Pediatric and adolescent gynecology

Abstract

How does one obtain a history from a pediatric gynecologic patient? How does one proceed with the physical examination of reproductive organs? Winning the patient's confidence and making the experience into an ''educational event'' with the patient feeling ''in control'' emerge as key factors. Preexamination education should include information addressing correct patient positioning; for the child, a frog-legged or knee-chest position is helpful. The ability to aspirate vaginal secretions for microscopic assessment is important as well as knowledge of ''normal variation'' of the hymen. For the adolescent a ''no hand-holding'' approach is emphasized, and it is preferable for the parent or guardian not to be present in the examination room. What information is desired? What goals have been established for the assessment? With respect to vulvovaginitis, one must distinguish between physiologic discharge prior to onset of menarche, and nonspecific vs. specific vulvovaginitis. Perineal hygiene, and proper method of wiping fecal contents following bowel movements, i.e., away from the vagina, must be stressed. Specific vulvovaginitis requires appropriate differential diagnoses with the armamentarium to allow one to proceed with appropriate therapy. When evaluating hirsutism, a clear differentiation from virilization is of paramount importance. Ideally, the hirsutism should be ''quantitated'' and followed by appropriate therapy. One must distinguish the problem of anovulatory (dysfunctional) uterine bleeding (AUB) from excessive menstrual flow at the time of menarche and determine whether or not the AUB is associated with recurrent episodes. Treatment of AUB in the adolescent rarely requires dilation and curettage. With respect to pubertal aberration, the importance of gonadotrophin-releasing hormone (GnRH) testing and proper evaluation must be stressed. Clinical applications of molecular biology - DNA probes in the treatment of gynecologic problems in this age group is now on the horizon - when to proceed with gonadectomy in light of chromosomal abnormalities is being examined as well as what role Y-DNA probes have in helping to discern who should have gonadectomy. The genes that regulate virilization and masculinization have been unraveled. The DNA probes appear to be most useful in assessment of the patient with congenital adrenal hyperplasia. Appropriate knowledge of these clinical areas will assist the physician in evaluating the pediatric adolescent gynecology (PAG) patient.