GYNECOLOGIC PROBLEMS OF CHILDHOOD Breast Tanner Staging

Renna Cristina B. de Leon, MD • Stage 1: Prepubertal

OBGYNE • Stage 2: Breast bud with areolar widening
Pediatric and Adolescent Gynecology • Stage 3: Enlargement of breast and widening of areola;
no separation of contour
Course Outline • Stage 4: Secondary mound develops with separation
A. History & Physical Examination of a child • Stage 5: Mature breast
B. Vulvovaginitis
C. Bleeding Pubic Hair Tanner Staging
D. Breast Disorders • Stage 1: No pubic hair
E. Hirsutism & Polycystic Ovarian Syndrome • Stage 2: Straight hair is extending along labia
F. Neoplasms • Stage 3: Pubic hair is darker and is present in typical
G. Vulvovaginitis and Mullerian Anomalies female triangle, but in smaller quantity than in later
H. Gynecologic Imaging stages
• Stage 4: Pubic hair is more dense, curled and adult in
General Approach distribution, but less abundant than in adults
‣ Gentleness and patience —> build rapport “DO NOT • Stage 5: Abundant, adult-type pattern, hair may extend
FORCE” into the medial aspect of thigh.
‣ Developmentally appropriate social questions
‣ History and P.E —> collaborative effort —> child-
caregiver-doctor
‣ Ambience of the room
‣ Avoid interruptions
‣ Hide instruments

Problem-Focused History Taking

Vaginal Bleeding Vulvovaginal Irritation,

Pruritus or Discharge

• Recent growth and • Perineal hygiene

development
• Signs of pubertal
progression
• Trauma
• Vaginal discharge
• Medication exposure
• History of foreign objects
in the vagina
• Onset and duration of
symptoms
• Presence and quality of
discharge
• Exposure to skin irritants
• Recent antibiotic use
• Travel
• Medical comorbidities or
infections and other
systemic symptoms of
illness or skin conditions

Physical Examination
1. Obtain cooperation of the child
2. Allow child to have sense of control
3. Prevent multiple exams
General Pediatric Assessment
‣ Over-all inspection: assess habitus, hygiene and
presence of skin disorders
‣ Evaluate height and weight percentile
‣ Examination of the head, neck, chest, lungs, heart
and abdomen
‣ Breast Tanner Staging
‣ Abdominal and inguinal examination, then if
comfortable proceed to examination of the genitalia
Gynecologic Examination of a Child
Performance of the Gynecologic Exam:
✓ Inspection with visualization of the external
genitalia
✓ Non-invasive visualization of the vagina and cervix
✓ Rectal examination, if necessary
Gynecologic examination: Physical examination should be
tailored to the child’s age, complaint, and any other
concerns elicited in the history.
Indications of Genital Examination:
• Vaginal bleeding
• Vaginaal discharge
• History of vulvar trauma
• Suspicion of solid masses or vulvovaginal cysts
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 • Vulvovaginal ulcerative/inflammatory lesions Clitoromegaly and Ambiguous Genitalia
• Congenital anomalies
• Sexual abuse • Congenital Adrenal Hyperplasia - most common cause of
• Pregnancy ambiguous genitalia
• Exposure to STIs • Ovarian Enlargement:
• Abdominal or pelvic pain • large cysts (>4-5cm) or those of a complex nature
• Presence of foreign body —> risk of ovarian torsion, hemorrhage into the
• Perineal or pelvic masses cysts or uncommonly, an ovarian tumor.
• observe —> non-resolving or enlarging neonatal
Neonates: ovarian cysts —> expert consultation
✓ Obstetrician - examine the external genitals of • Cyst aspiration —> not recommended as the fluid
female infants aspirated is not reliable for diagnosis and fluid may
✓ Pediatrician - note any abnormal findings such as re accumulate
ambiguous genitalia, imperforate hymen, urogenital • Cystectomy —> cyst wall should be surgically
mass or inguinal hernia excised to prevent reaccumulation of fluid and to
provide a pathologic diagnosis.
Estrogenic Effects Noted in a neonate:
‣ Breast Infants and Prepubertal Child
• transient enlargement/breast buds ✓ Labia begin to flatten
• milk-like nipple discharge ✓ Hymenal membrane becomes translucent
‣ External Genitalia ✓ Vaginal epithelium appears thin and red
• prominence of labia majora ✓ Vaginal mucosa can have longitudinal ridges
• white vaginal discharge ✓ Cervix usually appears flat and flush with the vaginal
• labia minora and hymen may protrude slightly from vault
the vestibule ✓ Uterus regresses in size
• vaginal bleeding ✓ Prepubertal fundus:cervix ratio is 1:2

