Gynecology Topic 15. Pediatric gynecology

I. Pediatric Gynecology: Typical Problems

Typical complaints

• Infections: vulvovaginitis, STI/STD, urinary tract infection.
• Amenorrhea and menstrual disorders.
• Pubertal problems: precocious puberty, delayed puberty, incomplete sexual precocity.
• Congenital abnormalities: hymenal/vaginal/uterine malformations.
• Trauma, genital bleeding, foreign body, tumor.
• Adolescent issues: contraception, pregnancy, PCOS, endometriosis, psychosexual problems.

Examination principles

• Age-appropriate communication; explain each step and reduce fear.
• External inspection is usually enough in prepubertal children.
• Speculum/internal examination: only if clearly indicated, usually by an experienced clinician.
• Unexplained trauma, bleeding, discharge, STI, or concerning behavior → consider sexual/physical abuse and follow safeguarding rules.

II. Precocious Puberty

Definition and importance

• Precocious puberty: onset of secondary sex characteristics before 8 years in girls or 9 years in boys.
• Main risks: accelerated growth + advanced bone age → early epiphyseal closure → short adult height; psychosocial distress.

Classification

1. Central precocious puberty: true / GnRH-dependent

• Mechanism: early activation of hypothalamic-pituitary-gonadal axis → normal sequence, too early.
• Causes: idiopathic, CNS lesion/tumor, infection, hydrocephalus, trauma, CNS radiation.
• Idiopathic is common in girls; CNS pathology is more concerning in boys or very young girls.

2. Peripheral precocious puberty: pseudo / GnRH-independent

• Mechanism: excess sex hormones independent of GnRH.
• Causes: ovarian/adrenal tumor, congenital adrenal hyperplasia, hCG-producing germ-cell tumor/choriocarcinoma, exogenous steroid.
• Pattern may be discordant: e.g. virilization without true gonadarche.

3. Incomplete sexual precocity

• Premature thelarche/adrenarche or isolated pubarche without progressive full puberty.

Diagnosis

1. Confirm progression: history, growth velocity, Tanner stage, height/weight/BMI, neurologic symptoms.
2. Wrist/hand X-ray: bone age compared with chronological age.
3. Bone age > 2 years advanced or rapid progression → hormonal evaluation / GnRH stimulation test.
4. LH increases after GnRH: central / GnRH-dependent → brain MRI.
5. No pubertal LH rise after GnRH: peripheral / GnRH-independent → pelvic/adrenal imaging + estradiol/testosterone, DHEA-S, 17-OH-progesterone, beta-hCG as indicated.
6. Basal ultrasensitive LH can support central activation, but stimulation testing is the classic exam test.

Treatment

• Central idiopathic/progressive: continuous GnRH agonist, e.g. leuprolide → pituitary desensitization → suppressed HPG axis.
• Central due to brain disease: treat the underlying cause.
• Peripheral: treat cause → resection of ovarian/adrenal tumor, glucocorticoids for CAH, remove exogenous steroid.
• Slow/non-progressive isolated thelarche/adrenarche: observation with growth and Tanner follow-up may be enough.

III. Delayed Puberty

Definition

• Delayed puberty: no onset of secondary sex characteristics by 13 years in girls or 14 years in boys.
• Girls: no breast development / thelarche by 13 years.
• Boys: no testicular enlargement by 14 years.
• Also evaluate: no menarche by 15 years or > 3 years after thelarche.

Classification and Causes

1. Constitutional delay

• Delayed HPG-axis activation; often familial.
• Bone age delayed; puberty usually occurs spontaneously.

2. Hypergonadotropic hypogonadism: primary gonadal defect

• Mechanism: gonads fail → low sex steroids → high FSH/LH.
• Causes: Turner syndrome, Klinefelter syndrome, gonadal dysgenesis, radiation, chemotherapy.

3. Hypogonadotropic hypogonadism: hypothalamic/pituitary defect or suppression

• Mechanism: insufficient GnRH/FSH/LH → low sex steroids.
• Causes: Kallmann syndrome, pituitary/hypothalamic tumor, CNS disease/radiation.
• Functional causes: chronic disease, diabetes, IBD, cystic fibrosis, malnutrition/eating disorder, excessive exercise.

Diagnosis

1. Detect delay: Tanner staging, height measurement/growth velocity, BMI, family pubertal history.
2. Wrist/hand X-ray: bone age; delayed bone age supports constitutional delay or chronic disease.
3. Hormones: FSH, LH, estradiol/testosterone.
4. High FSH/LH: hypergonadotropic hypogonadism → primary gonadal failure; karyotype if Turner/Klinefelter suspected.
5. Low/normal FSH/LH: constitutional delay or hypogonadotropic hypogonadism → TSH, prolactin, cortisol and chronic-disease screen as indicated.
6. Brain MRI: neurologic symptoms, high prolactin, pituitary hormone deficits, or suspected hypothalamic-pituitary lesion.

Treatment

• Constitutional delay: reassurance and follow-up; puberty eventually occurs.
• Treat underlying disease: nutrition, chronic disease control, reduce excessive exercise, treat CNS/endocrine lesion.
• Hormone replacement: testosterone in boys; gradual estrogen then cyclic progesterone in girls.
• Future fertility in hypogonadotropic hypogonadism: gonadotropin or pulsatile GnRH therapy may be needed later.
• Turner syndrome/growth failure: specialist care; growth hormone may be relevant before pubertal induction.

IV. Other Pediatric-Adolescent Gynecology Points

Vulvovaginitis and UTI

• Common in prepubertal girls because low estrogen → thin mucosa, neutral/alkaline pH, less protective flora.
• Symptoms: discharge, itching, erythema, dysuria, odor, vulvar pain.
• Causes: irritation/poor hygiene, soaps, foreign body, pinworm, bacterial infection; candidiasis is less common before estrogenization.
• Treatment: hygiene, avoid irritants, cotton underwear, treat specific pathogen if identified.

Bleeding, trauma and adolescent points

• Genital bleeding differential: trauma, foreign body, vulvovaginitis, urethral prolapse, lichen sclerosus, precocious puberty, tumor.
• Trauma: document carefully; distinguish accidental straddle injury from abuse by history and lesion pattern.
• Persistent mass, bleeding, or unexplained discharge → specialist evaluation.
• Adolescents: consider pregnancy and STI testing when clinically relevant; balance confidentiality with safeguarding and local law.