KEY POINTS
1 The causes of abnormal bleeding vary by age, with anovulatory bleeding most likely
in adolescents and perimenopausal women.
2 Pelvic masses in adolescents are most commonly functional or benign neoplastic
ovarian masses, whereas the risks of malignant ovarian tumors increase with age.
3 Although pelvic ultrasonography is an excellent technique for imaging pelvic masses
and ultrasonographic characteristics may suggest reassuring characteristics of an
ovarian mass, the possibility of malignancy must be kept in mind.
4 Vulvovaginal symptoms of any sort in a young child should prompt the consideration
of possible sexual abuse.
5 Preventive services for adolescents should be based on knowledge of the behavioral
and medical health risks that can affect their future health, including substance use
and abuse, sexual behaviors that invite unintended pregnancy and sexually
transmitted diseases (STDs), and the symptoms of impaired mental health.
The gynecologic problems of prepubertal girls and adolescents differ from
those of adult women. In the case of prepubertal girls, there are significant
differences from adolescents and adult women in the anatomy, bacteriology,
physiology, pathophysiology, and epidemiology of gynecologic conditions
that are likely to occur. While gynecologists tend to think of menarche as the
dividing line between young girls and adolescents, the real differences in the
types of gynecologic conditions that occur during adolescence typically begin
with the onset of puberty, when steroid hormone production causes changes in
breast development (Fig. 9-1), the vaginal epithelium, growth of the uterus, and
vulvar changes of hair growth.
403FIGURE 9-1 Tanner breast stage at menarche.
Menarche signals the onset of cyclic ovarian hormone production leading to
menstrual bleeding, although many early menstrual cycles are anovulatory. Some
conditions, potential developmental genital anomalies, are more likely to be
diagnosed during adolescence than in adults. The incidence of ovarian tumors
varies by age, with young girls and adolescents more likely to develop germ cell
tumors than adults. Some of the gynecologic conditions that occur during
adolescence are related to sexual behaviors, including greater risks of sexually
transmitted infections and pelvic inflammatory disease (PID). The gynecologist’s
interactions with an adolescent are sometimes more challenging, given that
404adolescents are developing in a number of spheres: physical maturity,
cognitive development, psychosocial development, relationships with family
and peers, and sexuality.
All those spheres do not develop synchronously, and a young adolescent may
appear physically more mature than her psychosocial or cognitive development
allows her to behave. These are some of the aspects of relating to adolescents with
regard to their gynecologic problems that make it challenging. On the other hand,
adolescents will often be refreshingly candid if a trusting relationship has been
established with their physician. Observing adolescents’ growth and development
into young adulthood can be immensely rewarding, as they have the capacity to
make behavioral changes that adults often find difficult.
The gynecologic examination of prepubertal girls and adolescents is discussed
in Chapter 1, as are elements of communication that apply equally to adolescents
and to adults. However, there are some aspects of communication with
prepubertal girls and adolescents that are unique to these age groups. It is
important to keep in mind that most medical problems in children lead to
maternal anxiety, and maternal or parental anxiety may manifest in
different ways. The clinician may occasionally interact with a parent who is not
accepting of their parental roles and responsibilities and who is neglectful of the
child’s health, or who because of their own medical or mental health issues
including substance use disorders, is unable to appropriately provide care for their
child. These situations are rare, but typically require multidisciplinary
interventions, including the services of a social worker or mandatory reporting to
local child protective services. Gynecologic conditions for a daughter may be
particularly fraught, as they may revive the mother’s history of interpersonal
violence, sexual abuse, exploitation, reproductive coercion, or adverse
interactions with the health care system. Parents may be concerned that a
gynecologic condition will impact their daughter’s future fertility or ability
to lead a sexually satisfying adult life. The clinician must recognize that these
concerns are quite common, and should address them directly with accurate
information.
Communication with toddlers and infants will be primarily with the child’s
mother. The gynecologic history in a young child will include issues described in
Table 9-1.
Adolescents who present for gynecologic consultation are often accompanied
by a parent, typically their mother. ACOG recommends that an adolescent’s
initial visit to a gynecologist for reproductive health guidance, screening, and
provision of preventive services should take place between the ages of 13 and
15 years (1). This visit provides an opportunity to directly observe mother–
daughter communication during the visit, and to assess whether the
405relationship appears to be an open and trusting one or whether the mother
appears excessively anxious, controlling, domineering, authoritarian, or
permissive. Adolescents must be afforded confidentiality during a visit in
which it is essential to obtain a history of risk-taking behaviors including
sexual behaviors, substance use/abuse, and mental health concerns (1,2).
Concerns about confidentiality can be a major obstacle to adolescents’
willingness to seek health care services.
Table 9-1 Pediatric Gynecology—History
Child’s description of symptoms (if child is verbal)
Slang/colloquial terms (explained by mother)
Extent of current symptoms compared to previously
History from mother
Symptoms
Itching
Pain
Burning
Erythema or rash (consider photodocumentation)
Location of symptoms
“Vagina” usually = vulva or vaginal vestibule
Urinary symptoms
External “dysuria”
Dribbling
Urinary leakage
Vaginal discharge
Vaginal bleeding
Constipation
406Symptoms
Onset
Frequency
Duration
Exacerbating factors
Alleviating factors
Extent of disruption of activities of daily living including preschool/school
Treatments
Previously prescribed therapies and efficacy
Home remedies
Hygiene
Baths vs. showers and frequency
Bubble baths, soaps, shampoos
Cultural beliefs and previous recommendations about baths
Toileting supervision
Birth history
Past medical history
General health
Chronic medical conditions
Medications
Hospitalizations
Surgeries
Immunizations
Allergies
407History of abuse/molestation
Safety discussion with child: “No, Go, Tell”
One structure of an adolescent’s gynecologic consultation visit has been
described in which the adolescent and her parent (typically her mother) meet
together initially, followed by time in which the physician addresses the mom’s
concerns and ascertains her concerns about such issues as risk-taking behaviors
(Table 9-2) (3). Concepts of confidentiality are explained to the mother at this
time, and preventive guidance about adolescent development is provided. The
order in which the mother and daughter are seen is intentional, in that the clinician
has not yet spoken privately with the adolescent, allowing the clinician to speak in
generalities about adolescent behaviors. Subsequently, the adolescent is seen
alone, concepts of confidentiality are explained, and psychosocial issues are
addressed. Among adolescent medicine clinicians, this assessment is often
referred to as the HEEADSSS assessment (Table 9-3) (4).
[5] Preventive services for adolescents should be based on knowledge of the
behavioral and medical health risks that can affect their future health, including
substance use and abuse, sexual behaviors that invite unintended pregnancy and
sexually transmitted diseases (STDs), and the symptoms of impaired mental
health.
This chapter will address the gynecologic problems of prepubertal girls and
adolescents. The gynecologic problems that will be addressed by age group
include bleeding, pelvic masses, and vulvovaginal conditions.
PREPUBERTAL AGE GROUP
Prepubertal Bleeding
Prior to menarche, which frequently does not occur before 9 years of age,
any vaginal bleeding requires evaluation. To appropriately evaluate a young
girl with vaginal bleeding, a practitioner should understand the events of puberty
(5–7). The hormonal changes that control the cyclic functioning of the
hypothalamic–pituitary–ovarian axis are described in Chapter 7. An
understanding of the normal sequence and timing of these events is critical to an
appropriate assessment of a girl at the onset of bleeding (see Chapter 8).
Menarche typically occurs when an adolescent has reached Tanner stage 3 or 4 of
breast development (Fig. 9-1). Bleeding in the absence of breast development
must be evaluated.
Differential Diagnosis of Prepubertal Vaginal Bleeding
Slight vaginal bleeding can occur within the first few days of life because of
408withdrawal from exposure to high levels of maternal estrogen. New mothers of
female infants should be informed of this possibility to preclude unnecessary
anxiety. After the neonatal period, causes of bleeding that should be considered in
the prepubertal age group include sexual abuse, precocious puberty, benign and
malignant ovarian tumors, as well as vulvar, vaginal, and cervical lesions or
tumors (Table 9-4). Menses do not normally occur before breast budding (8,9).
[4] The causes of bleeding in this age group range from the medically
mundane to malignancies that may be life-threatening. The source of
bleeding is sometimes difficult to identify, and parents who observe blood in
a child’s diapers or panties may be unsure of the source—whether from the
urinary tract, the vagina, or the rectum. Pediatricians usually look for
urinary causes of bleeding, and gastrointestinal factors such as constipation
and/or anal fissure, or inflammatory bowel disease should be considered. The
possibility of abuse should always be assessed in girls with any vulvovaginal
symptoms, particularly if bleeding is present (10). Failure to diagnose sexual
abuse may leave a child in significant danger.
