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Janice Bernal-Lacuna,MD, FPOGS, FPSREI
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Objectives
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Infancy to Puberty
Vulvovaginitis
A!esive vulvitis
Acciental genital trau"a Ovarian tu"ors
Precocious #u$ert%
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Gynecologic examination
of a child Slo& #ace, gentleness an #atience
A"$iance
Ra##ort Reassurance
Parental #resence
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Components
'istor% A$o"inal e(a"
Ins#ection &it! visuali)ation o* t!e
vagina an cervi( A##ro#riate cultures o* t!e vagina
Rectal e(a" i* &it! $leeing ora$o"inal or #elvic #ain
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PE
'%"en + crescentic, reunant,i"#er*orate
Vaginal e#it!eliu" + re, t!in Vaginal canal -c" long
Secretions + neutral #'
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Inspection and
visualization .ounger c!il can $e e(a"ine on
!er "ot!er/s la#
For oler c!il, 0nee c!est #osition orsu#ine &it! 0nees a#art
1ultures + using saline saturatecotton ti# a##licator, #lastic"eicine ro##er
2arro& enosco#es
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Rectal exam
Ma% $e o"itte
2on #al#a$le uterus
345 ratio, cervi(4uterus Inications
Bleeing
Pelvic #ain Foreign $o%
Pelvic "ass
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ulvovaginitis
Most co""on g%ne #ro$le" in#re"enarc!eal
678 to 978 o* o# visits Introital irritation
Disc!arge :;8 non-s#eci<c etiolog% =GI >ora?
2@ gonorr!ea, @ vaginalis, 1!la"%ia,'SV, S!igella
M%cotic or $acterial vaginosis
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ulvovaginitis ! vulvar
irritation o#ical allerg%
S0in or res#irator% in*ection
Foreign $o% I
Vulvar s0in isease
Ecto#ic ureter Pin&or" in*ection
Se(ual a$use
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"usceptibility to
vulvovaginitis Lac0 o* la$ial *at #as an #u$ic !air
E#it!eliu" lac0s estrogen
#' is neutral Vagina lac0s gl%cogen, lacto$acilli
an anit$oies
Poor #erineal !%giene
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#reatment
'%giene + clean, r% an cool Cee#ing lesions + !ot sit) $at!
containing 3 t$s# o* $a0ing soa
Ci#e *ront to $ac0 Loose cotton gar"ents Avoi $u$$le $at!s !ars! soa#s i* allergic
1ala"ine lotion or cornstarc! #o&er ont!e vulva o#ical crea"s an anti$iotics *or 3
&ee0s
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$oreign body
Bet&een to 9 %o
oilet #a#er, to%s, cra%ons, san
Vaginal isc!arge Re"ove $% *orce#s, irrigation
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aginal bleeding
Foreign $o% 2eo#lasia Precocious #u$ert%
ret!ral #rola#se rau"a Se(ual assault Vulvovaginitis
Lic!en sclerosis 1on%lo"a accu"inata Bloo %scrasia E(#osure to estrogen
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aginal bleeding
S!igella
Grou# A $eta-!e"ol%tic
stre#tococcus :-57 a%s a*ter a sore t!roat
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%dhesive vulvitis
Sel*-li"iting conseuence o* c!ronicvulvitis
La$ia "inora agglutinates an *uses
Mista0en *or congenital a$sence o* vagina
1o""on $et&een to %o
2o s%"#to"s e(ce#t *or icult% in
voiing i* *usion involves t!e uret!ra 2o treat"ent necessar%
Estrogen crea" 3( ail%
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%ccidental genital
trauma Fall, strale inur% Se(ual a$use 'e"ato"a or laceration General anest!esia "a% $e neee to
investigate t!e e(tent o* t!e inur% I* non-e(#aning4 o$servation, serial
e(a"ination, ice #ac0 t!en !ot sit)
I* retro#eritoneal !e"ato"a or internalorgan inur% is sus#ecte, la#arosco#%or la#aroto"% "a% $e inicate
etanus to(oi inection
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Ovarian #umors
A$o"inal #ain
A$o"inal enlarge"ent + increasing
a$o"inal girt! ltrasoun, a$o"inal 1, MRI
1A 53;, AFP, !1G, in!i$in, 1EA, LD',
estraiol an testosterone
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Ovarian tumors
nilateral
Benign or "alignant
Ger" cell tu"or + "ost co""on in#reaolescents I""ature terato"as + surger% alone is
curative regarless o* grae
