Pediatric gynaecology or pediatric gynecology
[See ]American and British English spelling differences
Despite the various List of dialects of English, English dialects spoken from country to country and within different regions of the same country, there are only slight regional variations in English orthography, the two most notable variatio ...
. ''Gynecology'' is the American spelling, but it is also common in international contexts, e.g. International Federation of Gynecology and Obstetrics
The International Federation of Gynaecology and Obstetrics, usually just FIGO ("fee'go") as the acronym of its French name Fédération Internationale de Gynécologie et d'Obstétrique, is a worldwide non-governmental organisation representing ob ...
an
International Society of Ultrasound in Obstetrics and Gynecology
is the medical practice dealing with the health of the
vagina
In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vestibule to the cervix. The outer vaginal opening is normally partly covered by a thin layer of mucosal tissue called the hymen ...
,
vulva
The vulva (plural: vulvas or vulvae; derived from Latin for wrapper or covering) consists of the external sex organ, female sex organs. The vulva includes the mons pubis (or mons veneris), labia majora, labia minora, clitoris, bulb of vestibu ...
,
uterus
The uterus (from Latin ''uterus'', plural ''uteri'') or womb () is the organ in the reproductive system of most female mammals, including humans that accommodates the embryonic and fetal development of one or more embryos until birth. The uter ...
, and
ovaries
The ovary is an organ in the female reproductive system that produces an ovum. When released, this travels down the fallopian tube into the uterus, where it may become fertilized by a sperm. There is an ovary () found on each side of the body. T ...
of infants, children, and adolescents. Its counterpart is
pediatric andrology, which deals with medical issues specific to the
penis
A penis (plural ''penises'' or ''penes'' () is the primary sexual organ that male animals use to inseminate females (or hermaphrodites) during copulation. Such organs occur in many animals, both vertebrate and invertebrate, but males do n ...
and
testes
A testicle or testis (plural testes) is the male reproductive gland or gonad in all bilaterians, including humans. It is homologous to the female ovary. The functions of the testes are to produce both sperm and androgens, primarily testoster ...
.
Etymology
The word "gynaecology" comes from the Greek γυνή ''gyne''. "woman" and ''-logia'', "study."
History
Examination
Assessment of the external genitalia and
breast development
Breast development, also known as mammogenesis, is a complex biological process in primates that takes place throughout a female's life.
It occurs across several phases, including prenatal development, puberty, and pregnancy. At menopause, br ...
are often part of routine physical examinations. Physicians also can advise pediatric gynecology patients on anatomy and sexuality. Assessment can include an examination of the vulva, and rarely involve the introduction of instruments into the vagina. Many young patients prefer to have a parent, usually a mother, in the examination room. Two main positions for examination can be used, depending on the patient's preference and the specific examination being performed, including the frog-leg position (with the head of the examination table raised or lowered), the
lithotomy position
The lithotomy position is a common position for surgical procedures and medical examinations involving the pelvis and lower abdomen, as well as a common position for childbirth in Western nations. The lithotomy position involves the positioning of ...
with stirrups, or either of these with a parent holding the child. A hand mirror can be provided to allow the child to participate and to educate the child about their anatomy.
Anesthesia
Anesthesia is a state of controlled, temporary loss of sensation or awareness that is induced for medical or veterinary purposes. It may include some or all of analgesia (relief from or prevention of pain), paralysis (muscle relaxation), ...
or
sedation
Sedation is the reduction of irritability or agitation by administration of sedative drugs, generally to facilitate a medical procedure or diagnostic procedure. Examples of drugs which can be used for sedation include isoflurane, diethyl ether, ...
should only be used when the examination is being performed in an emergency situation; otherwise it is recommended that the clinician see a reluctant child with a gynecologic complaint over several visits to foster trust.
Examination of the external genitalia should be done by gently moving the labia minora to either side, or gently moving them towards the anterior (front) side of the body to expose the vaginal introitus.
Routine physical examinations by a pediatrician typically include a visual examination of breasts and vulva; more extensive examinations may be performed by a pediatrician in response to a specific complaint. Rarely, an internal examination may be necessary, and may need to be conducted under anesthesia. Cases where an internal examination may be necessary include vaginal bleeding, retained foreign bodies, and potential tumors.