Table 9-2 Visit Structure for Adolescent Consultation Visit
Step Topics Covered The Clinician in Consultation
With
1 Review structure of visit
Obtain history of present illness/chief
concerns
Obtain past medical history and family
history
Adolescent and parent(s)
2 Address parental concerns
Provide preventive guidance about
adolescent development
Address confidentiality
Parent(s)
3 Address confidentiality
Obtain history, including sexuality and
risk-taking behaviors
Adolescent
4 Perform physical examination, as
indicated
Adolescent (+/- parent, per
adolescent’s preference)
5 Summarize findings and
recommendations
Determine parameters of parental
Adolescent
409involvement
Determine method of notification of
laboratory results
Provide preventive guidance
6 Summarize findings and
recommendations, as appropriate
Adolescent and parent(s)
Vulvar Lesions
Vulvar irritation can lead to pruritus with excoriation, maceration of the vulvar
skin, or fissures that can bleed. Other visible external causes of bleeding in this
age group include urethral prolapse, condylomas, lichen sclerosus, or molluscum
contagiosum. Urethral prolapse can present acutely with a tender mass that
may be friable or bleed slightly; it is most common in African American girls
and may be confused with a vaginal mass (Fig. 9-2). The classic presentation is
a donut-shaped mass symmetrically surrounding the urethra. This condition can
typically be managed medically with the topical application of estrogens,
although some authors have advocated primary surgical excision (11). The
presence of condyloma should prompt questioning about abuse, although it has
been suggested that condyloma that appear during the first several years of
life may be acquired perinatally from maternal infection with human
papillomavirus (HPV) (Fig. 9-3) (12). Excoriation and subepithelial hemorrhage
(“blood blisters”) into the skin can cause external bleeding in the presence of
prepubertal lichen sclerosus; this finding may mistakenly be identified as abuse,
and the conditions are not mutually exclusive (Fig. 9-4) (13). Although most
gynecologists recognize the appearance of lichen sclerosus in postmenopausal
women, the condition can occur in prepubertal girls and may not be
recognized by clinicians who are unfamiliar with this condition. As with
adults, the cause of lichen sclerosus remains uncertain; a familial incidence has
been identified (14).
Table 9-3 HEEADSSS Psychosocial Assessment for Adolescents
H Home
E Education and employment
E Eating
A Activities
D Drugs
410S Sexuality
S Suicide/depression
S Safety
Adapted from Klein DA, Goldenring JM, Adelman WP. HEEADSSS 3.0: The
psychosocial interview for adolescents updated for a new century fueled by media.
Contemp Pediatr (serial online) 2014. Available online at
https://mmcp.dhmh.maryland.gov/epsdt/healthykids/…/sec._4_add_heeadsss.pdf.
Accessed September 25, 2017. Available online at
https://mmcp.dhmh.maryland.gov/epsdt/healthykids/…/sec._4_add_%20heeadsss.pdf.
Accessed September 25, 2017.
Table 9-4 Causes of Vaginal Bleeding in Prepubertal Girls
Vulvar and external
Vulvitis with excoriation
Trauma (e.g., accidental injury [straddle injury] or sexual abuse)
Lichen sclerosus
Condylomas
Molluscum contagiosum
Urethral prolapse
Vaginal
Vaginitis
Vaginal foreign body
Trauma (abuse, penetration)
Vaginal tumor
Uterine
Precocious puberty
Ovarian tumor
Granulosa cell tumor
411Germ cell tumor
Exogenous estrogens
Topical
Enteral
Other
McCune–Albright syndrome
FIGURE 9-2 Urethral prolapse in prepubertal girl.
412FIGURE 9-3 Perianal condyloma in a prepubertal girl.
413FIGURE 9-4 Prepubertal lichen sclerosus.
414Foreign Body
A foreign body in the vagina is a common cause of vaginal discharge, which
may appear purulent or bloody. Young children explore all orifices and may
place all varieties of small objects inside their vaginas (Fig. 9-5). An object, such
as a small plastic toy, can sometimes be palpated on rectal examination, and
occasionally “milked” toward the vaginal introitus to allow removal. The most
common foreign bodies found in the vagina are small pieces of toilet paper (15).
Although it has been suggested that the presence of vaginal foreign bodies might
be a marker for sexual abuse, this is not always the case; but the possibility of
abuse should always be considered.
Precocious Puberty
Vaginal bleeding in the absence of other secondary sexual characteristics
may result from precocious puberty (see Chapter 8), although as with normal
puberty, the onset of breast budding or pubic hair growth is more likely to occur
before vaginal bleeding. A large observational study suggested that the onset of
pubertal changes—breast budding and pubic hair—might occur earlier than
previously thought (6). Evaluation for precocious puberty was recommended for
girls with pubertal development younger than age 8 years. Guidelines proposed
evaluation of white girls younger than age 7 years and African American girls
younger than age 6 years who have either breast development or pubic hair, rather
than the traditional age of 8 (16). An expert panel concluded that there is
reasonable evidence that pubertal milestones are occurring at a younger age
in girls (17).
415FIGURE 9-5 Foreign body (plastic toy) in the vagina of an 8-year-old girl.
Trauma
Trauma can be a cause of genital bleeding. A careful history should be obtained
from one or both parents or caretakers and the child herself, because trauma
caused by sexual abuse often is not recognized. Trauma can be characterized
as accidental or nonaccidental, which is described as child abuse. Physical
findings that are inconsistent with the description of the alleged accident should
prompt consideration of abuse and appropriate consultation or referral to an
experienced social worker or sexual abuse team. All states impose a mandatory
legal obligation to report suspected child physical abuse; most states
specifically require reporting child sexual abuse, but even in those that do not, the
laws are broad enough to encompass sexual abuse implicitly (10). Notification is
required even with the suspicion of sexual abuse. In general, a straddle injury
occurring with accidental trauma affects the anterior and lateral vulvar area,
whereas penetrating injuries with lesions of the fourchette or lesions that extend
through the hymenal ring are less likely to occur as a result of accidental trauma
(Fig. 9-6) (18).
Abuse
416The medical evaluation of suspected child sexual abuse is best managed by
individuals who have experience in assessing the physical findings,
laboratory results, and the children’s statements and behaviors. Genital
findings have been categorized as follows (10):
1. Findings documented in newborns or commonly seen in nonabused children
2. Findings with no expert consensus on interpretation with respect to sexual
contact or trauma
3. Findings caused by trauma and/or sexual contact
Most cases of child sexual abuse do not come to light with an acute injury
and instead are associated with normal or nonspecific genital findings (10).
Forms of abuse such as fondling or digital penetration may not result in visible
genital lesions.
Other Causes
Other serious but rare causes of vaginal bleeding include vaginal tumors.
The most common tumor in the prepubertal age group is a
rhabdomyosarcoma (sarcoma botryoides), which is associated with bleeding
and a grapelike clustered mass (see Chapter 38). Other forms of vaginal tumor
are rare but should be ruled out with a thorough examination under anesthesia
with vaginoscopy if no other obvious external source of bleeding is found.
Hormonally active ovarian tumors can cause endometrial proliferation and
bleeding. Likewise, exogenously administered estrogens can result in bleeding.
Rarely, bleeding can result from the prolonged use of topical estrogens prescribed
as therapy for vulvovaginitis or labial adhesions or from accidental ingestion of
prescription estrogens.
Diagnosis of Prepubertal Bleeding
Examination
A careful examination is indicated when a child has genital symptoms. The
technique of examining the prepubertal child is described in Chapter 1. If no
obvious cause of bleeding is visible externally or within the distal vagina, an
examination can be performed using anesthesia with vaginoscopy to
completely visualize the vagina and cervix. This examination should be
performed by a clinician who has experience in pediatric and adolescent
gynecology.
417FIGURE 9-6 Straddle injury—vulvar hematoma in a 13-year-old girl.
Imaging
If an ovarian or vaginal mass is suspected, a transabdominal pelvic
ultrasonographic examination can provide useful information. The appearance of
the ovaries (normal prepubertal size and volume, follicular development, cystic,
or solid) can be noted, as well as the size and configuration of the uterus. The
prepubertal uterus has a distinctive appearance, with equal proportions of
cervix and fundus and a size of approximately 2 to 3.5 cm in length and 0.5 to
1 cm in width (Fig. 9-7). The uterine fundus enlarges with estrogen stimulation,
resulting in the postmenarchal appearance in which the uterine fundus is larger
than the cervix (19). An ultrasonographic examination should be the first imaging
study performed; more sophisticated imaging techniques, such as magnetic
resonance imaging (MRI) or computed tomography (CT) scanning, are rarely
418indicated as initial diagnostic modalities, and they add unnecessary expense and
radiation exposure with CT.
Management of Prepubertal Vaginal Bleeding
The management of bleeding in prepubertal-age girls is directed toward the cause
of bleeding. If bloody discharge believed to result from nonspecific
vulvovaginitis persists despite therapy, further evaluation may be necessary to
rule out the presence of a foreign body. Skin lesions (chronic irritation) and lichen
sclerosus may be difficult to manage but can be treated with a course of topical
steroids; lichen sclerosus often requires the use of ultrahigh-potency topical
steroids and ongoing maintenance therapy. Vaginal and ovarian tumors should
be managed in consultation with a gynecologic oncologist.
Prepubertal Pelvic Masses
Presentation of Prepubertal Pelvic Masses
The probable causes of a pelvic mass found on physical examination or
through radiologic studies are vastly different in prepubertal children than
they are in adolescents or postmenopausal women (Table 9-5). A pelvic mass
may be gynecologic in origin, or it may arise from the urinary tract or bowel.
The gynecologic causes of a pelvic mass may be uterine, adnexal, or more
specifically ovarian. Because of the small pelvic capacity of a prepubertal child,
a pelvic mass very quickly becomes abdominal in location as it enlarges and may
be palpable on abdominal examination. Ovarian masses in this age group may be
asymptomatic, associated with chronic pressure-related bowel or bladder
symptoms, or may present with acute pain caused by rupture or torsion.
Abdominal or pelvic pain is one of the most frequent initial symptoms. The
diagnosis of ovarian masses in prepubertal girls is difficult because the condition
is rare in this age group and, consequently, there is a low index of suspicion.
Many symptoms are nonspecific, and acute symptoms are more likely to be
attributed to more common entities such as appendicitis. Abdominal palpation
and bimanual rectoabdominal examination are important in any child who
has nonspecific abdominal or pelvic symptoms. An ovarian mass that is
abdominal in location can be confused with other abdominal masses occurring in
children, such as Wilms tumor or neuroblastoma. Acute pain is often associated
with torsion. The ovarian ligament becomes elongated as a result of the
abdominal location of ovarian tumors, thus creating a predisposition to torsion.
