Paediatric Gynaecology

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2. Objectives. To discuss the following common conditionsPrepubertal girlsVaginal dischargesPerineal traumaAdolescentsPelvic painAbnormal Bleeding. 3. Vaginal Discharge. Common prepubertal gynaecologic complaintLack of oestrogenic affect on vaginal mucosa increases susceptibility to infectio

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Paediatric Gynaecology

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1. 1 Paediatric Gynaecology Tarek Motan Division of Reproductive Endocrinology & Infertility Adolescent & Paediatric Gynaecology University of Alberta 25 September 2009

2. 2 Objectives To discuss the following common conditions Prepubertal girls Vaginal discharges Perineal trauma Adolescents Pelvic pain Abnormal Bleeding

3. 3 Vaginal Discharge Common prepubertal gynaecologic complaint Lack of oestrogenic affect on vaginal mucosa increases susceptibility to infection Thin mucosa with alkaline pH 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 creamHypoestrogenic 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

4. 4 Vaginal Discharge Non Infectious Vulvovaginitis Foreign body Systemic disorders Tumours Anomalies Infectious Grp A Strep Shigella Pinworms Gonococcus Chlamydia Trichomonas Bacterial vaginosis

5. 5 Vaginal Discharge Bloody Grp A Strep Shigella Foreign body Trauma Scratching Condyloma Green Staphylococcus Streptococcus Haemophilus Gonococcus Foreign body

6. 6 History 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 Examination 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 Examination Swab discharge Prefer dacron male urethral swab Avoid touching post hymen Request Aerobic culture Gonorrhoea & chlamydia culture Consider wet mount

9. 9 Vulvovaginitis 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 Vulvovaginitis - 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 Vulvovaginitis - 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 Vulvovaginitis 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 Foreign 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 Perineal 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 Perineal 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 Perineal 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 Perineal 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 Adolescent 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 Primary 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 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 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

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 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 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

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 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 pathwaySOGC 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

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 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 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

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 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% 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%

24. 24 Adolescent 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 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 Laufer et al Pediatr Adolesc Gynecol 1997;10:199-202 Ballweg et al Pediatr Adolesc Gynecol 2003, 16: s21 - 6 Laufer et al Pediatr Adolesc Gynecol 1997;10:199-202 Ballweg et al Pediatr Adolesc Gynecol 2003, 16: s21 - 6

26. 26 Adolescent 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% 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 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

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 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)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)

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 Wright et al Fertil Steril 2005, 83: 1830 -6 Wright et al Fertil Steril 2005, 83: 1830 -6

29. 29 Abnormal 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 Aetiology 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 Exclude pregnancy & related conditions (ectopics, etc) Dx: ?-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 Bleeding

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 Bleeding

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 Bleeding

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 Bleeding

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 Bleeding

36. 36 Questions Please

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