Diseases and conditions
There are a number of common pediatric gynecologic conditions and complaints, both pathological and benign.
Hernias
Intersex conditions
A pediatric gynecologist can care for children with a number of
intersex
Intersex people are individuals born with any of several sex characteristics including chromosome patterns, gonads, or genitals that, according to the Office of the United Nations High Commissioner for Human Rights, "do not fit typical bina ...
conditions, including
Swyer syndrome (46,XY
karyotype
A karyotype is the general appearance of the complete set of metaphase chromosomes in the cells of a species or in an individual organism, mainly including their sizes, numbers, and shapes. Karyotyping is the process by which a karyotype is disce ...
).
Amenorrhea
Amenorrhea, the lack of a
menstrual period
The menstrual cycle is a series of natural changes in hormone production and the structures of the uterus and ovaries of the female reproductive system that make pregnancy possible. The ovarian cycle controls the production and release of eggs ...
, may indicate a congenital anomaly of the reproductive tract. Typically obvious on an external visual examination of a child's vulva,
imperforate hymen
An imperforate hymen is a congenital disorder where a hymen without an opening completely obstructs the vagina. It is caused by a failure of the hymen to perforate during Prenatal development, fetal development. It is most often diagnosed in adole ...
is the presence of a
hymen
The hymen is a thin piece of mucosal tissue that surrounds or partially covers the external vaginal opening. It forms part of the vulva, or external genitalia, and is similar in structure to the vagina.
In children, a common appearance of the h ...
that completely covers the introitus. Other anomalies that can cause amenorrhea include
Müllerian agenesis
Müllerian agenesis, also known as Müllerian aplasia, vaginal agenesis, or Mayer-Rokitansky-Küster-Hauser syndrome (MRKH syndrome), is a congenital malformation characterized by a failure of the Müllerian ducts to develop, resulting in a missi ...
affecting the uterus, cervix, and/or vagina;
obstructed uterine horn
Obstruction may refer to:
Places
* Obstruction Island, in Washington state
* Obstruction Islands, east of New Guinea
Medicine
* Obstructive jaundice
* Obstructive sleep apnea
* Airway obstruction, a respiratory problem
** Recurrent airway ob ...
;
OHVIRA syndrome
Herlyn-Werner-Wunderlich syndrome, also known as OHVIRA (obstructed hemivagina and ipsilateral renal anomaly) is an extremely rare syndrome characterized by a congenital birth defect of the lower abdominal and pelvic organs. It is a type of abnorma ...
; and the presence of a transverse
vaginal septum
A vaginal septum is a vaginal anomaly that is partition within the vagina; such a septum could be either longitudinal or transverse. In some affected women, the septum is partial or does not extend the length or width of the vagina. Pain during ...
. OHVIRA and uterine horn obstruction can also cause increasingly painful menstruation (
dysmenorrhea
Dysmenorrhea, also known as period pain, painful periods or menstrual cramps, is pain during menstruation. Its usual onset occurs around the time that menstruation begins. Symptoms typically last less than three days. The pain is usually in the ...
) in the months following
menarche
Menarche ( ; ) is the first menstrual cycle, or first menstrual bleeding, in female humans. From both social and medical perspectives, it is often considered the central event of female puberty, as it signals the possibility of fertility.
Gir ...
.
Abnormal vaginal bleeding
Vaginal bleeding not associated with menarche may be cause for concern in a child. In the first few days of life, some amount of vaginal bleeding is normal, prompted by the drop in transplacental hormones. Causes of vaginal bleeding in children include trauma, condyloma acuminata, lichen sclerosus, vulvovaginitis, tumors, urethral prolapse, precocious puberty, exogenous hormone exposure, and retained foreign body. Most causes can be diagnosed with a visual examination of the vulva and a careful medical history, but some may require vaginoscopy or a speculum exam.
Vulvovaginitis
Vulvovaginitis in children may be "nonspecific", or caused by irritation with no known infectious cause, or infectious, caused by a pathogenic organism. Nonspecific vulvovaginitis may be triggered by fecal contamination, sexual abuse, chronic diseases,
foreign bodies
A foreign body (FB) is any object originating outside the body of an organism. In machinery, it can mean any unwanted intruding object.