Adnexal torsion is more likely to occur with an ovarian mass than with a normalsize ovary. While torsion of a normal ovary is rare in adolescents and adults, it is
more likely to occur in prepubertal girls. Symptoms of torsion include the acute
419onset of severe abdominal pain, accompanied by nausea and vomiting.
Recurrent torsion is also a possibility, noted by intermittent episodes of severe
pain.
FIGURE 9-7 Pelvic ultrasound (transabdominal) of a premenarchal 10-year-old girl. U,
uterine fundus; C, cervix. In prepubertal child, uterine fundus and cervix are similar in size.
Diagnosis of Prepubertal Pelvic Masses
[3] Ultrasonography is the most valuable tool for diagnosing ovarian masses. The
characteristics of a pelvic mass can be determined. Whereas both uni- and
multilocular cysts frequently resolve with observation, the finding of a solid
component mandates surgical assessment because of the high risk of a germ cell
tumor (20). Additional imaging studies, such as CT scanning, MRI, or Doppler
flow studies, may be helpful in establishing the diagnosis (21).
Table 9-5 Causes of Pelvic Mass by Approximate Frequency and Age
420Differential Diagnosis
Fewer than 2% of ovarian malignancies occur in children and adolescents
(22,23). Ovarian tumors account for approximately 1% of all malignant
tumors in these age groups. Germ cell tumors make up one-half to two-thirds
of ovarian neoplasms in individuals younger than 20 years of age. A review of
studies conducted from 1940 until 1975 concluded that 35% of all ovarian
neoplasms occurring during childhood and adolescence were malignant (24). In
girls younger than 9 years of age, approximately 80% of the ovarian
neoplasms were malignant. Germ cell tumors account for approximately 60% of
ovarian neoplasms in children and adolescents compared with 20% of these
tumors in adults (24). Epithelial neoplasms are rare in the prepubertal age group;
thus, data usually are reported from referral centers. Some reports include only
neoplastic masses, whereas others include nonneoplastic masses; some series
combine data from prepubertal and adolescent girls. One community survey of
ovarian masses revealed that the frequency of malignancy was much lower than
previously reported; of all ovarian masses confirmed surgically in childhood
and adolescence, [2] only 6% of patients with ovarian enlargement had
malignant neoplasms, and only 10% of neoplasms were malignant (25). Surgical
decision making influences the statistics on incidence; the surgical excision of
functional masses that would resolve in time inflates the percentage of benign
masses. In one series, nonneoplastic masses in young women and girls younger
than 20 years of age constituted two-thirds of the total (26). Even in girls younger
than 10 years of age, 60% of the masses were nonneoplastic, and two-thirds of the
neoplastic masses were benign. Authors of older case series were less aware of
the benign and functional masses that are now found incidentally with routine
sonographic images. Functional, follicular cysts can occur in fetuses, newborns,
and prepubertal children (27). Rarely, they may be associated with sexual
precocity.
421FIGURE 9-8 Management of pelvic masses in premenarchal and adolescent girls.
Management of Prepubertal Pelvic Masses
422A plan for the management of pelvic masses in prepubertal-age girls is shown in
Figure 9-8. Unilocular cysts are virtually always benign, even in this age
group, and will regress in 3 to 6 months; thus, they do not require surgical
management with oophorectomy or oophorocystectomy. Close observation is
recommended, and there is a risk of ovarian torsion that must be discussed with
the child’s parents (28). Recurrence rates after cyst aspiration (either
ultrasonographically guided or with laparoscopy) may be as high as 50%.
Attention should be directed to long-term effects on endocrine function and future
fertility; preservation of ovarian tissue is a priority for patients with benign
tumors. Oophorectomy should be avoided if at all possible for benign masses
(29–31). Premature surgical therapy for a functional ovarian mass can result
in ovarian and tubal adhesions that can adversely affect future fertility. Solid
masses, those larger than approximately 8 cm, and enlarging masses require
surgical intervention, as the likelihood of neoplasm is high.
Prepubertal Vulvar Conditions
Neonatal Vulvar Conditions
Various developmental and congenital vulvovaginal abnormalities are detected in
the neonatal age group. Obstetrician-gynecologists will recognize that they must
be prepared to deal with the parents and family when an infant is born with
ambiguous genitalia. The etiology of these problems and intersex disorders (now
termed disorder of sex development [DSD]) that may be discovered in an older
child can be complex (32). Chromosomal abnormalities, enzyme deficiencies
(including 17- or 21-hydroxylase deficiency as causes of congenital adrenal
hyperplasia), or prenatal masculinization of a female fetus resulting from maternal
androgen-secreting ovarian tumors or, rarely, drug exposure can all result in
genital abnormalities that are noted at birth. These abnormalities are described in
Chapter 34.
Ambiguous genitalia represent a social and potential medical urgency that
is best handled by a team of specialists, which may include urologists,
neonatologists, endocrinologists, and pediatric gynecologists (32). The first
question parents ask after a baby is born “is it a boy or a girl?” In the case of
ambiguous genitalia, the parents should be informed that the baby’s genitals are
not fully developed and, therefore, a simple examination of the external genitalia
cannot determine the actual sex. The parents should be told that data will be
collected but that it may take several days or longer to determine the baby’s
intended sex. In some situations, it may be best to state simply that the baby has
some serious medical complications. The issues of sex assignment and
appropriateness or timing of surgical therapy are controversial and should be
423managed by clinicians with extensive experience in this area (32).
Other genital abnormalities may be noted at birth, although few obstetricians or
pediatricians carefully examine the external genitalia of female neonates. It is
argued that careful inspection of the external genitalia of all female infants
should be performed, with gentle probing of the introitus and anus to
determine the patency of the hymen or a possible imperforate anus. If
patency is in doubt, a rectal thermometer may be used to gently test the patency. It
is suggested that this examination should be performed on all female infants in
the delivery room (33). Various types of hymenal configurations in the newborn
are described, ranging from imperforate to microperforate, to cribriform, to
hymenal bands, and to hymens with central anterior, posterior, or eccentric
orifices (34). An examination during the neonatal period would prevent the
discovery of an imperforate hymen or vaginal septum after a young woman
experiences periodic pelvic and abdominal pain with the development of a large
hematometra or hematocolpos.
Congenital vulvar tumors may include strawberry hemangiomas, which are
relatively superficial vascular lesions, and large cavernous hemangiomas.
Treatment is controversial, and many lesions will spontaneously regress.
Childhood Vulvar Conditions
Vulvar and vaginal symptoms, such as burning, dysuria, itching, or a rash, are
common initial symptoms among children that are reported to gynecologists. It
may be difficult for a young child to describe vulvar sensations. Parents may
notice the child crying during urination, scratching herself repeatedly, or
complaining of vague symptoms. Often, the child’s pediatrician will have
evaluated the child for urinary tract infection (UTI). Evaluation for pinworms is
warranted, because pinworms can cause severe itching in the vulvar and perianal
area. Vulvovaginitis is the most common gynecologic problem of childhood.
Prepubertally, the vulva, vestibule, and vagina are anatomically and histologically
vulnerable to bacterial infection, with the bacteria typically present in the perianal
area. The physical proximity of the vagina and vestibule to the anus can result in
overgrowth of bacteria that can cause primary vulvitis and secondary vaginitis.
Yeast infections are rare in prepubertal children who are toilet trained and out of
diapers (35).
The clinician should be familiar with normal prepubertal genital anatomy and
hymenal configuration. The unestrogenized vulvar vestibule is mildly
erythematous and can be confused with infection. In addition, smegma in the
interlabial sulci and beneath the clitoral prepuce may resemble patches of
candida vulvitis. In prepubertal girls, the vulvar area is quite susceptible to
chemical irritants.
424Chronic skin conditions such as lichen sclerosus, psoriasis, seborrheic
dermatitis, and atopic vulvitis may occur in children (11). Lichen sclerosus, the
cause of which is not well-established, has a characteristic “cigarette paper”
appearance in a keyhole distribution (around the vulva and anus) (Fig. 9-4).
Lichen sclerosus should be treated in pediatric patients as it is in adults; there is
some evidence that the condition may regress as the child progresses through
adrenarche and menarche, although this appears to be infrequent. The use of
ultrapotent steroids topically has been successful in children and adolescents (36).
Labial agglutination or adhesions may occur as a result of chronic vulvar
inflammation from any cause (Fig. 9-9A). The treatment of labial adhesions
consists of observation, if they are asymptomatic. With urinary or vulvovaginal
symptoms, a brief course (2 to 6 weeks) of externally applied estrogen cream or
topical steroid is appropriate (37). The area of agglutination (adhesion) will
become thin as a result, and separation can usually be performed in the office with
the use of a topical anesthetic (e.g., lidocaine jelly) (Fig. 9-9B). Manual
separation in the office without pretreatment and without anesthesia is
discouraged, as this practice may be so traumatic to the child that she will not
allow subsequent examination. In the absence of a previously traumatic
examination, failure of medical therapy, or acute symptoms such as urinary
retention, surgical separation is infrequently required (37). Treatment with a
topical emollient (such as petrolatum) is indicated after lysis to prevent recurrent
adhesions. Urethral prolapse may cause acute pain or bleeding, or the presence of
a mass may be noted (Fig. 9-2).
Vulvovaginal symptoms of any sort in a young child should prompt the
consideration of possible sexual abuse. Sexually transmitted infections may
occur in prepubertal children (38). Although vulvar condyloma presenting before
age 2 to 3 years can be transmitted during vaginal delivery from the mother or
from warts on caretakers’ hands, the possibility of abuse should be considered in
all children with genital warts. Condyloma in older girls may be spread in a
nonsexual manner, but was classified as “indeterminant” in classification findings
that may be associated with sexual abuse (39). Sensitive, but direct, questioning
of the parent or caretaker and the child should be a part of the evaluation; if
sexual abuse is suspected, the incident must be reported to the appropriate social
services agency.