Neonatal Examination Comparative measurements of the neonatal, prepubertal

• Gentle lateral traction on the labia majora —> allows and adult vagina and cervix.
complete visualization of the hymen and vaginal orifice.
Newborn Early Late Adult
childhood childhood
(2-6 yrs. (7-10 yrs.
old) old)

Vaginal 4 cm 4-6 cm 7-8.5 cm 8-12 cm

length

Corpus:cervix 1:3 1:2 1:1 2:1 - 3:1

ration

• Forcible restraint is never indication; if optimal evaluation

is not possible, the clinical must assess the acuity of the
complaint and pathology and determine the potential
need for multi-visit examination or an examination under
anesthesia.

Positioning
Hymen Tanner Staging:
• Tanner 1: Prepubertal
• Tanner 2: Vascular pattern of hymen becomes less
prominent due to thickening
• Tanner 3: Hymen becoming thicker; labia still small;
clear secretions
• Tanner 4: Darker labial pigment; vestibule skin
textured; redundant hymen folds; clear secretions
• Tanner 5: Hymen more redundant; abundant
secretions; long, rugated, pigmented labia mnora
Imperforate hymen in a neonate: MUCOCOLPOS
• Frog-leg Position - most commonly used; allows the
child to have a direct view of the examiner and herself.
• Frog-leg position with the aid of her mother - for the
anxious child; have the guardian sit on the table in a
semi-reclined position with the child’s legs straddling
her thighs.
• Lithotomy Position - for the older, cooperative child
(>4-5 years old); for adolescent
• Knee-Chest Position - for older child (>2 years old);
allows for better visualization of the lower and upper
vagina and the cervix.

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Examination of the Vestibule, Hymen and Anterior
Vaginal Wall:
✓ Gentle lateral retraction
✓ Gentle gripping of the labia and pulling
anteriorly

Visualization Techniques (Vagina and Cervix)

✓ Nasal Speculum
✓ Otoscope
✓ Vaginoscopy

• Post-Gynecologic Examination - after the

examination, praise the young child for her VULVOVAGINITIS
cooperation and bravery thus establishing the clinician- Usual Symptoms:
patient relationship so important for future examinations.
• Perianal redness
• Inflamed introitus
Adolescent
• Yellow-green or mildly bloody discharge
✓ History taking:
• initially with the parents, then without the parents
• confidentiality issue VULVITIS VAGINITIS
• provide a relaxed atmosphere
✓ PUBERTAL DEVELOPMENT AND MENSTRUATION external genital pruritus, inflammation of the vagina
✓ MENSTRUAL DIARY burning, redness or rash (discharge with or without
an odor or bleeding)
Remember get into adolescents’ heads:
Home History:
Education • hygiene (wiping from front to back)
Eating • chemical irritants (bath soaps, laundry detergents,
Activities swimming pools, or hot tubs)
Drugs • history of diarrhea, perianal itching or nighttime
Sexuality itching
Suicide/Depression • possibility of foreign objects being placed into the
Safety from injury and violence vagina

Pelvic Examination Why are prepubertal girls at risk?

• Inspect vulva • Behavioral factors
• Palpate Bartholin’s & Skene’s glands • Children’s tendency to poor hygiene
• Clitoris (>10mm is abnormal) • Poor hand washing
• Hymen • Spread of respiratory bacteria from hand to
• Speculum perineum
• BPE • Inadequate cleansing of the vulva after voiding or
• Vaginal wall, cervix, uterus, adnexa and cut de sac after bowel movements
• Virgin: single digit exam with lubricated, gloved • Children’s tendency to explore their bodies
finger • Irritants against the vulva