Most references to foreign bodies involve propulsion through natural orifices into hollow organs.
Foreign bo ...
, nonestrogenized epithelium, chemical irritants,
eczema
Dermatitis is inflammation of the Human skin, skin, typically characterized by itchiness, erythema, redness and a rash. In cases of short duration, there may be small blisters, while in long-term cases the skin may become lichenification, thick ...
,
seborrhea
A sebaceous gland is a microscopic exocrine gland in the skin that opens into a hair follicle to secrete an oily or waxy matter, called sebum, which lubricates the hair and skin of mammals. In humans, sebaceous glands occur in the greatest numbe ...
, or immunodeficiency. It is treated with topical steroids; antibiotics may be given in cases where itching has resulted in a secondary infection.
Infectious vulvovaginitis can be caused by
group A beta-hemolytic ''Streptococcus'' (7–20% of cases), ''
Haemophilus influenzae
''Haemophilus influenzae'' (formerly called Pfeiffer's bacillus or ''Bacillus influenzae'') is a Gram-negative, non-motile, coccobacillary, facultatively anaerobic, capnophilic pathogenic bacterium of the family Pasteurellaceae. The bacteria ...
,
Streptococcus pneumoniae
''Streptococcus pneumoniae'', or pneumococcus, is a Gram-positive, spherical bacteria, alpha-hemolytic (under aerobic conditions) or beta-hemolytic (under anaerobic conditions), aerotolerant anaerobic member of the genus Streptococcus. They are ...
,
Staphylococcus aureus
''Staphylococcus aureus'' is a Gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often positive ...
,
Shigella
''Shigella'' is a genus of bacteria that is Gram-negative, facultative anaerobic, non-spore-forming, nonmotile, rod-shaped, and genetically closely related to ''E. coli''. The genus is named after Kiyoshi Shiga, who first discovered it in 1897. ...
,
Yersinia
''Yersinia'' is a genus of bacteria in the family Yersiniaceae. ''Yersinia'' species are Gram-negative, coccobacilli bacteria, a few micrometers long and fractions of a micrometer in diameter, and are facultative anaerobes. Some members of ''Ye ...
'', or common STI organisms (''
Neisseria gonorrhoeae
''Neisseria gonorrhoeae'', also known as ''gonococcus'' (singular), or ''gonococci'' (plural), is a species of Gram-negative diplococci bacteria isolated by Albert Ludwig Sigesmund Neisser, Albert Neisser in 1879. It causes the sexually transmit ...
,
Chlamydia trachomatis
''Chlamydia trachomatis'' (), commonly known as chlamydia, is a bacterium that causes chlamydia, which can manifest in various ways, including: trachoma, lymphogranuloma venereum, nongonococcal urethritis, cervicitis, salpingitis, pelvic inflamma ...
,
Trichomonas vaginalis
''Trichomonas vaginalis'' is an anaerobic, flagellated protozoan parasite and the causative agent of a sexually transmitted disease called trichomoniasis. It is the most common pathogenic protozoan that infects humans in industrialized countries ...
'',
herpes simplex virus
Herpes simplex virus 1 and 2 (HSV-1 and HSV-2), also known by their taxonomical names ''Human alphaherpesvirus 1'' and '' Human alphaherpesvirus 2'', are two members of the human ''Herpesviridae'' family, a set of viruses that produce viral inf ...
, and
human papillomavirus
Human papillomavirus infection (HPV infection) is caused by a DNA virus from the ''Papillomaviridae'' family. Many HPV infections cause no symptoms and 90% resolve spontaneously within two years. In some cases, an HPV infection persists and res ...
)''.'' Symptoms and treatment of infectious vulvovaginitis vary depending on the organism causing it. ''Shigella'' infections of the reproductive tract usually coexist with infectious of the gastrointestinal tract and cause mucous, purulent discharge. They are treated with
trimethoprim-sulfamethoxazole
Trimethoprim/sulfamethoxazole, sold under the brand name Bactrim among others, is a fixed-dose combination antibiotic medication used to treat a variety of bacterial infections. It consists of one part trimethoprim to five parts sulfamethoxazo ...
. ''Streptococcus'' infections cause similar symptoms to nonspecific vulvovaginitis and are treated with
amoxicillin
Amoxicillin is an antibiotic medication used to treat a number of bacterial infections. These include middle ear infection, strep throat, pneumonia, skin infections, and urinary tract infections among others. It is taken by mouth, or less c ...
