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Gynaecology

For Healthcare Professionals

This section is designed to assist Healthcare Professionals in managing specific paediatric and adolescent gynaecological issues such as:

 The information contained in this website should be used as a guideline only. For any emergency, please do not hesitate to contact our paediatric gynecology centre.

Menstrual Suppression in Adolescents with Disabilities

  • General parental concerns include the additional physical demands menstruation brings tocaring for a child with disability ,as well as, issues such as menorrhagia, dysmenorrhea, behavioural changes perimenstrually and issues of sexuality, including fear of pregnancy.
  • We recommend waiting until the adolescent begins menstruating to begin treatment because most girls and their families are easily able to adapt to the care required, as well as to not not  interfere with final growth potential, and avoid side effects of the treatment before necessary.

The following information can be used to assist families with decision making.

Hormonal Therapy Options

i) Combined oral contraceptive: birth control pill or patch

  • The pill requires daily adherence to therapy.
  • The patch is waterproof and changed weekly.

    Both can be used either:

    Cyclically with a break and a period once a month

    Extended or continuously with a break and a period once every 2-4 months or less often. Over time there may be no breaks from the pill or the patch and hence no periods.

Benefits: Lighter period, reduced pain, less anemia, treatment for acne, decreased lifetime risk of ovarian and endometrial cancer. 

Side Effects: Often there are no side effects or they can be mild and temporary such as headache, mood changes, breast tenderness, abdominal bloating, nausea, leg cramps and breakthrough bleeding.

Note:  In patients with a contraindication to estrogen therapy an alternative choice should be considered. Consider drug interactions of specific medications. G-tube absorption of oral contraceptive pills is unclear. The risk of venous thromboembolism in patients with restricted mobility may be increased.

ii)  Depo-Medroxyprogesterone Acetate (DMPA) Injections

  • DMPA is given as an injection once every 3 months.
  • DMPA is a progesterone only method.

Benefits:  Less menstrual pain.  Over time, periods become shorter and lighter. Many users find their periods have stopped altogether within one year.  Less risk of anemia and can be used in patients with a contraindication to estrogen therapy.

Side Effects:  Risk of loss of bone density, usually considered reversible. Bone health can be monitored by doing a baseline bone density test repeated every 2 to 3 years. Calcium and Vitamin D supplementation should be recommended.  Adding estrogen by pill or patch may be beneficial.

Other effects can be mild and temporary such as headache, mood changes, weight gain and irregular or breakthrough bleeding.

Assent or consent from the adolescent as is appropriate must be obtained for the intramuscular injection.

iii)    Progesterone Intrauterine device (IUD) 

  • Placed into the uterus, usually under general anesthetic or under awake sedation.
  • It is effective for 5 years.
  • Preinsertion ultrasound is recommended to ensure adequate uterine size for placement.

Benefits:  Very light periods over time with little or no pain. Less side effects as lower levels of circulating exogenous hormone.

Side Effects:  Mild but can include headache, mood changes, weight gain and irregular or breakthrough bleeding. There is slight risk of pelvic infection in the first 3 weeks after insertion. The correct placement of the IUD should be checked, often with an ultrasound post insertion to rule out perforation or expulsion.


Vulvovaginitis

Can be caused by bacteria, yeasts, viruses, and other parasites. Some sexually transmitted infections (STIs) can also cause vulvovaginitis, as can various chemicals found in bubble baths, soaps, and perfumes. Environmental factors such as poor genital hygiene and allergens may also cause this condition.

  • The most common physical sign is inflammation and redness in the skin around the genitalia that may be accompanied with itching, pain, discharge and burning during urination.
  • Some infections can occur from outdoor play (sandboxes, slides),  bacteria from the anal area or from a throat or skin infection, soiled underpants, wet or very tight clothing.
  • Skin conditions such as eczema may also affect the genital skin.
  • Experience shows that about half the girls who have this problem will have more than one episode during their childhood.
  • Repeat or recurrent inflammation should be reassessed for other causes.
  • Once puberty begins, the vagina becomes more acidic, which tends to help prevent infections

Please call us if the child experiences sudden pain or bleeding in the genital area.

Treatment

  • If an infection or skin condition is discovered, special creams or tablets may be prescribed.
  • Ensure by asking questions that there has been no sexual interference.
  • In the absence of a specific infection or skin condition, changes in hygiene practices will often reduce or eliminate symptoms.