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Non-specific Vulvovaginitis 2. Physiologic Leukorrhea
- accounts for 25%-75% of cases - white or clear or mucus discharge, which is a physiologic
- caused by subtle alterations in the local microbiologic effect of estrogen
flora and or host defense secondary to poor perineal and - complain of moisture and mucus
fecal hygiene
3. Pathologic Vaginal Discharge
Summary of therapy for Non-specific Vulvovaginitis - color —> odor —> duration
• General measures - common causes of vulvovaginitis
• Sitz bath 1-3 times a day with plain warm water. - poor perineal hygiene
The vulva should be gently washed with no soap. - Candidiasis
If soap is needed, only a mild, unscented soap. - Foreign body
Sitz bath is followed by careful drying (patting, not
rubbing) Infective Causes of Vaginal Discharge
• Urination with legs spread apart and labia
separated Infection Organism Discharge Tests Treatment
• For sever inflammation, topical estrogen cream or
low potency steroid may facilitate healing Gonorrhoea N. gonnorhea Watery/ • Endocervical Ciprofloxacin
(gram (-), yellow, +/- swab and 500 mg stat
• Estrogen cream 2x/day intracellular dysuria, IMB, smear
• Low potency steroid (0.05% to 1% diplococcus) pelvic pain • Rectal/
Hydrocortisone cream) once daily at bedtime throat
for 1-2 weeks, then every other day for 1 swabs
week.
Chlamydia C. trichomatis Altered, +/- • Endocervical • Doxycycline
Specific/Infectious Vulvuvaginitis (obligate, dysuria, IMB, swab 100 mg bd
- specific pathogen is isolated as the cause of symptoms intracellular ICB, PCB, low • First void PO 1/52
- may be caused by fecal or respiratory pathogens bacteria) abdo. pain urine • Azithromyci
sample n 1g stat (if
- cultures might reveal:
pregnant)
• E.coli
• S. pneumoniae T. vaginalis T. vaginalis Offensive, High vaginal Metronizadole
• S. aureus (flagellated frothy, yellow/ swab, 400mg bd PO
• H. influenzae protozoon) green, +/- increase pH 5-7/7
• E. vermicularis itchy and sore
• Candida spp.
Bacterial Various Offensive, High vaginal Metronizadole
vaginosis gram(+/-) fishy, white/ swab, 400mg bd PO
Enterobiasis bacterium, yellow increase pH 5-7/7
- pinworms decrease
- perennial pruritus (eggs on skin) lactobacilli
- GI symptoms (adult worms on stool)
- Diagnosis: transparent adhesive tape or an anal swab - Cervicitis Related to Purulent Endocervical Doxycycline
anal region in the morning before defecation or bathing NSU (Gon/ +/- PCB swab 100 mg bd PO
—> placed on a slide Chi) 1/52
- eggs seen on microscopic examination
- pinworms seen at the anal verge Candida C. albicans Curdy, white, Clinical Topical anti
yeasty, +/- diagnosis (but fugal:
- Treatment: Mebendazole 2 doses, 2 weeks apart itchy and sore can do a high Clotimazole
vaginal swab) or:
Clinical Manifestions Fluconazole
1. Diaper Dermatitis 150mg PO
- most common dermatologic problem in infancy stat
- occurs in half of all diaper-
4. Genital Ulcers
wearing infants and - infectious causes: Epstein-Barr, Cytomegalovirus,
children
- moisture and contact with Mycoplasma and Influenza A
- idiopathic vulvar aphthoses
urine and feces irritates the - inflammatory bowel disease, Behçet disease,
skin
- colonization with Candida spp. pemphigoid, Stevens-Johnson syndrome, drug eruption,
or mouth and genital ulcers with inflamed cartilage
increases the severity
- First-line treatment: (MAGIC) syndrome
- usually appear on the mucosal surfaces of the introitus
hygiene measures (increasing - painful red or white lesions that evolve into sharply
the frequency of diaper changes, allowing the infant to
demarcated red-rimmed ulcers with a necrotic or eschar-
be diaper free, frequent bathing and application of
like base
water-repellant barriers such as zinc oxide) - time course - 10 to 14 days until remission occurs
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- Evaluation
• culture for HSV
• special testing for systemic disease
• Biopsies - usually non diagnostic
- Treatment
• topical xylocaine jelly
• sitz bath
• good hygiene
• acetaminophen
• hospitalization
- pain management not controlled with oral
narcotics
- urinary retention
- whirlpool debridement