. STI-associated vulvovaginitis may be caused by sexual abuse or
vertical transmission Vertical transmission of symbionts is the transfer of a microbial symbiont from the parent directly to the offspring. Many metazoan species carry symbiotic bacteria which play a mutualistic, commensal, or parasitic role. A symbiont is acquire ...
, and are treated and diagnosed like adult infections.
Vulvitis
Vulvitis, inflammation of the vulva, can have a variety of etiologies in children and adolescents, including
allergic dermatitis
Dermatitis is inflammation of the Human skin, skin, typically characterized by itchiness, erythema, redness and a rash. In cases of short duration, there may be small blisters, while in long-term cases the skin may become lichenification, thick ...
,
contact dermatitis
Contact dermatitis is a type of acute or chronic inflammation of the skin caused by exposure to chemical or physical agents. Symptoms of contact dermatitis can include itchy or dry skin, a red rash, bumps, blisters, or swelling. These rashes are ...
,
lichen sclerosus
Lichen sclerosus (LS) is a chronic, inflammatory skin disease of unknown cause which can affect any body part of any person but has a strong preference for the genitals (penis, vulva) and is also known as balanitis xerotica obliterans (BXO) when ...
, and infections with bacteria, fungi, and parasites. Dermatitis in infants is commonly caused by a soiled diaper being left on for an extended period of time. Increasing the frequency of diaper changes and topical application of
emollients
A moisturizer, or emollient, is a cosmetic preparation used for protecting, moisturizing, and lubricating the skin. These functions are normally performed by sebum produced by healthy skin. The word "emollient" is derived from the Latin verb ''mo ...
are sufficient to resolve most cases. Dermatitis of the vulva in older children is usually caused by exposure to an irritant (e.g. scented products that come into contact with the vulva, laundry detergent, soaps, etc.) and is treated with preventing exposure and encouraging
sitz bath
A sitz bath or hip bath is a bath in which a person sits in water up to the hips. It is used to relieve discomfort and pain in the lower part of the body, for example, due to hemorrhoids (piles), anal fissures, perianal fistulas, rectal surgery, ...
s with
baking soda
Sodium bicarbonate (IUPAC name: sodium hydrogencarbonate), commonly known as baking soda or bicarbonate of soda, is a chemical compound with the formula NaHCO3. It is a salt composed of a sodium cation ( Na+) and a bicarbonate anion ( HCO3−) ...
as the vulvar skin heals. Other treatment options for vulvar dermatitis include oral
hydroxyzine hydrochloride or topical
hydrocortisone
Hydrocortisone is the name for the hormone cortisol when supplied as a medication. Uses include conditions such as adrenocortical insufficiency, adrenogenital syndrome, high blood calcium, thyroiditis, rheumatoid arthritis, dermatitis, asthma, ...
.
Lichen sclerosus is another common cause of vulvitis in children, and it often affects an hourglass or figure eight-shaped area of skin around the anus and vulva. Symptoms of a mild case include skin fissures, loss of skin pigment (
hypopigmentation
Hypopigmentation is characterized specifically as an area of skin becoming lighter than the baseline skin color, but not completely devoid of pigment. This is not to be confused with depigmentation, which is characterized as the absence of all pi ...
), skin atrophy, a parchment-like texture to the skin, dysuria, itching, discomfort, and excoriation. In more severe cases, the vulva may become discolored, developing dark purple bruising (
ecchymosis
A bruise, also known as a contusion, is a type of hematoma of tissue, the most common cause being capillaries damaged by trauma, causing localized bleeding that extravasates into the surrounding interstitial tissues. Most bruises occur close e ...
), bleeding, scarring, attenuation of the labia minora, and fissures and bleeding affecting the posterior
fourchette. Its cause is unknown, but likely genetic or autoimmune, and it is unconnected to malignancy in children. If the skin changes are not obvious on visual inspection, a biopsy of the skin may be performed to acquire an exact diagnosis. Treatment for vulvar lichen sclerosis may consist of topical hydrocortisone in mild cases, or stronger topical steroids (e.g.
clobetasol propionate
Clobetasol propionate is a corticosteroid used to treat skin conditions such as eczema, contact dermatitis, seborrheic dermatitis, and psoriasis. It is applied to the skin as a cream, ointment, or shampoo. Use should be short term and only if ot ...
