Part 25. Gynecologic Problems in Childhood

Chapter 503. Vulvovaginitis

   -M/C childhood & adolesent gynecologic problem

 

  (Cl/M)

  --Physiologic vaginal discharge

      menarche가 시작되기 6-12개월 전에 vaginal discharge 가 정상적으로 증가됨.

      특징: yellowish

            no spesific malodor

            vulva is not inflamed

            주로 Doderlein's bacilli로 구성됨

Pathologic Vaginal Discharge

primary sx. of vulvitis, vaginitis, or vulvovaginitis

associated sg. & sx.

   :pruritis, frequent urination, dysuria, enuresis

Nonspecipic Vulvovaginitis

# 70% of all pediatric vulvovaginitis case

# discharge

    ; brown or green

  ; fetid odor

  ; asso. with a vaginal pH.4.7-6.5

#원인균

    ; *Coliform bacteria(68%) - ▲common

  ; β-hemolytic streptococcus, coagulase positive staphylococcus  

# ★Treatment

    ; perineal hygiene

    ; switching from tight-fitting underwear

    ; use of sitz baths with mild soap

    ; air drying the vulva

    ; systemic antibotics

           - recurrent vulvovaginitis인 경우

           - amoxicillin or cephalosporins

    ; *topical estrogens or polysporin ointment

Specific Vulvoviginitis

# ★Gardnerella vaginitis

    - *▲common

# candida - second

# others

    ; peptococcus, peptostreptococcus, veillonella parvula, eubacterium, propionibacterium, bacteroides species

    ; protozoa, helminths, virus

★Table 503-1

Labial Adhesions

Candidiasis

Diaper Dermatitis

Molluscum Contagiosum

Intertrigo

Impetigo

Pitryasis Versicolor

# Causes

    ; *pityrosporum orbiculare

# Clinical Manifestation

    ; *scaly macules on trunk

           - sometimes on face, genial lesions

# Diagnosis

    ; visualization on wet prep of hyphae and spores with 10% potassium hydroxide

# Treatment

    ; *topical imidazoles

Herpes Simplex Virus

Hyman Papilloma Virus

# serotypes

    ; *6, 11, 16, 18

           - *16, 18 : asso. with malignant and premalignant lesion

Lichen Sclerosus

; onic atrophic skin disease

; small, pink to ivory, flat-topped papules

    - several millimeters in diameters

; coalesce into plaques

; ★“hourglass” or “figure 8” features in anogenital lesion

Lichen Planus

Lichen Simplex Chronicus

Seborrheic Dermatitis

Atopic Dermatitis

Contact Dermatitis

Vulvar Psoriasis

Chapter 504. Bleeding

# ★Causes

    ; exposure sex steroids

    ; foreign body

    ; hemorrhagic cystitis

    ; hypothyrodism

    ; precocious puberty

    ; presence of an ovarian cyst

    ; trauma asso. with sexual abuse

    ; urethral prolapse

    ; vulvovaginitis

  ; neoplasms

         - rhabdomyosarcoma, clear cell sarcoma, endodermal sinus tumors, mesonephric carcinoma

Chapter 505. Breast Disorder

Congenital Anomalies

   --amastia : rare, unilateral

              asso. with other anomalies  

      * Doland syndrome

        - aplasia of the pectoralis m.

          rib deformities

          webbed finger, radial nerve aplasia

   --Polymastia (supernumeray breast's and supernumerary nipple(polythelia)

    : relatively common

     along the midline

     usually asymptmatic

   --hypoplasia of the breasts

     :cause: 1. delayed onset of breast development

            2, family history of late breast develoment

            3. suppressed or failed ovarian function

Breast Mass

    retrospective review of breast ds, in adolesent female

            1. fibroaenoma 54%

            2. vaginal hypertrophy 13%

            3. fibrocytic or proliferative breasrt ds. 24%

            4. primary and metastatic Rabdomyosarcoma, metastatic neuroblastoma.

              non-Hodgkin's lymphoma 2-3%

Malignant Tumor Of Breast

      rare occur in adolescent

    1. Cystosarcoma phylloides

      uncommon

      firm,mobile circomscribed mass

    2. radiation induced sarcoma

    3. liphosarcoma

    4. extramedulllary manifestation of ALL

Macromastia (Vaginal Hypertrophy)