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5. Dermatoses - sharply demarcated
I. Lichen Sclerosus hypopigmented patches,
- sclerotic, atrophic, parchment-like plaque with in often symmetric in vaginal
hourglass or keyhole appearance and anal regions
- if untreated —> destruction and scarring of normal - Diagnosis - clinical
genital architecture, including labial resorption, • association with other
obliteration of the clitoris, narrowing of the introitus, and autoimmune or
painful fissures. endocrine disorders
- Symptoms: perineal itching, soreness or dysuria (hypothyroidism,
- Diagnosis - visual inspection Grave’s disease,
- Biopsy - reserved for when the diagnosis is in Addison disease,
question pernicious anemia,
- Treatment insulin-dependent DM)
• Ultrapotent - Treatment: Mild topical
topical corticosteroid cream or ointment
corticosteroids
- first line III - Vulvar Psoriasis
therapy - pruritic, eel-demarcated nonscaly, erythematous,
• Clobetasol symmetrical plaques
propionate - lesions on the mons-pubis - scaly appearance
ointment - - Diagnosis - locating other affected areas on the scalp or
0.05% - 1-2 in the nasolabial folds or behind the ears
times/day - Treatment: moisturizers, topical steroids and light
for 4-8 weeks therapy
• Teens: coal tar, retinoids, tacrolimus and
II - Vitiligo calcipotriene (derivative of Vitamin D3)
- acquired skin depigmentation resulting from an auto-
immune process directed at epidermal melanocytes

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6. Phthribus pubis • Neoplasms
- Pediculosis pubis - Infantile hemangioma - most common benign
- Signs and symptoms: vascular neoplasm of infancy (5%)
- Pruritus - Treatment: Propanolol, laser therapy,
- Excoriation surgical excision
- Sky-blue macule - Hymenal polyps - benign
- mostly at inner thigh or lower abdomen - Yolk sac tumor
- Nits on hair shaft; lice at skin and clothing - Marker: AFP
- Treatment: Lindane lotion - Rhabdomyosarcoma - Sarcoma botryoides
- Treatment: Surgery, chemoradiation
7. Scabies • Trauma
- Sarcoptes scabei - rule out sexual abuse
- nocturnal pruritis - (+) hematoma
- vesicles - ice packs, pressure application
- pustules - Trauma to the Vulva and Vagina
- Mites, black ova, dots or feces • If there are no eyewitnesses to the injury, if
- Treatment: 1% Lindane there is no history to explain the clinical
findings and especially if there is a
Other Lesions laceration of the hymen, abuse must be
Labial Adhesions considered in the differential diagnosis, and
- often asymptomatic a forensic interview of the patient and family
- <6 years old should take place.
- (+) recurrent UTI • Precocious Puberty
- (+) recurrent - pubertal development that is 2.5-3.0 SD earlier
vulvovaginitis than the average age
- Treatment: - Etiology:
• topical estrogen • Gonadotropin-dependent or central
cream (every - premature enhancement of pulsatile
night x 1 week) gonadotropin releasing hormone release
• petrolatum or resulting in ovarian follicle growth and
zinc oxide (1-2 months until it separates) estrogen production
• mechanical separation • Gonadotropin-independent or peripheral
- estrogen production is not under
Vaginal Discharge Sampling hypothalamic control
• Techniques: - produced peripherally (ovarian/adrenal
- Swabs (gram stain, KOH), culture tumor or McCune Albright Syndrome)
- Catheter within a catheter - thorough physical exam:
- breast and pubic hair development using the
BLEEDING Sexual Maturation Index (Tanner Staging);
Causes: height and weight on the growth chart
• Vulvovaginitis - Diagnostic tests:
- respiratory, fecal, oral pathogens - left wrist x-ray - bone age
- serosanguineous drainage (shigella, strep) - serum LH levels - elevated —> highly
- irritation/excoriation of skin suggestive of central precocity
• Vaginal foreign bodies - Gold Standard: GnRH-Stimulation Test
- Bleeding + foul discharge - MRI/Pelvic Ultrasound
- Most common: toilet paper - Serum Estradiol
- Vaginoscopy - Treatment:
• Dermatologic conditions/Dematoses - Leuprolide, histrelin - central
- Lichen sclerosus - Surgery
• Urethral prolapse • Juvenile Hypothyroidism
- “vulvar mass” + dysuria - premature breast development, vaginal bleeding and
- present with a circular protrusion of the abdominal distention
urethral mucosa through the external meatus - TRH associated elevations of TSH cross reacting with
forming a friable vulvar mass FSH resulting in follicle maturation and estradiol
- predisposing factors: Low estrogen state, production.
trauma, chronic cough, and constipation
- Treatment: topical estrogen
• Endogenous/exogenous estrogenic effects
- ingestion of birth control pills, foods, beauty
products and plastics