D%sger"ino"a + "ost co""on "alignant Benign terato"a + "ost co""on $enign
Functional luteal c%sts
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Ovarian tumors
Goal o* surger%4 re"oval o*neo#lasia an #reservation o* *uture*ertilit%
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Precocious puberty
A##earance o* signs o* seconar% se(ual"aturation at an age "ore t!an 3@;stanar eviations $elo& t!e "ean *or
t!e #o#ulation to &!ic! t!e c!il $elongs Breast evelo#"ent an #u$ic !air
a##earance $e*ore age : *or 1aucasianan age *or A*rican A"erican girls
suall% &it! s!ort stature + li"itegro&t! s#urt $ecause o* accelerate$one "aturation an #re"ature closureo* t!e istal e#i#!%seal gro&t! centers
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Premature #helarche
Breast evelo#"ent
2eonatal + "a% $e nor"al u# to
"ont!s 5 + %o
3 + c" $reast $u
nilateral or $ilateral
Benign sel*-li"iting
2o treat"ent
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Premature Pubarche
Isolate evelo#"ent o* #u$ic !air
Pre"ature arenarc!e + a(illar% !air
2o clitoro"egal%, $one age is notavance
Increase D'EA an D'EA-S $% t!earenals
2ot #rogressive
2o treat"ent, o$servation
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GnR&'(ependent Precocious
Puberty Iio#at!ic evelo#"ent + :78 o*
cases
A$nor"al EEGs + 12S Pre"ature "aturation o* t!e 'PO a(is
Ma% evelo# ovarian *ollicular c%sts
As earl% as - %ears ol E"otional #ro$le"s + s!% an
&it!ra&n
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GnR&'(ependent Precocious
Puberty 'eaac!es
Visual istur$ance
Sei)ures &it! ina##ro#riate laug!ter=gelastic sei)ures?
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GnR&'(ependent Precocious
Puberty 12S lesions near !%#ot!ala"us near r ventricle
u$erculosis, ence#!alitis, trau"a,
!a"arto"as, terato"as, seconar%!%roce#!alus, neuro<$ro"atosis,granulo"as, cranio#!ar%ngio"as, cranialirraiation,
S#ace occu#%ing "asses are "ost icultto treat
Poorl% unerstoo &!% it #rouces#recocious #u$ert%
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GnR&'independent precocious
puberty Most co""on + estrogen-secreting
ovarian tu"or Granulosa cell tu"ors - H 6c"
!eco"as, luteo"as, terato"as,Sertoli-Le%ig cells,c!oriocarcino"as, an $enign
*ollicular c%sts + rare cause Prouce !1G or estrogen
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)cCune'%lbright syndrome
Pol%ostotic <$rous %s#lasia
ria4 ca*-au-lait s#ots, <$rous
%s#lasia, c%sts o* s0ull an long$ones
Facial as%""etr%
78 !as isose(ual #recocious#u$ert%
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%drenocortical neoplasms
Isose(ual or !eterose(ual
1ongenital arenal !%#er#lasia
I* treate uring neonatal #erio, nor"al#u$ert%
I* untreate, girl &ill evelo#!eterose(ual #u$ert% $ecause o*
anrogens I* treate late in c!il!oo, isose(ual
evelo#"ent "a% *ollo& initial treat"ento* arenal isease
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&ypothyroidism
suall% associate &it! ela%e#u$ertal evelo#"ent
Rare4 "a% cause #recocious #u$ert% Bone age is retare =s#eci<c?
'as!i"oto/s t!%roiitis
Lo& t!%roi !or"ones
negative*ee$ac0 increase S'
increase gonaotro#!ins
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Iatrogenic
Estrogen crea", #ills
Regresses a*ter iscontinuation
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(iagnosis
'istor% an PE
Rule-out li*e t!reatening neo#las"s
o* t!e ovar%, arenals or 12S Delineate s#ee o* "aturation
anner stage
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*aboratory exams
Brain 1 or MRI EEGs ltrasoun
Bone aging $% !an-&rist (-ra%s ever% "ont!s =i* 9;8 avance4 ovarianestrogen?
'or"onal assa%s incluing t!%roi *unction
GnR' sti"ulation test + L' increases i* true#recocious #u$ert%, L' oes not increase i*inco"#lete =#eri#!eral sources?
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)anagement of Precocious
Puberty E(tir#ation o* tu"ors =ovarian,!a"arto"as?
1ontinuous c!ronic GnR' analogue
a"inistration =agonists? + "osteective $et&een -%o Do&n regulation o* GnR' rece#tors
Mini"al $ene<t &it! gro&t! !or"ones estolactone =aro"atase in!i$itor? +
Mc1une Al$rig!t 1ounseling