Nonsexually transmitted vulvar ulcers can occur in peripubertal and adolescent
girls, often in association with systemic symptoms suggestive of a viral illness
(40). Herpes simplex virus, syphilis, and Behçet disease can cause vulvar ulcers,
and they may occur as a form of genital aphthosis (Fig. 9-10).
425FIGURE 9-9 A: Labial adhesions. B: Cotton-tipped applicator placed inside the labial
adhesions shown in A.
Prepubertal Vaginal Conditions
Vaginal Discharge in Prepubertal Girls
The symptom of vaginal discharge in the prepubertal age group is almost always
caused by inflammation and irritation. In prepubertal girls, the primary site
typically is the vulva with vaginitis following secondarily, whereas in adolescents
and adults, vaginitis typically is the primary finding with vulvitis occurring
secondarily. Sexual abuse should always be considered in prepubertal
children with vaginal discharge or a foreign body (41). Although the routine
use of cultures to detect STDs in girls with a history of sexual abuse was
questioned, vaginal testing for gonorrhea and chlamydia should be performed in
girls who have symptoms that include vaginal discharge (10). In prepubertal girls,
vulvovaginitis is usually caused by multiple organisms that are present in the
perineal area, although a single organism such as Streptococcus, or even rarely
426Shigella, may be causative (42). When the cause is related to poor perineal
hygiene, cultures often reveal a mixture of bacterial organisms. In this situation,
the typical history is intermittent symptoms of irritation, itching, discharge, and
odor over many months to years. Treatment should be initiated with a focus on
hygiene and cleansing measures (11). A short-term (less than 4 weeks) course of
treatment with topical estrogens and broad-spectrum antibiotics may be
necessary. The problem is frequently recurrent. In girls who have a relatively
acute onset of vaginal discharge and vulvovaginal symptoms, a single bacterial
organism is more likely to be the cause of their symptoms.
Pokorny and Stormer described a technique for obtaining vaginal cultures and
for performing vaginal irrigation (43). A catheter within a catheter can be
fashioned using the tubing from an intravenous butterfly setup within a sterile
urethral catheter. Nonbacteriostatic saline (1 to 3 mL) can be injected, aspirated,
and sent for culture (Fig. 9-11). Cultures taken in this manner are almost always
better tolerated than cultures obtained using a cotton-tipped applicator. A larger
quantity of saline can be used to irrigate the vagina while the catheter is still
within the vagina. Small foreign bodies can often be flushed from the vagina in
this manner. The most common foreign body is a small piece of toilet paper,
although children will place other objects (toys, beans, coins) within their vaginas
(Fig. 9-5). A persistent vaginal discharge after treatment or a discharge that
is bloody or brown in color without other obvious external lesions should
prompt vaginal irrigation or vaginoscopy to rule out a foreign body (15).
ADOLESCENT AGE GROUP
The adolescent’s experience and expression of illness and pain should be viewed
within the context of her life experiences. Most adolescents have limited life
experiences with problems such as pain, discomfort, or bleeding. An adolescent
may state that she is experiencing the “worst pain of her life” and yet may appear
to be reasonably comfortable. She may well be stating the truth about this
experience, which the clinician must interpret differently from the symptoms of
an adult woman who, for instance, may be in active labor. It should be
remembered that an individual’s response to illness and pain is to some extent a
learned behavior.
427FIGURE 9-10 Vulvar aphthosis in a prepubertal girl.
428Adolescent Abnormal Bleeding
Normal Menses in Adolescents
[1] To assess vaginal bleeding during adolescence, it is necessary to
understand the range of normal menstrual cycles (see Chapter 7). During the
first 2 to 5 years after menarche, most cycles are anovulatory. Despite this,
they are somewhat regular, within a range of approximately 21 to 45 days, in
contrast to adult women, whose cycles typically range between 21 and 38
days (44–46). A pattern of plus or minus 10 days and a cycle length of 21 to
approximately 45 days are established within 2 years of menarche (Table 9-6).
The mean duration of menses is 4.7 days; 89% of cycles last 7 days. The
average blood loss per cycle is 35 mL, and the major component of menstrual
discharge is endometrial tissue (47). An 80 mL/cycle is used as a definition of
heavy menstrual bleeding and recurrent bleeding in excess of 80 mL/cycle
results in anemia, although the clinical utility of the 80 mL/cycle is question
able as neither women nor clinicians can easily estimate this volume (48,49).
FIGURE 9-11 Catheter technique for obtaining vaginal culture and irrigation.
429The common clinical practice of asking how many pads or tampons are soaked
on a heavy day or per cycle can give a rough approximation of blood loss (three
to five pads per day is typical). Individual variations in fastidiousness, lack of
familiarity with the volume of blood loss other than one’s own, and errors in
estimation or recollection result in inaccuracies in estimations of menstrual
volume. One study found that one-third of individuals who estimated their cycles
to be moderate or light had bleeding in excess of 80 mL/cycle, whereas nearly
one-half of those who described the bleeding as heavy had flow less than 80
mL/cycle (50). In addition, the amount of menstrual blood contained in each
tampon or pad may vary both within brands as well as from one brand to another.
However, changing a pad hourly, clots larger than “50-pence size,” and requiring
a change overnight are associated with a measured volume of greater than 80 mL
(49).
The transition from anovulatory to ovulatory cycles during adolescence
takes place during the first several years after menarche. It results from the
so-called maturation of the hypothalamic–pituitary–ovarian axis, characterized
by positive feedback mechanisms in which a rising estrogen level triggers a surge
of luteinizing hormone and ovulation. Most adolescents have ovulatory cycles
by the end of their second year of menstruation, although most cycles (even
anovulatory ones) remain within a rather narrow range of approximately 21
to 42 days.
Table 9-6 Parameters for Normal Menstrual Cycles in Adolescents
Normal
Menstrual cycle frequency 21–45 days
Cycle variation from cycle to cycle Less than in adults
Duration of flow 4–8 days
Volume of flow 4–80 mL
From Hillard PJ. Menstruation in young girls: a clinical perspective. Obstet Gynecol
2002;99:655–662.
Differential Diagnosis of Adolescent Abnormal Bleeding
Cycles that are longer than 42 days, bleeding that occurs more frequently
than 21 days, and bleeding that lasts more than 7 days should be considered
abnormal, particularly after the first 2 years from the onset of menarche.
Bleeding occurring less frequently than in an interval of 90 days is abnormal,
430even in the first gynecologic year after menarche (44). The variability in cycle
length is greater during adolescence than adulthood; thus, greater irregularity is
acceptable if neither significant anemia nor hemorrhage is present. However,
consideration should be given to an evaluation of possible causes of abnormal
menses (particularly underlying causes of anovulation such as androgen excess
syndromes or causes of oligomenorrhea such as eating disorders) for girls whose
cycles are consistently outside normal ranges or whose cycles were previously
regular and become irregular (45). Conditions that are associated with abnormal
bleeding are listed in Table 9-7 and more fully discussed in Chapter 10.
Anovulation
Anovulatory bleeding can be too frequent, prolonged, or heavy, particularly
after a long interval of amenorrhea. The physiology of this phenomenon relates
to a failure of the feedback mechanism in which rising estrogen levels result in a
decline in follicle-stimulating hormone (FSH) with subsequent decline of estrogen
levels. In anovulatory cycles, estrogen secretion continues, without opposing
progesterone, resulting in endometrial proliferation with subsequent unstable
growth and incomplete shedding. The clinical result is irregular, prolonged, and
heavy bleeding.
Table 9-7 Conditions Associated With Anovulation and Abnormal Bleeding
Eating disorders
Anorexia nervosa
Bulimia nervosa
Excessive physical exercise
Chronic illness
Primary ovarian insufficiency (POI) (previously termed premature ovarian failure
[POF])
Alcohol and other drug abuse
Stress
Thyroid disease
Hypothyroidism
Hyperthyroidism
431Diabetes mellitus
Androgen excess syndromes (e.g., polycystic ovary syndrome [PCOS])
Studies of adolescent menses show differences in rates of ovulation based on
the number of months or years postmenarche. The younger the age at
menarche, the sooner regular ovulation is established. In one study, the time
from menarche until 50% of the cycles were ovulatory was 1 year for girls whose
menarche occurred when they were younger than 12 years of age, 3 years for girls
whose menarche occurred between 12 and 12.9 years of age, and 4.5 years for
girls whose menarche occurred at 13 years of age or older (51).
Pregnancy-Related Bleeding
The possibility of pregnancy must be considered when an adolescent seeks
treatment for abnormal bleeding (Table 9-8). Bleeding in pregnancy can be
associated with a spontaneous abortion, ectopic pregnancy, or other pregnancyrelated complications, such as a molar pregnancy. In the United States, 11% of
15-year-old adolescent girls have had sexual intercourse, as have 55% of those 18
years old (52). Issues of confidentiality for adolescent health care are critical to an
adolescent’s willingness to seek appropriate reproductive health care (see Chapter
1).
Table 9-8 Causes of Bleeding by Approximate Frequency and Age Group
Exogenous Hormones
The cause of abnormal bleeding that is experienced while an individual is taking
exogenous hormones usually is very different from bleeding that occurs without
hormonal manipulation (53). Oral contraceptive use is associated with
breakthrough bleeding, which occurs in as many as 30% to 40% of
individuals during the first cycle of combination pill use. In addition,
irregular bleeding can result from missed pills (54,55). Strict adherence to
432correct and consistent pill taking is difficult for many individuals who take oral
contraceptives; one study reported that only 40% of women took a pill every day
(56). Other studies suggest that adolescents have an even more difficult time
taking oral contraceptives than do adults. A study of urban teens reported
approximately two episodes of three or more consecutive missed pills occurring
during each 3-month interval (57). With this many missed pills, it is not
surprising that some individuals experience irregular bleeding. The solution is to
emphasize consistent pill taking; if the individual is unable to comply with daily
pill use, an alternative contraceptive method may be preferable.