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 BREAST CONCERNS Amastia
- complete absence of the
Breast Development breast
- lack of formation or
obliteration of the
mammary ridge
- congenital/systemic
disorders (e.g., ectodermal
dysplasia, Crohn’s disease)
or endocrine disorders
(e.g., congenital adrenal
hyperplasia, gonadal dysgenesis, hypogonadotropic
hypogonadism)
- Poland Syndrome (aplasia of the pectorals muscles,
rib deformities, webbed fingers and radial nerve
aplasia)
- can be iatrogenic (injuries sustained during
thoracotomy, chest tube placement, radiotherapy,
severe burns and inappropriate biopsy of the breast
bud)
- Treatment: Surgical correction

Polymastia and Polythelia

- Supernumerary breast tissue
- accessory nipples
- usually noted on the chest, upper abdomen or just
inferior to the normally positioned breast
- Treatment:
- Surgical excision of the accessory breasts or nipple
- not usually needed
- Resection of accessory tissue - may be warranted
Breast Self Examination if the patient has pain or for cosmetic reasons.

Breast Asymmetry and Hypomastia

-some degree of asymmetry —> normal
- hypoplasia of the breasts
- onset of the breast development may be
delayed with normal secondary sex
characters
- breasts develop slowly but are normal in all
other respects
- patient’s family history
- ovarian dysfunction
- hypothyroidism
- chest wall irradiation
- tuberous breast anomaly

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Juvenile or Virginal
Hypertrophy
- spontaneous massive
growth of the breasts
during puberty and
adolescence
- excessive end-organ
sensitivity ti gonadal
hormones (hormone
receptor and serum estradiol levels are normal)
- Macromastia/Gigantomastia - growth is extreme
- Management: individualized
- reassurance
- use of supportive brassieres
- reduction mammoplasty
- mastectomy
- Tamoxifen - slow breast growth in extreme cases until
surgery can be performed

Mastitis
- nonlactational mastitis
- irritation of the skin (through shaving or nipple
stimulation)
- trauma
- foreign body (e.g., piercing)
- ductal abnormality (such as ductal ectasia)
- infection of an epidermal cyst
- Initial therapy: antibiotics and analgesics
- Staphylococcus aureus or anaerobic bacilli (bacteroides)
Nipple Discharge
- benign conditions —> milky, sticky, thick discharge
- infection —> purulent discharge
- intraductal papilloma and cancer —> serous
serosanguineous or bloody discharge
- biopsy is needed for accurate diagnosis
Galactorrhea
- cytologic evaluation of nipple discharge —> not
recommended
- Serum pregnancy testing - r/o pregnancy
- prolactin levels - r/o pituitary prolactinoma
- if high —> perform visual filed test and MRI
- thyroid levels - r/o thyroid abnormality
- Treatment: Bromocriptine or cabergoline - dopamine
agonists
Bloody Discharge
- adolescent athletes
- chronic nipple irritation (jogger’s nipple)
- discharge from the ducts of Montgomery (on the
edge of the areola, not through the nipple)
- duct ectasia
- Cytologic assessment should be performed
- Infants: mammary duct ectasia
Mastalgia
- Adolescents
- most common causes: exercise and benign breast
changes
• Physiologic swelling and tenderness - cystic basis
- commonly during the premenstrual phase
- secondary to hormonal stimulation and
resulting proliferative changes
• Hormonal imbalance - exaggerated responses in
the breast tissue (upper and outer quadrants)
- Nodularity, poorly localized tenderness, and a
soreness radiating to the axilla and arm.
- Treatment:
• Firm supportive sports-type bra
• Heat
• Analgesics
• Oral contraceptives
• Nonsteroidal anti-inflammatory drugs
• Methylxanthines (caffeine in coffee, tea,
carbonated drinks) and smoking should be
eliminated
• Evening prim-rose oil
• Vitamin E

