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Part I
THE EARLY YEARS/GROWING UP
Introduction
Adolescent gynaecology is perhaps one of the less familiar areas of gynaecology, traditionally under the remit of paediatricians and poorly taught in the Obstetrics and Gynaecology syllabus. However, with the move towards a life course approach to women’s health, gynaecological care of adolescents has evolved into an area of special interest, addressing the health needs of girls aged 10–19 years.
The “Early Years/Growing Up” section starts with discussion of history and examination as this cannot simply be transferred from that undertaken in adult women. Fundamental differences lie in the fact that there are usually two stakeholders — the teenager and her parent (usually mother or another responsible female but sometimes the father). The health needs and concerns of both should be addressed for a successful consultation. Confidentiality, informed consent and the legal aspects relating to sex can be challenging. Sometimes, you may have to see each party separately to get the full picture and assess child protection. Finally, as the majority will not be sexually active, traditional vaginal examination is not possible and alternative approaches, usually in the form of non-invasive imaging, are required.
Following history and examination, puberty and adolescence are discussed, firstly with an outline of normal development and function, focusing on the significant endocrinological, anatomical and psychosocial changes which occur. A comprehensive review of common and less common adolescent problems follows. These may be temporary or may debut long-term issues and may present to the out-patient department or as acute, life threatening emergencies. Abnormal puberty (too early, too late and slow), abnormal uterine bleeding (absent, too little, too much, too painful), the pelvic mass and sexual health (contraception, teenage pregnancy, sexual assault and abuse, sexually transmitted infection) are highlighted owing to their common presentation or importance for future sexual and reproductive function.
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1
GYNAECOLOGY HISTORY TAKING AND EXAMINATION
Stephen Chew
History
A careful and detailed history is the first necessary step in any good gynaecological assessment of a patient. Questions should be directed to obtain information on the following.
General. Name, age, years of marriage and parity. This can be conveniently represented as a four box gynaecological code. The first box on the left being for the age of patient, the next box the years of marriage, the third box the number of miscarriages or abortions and the last box for the number of livebirths.
History of presenting illness. This should focus on the presenting problem/complaint that brings the lady to see you. This may be a menstrual problem, infertility or an issue of urinary incontinence. Duration, severity and time course of her illness should be sought.
Menstrual History
Age of menarche. Usually around 12 years, but can range from 9–16 years.
Interval between periods. Classically, the first day (Day 1) of her period is when she has her first heavy flow (vaginal spotting doesn’t count). Her menstrual cycle is thus the interval between Day 1 of two menstrual bleeds. As such, most women will report a regular 28 day cycle but this can range between 21–35 days.
Menstrual flow. The amount of menstrual flow should be assessed. Most have 3–4 days of heavy flow followed by another 3 to 4 days of spotting. Presence of blood clots and flooding should be recorded.
Last menstrual period. This refers to Day 1 of heavy flow of the last menstrual period.
Intermenstrual bleeding, post-coital bleeding, postmenopausal bleeding should be specifically sought as these may point to possible gynaecological malignancy.
Dysmenorrhoea. Severity and duration are important as this may point to endometriosis or adenomyosis.
Sexual and Contraceptive History
Information on sexual activity, dyspareunia and the use of any contraception must be obtained in a sensitive manner.
Past History
Previous medical conditions (e.g. diabetes) or previous surgery must be asked about.
Obstetric History
Previous pregnancies, especially miscarriages, ectopic pregnancies and deliveries by caesarean section are important.
Drug History and Allergies
Failure to recognise known drug allergies can lead to serious mistakes with medicolegal consequences.
Family History
Information on diabetes, hypertension and cancers in family members should be sought.
Social History
Occupation, smoking and alcohol intake should be elicited.
Physical Examination
Any examination should be carried out with the patient’s consent and in the presence of a chaperone.
General Examination
- General condition
- Vital signs — pulse, blood pressure
- Peripheral signs — anaemia, peripheral oedema, leg swelling
- Neck for any enlarged supraclavicular node
- Heart
- Lungs
Breast Examination is also important, as missing a malignant breast lump has clinical implications for fertility treatment and management of any subsequent pregnancy. Remember, too, that breast cancer can spread to the ovaries (Krukenberg tumours) and may initially present as suspicious ovarian cysts for gynaecological assessment.
Abdominal Examination
The patient should be lying comfortably on her back with the area between xiphisternum and symphysis pubis exposed. Remember to empty the bladder before examination.1–5
Inspection
Look out for surgical scars and hernias that may be “hidden” until she is made to cough.
Palpation
Palpation of the abdomen is critical in the assessment of any pelviabominal mass. Hepatomegaly and the presence of shifting dullness are important abdominal signs of malignancy. Generally speaking, one may be able to get below an ovarian mass whereas a uterine mass will rise up above the symphysis pubis, defying all efforts to “get below” it.
Abdominal palpation is also critical in the assessment of a gynaecological patient presenting with pain. Guarding and rebound tenderness are important signs of peritoneal irritation and are present in pelvic inflammatory disease, twisted ovarian cysts, bleeding ectopics/corpus luteums and acute appendicitis.
Percuss for any free fluid in the abdomen.
Auscultation
Auscultation of bowel sounds is also important as gynaecological patients can also present with postoperative ileus.
Pelvic Examination
The pelvic examination must be conducted in a sensitive manner with a chaperone present throughout. The bladder is best emptied unless she complains of stress incontinence.
Inspection
The external genitalia should be inspected and the labia parted to visualise the urethra and introitus.
- Distribution of pubic hair
- Presence of any vaginal discharge, any accompanying skin irritation suggesting a genital tract infection
- Coughing to check for stress incontinence
- Straining to elicit any genital prolapse
Speculum examination
The Cusco or bivalve speculum is the instrument most commonly used to visualise the cervix and vagina. Increasingly, plastic disposable speculums are used and come in standard small/medium and large sizes. However, longer metallic speculums are still useful, especially in cases where...