). Preliminary studies show that 75% of cases do not resolve with puberty.
Organisms responsible for vulvitis in children include pinworms (''
Enterobius vermicularis
The pinworm (species ''Enterobius vermicularis''), also known as threadworm (in the United Kingdom, Australia and New Zealand) or seatworm, is a parasitic worm. It is a nematode (roundworm) and a common intestinal parasite or helminth, esp ...
''), ''
Candida'' yeast, and
group A hemolytic ''Streptococcus''. Though pinworms mainly affect the perianal area, they can cause itching and irritation to the vulva as well. Pinworms are treated with
albendazole
Albendazole (also known as albendazolum) is a broad-spectrum anthelmintic and antiprotozoal agent of the benzimidazole type. It is used for the treatment of a variety of intestinal parasite infections, including ascariasis, pinworm infection, h ...
. Vulvar ''
Candida''
infections
An infection is the invasion of tissue (biology), tissues by pathogens, their multiplication, and the reaction of host (biology), host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmiss ...
are uncommon in children, and generally occur in infants after antibiotic therapy, and in children with
diabetes
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...
or
immunodeficiency
Immunodeficiency, also known as immunocompromisation, is a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent. Most cases are acquired ("secondary") due to extrinsic factors that a ...
. ''Candida'' infections cause a red raised vulvar rash with satellite lesions and clear borders, and are diagnosed by microscopically examining a sample treated with potassium hydroxide for hyphae. They are treated with topical
butoconazole
Butoconazole (trade names Gynazole-1, Mycelex-3) is an imidazole antifungal used in gynecology. It is administered as a vaginal cream.Butoconazole
Synthesis
Reaction of epichlorohydrin with 4-Chlorobenzyl magnesium bromide leads to 1-chloro-4 ...
,
clotrimazole
Clotrimazole, sold under the brand name Lotrimin, among others, is an antifungal medication. It is used to treat vaginal yeast infections, oral thrush, diaper rash, tinea versicolor, and types of ringworm including athlete's foot and jock itch ...
, or
miconazole
Miconazole, sold under the brand name Monistat among others, is an antifungal medication used to treat ring worm, pityriasis versicolor, and yeast infections of the skin or vagina. It is used for ring worm of the body, groin (jock itch), and fee ...
. ''Streptococcus'' infections are characterized by a dark red discoloration of the vulva and introitus, and cause pain, itching, bleeding, and dysuria. They are treated with antibiotics.
Breast abnormalities
An abnormal mass in a child's developing breast or early development of breast tissue may prompt concern. Neonates can have small breast buds at birth or white discharge (witches' milk), caused by exposure to transplacental hormones in utero. These phenomena are not pathological and typically disappear over the first weeks to months of life. Accessory nipples (
polythelia
A supernumerary nipple is an additional instance of nipple occurring in mammals, including humans. They are often mistaken for moles. Studies variously report the prevalence of supernumerary nipples as approximately 1 in 18 and 1 in 40. https:// ...
) occur in 1% of children along the
embryonic milk line and are benign in most cases. They may be removed surgically if they develop glandular tissue and cause pain, have discharge, or develop fibroadenomas.
Some asymmetric breast growth is normal in early adolescence, but asymmetry may be caused by trauma,
fibroadenoma
Fibroadenomas are benign breast tumours characterized by an admixture of stromal and epithelial tissue. Breasts are made of lobules (milk producing glands) and ducts (tubes that carry the milk to the nipple). These are surrounded by glandular, ...
, or cysts. Most non-pathological asymmetry resolves spontaneously by the end of puberty; if it does not, surgical intervention is possible. Some adolescents may develop tuberous breasts, wherein the normal fat and glandular tissue grows directly away from the chest due to the adherence of breast fascia to the underlying muscle.
Hormone replacement therapy
Hormone replacement therapy (HRT), also known as menopausal hormone therapy or postmenopausal hormone therapy, is a form of hormone therapy used to treat symptoms associated with female menopause. These symptoms can include hot flashes, vaginal ...
or
oral contraceptives Oral contraceptives, abbreviated OCPs, also known as birth control pills, are medications taken by mouth for the purpose of birth control.