Recommendations for parents

  • The child should be taught to clean herself properly after using the toilet, wiping from front to back. Frequent changes of underwear and the use of cotton underwear are recommended.
  • It is easier for children to use wet wipes (alcohol and perfume free) after using the toilet especially when they are at school or daycare, rather than dry toilet paper.
  • The use of shallow baths after the child comes home can help solve the problem, especially if there is itchiness as scratching can introduce infection. When symptoms are present, bathing 2 to 3 times a day can be helpful.
  • Oilated Aveeno bath powder or other non allergenic softener may help soothe the genital area.
  • After bathing, gentle blotting to dry the genital area or even using a hairdryer on low cool setting is helpful.
  • It is helpful to have the child run around the house without underwear to allow air to reach the area. Similarly
  • Avoid any irritants: perfumed soaps, bubble bath, topical medications (non prescribed), wet or tight fitting clothing (i.e. bathing suits, tights).
  • Vaseline (petroleum jelly) or zinc oxide creams can be soothing and are harmless.

Urethral Mucosal Prolapse

  • Urethral prolapse is a benign extrusion of the terminal urethra that is associated with genital bleeding.  It is a rarely diagnosed condition that occurs most commonly in prepubertal black or Hispanic females.
  • Genital bleeding is the most common presenting symptom of urethral prolapse. Upon examination, round doughnut-shaped mucosa is observed protruding from the urethral opening.  It rarely interferes with voiding.
  • The exact cause is unknown, but it can occur if tissues around the urethra are weak or when estrogen levels are low, usually before puberty.
  • It is more likely when individual has a history of increased intraabdominal pressure such as heavy coughing, constipation, urinary tract infection, obesity, or trauma.

Diagnosis

  • Demonstration of prolapsed urethral mucosa separate from vagina.
  • Associated bleeding.
  • Examination under sedation may rarely be required and only if source of bleeding cannot be identified during pediatric exam.

Treatments 

i)    Estrogen Cream: Premarin

Application: a pea-sized amount directly to prolapsed mucosal tissue once or twice a day using a cotton swab or fingertip.

Usually prescribed in small amounts for a short time as temporary side effects include enlarged breasts in child.  Put a barrier cream such as petroleum jelly or zinc oxide on area to keep it moist between uses of Premarin cream.

ii)     Sitz Baths

A warm, shallow sitz bath twice a day for 15 minutes will help healing and keep the area clean.  Bubble baths and harsh soaps should be avoided.

iii)  Antibiotics

May be prescribed only when there is an infection.

iv)    Surgery

Surgery may be required if:

  • The prolapse does not heal after use of cream and baths
  • The prolapse reoccurs
  • The prolapse is large
  • The prolapse is associated with significant bleeding.

To Avoid Recurrence after Treatment

  • If the child is coughing, antitussives may be prescribed
  • Recommend fibre rich foods and lots of fluids to prevent constipation and to avoid straining when the child goes to the bathroom.  Prune juice or medication can be recommended if the child is already constipated.
  • Avoid strong deodorant soaps and bubble baths.

Labial Agglutination

Labial agglutination is a dermatologic disorder usually of prepubescent girls. It is also referred to as labial adhesions or labial fusion.  Most children with this condition are asymptomatic. However, some may present with urinary symptoms such as leaking of urine that pooled behind the adhesions, urinary tract infections (UTIs), or vulvovaginitis.

Causes

  • Thin and delicate labial skin in young girls is easily irritated. When low levels of estrogen combine with local irritation or vulvar inflammation from any cause, tissue injury can occur. As the upper epithelial layer of the labial mucosa heals, a connective tissue bridge may form between the labia producing these adhesions.  
  • The problem usually disappears when girls enter puberty and estrogen levels rise.

Diagnosis

  • Made by visual inspection of the vulva.
  • Upon separating the labia majora, the labia minora are found to be partially or completely sealed together by a thick or thin, gray, semi-transparent membrane (raphe).
  • To make the correct diagnosis, it is important to sequentially identify the labia majora, labia minora, and vagina.

Treatment

  • Usually expectant if child is asymptomatic
  • Can be treated with a topical estrogen cream such as Premarin and applied to the labial area twice a day until the adhesions are totally lysed.  Premarin should be prescribed in small amounts for a short time as temporary side effects include enlarged breasts in a child. 
  • Very gentle traction on either side of the adhesions aids in visualizing where to place the Premarin
  • After separation of the adhesions, a petroleum ointment (such as Vaseline) may be applied twice a day to the labia minora for at least 1 month.
  • The introital area should be carefully rinsed twice each day before application of either the estrogen cream or the petroleum ointment.
  • No treatment is necessary if labial agglutination only part way across the urethral  and vaginal openings.

Hygiene

  • Girls should be encouraged to urinate with their legs wide open while on the toilet and wipe in a front to back motion.
  • With partial or small adhesions double voiding (stand up and sit down again) will prevent urine from pooling behind the labia.
  • Warm  shallow sitz baths once a day will keep the area clean. Vaseline (petroleum jelly) or zinc oxide creams should  be applied after the bath.
  • Avoid strong deodorant soaps and bubble baths