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Fibroadenomas
- upper outer quadrant of the breast
- average size in 2-3cm and 10-25% of patients have
multiple lesions
- well circumscribed, rubbery, mobile, and not tender
- ultrasound
- Mammography —> not indicated in the adolescent
patient
- develop because of a local exaggerated response to
estrogen stimulation
- can enlarge during the menstrual cycle
- -10% - regress spontaneously
- expectant management - serial ultrasounds every 6-12
months
- FNA or excision is recommended:
- mass is enlarging
- grows >5cm (because of the risk of giant
fibroadenoma or cystosarcoma phyllodes)
- mass is causing anxiety
Breast Cancer
- rare in adolescents
• Cystosarcoma phyllodes
- asymmetric breast enlargement in association with a
firm, mobile, circumscribed mass
- can mimic a giant fibroadenoma
- grows rapidly and can become quite large
- favorable prognosis
- excision with 1cm margins - preferential initial
therapy in adolescent patients
• Juvenile papillomatosis
- marker for increased breast cancer risk in family
members
- Treatment: total resection of the lesion with
preservation of the breast
• Secondary cancers:
- Rhabdomyosarcoma - most common to metastasize
to the breast
- may be the first manifestation of relapse
(extramedullary) in acute lymphoblastic leukemia.
Recommendations for Daughters of Women with Breast
cancer:
✓ Risk Reduction:
✓ regular physical activity
✓ limit alcohol
✓ maintain a healthy weight
✓ Screening procedures:
✓ Breast self examination - 20’s
✓ Clinical breast exam
✓ 20s and 30s every 3 years
✓ 40s every year
✓ Screening mammogram - 40s every year
HIRSUTISM AND POLYCYSTIC OVARIAN
SYNDROME
• Hirsutism - excessive hair growth
• Virilization - hirsutism + acne, deepening of voice,
change in body habitus or clitoromegaly
• Premature pubarche - (+) genital and/or axillary hair
before 8 years old
• Adrenarche - increase androgen from the adrenals
between 12-18 years old
Polycystic Ovarian Syndrome (PCOS)
- common disorder of reproductive hormone function
- characterized by there triad:
• oligoovulation or anovulation
• clinical or biochemical hyperandrogenism
• ovaries with a polycystic morphology on ultrasound
examination (≥12 follicles in 1 ovary and/or ovarian
volume >10mm3)
- most commonly diagnosed ovarian cause of hirsutism
- associated abnormalities:
• Obesity
• Insulin resistance
• Metabolic syndrome
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• Higher LH > FSH NEOPLASM
• increased ovarian production of androgen
• impaired folliculogenesis Neoplasms
• Insulin Resistance - the most common gynecologic neoplasm in children is of
• Enhanced ovarian androgen production ovarian origin.
• Elevation of free testosterone thru suppression of - 1% of all childhood malignancies
SHBG production - 8% of all malignant and abdominal tumors
- Lifeling disorder - 10-30% operated on during childhood and
- Clinical hallmarks: adolescence are malignant
- menstrual abnormalities
- manifestations of hyperandrogenism Pre-pubertal Children:
- Diagnosis of PCOS in adolescents is difficult, why? Ovarian cysts
- lack of resolution of the normal pattern of - frequency is low
anovulatory menstrual cycles present in the 1st 2 - majority are benign
postmenarchal years - Functional - Follicular cysts
- Serum androgen levels may be elevated and - Neoplastic - Teratomas
clinical findings of androgen excess are common - Clinical manifestations:
- Work-up: 1. Abdominal pain - most common
- Serum 17-hydroxyprogesterone 2. Presence of a mass
- careful history taken - behavioral patterns 3. Urinary frequency/obstruction
- Androgens (total testosterone, 4. Constipation/diarrhea
dehydroepiandrosterone (DHEAS) 5. Vaginal bleeding
- Prolactine - Complications:
- FSH 1. Torsion
- TSH 2. Rupture/Leak
- 75g OGTT 3. Malignancy
- Tasks: 4. Infection
• Fertility management - Diagnosis
• Prevention of endometrial cancer 1. Ultrasound
• Reduction in the likelihood and severity of the 2. CT scan
accompanying metabolic disorders - Treatment: Conservative surgery: Oophorocystectomy
- Treatment:
- 2° to Hyperprolactinemia: Bromocriptine Ovarian Cancer:
- 1° to Hypothyroidism: Thyroid Replacement Tx - most common - in decreasing frequency
- 2° to Medications: Eliminate exogenous agent - Dysgerminoma
- PCOS with hyperinsulinemia in obese patients: - Malignant teratomas
Metformin - Endodermal sinus tumor
- OCP - Embryonal carcinoma
- GnRH agonists - Epithelial cell tumors
- Spironolactone or cyproterone + OCP - Serum Tumor Markers:
• Alpha feto protein (AFP): Endometrial sinus tumors
• HcG: Choriocarcinoma and Embryonal carcinoma
• LDH: Dysgerminoma
• CA-125: Epithelial cell tumors