Female
Two types of female oral contraceptive pill, taken once per day, are widely available:
* The combin ...
are used to encourage outward growth of the breast base.
Hypertrophy of breast tissue may or may not be a problem for an individual adolescent; back pain,
kyphosis
Kyphosis is an abnormally excessive convex curvature of the spine as it occurs in the thoracic and sacral regions. Abnormal inward concave ''lordotic'' curving of the cervical and lumbar regions of the spine is called lordosis. It can result fr ...
, shoulder pain, and psychologic distress may be cause for
breast reduction surgery
Reduction mammoplasty (also breast reduction and reduction mammaplasty) is the plastic surgery procedure for reducing the size of large breasts. In a breast reduction surgery for re-establishing a functional bust that is proportionate to the woma ...
after development is complete. On the opposite end of the spectrum, breast tissue may not develop for a variety of reasons. The most common cause is low levels of estrogen (
hypoestrogenism
Hypoestrogenism, or estrogen deficiency, refers to a lower than normal level of estrogen. It is an umbrella term used to describe estrogen deficiency in various conditions. Estrogen deficiency is also associated with an increased risk of cardiova ...
), which may result from chronic disease, radiation or chemotherapy,
Poland syndrome
Poland syndrome is a birth defect characterized by an underdeveloped chest muscle and short webbed fingers on one side of the body. There may also be short ribs, less fat, and breast and nipple abnormalities on the same side of the body. Typical ...
, extreme physical activity, or
gonadal dysgenesis
Gonadal dysgenesis is classified as any congenital developmental disorder of the reproductive system
in the male or female. It is the atypical development of the gonads in an embryo,
with reproductive tissue replaced with functionless, fibrous ti ...
.
Amastia
Amastia refers to a rare clinical anomaly in which both internal breast tissue and the visible nipple are absent on one or both sides. It affects both men and women. Amastia can be either isolated (the only medical condition) or comorbid with othe ...
, which occurs when a child is born without glandular breast tissue, is rare.
More than 99% of breast masses in children and adolescents are benign, and include fibrocystic breast changes, cysts, fibroadenomas, lymph nodes, and abscesses. Fibroadenomas make up 68–94% of all pediatric breast masses, and can be simply observed to ensure their stability, or excised if they are symptomatic, large, and/or enlarging.
Mastitis
Mastitis, infection of the breast tissue, occurs most commonly in neonates and children over 10, though it is rare overall in children. Most often caused by ''S. aureus'', mastitis in children is caused by a variety of factors, including trauma, nipple piercing, lactation and/or pregnancy, or shaving periareolar hair. The development of abscesses from mastitis is more common in children than in adults.
Contraception
Pregnancy
Precocious puberty
Precocious puberty occurs when children younger than 8 experience changes indicative of
puberty
Puberty is the process of physical changes through which a child's body matures into an adult body capable of sexual reproduction. It is initiated by hormonal signals from the brain to the gonads: the ovaries in a girl, the testes in a boy. ...
, including development of
breast buds (thelarche),
pubic hair
Pubic hair is terminal body hair that is found in the genital area of adolescent and adult humans. The hair is located on and around the sex organs and sometimes at the top of the inside of the thighs. In the pubic region around the pubis bon ...
, and a
growth spurt
Human height or stature is the distance from the bottom of the feet to the top of the head in a human body, standing erect. It is measured using a stadiometer, in centimetres when using the metric system or SI system, or feet and inches when u ...
. Thelarche before 8 is considered abnormal. Though not all precocious puberty has a specific pathological cause, it may indicate a serious medical problem and is thoroughly evaluated. In most cases, the cause of precocious puberty cannot be identified. "
Central precocious puberty
In medicine, precocious puberty is puberty occurring at an unusually early age. In most cases, the process is normal in every aspect except the unusually early age and simply represents a variation of normal development. In a minority of childr ...
" or "true precocious puberty" stems from early activation of the
hypothalamic-pituitary-ovarian axis. It occurs in 1 in 5,000 to 1 in 10,000 people and can be caused by a lesion in the central nervous system or
have no apparent cause. "Peripheral precocious puberty" or "GnRH independent precocious puberty" does not involve the hypothalamic-pituitary-ovarian axis, instead, it involves other sources of hormones. The causes of peripheral precocious puberty include adrenal or ovarian tumors, congenital adrenal hyperplasia, and exogenous hormone exposure.