All forms of hormonal contraception, from combination and progestinonly minipills, to contraceptive patches, rings, intrauterine devices (IUDs),
and injectable and implantable contraception, can be associated with
abnormal bleeding, although studies assessing bleeding have not used uniform
methodologies and thus comparisons are difficult (58). Irregular bleeding occurs
frequently in users of depomedroxyprogesterone acetate (DMPA), although at the
end of 1 year, more than 50% of users will be amenorrheic (59). The mechanism
of bleeding associated with these hormonal methods is not well-established; an
atrophic endometrium or factors related to angiogenesis may be involved,
suggesting options for therapy (60,61). It should not be assumed that any bleeding
occurring while an individual is using a hormonal method of contraception is
caused by that method. Other local causes of bleeding, such as cervicitis or
endometritis, can occur during the use of hormone therapy and may be
particularly important to consider in adolescents who are at risk for STDs.
433FIGURE 9-12 Uterus didelphys.
Hematologic Abnormalities
In the adolescent age group, the possibility of a hematologic cause of abnormal
bleeding must be considered. One classic study reviewed all visits by adolescent
patients to an emergency room with the symptom of excessive or abnormal
bleeding (62). The most common coagulation abnormality diagnosed was
idiopathic thrombocytopenic purpura, followed by von Willebrand disease.
Subsequent studies confirmed this association, particularly with excessive
bleeding at the time of menarche. Von Willebrand disease occurs in
approximately 1% of women in the United States and, in its mildest form,
menorrhagia may be the only symptom (63). Adolescents who have severe
menorrhagia, especially at menarche, should be screened for coagulation
abnormalities, including von Willebrand disease.
Infections
Irregular or postcoital bleeding can be associated with chlamydial cervicitis.
Adolescents have the highest rates of chlamydial infections of any age group,
and sexually active teens should be screened routinely for chlamydia (64).
Menorrhagia can be the initial sign in patients infected with sexually
transmissible organisms. Adolescents have the highest rates of PID of any age
group of sexually experienced individuals (see Chapter 15).
434Other Endocrine or Systemic Problems
Abnormal bleeding can be associated with thyroid dysfunction. Signs and
symptoms of thyroid disease can be somewhat subtle in teens (see Chapter 35).
Hepatic dysfunction should be considered because it can lead to abnormalities in
clotting factor production. Hyperprolactinemia can cause amenorrhea or irregular
bleeding.
Polycystic ovary syndrome (PCOS) can occur during adolescence, and
manifestations of excess androgen (hirsutism, acne) should prompt evaluation,
although the diagnostic criteria for PCOS during adolescence are not wellestablished (65). Androgen disorders occur in about 5% to 10% of adult
women, making them the most common endocrine disorders in women (see
Chapter 35). Classic PCOS, functional ovarian hyperandrogenism, or partial
late-onset congenital adrenal hyperplasia can occur in adolescence. These
disorders often are overlooked, unrecognized, or untreated. Women with even
mild disorders are candidates for intervention, including lifestyle interventions to
normalize weight and pharmacologic interventions to manage abnormal bleeding
or hirsutism. These disorders may be a harbinger of type 2 diabetes, endometrial
cancer, and cerebrovascular disease. Acne, hirsutism, and menstrual
irregularities are often dismissed as normal during adolescence but may be
manifestations of hyperandrogenism (65,66). Androgen abnormality can persist
beyond adolescence. Obesity, hirsutism, and acne should be evaluated to
minimize the significant psychosocial costs. Androgenic changes are partially
reversible if detected early and managed appropriately. Behavioral changes in
lifestyle (diet and exercise) should be strongly encouraged but are often difficult
to achieve. Signs of insulin resistance (acanthosis nigricans) should be evaluated
and managed appropriately (67,68).
Anatomic Causes
Obstructive or partially obstructive genital anomalies typically present
during adolescence. Complex müllerian abnormalities, such as an obstructing
longitudinal vaginal septum with uterus didelphys, can cause hematocolpos or
hematometra (Fig. 9-12). If these obstructing anomalies have or develop a small
outlet, persistent dark-brownish discharge (old blood) may appear instead of or in
addition to a pelvic mass. Many varieties of uterine and vaginal anomalies exist,
and clinicians who have expertise with these anomalies should be involved in
their management. Figure 9-13 illustrates situations in which abnormal bleeding
can result from partially obstructing septa.
Diagnosis of Adolescent Abnormal Bleeding
Examination
435A careful general physical examination can reveal signs of androgen excess such
as acanthosis nigricans or facial, chest or periareolar, or abdominal terminal hair
growth. Because body hair is felt by many to be culturally unacceptable in women
and girls, sensitive questioning about specific hair removal techniques (bleaching,
waxing, use of depilatories, shaving, plucking, threading) is warranted during an
examination. A complete pelvic examination is appropriate in patients who are
sexually active, are having severe pain, or may have an anatomic anomaly.
Testing for gonorrhea and Chlamydia trachomatis infection is appropriate during
a speculum examination if the patient is sexually active. Some young teens who
have a history that is classic for anovulation, who deny sexual activity, and who
agree to return for follow-up evaluation may be managed with a limited
gynecologic examination supplemented with pelvic ultrasonography.
FIGURE 9-13 The types of obstructive or partially obstructive genital anomalies that can
occur during adolescence.
Laboratory Testing
Any adolescent with abnormal bleeding should undergo sensitive pregnancy
testing, regardless of whether she states that she has had intercourse. The
medical consequences of failing to diagnose a pregnancy are too severe to risk
missing the diagnosis. Complications of pregnancy should be managed
accordingly. In addition to a pregnancy test, laboratory testing should include a
complete blood count with platelet count and screening tests for coagulopathies
436and platelet dysfunction. An international expert panel made recommendations
about when a gynecologist should suspect a bleeding disorder and pursue a
diagnosis (Table 9-9). The consensus report recommends measurement of
complete blood cell count (CBC), platelet count and function, prothrombin time
(PT), activated partial thromboplastin time (aPTT), von Willebrand factor (VWF)
(measured with ristocetin cofactor activity and antigen, factor VIII), and
fibrinogen to be assessed in collaboration with a hematologist (69).
Thyroid studies may be relevant. Testing for STDs may be performed as
warranted on either a cervical or a urine specimen using DNA amplification
techniques. Cervical cytology testing is generally not appropriate for adolescents,
particularly at an emergency or urgent visit for excessive bleeding (70).
Imaging Studies
If the pregnancy test results are positive, pelvic imaging using
ultrasonography may be necessary to confirm a viable intrauterine
pregnancy and rule out a spontaneous abortion or ectopic pregnancy. If a
pelvic mass is suspected on examination, or if the examination is inadequate
(more likely to be the case in an adolescent than an older woman) and
additional information is required, pelvic ultrasonography may be helpful.
Although transvaginal ultrasonographic examination can be more helpful
than transabdominal ultrasonography in ascertaining details of pelvic
anatomy, the use of the vaginal probe may not be possible in a young girl or
one who has not used tampons or had intercourse. Direct communication
between the clinician and the radiologist can be helpful in identifying patients
who are appropriate candidates for transvaginal ultrasonographic examination,
such as those who are sexually active, rather than a blanket prohibition against
transvaginal ultrasound examination in adolescents.
Table 9-9 When Should a Gynecologist Suspect a Bleeding Disorder
Heavy menstrual bleeding since menarche
Family history of bleeding disorder
Personal history of any of the following:
Epistaxis in the last year
Bruising without injury >2 cm diameter
Minor wound bleeding
Oral or gastrointestinal bleeding without anatomic lesion
437Prolonged or heavy bleeding after dental extraction
Unexpected postoperative bleeding
Hemorrhage from ovarian cyst
Hemorrhage requiring blood transfusion
Postpartum hemorrhage, especially delayed >24 hrs
Failure to respond to conventional management of menorrhagia
From James AH, Kouides PA, Abdul-Kadir R, et al. Von Willebrand disease and other
bleeding disorders in women: consensus on diagnosis and management from an
international expert panel. Am J Obstet Gynecol 2009;201(1):12e11–12e18.
Other imaging studies are not indicated as initial testing but may be helpful in
selected instances. If a pelvic ultrasonographic examination does not lead to
clarification of the anatomy when vaginal septa, uterine septa, uterine
duplication, or vaginal agenesis is suspected, MRI can be helpful in
delineating anatomic abnormalities (71). This imaging technique is useful in
the evaluation of uterine and vaginal developmental anomalies, although
laparoscopy can still play a role in the clarification of abnormal anatomy (72). CT
scanning may be helpful in detecting nongenital intra-abdominal abnormalities.
Management of Abnormal Bleeding
Management of bleeding abnormalities related to pregnancy, thyroid dysfunction,
hepatic abnormalities, hematologic abnormalities, or androgen excess syndromes
should be directed to treating the underlying condition. Oral contraceptives can be
extremely helpful in managing androgen excess syndromes, inherited bleeding
disorders, and anovulation, although an appropriate evaluation should be
performed prior to initiation of hormonal contraception (67,73,74).
Treatment with mefenamic acid and other nonsteroidal anti-inflammatory
agents (NSAIDs) results in decreased menstrual bleeding when compared
with placebo (75). Tranexamic acid, an antifibrinolytic agent, is more effective in
decreasing heavy menstrual bleeding, and was approved by the U.S. Food and
Drug Administration (FDA) for this indication in late 2009. After specific
diagnoses are ruled out by appropriate laboratory testing, this condition can be
managed either expectantly or with hormone therapy, depending on the clinical
presentation and other factors, such as the need for contraception.