Cervical Cancer:
- prevalence of cervical dysphasia - 18.8/1000 (15-19 yrs
old)
- When to start doing a Pap smear? - 21 years of age

Uterine Cancer:
- Leiomyosarcoma - uncommon
- Myoma uteri - few cases

Vaginal cancer: Sarcoma botryoides

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 VULVOVAGINAL AND MULLERIAN ANOMALIES
PRESENTATION
I. Congenital Malformations
- deviations from normal anatomy resulting from Gynecology Obstetrics
embryological maldevelopment of the Mullerian or
• Pelvic pain, cyclic or • Pregnancy loss: first and
paramesonephric ducts
noncyclic second trimester
Classification:
• Dysmenorrhea • Cervical incompetence
1. Agenesis and Hypoplasia - portion of the entire
• Primary amenorrhea with • Preterm labor and
Mullerian duct, or for both ducts, affecting one or
pain delivery
multiple Mullerian structures
• Primary amenorrhea • Intrauterine growth
2. Lateral Fusion Defects - most common; failure of
without pain restriction
migration of one or both ducts, midline fusion of the
• Hematometra • Placental abruption
ducts, or absorption of the midline septum between the
• Abnormal uterine • Intrauterine fetal demise
ducts.
bleeding • Malpresentation
3. Vertical Fusion Defects - disordered fusion of the
• Dyspareunia • Cesarian delivery
Mullerian ducts with the urogenital sinus
• Pregnancy-induced
hypertension (related to
II. Imperforate Hymen
- Pseudoamenorrhea/cryptomenorrhea renal abnormalities)
- Cyclic lower abdominal pain • Pregnancy in
- Primary amenorrhea with normal secondary sexual rudimentary uterine horn
characteristics
- Urinary symptoms (acute urinary retention) IMAGING
Tubal Patency
III. Mayer-rokitansky-kuster-hauser Syndrome I - Hysterosalpingography
- congenital absence of the vagina - Tubal patency
- unknown cause, often discovered in adolescence - Contour of uterine cavity:
- primary amenorrhea - Septate Uterus
- normal female karyotype and phenotype - Asherman’s syndrome
- associated with other anomalies (renal 27% and - Bicornuate Uterus
skeletal 12%)
- Treatment: delayed until patient is ready to be
sexually active
- Dilators to create a functional vagina
- Laparoscopic vaginoplasty (98% functional
success)
- McIndoe Procedure

Frequency of Uterine Anomalies

3% 10% 8%

II - Two-Dimensional Ultrasonography
- effectively visualizes the uterine structure and
endometrial contour

III - Pelvic Magnetic Resonance Imaging

26% 35% 18% - delineation of internal and external uterine contours
- differentiate between a septet cervix and duplicated
cervix.

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IV - 3D Ultrasonography
- assess the architecture of the endometrial cavity and the
uterine fundus

GOAL:
1. Restoration of normal uterine architecture
2. Preservation of fertility

Surgical Interventions
Indications:
- Obstructive anomalies
- Pelvic pain
- Endometriosis
- Poor obstetric outcomes (recurrent pregnancy loss,
second trimester loss of preterm delivery)
Surgical procedures:
1. Laparoscopy/Abdominal metroplasty
2. Hysteroscopic metroplaty
• detailed uterine septum
• hysteroscopic metroplasty with bipolar system
3. Uterine Transplantation

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