Premature thelarche
Premature development of breast tissue is not necessarily indicative of precocious puberty; if it occurs without a corresponding growth spurt and with normal bone age, it does not represent pubertal development. It is associated with low birthweight and slightly elevated estradiol. Most premature breast development regresses spontaneously, and monitoring for other signs of precocious puberty is usually the only necessary management.
Labial adhesion
Labial adhesion is a fusion between the labia minora that may be small and posterior – and generally asymptomatic – or may involve the entire labia and seal off the vaginal introitus entirely. It is generally only treated when it causes urinary symptoms; otherwise it normally resolves when the vaginal mucosa becomes estrogenized at the onset of puberty. Treatments include topical application of estrogens or
betamethasone
Betamethasone is a steroid medication. It is used for a number of diseases including rheumatic disorders such as rheumatoid arthritis and systemic lupus erythematosus, skin diseases such as dermatitis and psoriasis, allergic conditions such ...
with gentle traction on the labia, followed with
vitamin A
Vitamin A is a fat-soluble vitamin and an essential nutrient for humans. It is a group of organic compounds that includes retinol, retinal (also known as retinaldehyde), retinoic acid, and several provitamin A carotenoids (most notably bet ...
,
vitamin D
Vitamin D is a group of fat-soluble secosteroids responsible for increasing intestinal absorption of calcium, magnesium, and phosphate, and many other biological effects. In humans, the most important compounds in this group are vitamin D3 (c ...
, and/or
petroleum jelly
Petroleum jelly, petrolatum, white petrolatum, soft paraffin, or multi-hydrocarbon, CAS number 8009-03-8, is a semi-solid mixture of hydrocarbons (with carbon numbers mainly higher than 25), originally promoted as a topical ointment for its h ...
to prevent re-adhesion. The labia may be separated manually with
local anesthesia
Local anesthesia is any technique to induce the absence of sensation in a specific part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It ...
or surgically under
general anesthesia
General anaesthesia (UK) or general anesthesia (US) is a medically induced loss of consciousness that renders the patient unarousable even with painful stimuli. This effect is achieved by administering either intravenous or inhalational general ...
(in a procedure called
introitoplasty) if topical treatment is unsuccessful. This is followed with estrogen treatment to prevent recurrence.
Ovarian mass
Ovarian masses in children are typically cystic, but 1% are malignant ovarian cancers. 30–70% of neonates with ovaries have cysts; they are caused by transplacental hormones ''in utero'' or by the postnatal spike in
gonadotropin
Gonadotropins are glycoprotein hormones secreted by gonadotropic cells of the anterior pituitary of vertebrates. This family includes the mammalian hormones follicle-stimulating hormone (FSH) and luteinizing hormone (LH), the placental/ chorioni ...
s. Neonatal ovarian cysts usually affect one ovary, do not cause symptoms, are classed as simple, and disappear by the age of 4 months. In rare cases, neonatal ovarian cysts may result in
ovarian torsion
Ovarian torsion (OT) or adnexal torsion is an abnormal condition where an ovary twists on its attachment to other structures, such that blood flow is decreased. Symptoms typically include pelvic pain on one side. While classically the pain is su ...
,
autoamputation Autoamputation is the spontaneous detachment (amputation) of an appendage or organ from the body. This is not to be confused with self-amputation. It is usually due to destruction of the blood vessels feeding an extremity such as the finger tips. O ...
of the ovary,
intracystic hemorrhage,
rupture
Rupture may refer to:
General
* Rupture (engineering), a failure of tough ductile materials loaded in tension
Anatomy and medicine
* Abdominal hernia, formerly referred to as "a rupture"
* Achilles tendon rupture
* Rupture of membranes, a "wate ...
, and compression of surrounding organs. Cysts smaller than 5 centimeters in diameter may be monitored with ultrasonography; larger cysts are more likely to cause complications are either drained by percutaneous aspiration or surgically removed.
In older children, cystic ovarian masses may cause a visible change in body shape, chronic pain, and precocious puberty; complications with these cysts cause acute, severe abdominal pain.