Anovulation: Mild Bleeding
438Adolescents who have mildly abnormal bleeding, as defined by adequate
hemoglobin levels and minimal disruption of daily activities, are best
managed with prospective menstrual charting, frequent reassurance, close
follow-up, and supplemental iron. If the patient is bleeding heavily or for a
prolonged interval, an apparent decrease in the bleeding does not necessarily
mean that therapy is not required. Intermittent bleeding characterizes anovulatory
bleeding and is likely to continue in the absence of therapy.
A patient who is mildly anemic will benefit from hormone therapy. If the
patient is not bleeding at the time of evaluation and has no contraindications to
the use of estrogen, a combination low-dose oral contraceptive can be
prescribed for use in the manner in which it is used for contraception. If the
patient is not sexually active, she should be reevaluated after three to six cycles to
determine whether she desires to continue this regimen. Parents may sometimes
object to the use of oral contraceptives if their daughter is not sexually active (or
if they believe her not to be or even if they would like her not to be). These
objections are frequently based on misconceptions about the potential risks of the
pill and can be overcome by careful explanation of the pill’s role as medical
therapy. Objections may be based on concerns that hormonal therapy for medical
indications is likely to hasten the onset of coitarche or sexual debut, although no
data support this fear. If the medication is discontinued when the young woman is
not sexually active and she subsequently becomes sexually active and requires
contraception, it may be difficult to explain the reinstitution of oral contraceptives
to the parents. Oral contraceptives are especially appropriate for the management
of abnormal bleeding in adolescents for a number of reasons:
1. Over 40% of adolescents in the United States are sexually experienced
(52).
2. Adolescents typically wait many months after initiating sexual activity to
seek medical contraception.
3. At least 80% of adolescent pregnancies are unintended (76).
4. Approximately one-quarter of adolescent pregnancies in the United States
end in abortion (77).
5. Approximately 11% of adolescent females in the United States give birth
before age 20, although these rates vary by race/ethnicity: 8% of white
teens, 16% of black teens, and 17% of Hispanic teens (78).
Consideration should certainly be given to continuing the oral contraception
use, and parents should be reassured that the medical risks are small in otherwise
healthy adolescents and that there are no significant risks associated with
prolonged use. Individuals may choose to continue oral contraceptives for
439contraception or their noncontraceptive benefits (improvement of acne, decreased
dysmenorrhea, and lighter, more regular menstrual flow, protective effect for
endometrial and ovarian cancer).
Sometimes, providing parents with accurate information about the safety of
oral contraceptives, emphasizing that currently available oral contraceptive
preparations contain lower doses of estrogens and progestins than those used in
the 1960s and 1970s, and emphasizing the hormonal rather than contraceptive
function may not be persuasive. In such cases, cyclic progestins are an alternative.
A systematic review of the use of combination hormonal therapy versus
progestins alone for the treatment of anovulatory bleeding found a paucity of
evidence supporting the efficacy of one management regimen over another (79).
Medroxyprogesterone acetate, 5 to 10 mg/day for 10 to 13 days every 1 to 2
months, prevents excessive endometrial buildup and irregular shedding
caused by unopposed estrogen stimulation. This therapy should be reevaluated
regularly and accompanied by oral administration of iron. Eventual maturation of
the hypothalamic–pituitary–ovarian axis usually will result in the establishment of
regular menses unless there are underlying conditions such as hyperandrogenism.
Acute Bleeding
Moderate
The initial assessment of an adolescent with acute heavy menstrual bleeding
requires assessment for hemodynamic instability and signs of hypovolemia.
Consideration should be given to the causes of acute heavy menstrual bleeding,
which are the same as the causes of chronic abnormal bleeding, and which have
been described by a classification system approved by the International
Federation of Gynecology and Obstetrics and ACOG (80). This system describes
the causes of abnormal bleeding as related or unrelated to structural abnormalities
and categorized by the acronym PALM-COEIN (see Chapter 10) (81). In
adolescents, structural abnormalities are much rarer than in women of older
reproductive age, and thus the COEIN etiologies: Coagulopathy, Ovulatory
dysfunction, Endometrial, Iatrogenic, and Not otherwise classified are more
likely to be causative.
Patients who are bleeding acutely but in a stable condition and do not
require hospital admission will typically require hormonal treatment to
effectively stop anovulatory bleeding. Limited evidence and expert opinion
suggest options for therapy, which in adolescents focus on medical rather than
surgical therapies. Options include IV estrogen, combined oral contraceptives,
and oral progestins (80). With hormonal therapy, bleeding usually stopped within
a few days, and the dosing is typically tapered or stopped to allow shedding of the
dyssynchronous endometrium and withdrawal bleeding. With this therapy, the
440patient and her parents should be given specific written and oral instructions
warning them about the potential side effects of high-dose hormone therapy—
nausea, breast tenderness, and breakthrough bleeding. The patient should be
instructed to call with any concerns rather than discontinue the hormonal
treatment, and she must understand that stopping the prescribed regimen may
result in a recurrence of heavy bleeding. Both the patient and her mother should
be warned to expect heavy withdrawal flow for the first period. Subsequently, the
institution of combination low-dose oral contraceptive therapy, given once daily
and continued for three to six cycles, allows regular withdrawal flow. If the
patient is not sexually active, hormonal therapy may be discontinued after the
recommended course of therapy and the menstrual cycles may be reassessed.
Emergency Management
The decision to hospitalize a patient depends on the rate of current bleeding
and the severity of any existing anemia. The actual acute blood loss may not
be reflected adequately in the initial blood count but will be revealed with
serial hemoglobin assessments. The cause of acute menorrhagia may be a
primary coagulation disorder; thus, measurements of coagulation and
hemostasis, including screening for coagulopathy, should be performed for
any adolescent patient with acute menorrhagia, as noted above in the
recommendations of an international panel (63). Von Willebrand disease,
platelet disorders, or hematologic malignancies can cause menorrhagia.
Depending on the patient’s level of hemodynamic stability or compromise, a
blood sample can be analyzed for type and screen. The decision to transfuse must
be considered carefully, and the benefits and risks should be discussed with the
adolescent and her parents. The need for transfusion is determined by
hemodynamic stability.
In patients who, by exclusion, are diagnosed as having anovulatory
bleeding, hormone therapy usually makes it possible to avoid surgical
intervention (dilation and curettage [D&C], operative hysteroscopy, or
laparoscopy). A patient who is hospitalized for severe bleeding requires
aggressive management as follows:
1. After stabilization, when appropriate laboratory assessment and an
examination establish a working diagnosis of anovulation, hormonal
management will usually control bleeding (80).
2. As noted for moderate bleeding, hormonal therapy is typically effective within
12 to 24 hours.
3. If this hormonal therapy is not effective, the patient should be reevaluated
and the diagnosis should be reassessed. The failure of hormonal
441management suggests that a local cause of bleeding is more likely. In this
event, consideration should be given to a pelvic ultrasonographic examination
to determine any anatomic causes of bleeding (such as uterine leiomyomas,
endometrial polyps, or endometrial hyperplasia) and to assess the presence of
intrauterine clots that may impair uterine contractility and prolong the
bleeding episode. Although anatomic causes of heavy menstrual bleeding are
rare in adolescents, they become increasingly common in women of
reproductive age (see Chapter 10).
4. If intrauterine clots are detected, consideration may be given to
evacuation of the clots (suction curettage or D&C); alternatively,
uterotonics such as misoprostol may be helpful. An intrauterine
tamponade with a 26F Foley catheter and 30 mL balloon may be
required. Although a D&C will provide effective immediate control of the
bleeding, it is unusual to use this approach in adolescents.
More drastic forms of treatment other than D&C (such as ablation of the
endometrium by laser or cryotherapy) are considered inappropriate for
adolescents because of concerns about future fertility.
If intravenous or oral administration of hormonal therapy controls the
bleeding, a tapering regimen of hormonal therapy may be given (80).
Subsequent hormonal therapy with combined oral contraceptives, the
levonorgestrel intrauterine system (IUS), progestin therapy, and
nonhormonal therapies are useful. Nonhormonal antifibrinolytic drugs, such
as tranexamic acid, have been shown to reduce chronic abnormal bleeding
by 30% to 55% (80). Tranexamic acid has been used for the treatment of
acute heavy bleeding.
In general, the prognosis for regular ovulatory cycles and subsequent normal
fertility in young women who experience an episode of abnormal bleeding is
good, particularly for patients who develop abnormal bleeding as a result of
anovulation within the first years after menarche and in whom there are no signs
of other specific conditions. Some girls, including those in whom there is an
underlying medical cause, such as PCOS, will continue to have abnormal
bleeding into middle and late adolescence and adulthood and will benefit from the
ongoing use of hormonal therapy including combined oral contraceptives to
manage hirsutism, acne, and irregular periods, or menstrual suppression using the
levonorgestrel IUS, or IM or oral progestins. Individuals with coagulopathies may
benefit from ongoing oral contraceptive use, use of tranexamic acid, or intranasal
desmopressin.
A levonorgestrel-releasing IUD can be effective in managing heavy
bleeding, with reductions of heavy bleeding by up to 90%, and can be
442appropriate for adolescent use (82–84). Because IUD insertion is viewed as
invasive by adolescents, particularly young teens, adjuncts to insertion, such
as the use of local anesthesia may be appropriate (85). The levonorgestrel IUD
is approved by the FDA for treatment of heavy menstrual bleeding in women
requiring contraception and is recommended as first-line medical therapy for this
group of women (86).