     - etiology is unknown but probably due to endodrgan increased sensitivity

       to circulating estrogen

     - bilateral

     - 13-17 yr old most commonly

Nipple Discharge

# galactorrhea

    ; ★Causes

           - prolactinoma

           - hypothyroidism

# hyperprolactinemia가 관찰되면 증상에 관계없이 brain imaging studies

Chapter 506. Hirsutism And Polycystic Ovarian Sydrome

Excessive Androgen Production Prior To Puberty

# Hirsutism(excessive hair growth) 은 virilization과 구별되어야 된다.

  ; Virilization

       - *increase body hair, acme, voice change, change in body habitus. due to increased musle mass, clitomegaly

  ; Premature pubarche 

       - appearance of genital hair or axillary hair or both before 8yr of age

    ; Adrenarche

       - *output of excess androgen from the adrenal gland

    - usually occurs between 12 and 18 yr of age

Hirsutism In The Adolescent

Table 506-1

Hair- An Syndrome

      : the acrom for the association of hirsutism, androgen excess.

        insulin resistance and acanthosis nigricans

      : pathogenesis is unknown

Hyperprolactnemia

      때로 hyperandrogenemia의 원인이 되기도 하는 CNS disorder(see Chapter 517)

      hyperprolactinena있는 40%에서 androgen abnormality 를 나타낸다.

      lab,.finding ; 1. free testotosterone 증가

 2 adrenal production of 17 hydroxyprogesterone and androstenedione 증가

Polycystic Ovary Synd. (Chronic Anovulation . Stein-Levental Syndrome)

    ; *▲common ovarian cause of hirsutism

    ; Laboratory Finding

           - altered LH release

                   / *LH to FSH rateio of 2:1 or 3:1

                   / *shortened pulse frequency, increased amplitude of LH

Treatment Of Hirsute Patient

     - Tx. of idiopathiand and PCO ; Table 506-2

     - Tx. of Hirsutism 2nd to hyperprolactinemia ;Bromocriptine

Chapter 507. Neoplasms

    -most common gynecologic neoplasm in children is of ovrian

Ovaries

    -18세 이하에서  pevic tumor의 발생순서

     1. ovarian tumor :M/C

     2. paraovarian tumor

     3. uterine tumor

   -clinical manifestation :abd. pain and mass

   -사춘기에서 가장 흔한 ovarian tumor 2가지

     1. teratoma

     2. ovarian adenoma

 

   * Teratoma of adenoma

     : usually benign but rarely malignant

       calcification on abd. X-ray is hallmark of benign teratoma

 

   -ovarian tumor 의 대부분은 Germ cell type이다.

 

   * germ cell tumor of ovary 의 발생순서

    1. dysgerminoma

    2. malignant teratoma

    3. endodermal sinus tumors

    4. embryonal carcinomas

    5. mixed cell neoplasms

Ovarian Follicular Cyst

    : occur from birth to puberty

      보통 3-32주 인에 저절로 없어짐

Autoamputation Of The Ovary

     : present as small calcified free - floating mass associated with absent adnexa

     : maybe asymptomatic

     : 진단에는 ultrasound 가 적합

 

   - Sex cord stromal tumor : 5% of ovarian neoplasm

     M/C : grannulosa cell tumor

Cervix

    ; prevalence of dysplasia and Ca-in-situ :  18.8/1000 for age 15-19 yr

  ; cervical intraepithelial neoplasia(CIN)

       - sexually activie한 teenage나 young adolt에서 간혹 진단되어짐

    - 소아 영역에서는 very rare

Cha pter 508. Developmental Anomalies

 (embryology)

    - uterus ; formed by fusion of the cordal elements of the mullerian ducts

               at and 8 wk of gestation

    -vagina : the terminal portion of the uterovaginal canal( Mullerian origian) 에서 형성이                  시작되어 

              --- posterior aspect of the urogenital sinus와 만나서 vagina형성

 

    이렇게 Mullerian duct 의 fusion 과정에 생기는 여러가지 anomaly 등이 있다.

      * Table 508-1, 508-2

Chapter 509. Athletics

   * 여자 운동선수들에게 생길 수 있는 gynecologic problems

    1. delayed menarche

       - average age of onset of menarche is 12.23 yr

       - athlets의 경우 : 13.58 yr

    2. menstrual irregularity

       주로 oligo menorrhea or amenorrhea 의 형태

    3. endocrinologic change

      - hypoestrogenism

      - FSH to LH ratio 의 변화

    4. premature bone loss

Chapter 511. Gynecologic Imaging

(신판 추가)

    1. transabdominal approach with use of a distended b;adder 

      - 7.5 or 5MHz transducer 사용

      * Table 511-1,511-2

    

     * pelvic mass 의 cause

         1. ovarian cyst

         2. hydrocolpos--dilation of the vagina

         3. hydrometroco;pos--dilatation of the uterus and the vagina

 

    2. ultrasound - a key screening tool

    3. MRI/CT - for further assessment