1 Adolescent Medicine in Egypt Facts may Start as DreamsMoustafa A. Abdel-lah, MD Professor Obstetrics & Gynecology Sohag Faculty of Medicine, Sohag

2 Adolescent GynecologyMoustafa A. Abdel-lah, MD Professor Obstetrics & Gynecology Sohag Faculty of Medicine, Sohag

3 Adolescent GynecologyAverage age of menarche in USA: y Usually occurs at Tanner 4 Physiologic leukorrhea precedes menses by 3-6mos (NORMAL) First two years = commonly irregular Cycle: days, Period: 2-8 days of flow, Amount of blood loss : 20-80ml

4 Gynecological ExaminationExternal: all Virginal: recto/vaginal exam Internal: all sexually active to check STIs PAP smear: 3 yrs after coitarche or at 21y

5 Gynecological ExaminationWet mount: pH <4.5 nl or candida Saline slide for clue cells, WBC, trich KOH slide for “whiff” and hyphae Ectropion: erythematous area surrounding the os, eversion of endocervix Bimanual exam: CMT, adnexal tenderness

7 Abdominal Pain GI Urinary Tract Gyn Other

8 Pelvic Pain Mittelschmerz Dysmenorrhea Endometriosis PID AdhesionsObstruction (congenital anomoly) Ovarian mass

9 Abdominal Pain (Gynecologic causes)Pregnancy: - ectopic, threatened, inevitable or incomplete abortion Endometritis PID Fitz-Hugh Curtis syndrome Ovarian Torsion Ruptured Ovarian Cyst Endometriosis Dysmenorrhea Mittelschmerz

10 Genital Tract ObstructionCyclic abdominal pain, constipation, urinary retention, abdominal mass Mullerian Duct Anomalies Imperforate hymen Transverse vaginal septum

11 Braverman, P. K. et al. Pediatrics in Review 1997;18:17-26Copyright ©1997 American Academy of Pediatrics

12 Amenorrhea No flow x 6mosPrimary – no menses by 16 yrs or within 4 yrs of puberty start or within 1-2 years of Tanner V Secondary – previously nl puberty and menses

13 Primary Amenorrhea HEAD – pituitary, hypothalamusGLANDS (adrenals) – enzyme deficiency GONADS (ovaries) – present/not present, working/not working, (testes) UTERUS/VAGINA – present/ not present, structural abnormality

14 Secondary Amenorrhea Pregnancy IdiopathicMeds/Drugs, hormonal contraceptives Stress – hypothalamic supression Exercise/Athletics,Weight loss/ ED Pituitary: tumors, infiltrative, infarct (Sheehan) Ovaries: Premature failure, PCOS, tumor Uterus: synechiae (Asherman) Adrenals - late onset CAH, tumor Chronic/ systemic illness, hypothyroidism

15 Polycystic Ovarian Syndrome/ HyperandrogenismHeavy irregular bleeding to secondary amenorrhea Increased testosterone, increased insulin, increased lipids Hirsutism, acne, obesity, acanthosis nigricans

16 Heavy Flow Pregnancy/ spontaneous abortion Immature HPO/ AnovulationBleeding disorder Thyroid disease Hormonal (PCOS) Trauma Infection

17 DUB Abnormal endometrial sloughing No structural abnormalityNo organic cause except anovulation

18 DUB: Evaluation & ManagementHistory Physical Exam Vital signs, orthostatics Tanner staging Gyn exam – internal vs. external Menstrual Journal HCG, CBC, PT/PTT, Bleeding time, TFT’s, Iron studies Pelvic US STI testing, LH/FSH, prolactin, testosterone, DHEAS, BMP/CMP Preferred treatment: fluids, iron, hormonal regulation Avoid: surgical

19 Dysmenorrhea Primary - due to prostaglandins > increased muscle tone of uterus and intestinal walls First 2-3 days of flow Cycles are ovulatory NSAIDS (ibuprofen, naproxen sodium) COCs Check school absences Secondary - secondary to pelvic pathology Treat underlying pathology

20 Adolescent Pregnancy Teen pregnancy - social, economical and educational problems Prevention starts in WCC visits Absolute contraindications to COC’s Thromboembolic disease CVA Reproductive Tract Tumor CAD Pregnancy Undiagnosed vaginal bleeding

21 Consequences of Sexual Behavior: Infections

24 Sexually Transmitted InfectionsHPV – warts, cervical cancer HSV – painful ulcers Trichomonas – frothy, strawberry cervix Chlamydia – most common bacterial STI, asymptomatic, PID, urethritis Gonorrhea – PID, treat for chlamydia as well, disseminated, urethritis, menometrorrhagia Syphilis – chancre (painless), progression Hepatitis - labs HIV – always on the checklist, opportunistic infections

27 HPV (mucosal type) Wart Rx - number, size, location, experience of provider Patient applied – podofilox, imiquimod Provider applied – cryotherapy*, podophyllin, TCA*, BCA*, Surgery Vaccine (6, 11,16, 18)

30 Pelvic Inflammatory DiseaseMinimum Criteria Lower abdominal pain Adnexal tenderness Cervical motion tenderness Additional Criteria Fever Discharge Elevated ESR or CRP Positive cultures Elaborate Criteria : TOA, endo bx, lap findings Risk for future ectopic pregnancy and infertility

31 I/P PID Cefoxitin 2gm IV q6hr + Doxycycline 100mg PO or IV q12 hrsCan D/C 24 hours after resolution of symptoms Need to complete Doxycycline x 14 days total

32 O/P PID Ceftriaxone 250mg IM x 1 + Doxycycline 100mg PO BID x 14 d (+/- metronidazole 500 mg PO BID x 14 days) F/U within hours

33 Cheers from Sohag !