Transabdominal ultrasonography can be used to diagnose and image pediatric ovarian cysts, because transvaginal probes are not recommended for use in children. Complex cysts are likely to be
benign mature cystic teratoma, whereas the most common malignancies in this age group are malignant germ cell tumors and
epithelial ovarian cancer
Surface epithelial-stromal tumors are a class of ovarian neoplasms that may be benign or malignant. Neoplasms in this group are thought to be derived from the ovarian surface epithelium (modified peritoneum) or from ectopic endometrial or Fallopi ...
.
Complaints
Common pediatric gynecologic complaints include
vaginal discharge
Vaginal discharge is a mixture of liquid, cells, and bacteria that lubricate and protect the vagina. This mixture is constantly produced by the cells of the vagina and cervix, and it exits the body through the vaginal opening. The composition, amou ...
, pre-
menarche
Menarche ( ; ) is the first menstrual cycle, or first menstrual bleeding, in female humans. From both social and medical perspectives, it is often considered the central event of female puberty, as it signals the possibility of fertility.
Gir ...
bleeding,
itch
Itch (also known as pruritus) is a sensation that causes the desire or reflex to scratch. Itch has resisted many attempts to be classified as any one type of sensory experience. Itch has many similarities to pain, and while both are unpleasant ...
ing, and accounts of
sexual abuse
Sexual abuse or sex abuse, also referred to as molestation, is abusive sexual behavior by one person upon another. It is often perpetrated using force or by taking advantage of another. Molestation often refers to an instance of sexual assa ...
.
A mass in the inguinal area may be a
hernia
A hernia is the abnormal exit of tissue or an organ (anatomy), organ, such as the bowel, through the wall of the cavity in which it normally resides. Various types of hernias can occur, most commonly involving the abdomen, and specifically the gr ...
or may be a testis in an intersex child.
Prepubertal anatomy
The
vaginal mucosa
In mammals, the vagina is the elastic, muscular part of the female genital tract. In humans, it extends from the vestibule to the cervix. The outer vaginal opening is normally partly covered by a thin layer of mucosal tissue called the hymen. ...
in prepubertal children is markedly different from that of postpubertal adolescents; it is thin and red colored.
In neonates, the uterus is spade-shaped, contains fluid 25% of the time, and often has a visible
endometrial stripe. This is normal and due to the hormones that have passed to the neonate across the
placenta
The placenta is a temporary embryonic and later fetal organ that begins developing from the blastocyst shortly after implantation. It plays critical roles in facilitating nutrient, gas and waste exchange between the physically separate mater ...
. The shape of the uterus is influenced by the anteroposterior diameter of the
cervix
The cervix or cervix uteri (Latin, 'neck of the uterus') is the lower part of the uterus (womb) in the human female reproductive system. The cervix is usually 2 to 3 cm long (~1 inch) and roughly cylindrical in shape, which changes during ...
, which is larger than the
fundus at this age. By premenarchal age, the uterus is tubular, because the fundus and the cervix are the same diameter. The
ovaries
The ovary is an organ in the female reproductive system that produces an ovum. When released, this travels down the fallopian tube into the uterus, where it may become fertilized by a sperm. There is an ovary () found on each side of the body. T ...
are small in neonates and grow throughout childhood to a volume of 2–4 cubic centimeters. On
vaginoscopy, the prepubertal cervix is usually level with the proximal vagina.
Puberty
During puberty, the vaginal mucosa becomes
estrogen
Estrogen or oestrogen is a category of sex hormone responsible for the development and regulation of the female reproductive system and secondary sex characteristics. There are three major endogenous estrogens that have estrogenic hormonal acti ...
ized and becomes a dull pink color and gains moisture.
Secondary sex characteristic
Secondary sex characteristics are features that appear during puberty in humans, and at sexual maturity in other animals. These characteristics are particularly evident in the sexually dimorphic phenotypic traits that distinguish the sexes of a sp ...
s develop under the influence of estrogen on the
hypothalamic-pituitary-gonadal axis, typically between the ages of 8 and 13. These characteristics include breast buds, pubic hair, and accelerated growth. Higher body mass index is correlated with earlier puberty.
References
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Gynaecology