Long-Term Menstrual Suppression
For patients with underlying medical conditions, such as coagulopathies, a
malignancy requiring chemotherapy, or developmental disabilities, longterm therapeutic amenorrhea with menstrual suppression using the
following regimens may be necessary or helpful (87,88):
1. Progestins such as oral norethindrone, norethindrone acetate, or
medroxyprogesterone acetate on a continuous daily basis.
2. Continuous (noncyclic) combination regimens of oral estrogen and progestins
(birth control pills) or other forms of combination estrogen/progestins
(transdermal patch, vaginal ring) that do not include a withdrawal bleeding–
placebo week.
3. Depot formulations of progestins (DMPA), with or without concurrent
estrogens.
4. Gonadotropin-releasing hormone (GnRH) analogs with or without hormonal
add-back therapy.
5. Levonorgestrel IUS.
The choice of regimen depends on the presence of any contraindications (such
as active liver disease precluding the use of estrogens) and the clinician’s
experience. Although the goal of these long-term suppressive therapies is
amenorrhea, all of these regimens may be accompanied by breakthrough
bleeding, especially in the initial months of use (87). At 1 year, rates of
amenorrhea approach 60% with extended cycle combination oral contraceptives,
50% with DMPA, and 50% with the levonorgestrel IUS (59,88–90). Because
DMPA and GnRH analogs are associated with disadvantageous effects on bone
mineral density, the potential risks must be weighed against their medical
benefits. Regular follow-up visits and continued patient encouragement are
required with all of these options. Episodes of spotting and breakthrough bleeding
that do not result in a lowered hemoglobin level may be managed expectantly.
When breakthrough bleeding affects the hemoglobin level, it should be evaluated
with respect to the underlying disease. For example, in a patient with underlying
platelet dysfunction, breakthrough bleeding may reflect a lowered platelet count.
443Bleeding in a patient with hepatic disease may reflect worsening hepatic function.
The U.S. Selected Practice Recommendations from the Centers for Disease
Control summarize the evidence for management of breakthrough bleeding
during hormonal contraceptive use (61).
Adolescent Pelvic Masses
Presentation
Adolescents with pelvic masses may be asymptomatic or may have chronic or
acute symptoms. An ovarian mass may be discovered incidentally when an
ultrasonographic examination is performed to evaluate the urinary system or
when imaging is performed to evaluate pelvic pain. The mere presence of a mass
on imaging studies does not always indicate that the mass is the cause of pelvic
pain. A “ruptured ovarian cyst” is a classic diagnosis when an adolescent
presents with pelvic pain, even if ultrasonography findings suggest only a
simple cystic follicle and a physiologic amount of pelvic fluid that are
unlikely to cause pain. An adnexal mass is not always of ovarian origin. The
algorithm in Figure 9-14 illustrates a framework for thinking about adnexal
masses in adolescents. Alternatively, ovarian masses can cause severe, acute, or
intermittent symptoms caused by torsion, intraperitoneal rupture, or bleeding into
the ovarian tissue (Fig. 9-15). These conditions can represent a true surgical
emergency or urgency, and their diagnoses can be challenging. The pressure of an
enlarging ovarian mass can cause bowel-related symptoms such as constipation,
vague discomfort, and early satiety; urinary frequency; or even ureteral or bladder
neck obstruction.
444FIGURE 9-14 Algorithm for adnexal masses in adolescents—“dichotomies” of ovarian
and other/functional (follicular and corpus luteum cysts) and neoplastic ovarian masses
(benign and malignant [germ cell and epithelial]).
445FIGURE 9-15 Adnexal mass with torsion.
Diagnosis
The history and pelvic examination are critical in the diagnosis of a pelvic mass.
Considerations in adolescents include the anxiety associated with a first pelvic
examination, and issues of confidentiality related to questions about sexual
activity. Techniques for history taking and the performance of the first
examination are discussed in Chapter 1.
Laboratory studies should always include a pregnancy test (regardless of
stated sexual activity), and a complete blood count may be helpful in diagnosing
inflammatory masses. Tumor markers, including α-fetoprotein and human
chorionic gonadotropin (hCG), may be elaborated by germ cell tumors and can be
useful in preoperative diagnosis and follow-up (see Chapter 39).
As in all other age groups, the primary diagnostic technique for evaluating
pelvic masses in adolescents is ultrasonography. Although transvaginal
ultrasonographic examinations may provide more detail than transabdominal
ultrasonography, particularly with inflammatory masses, a transvaginal
446examination may not be well-tolerated by adolescents (91,110). Ultrasonography
usually is the most helpful imaging technique for assessing ovarian masses. For
cases in which the suspected diagnosis is appendicitis or another
nongynecologic condition, or if the results of the ultrasonographic
examination are inconclusive, CT or MRI may be helpful. An accurate
preoperative assessment of anatomy is critical, particularly in cases of
uterovaginal malformations. MRI can be useful for evaluating this group of rare
anomalies (88). Adolescents who present with abdominal pain should be
evaluated with some type of imaging procedure because an unexpected finding of
a complex uterine or vaginal anomaly requires careful surgical planning and
management.
Differential Diagnosis of Adolescent Pelvic Masses
Ovarian Masses in Adolescents
Many studies of ovarian tumors in the pediatric and adolescent age group do
not distinguish between prepubertal or premenarchal girls and menarchal
adolescents. The findings of some reports are based on the age group,
although this is less helpful than a distinction by pubertal development. In
evaluating a pelvic or abdominal mass, the clinician must take into
consideration the patient’s pubertal status because the likelihood of
functional masses increases after menarche (Table 9-4). The risk of malignant
neoplasms is lower among adolescents than among younger children. Germ cell
tumors are the most common tumors of the first decade of life but occur less
frequently during adolescence (see Chapter 39). Mature cystic teratoma is the
most frequent neoplastic tumor of children and adolescents, accounting for more
than one-half of ovarian neoplasms in women younger than 20 years of age (92).
Epithelial neoplasms occur with increasing frequency beyond adolescence.
It is well-established that neoplasia can arise in dysgenetic gonads. The risk of
malignant tumors in dysgenetic gonads of patients with a Y chromosome depends
on the nature of the DSD, the presence of the gonadoblastoma region of the Y
chromosome, and other factors—both established and as yet unknown (93). A
number of genes involved in gonadal differentiation were described. Recent
perspectives suggest that the estimation of individual risk of malignancy should
be assessed, and that this may permit a more conservative approach to
gonadectomy or its timing (94,95). A multidisciplinary approach to diagnosis of
disorders of sex development with attention to biologic, genetic, and
psychological factors is advocated (96). Functional ovarian cysts occur
frequently in adolescence. They may be an incidental finding on examination or
may be associated with pain caused by torsion, leakage, or rupture. Paratubal
cysts represent embryologic remnants that may be confused with an ovarian mass;
447they are typically asymptomatic, but can be associated with adnexal torsion (Fig.
9-15). Adnexal or ovarian torsion is a challenging diagnosis to make in
prepubertal girls or adolescents; torsion of a mass is more likely to occur than
torsion of normal adnexa, although this can occur. Doppler ultrasound
examination may not predict the presence of torsion, although discrepancy in
ovarian volume and large volume of the torsed adnexa may be helpful in making
the diagnosis (91,97). Management should consist of detorsion rather than
oophorectomy, even if the mass appears to have no blood flow, as recovery of
ovarian function is likely (98).
Endometriosis is less common during adolescence than in adulthood, although
it can occur during adolescence. Of adolescents not responding to conventional
medical management of pelvic pain and dysmenorrhea, up to 70% may be found
to have endometriosis at the time of laparoscopy (99). Although endometriosis
can occur in young women with obstructive genital anomalies (presumably as a
result of retrograde menstruation), most adolescents with endometriosis do not
have associated obstructive anomalies. In young women, endometriosis may have
an atypical appearance characterized by nonpigmented or vesicular lesions,
peritoneal windows, and puckering (99).
Uterine Masses in Adolescents
Other causes of pelvic masses, such as uterine abnormalities, are rare in
adolescence. Uterine leiomyomas are not often seen in this age group.
Obstructive uterovaginal anomalies occur during adolescence, at the time of
menarche, or shortly thereafter. Frequently, the correct diagnosis either is not
suspected or is delayed (100). A wide range of anomalies can occur, from
imperforate hymen to transverse vaginal septa, from vaginal agenesis with a
normal uterus and functional endometrium to vaginal duplications with
obstructing longitudinal septa, and obstructed uterine horns (Fig. 9-13). Patients
may seek treatment for cyclic pain, amenorrhea, vaginal discharge, or an
abdominal, pelvic, or vaginal mass. A hematocolpos, hematometra, or both,
frequently will be present, and the resulting mass can be quite large (101).
Inflammatory Masses in Adolescents
Adolescents comprise 20% of all diagnoses of PID in the United States (102).
An adolescent who has pelvic pain may have an inflammatory mass. Such masses
may consist of a tubo-ovarian complex (a mass of matted bowel, tube, and ovary),
tubo-ovarian abscess (a mass consisting primarily of an abscess cavity within an
anatomically defined structure such as the ovary), pyosalpinx, or, chronically,
hydrosalpinx.
The diagnosis of PID is primarily a clinical one based on the presence of lower
448abdominal, pelvic, and adnexal tenderness; cervical motion tenderness; a
mucopurulent discharge; and elevated temperature, white blood cell count, or
sedimentation rate (see Chapter 15). The US Centers for Disease Control
recommends that clinicians should maintain a low threshold for making this
diagnosis, given the potential risks of missing the diagnosis (64). The risk of PID
is clearly associated with that of acquiring STDs, and methods of contraception
may either decrease the risk (male latex condoms) or increase it (the IUD in the 3-
week interval immediately after insertion) (103,104).
