
d for
f 3yrs;
3
ll
 Skyla-progestin
smaller
than mirena
 Mirena-progestin only; good for 5yrs;
 Paragard-hormone free; copper based; good for
10yrs
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Implanon
“ d in
i arm””
 “rod
 3yrs
 Monitor for irregular bleeding-#1
discontinuation reason
 Progestin only
Barrier/Condom
d l
t should
h ld b
i th
 All adolescents
be using
them b
because
other methods on contraception are not
preventing std’s
 If latex allergic the polyurethane condoms
 Condom education for each pt.
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5/13/2013
 Clinical Protocols in Pediatric and Adolescent
Gynecology Perlman,
Perlman Nakajima,
Nakajima and Hertweck.
Hertweck
Gynecology.
2004.
 Pediatric and Adolescent Gynecology 5th Ed. Emans
et al. 2005.
2005.
 Clinical Gynecologic Endocrinology And Infertility
7th Ed. Speroff, et al.
al. 2005.
 Uptodate.com
Uptodate.com;; 2013.
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