GYNECOLOGIC CARE
From Pediatrics for the Primary Care Physician, presented June 29 to July 1, 2007, by Nemours
Patricia M. Simmons, MD, Professor of Pediatrics, Mayo College of Medicine, the Mayo Clinic, Rochester, MN
Amenorrhea in Adolescents
| Introduction: problems with menstrual cycle number one reason adolescent girls seek medical care; several
causes for amenorrhea; menarche—average age decreasing in United States; mean age ≈12 yr, with
racial and ethnic differences in normal range; range 9.5 to 10 yr, up to 16 yr of age; some genetic component
to when girls begin menstruation; primary amenorrhea—absence of menarche by 16 yr of age; secondary
amenorrhea—in adults, >2 times usual interval between menses; more tricky in adolescents; adult
pattern of mature cycles (once-monthly menses) not achieved until ≈2 yr after menarche; normal range
for menstrual cycle broad; dysmenorrhea number one reason for school absences
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| Hormonal control of menstrual cycle: primary control for menstrual cycle in brain; girls born fully capable
of menstruating, but do not because of absence of pulsatile release of gonadotropin-releasing hormone
(GnRH); reasons include central nervous system (CNS) factors and thresholds for feedback (or
combination); at some point, once-monthly hormone spikes begin, which trigger pituitary gland for pulsatile
release of luteinizing hormone (LH) and follicle-stimulating hormone (FSH); LH and FSH “tell”
ovaries to produce estrogen and prostegerone in right amounts; thyroid another factor; uterus end organ;
must have intact unobstructed outflow tract for menstruation; under influence of LH and FSH, cyclic elevation
of estrogen and late-cycle elevation of progesterone occur; early in cycle, development of endometrium
influenced by estrogen; later in cycle, development influenced by estrogen and progesterone;
menstrual periods result of withdrawal of estrogen from stimulated endometrium
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| Amenorrhea: goal of management not establishment of periods but prevention of long-term consequences
of amenorrhea; these consequences include osteopenia (with increased risk for osteoporosis) and unopposed
estrogen stimulation of endometrium (increased risk for endometrial dysplasia and, subsequently,
endometrial cancer); CNS causes—prehypothalamic, hypothalamic, and pituitary; hyper- and hypothyroidism
associated with menstrual cycle disorder; adrenal gland can compound problems because it produces
similar spectrum of hormones; gonads (ovary and testes) and outflow tract; pregnancy—>900,000
cases annually; always consider
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| Etiology: 20% to 40% of cases of primary amenorrhea caused by morphologic or chromosomal factors;
determine Tanner stage of patients throughout pubertal years; determine Tanner stage of breasts and pubic
hair separately; morphogenic causes—involve outflow tract abnormalities (eg, absent uterus, obstructed
vagina, imperforate hymen, vaginal septum); also include congenital spine and urinary tract
anomalies; chronic diseases—cause primary or secondary amenorrhea; in Crohn’s disease, amenorrhea
may present before gastrointestinal (GI) symptoms or weight loss; endocrinopathies—thyroid, pituitary,
and ovarian; drugs—therapeutic and recreational; ovarian causes—ovarian dysgenesis; premature ovarian
failure; ovarian tumor; uterine causes—least common; more often congenital anomaly than unresponsive
endometrium; anorexia nervosa and psychiatric conditions—patients with eating disorders who
regain normal weight may have long lag time before menstruation reinitiated; apparently more than
weight factor causing menstrual cycle disruption; number of psychiatric conditions implicated, and
mechanism probably suppression of hypothalamus, which results in noncyclic production of GnRH;
physiologic factors—severe weight loss or gain; exercise; pregnancy
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| Red flags: no menstrual period by 16 yr of age; no menses by 1 yr after mother’s age at menarche; no
menses by 2 yr after development of secondary sexual characteristics; associated congenital anomalies;
virilization (hyperandrogenic state); short stature; bone age (further evaluation warranted if markedly
different from chronologic age)
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| Evaluation of amenorrhea: categorize; determine whether pubertal development present; obtain good
history and perform physical examination; exclude pregnancy; history and physical examination may reveal
findings such as galactorrhea, virilization, obesity, significantly underweight, or genital anomaly;
most congenital gynecologic anomalies present during adolescence (genital examination necessary);
galactorrhea—differential diagnosis includes pregnancy, hypothyroidism, hyperprolactinemia, and drugs;
virilization—subtle in adolescents (look for, eg, hirsutism, acne, clitorimegaly); evaluate for hyperandrogenic
state; determine testosterone (free or bioactive); dehydroepiandrosterone sulfate (DHEAS; to determine