Pregnancy
In adolescents, pregnancy should always be considered as a cause of a pelvic
mass. In the United States, more than 40% of adolescent women have
experienced sexual intercourse (52). Most pregnancies in adolescents are
unintended, and the younger the adolescent, the greater the likelihood that a
pregnancy is unintended. Adolescents may be more likely than adults to deny the
possibility of pregnancy because of wishful thinking, anxiety about discovery by
parents or peers, or unfamiliarity with menstrual cycles and information about
fertility. Ectopic pregnancies may cause pelvic pain and an adnexal mass. With
the availability of quantitative measurements of β-hCG, more ectopic pregnancies
are being discovered before rupture, allowing conservative management with
laparoscopic surgery or medical therapy (see Chapter 32). The risk of ectopic
pregnancy varies by the method of contraception; users of no contraception have
the highest risk, whereas oral contraceptive users have the lowest risk; while
levonorgestrel IUSs have a very low risk of failure and pregnancy; if a pregnancy
occurs, there is a higher risk of ectopic than if no contraception were used (105).
As with older patients, paraovarian cysts and nongynecologic masses can appear
as a pelvic or abdominal mass in adolescents (Fig. 9-16).
Management of Pelvic Masses in Adolescents
The management of masses in adolescents depends on the suspected diagnosis
and the initial symptom. Figure 9-8 outlines a plan of management for pelvic
masses in adolescents. Asymptomatic unilocular cystic masses are best
managed conservatively because the likelihood of malignancy is low. If
surgical management is required based on symptoms or uncertainty of
diagnosis, attention should be directed to minimizing the risks of subsequent
infertility resulting from pelvic adhesions. Every effort should be made to
conserve the ovarian tissue. In the presence of a malignant unilateral ovarian
mass, management may include unilateral oophorectomy rather than more
radical surgery, even if the ovarian tumor metastasized (see Chapter 39).
Analysis of frozen sections may not be reliable. In general, conservative
449surgery is appropriate; further surgery can be performed, if necessary, after
an adequate histologic evaluation of the ovarian tumor.
When symptoms persist in a patient with the clinical diagnosis of PID or
tubo-ovarian abscess, laparoscopy should be considered to confirm the
diagnosis. A clinical diagnosis may be incorrect in as many as one-third of
patients. The surgical management of inflammatory masses is rarely
necessary in adolescents, except to treat the rupture of tubo-ovarian abscess
or failure of medical management with broad-spectrum antibiotics (see
Chapter 15). Some surgeons advocated laparoscopy to perform irrigation, lysis of
adhesions, drainage of unilateral or bilateral pyosalpinx or tubo-ovarian abscess,
or extirpation of significant disease. If surgical management is required because
of failed medical therapy, conservative, unilateral adnexectomy usually can be
performed in these situations, rather than a pelvic clean-out, thereby maintaining
reproductive potential. Percutaneous drainage, transvaginal ultrasonographic
drainage, and laparoscopic management of tubo-ovarian abscesses are being done
more often, although evidence supporting this approach is sparse (106). As with
the laparoscopic management of ovarian masses, the clinician’s skill and
experience with this procedure are critical, and prospective studies on its
effectiveness are lacking. Laparoscopic management is associated with a risk of
major complications, including bowel obstruction and bowel or vessel injury.
450FIGURE 9-16 A: Paratubal cyst. B: Paratubal cyst, incised.
Adolescent Vulvar Conditions
Disorders of sex development may cause genital ambiguity, typically noted at
birth, although virilization may occur at puberty (32). Adolescents with
gonadal dysgenesis or androgen insensitivity may have abnormal pubertal
development and primary amenorrhea (see Chapters 8, 34, and 35). Various
developmental anomalies—vaginal agenesis, imperforate hymen, transverse and
longitudinal vaginal septa, vaginal and uterine duplications, hymenal bands, and
septa—most frequently are diagnosed in early adolescents with amenorrhea (for
the obstructing abnormalities) or with concerns such as inability to use tampons
(for hymenal and vaginal bands and septa). These developmental abnormalities
must be evaluated carefully to determine both external and internal anatomy.
A tight hymenal ring may be discovered when the patient seeks care
because of concerns about the inability to use tampons or have intercourse.
Both manual dilation and small relaxing incisions at 6 and 8 o’clock in the
hymenal ring can be effective. This procedure can sometimes be done in the
office using local anesthesia but may require conduction or general anesthesia in
the operating room. Hymenal bands are not rare and lead to difficulty in using
451tampons; they often can be incised in the office using local anesthetic (Fig. 9-17).
“Hypertrophy” of the labia minora may be considered a variant of normal, and
reassurance rather than a cosmetic surgical reduction is usually appropriate as the
primary therapy (107). Surgical management has been described, although the
procedure could be considered to be esthetic rather than medically mandated, and
rarely indicated in adolescents (108). Genital ulcerations may occur in girls with
leukemia or other cancers requiring chemotherapy. Vulvar ulcerations in the
absence of sexual activity or infectious etiology are described as vulvar aphthosis
(Fig. 9-10) (40). The possibility of sexual abuse, incest, or involuntary intercourse
should be considered for young adolescents with vulvovaginal symptoms, STDs,
or pregnancy.
The presence of vulvar symptoms such as itching or burning may prompt a
patient to seek care; however, this anatomic site is not one that is easily inspected
by the patient. Thus, vulvar lesions that were not noticed by the patient may be
found on examination. Vulvar self-examination should be encouraged and
could potentially result in the earlier diagnosis of vulvar lesions such as
melanoma. Adolescents presenting with vulvar itching may have lichen
sclerosus; this condition can be relatively asymptomatic, even when an
examination reveals loss of anatomic structures and scarring (Fig. 9-4) (36).
Adolescents and adults often incorrectly self-diagnose vulvovaginal
candidiasis; in one study, only one-third of women with self-diagnosed yeast
vaginitis were found to have this infection (see Chapter 15) (109). A clinical
examination and appropriate testing can be performed even on young adolescents
using a clinician or self-obtained cotton swab to obtain vaginal secretions for pH
testing and microscopic examination (Fig. 9-18).
Vulvar condyloma is an extremely common cause of vulvar lesions in
adolescents (see Chapter 15). Genital warts can affect the vulva, perineum, and
perianal skin, and the vagina, urethra, and anus (Fig. 9-19). Condyloma in
adolescents typically is sexually transmitted. They may be asymptomatic or cause
symptoms of itching, irritation, or bleeding. Symptomatic, enlarging, or extensive
vulvar condyloma can be managed with topical medication applied by the patient
or clinician. The choice of treatment should be guided by patient preference,
available resources, and the clinician’s experience; no one treatment is superior to
the others (64). The recent availability of an HPV vaccine that includes HPV
types 6 and 11 has had a beneficial impact on the incidence of vulvar condyloma
and potentially on HPV-related vulvar intraepithelial neoplasia (VIN).
452FIGURE 9-17 Hymenal band.
453FIGURE 9-18 Candidal vulvitis.
454FIGURE 9-19 Extensive vulvar condyloma.
Adolescent Vaginal Conditions
Vulvovaginal symptoms in adolescents may be caused by a variety of
conditions, ranging from vulvar lichen sclerosus to UTI to C. trachomatis to
non–STD-related vaginitis. Urinary or vaginal symptoms do not differentiate
well between UTIs and vaginitis. Adolescent girls who are screened for both C.
trachomatis and UTI have high rates of concurrent disease (110). Because clinical
diagnosis based on symptoms is imprecise, female adolescents with vaginal or
urinary symptoms should be tested for C. trachomatis and UTI. Testing with
DNA-based procedures may be performed on samples obtained from the cervix,
from swabs of vaginal secretions (either clinician or patient obtained), and from
urine specimens. Testing that does not involve a speculum examination may be
particularly helpful for adolescents; a rigorous review concluded that noninvasive
chlamydia testing was comparable to cervical or urethral screening, although this
was not the case with testing for gonorrhea (111).
Discharge is one of the most common vaginal symptoms. Conditions ranging
455from vaginal candidiasis to chlamydia cervicitis to bacterial vaginosis may cause
vaginal discharge in adolescents. Infectious vaginal conditions are described in
more detail in Chapter 15. The risks of self-diagnosis of vaginal discharge in
adolescents may be greater than in adult women, as infection with STDs—
including Neisseria gonorrhoeae, Trichomonas vaginalis, C. trachomatis, herpes
simplex, and Condyloma accuminata—are common in adolescents and may be
less likely recognized.
Use of tampons is associated with microscopic and macroscopic ulcerations.
Healing of the macroscopic ulcerations occurs within several weeks without
specific therapy if tampon use is suspended. A follow-up examination to
demonstrate healing is appropriate, with biopsy of any persistent ulceration to rule
out other lesions.
Toxic shock syndrome (TSS) is associated with tampon use and vaginal
exotoxins produced by Staphylococcus aureus. This syndrome consists of fever,
hypotension, a diffuse erythroderma with desquamation of the palms and soles,
plus involvement of at least three major organ systems (112). Vaginal
involvement includes mucous membrane inflammation. The frequency of TSS
appears to be declining, and an increasing percentage of cases are not associated
with menses. Approximately one-half of all cases of TSS are menstrual related
(113). Epidemiologic studies suggest that adolescents are at greater risk of
menstrual TSS than older women; however, this finding does not appear to be
explained by differences in the detection of antibodies to the TSST-1 toxinproducing strain of S. aureus or in S. aureus vaginal colonization rates (114).
Abscesses of Bartholin and Skene glands are related to both aerobic and
anaerobic organisms, with mixed infections accounting for approximately 60% of
these and other vulvar and labial abscesses, although the possibility of
methicillin-resistant S. aureus (MRSA) infections must be considered (115).
Therapy consists of surgical drainage, with use of antibiotics as a secondary
measure. In younger adolescents, incision and drainage may require general
anesthesis
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