whether etiology ovarian or adrenal if girl hyperandrogenized); androstenedione not necessary
for diagnosis (may be only androgen measurably elevated in polycystic ovary syndrome [PCOS]); LH
and FSH not helpful; obesity—differential diagnosis includes PCOS, diabetes, and Cushing’s syndrome;
tailor evaluation to clinical presentation; consider pelvic ultrasonography (US; bimanual examination of
ovaries usually insufficient); underweight—speaker performs erythrocyte sedimentation rate once
yearly; consider looking for chronic disease; differential diagnosis includes eating disorders, overexercise,
and chronic disease; genital anomaly—presence of externally obvious genital anomaly requires imaging
of upper tract; increased prolactin—if patient not pregnant, consider pituitary adenoma; rule out
hypothyroidism and drug use; nipple stimulation (eg, nipple friction in athletes) may cause slightly elevated
prolactin; if patient has normal physical examination, consider checking LH and FSH early in
evaluation; if FSH and LH elevated—consider premature ovarian failure; consider Turner’s syndrome or
other type of gonadal dysgenesis; consider secondary ovarian failure due to pelvic irradiation or chemotherapy;
if karyotype analysis normal, and patient has no history of irradiation or chemotherapy, consider
autoimmune oophoritis; if FSH and LH low—consider hypothalamic suppression; if extremely low, consider
cranial computed tomography to rule out CNS mass lesion
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| Next steps (if physical examination and tests normal): consider hypothalamic suppression; give progesterone
(medroxyprogesterone 10 mg/day) for 5 days, then wait 1 wk for withdrawal bleeding; if withdrawal
bleeding occurs, patient capable of menstruating and “estrogenizing,” but not producing progesterone; patient
would benefit from cyclic progesterone (to protect endometrium from unopposed estrogen); if progesterone
withdrawal test negative, patient likely not producing sufficient estrogen; patient at risk for
osteopenia and osteoporosis; give estrogen (3 mo of oral contraceptives), then see whether bleeding occurs
(majority bleed; if not, endometrium may be unresponsive)
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| Management of amenorrhea: treat root cause; assure adequate estrogenization to protect bone mineralization;
in long-term amenorrhea, prevent unopposed estrogenization by cycling with progesterone or estrogen-progesterone
combination, particularly if girl sexually active; reassure patient of her “normalness”
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| Menstrual dysfunction in athletes: several variables affect athlete’s menstrual cycle; same red flags apply
for determining whether to work up athlete (unless clearly shown that menstrual problem occurs
solely during sporting season)
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Gynecologic Care of Prepubertal Girls
| Vulvovaginitis: first gynecologic examination in newborn nursery; most cases not sexually transmitted;
can be caused by parasites (eg, pinworms), specific bacterial infections, fungus (true vulvovaginitis in
prepubertal girls not usually due to yeast), and most commonly, nonspecific (overgrowth of bacterial
flora); irritant vulvitis more common than specific infections (more likely local phenomenon than true
infection); can also be caused by foreign body; consider infection if vaginal exudate present (may be
blood-tinged) or local treatment not effective; bacteria include respiratory, GI, and skin flora;
Gardnerella—more often marker for disruption of normal flora; in adolescents and adults, treated with
metronidazole (in vitro, does not respond to metronidazole); if culture shows usual flora, probably represents
overgrowth or anaerobe
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| Evaluation: obtain relevant history; presence or absence of exudate and blood key in genital examination
(differentiates vaginitis from vulvitis); speaker does not culture for yeast; obtain vaginal culture (not vulvar);
speaker uses urethral swab to obtain specimen for culture
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| Foreign body in vagina: history often revealing; toilet paper most common (not visible on imaging); suspect
if patient has recurrent or refractory vulvovaginitis; test with vaginal irrigation (use soft blunt-tipped
feeding tube to flush vagina with saline; diagnostic and therapeutic maneuver); if unable to perform vaginal
irrigation in prepubertal child, examine under anesthesia
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| Management of vulvovaginitis: hygiene (wipe from front to back), cotton underwear, sleeping without
underwear, and soaks (must spread labia majora for water to get into vulvar mucosa); topical steroids
helpful when significant inflammation present (secondary irritation may occur with frequent use);
creams “burn” more than ointments; for severe inflammation, gels better (available only in medium- and
high-potency formulations) and easy to use; bacterial infection treated systemically; if child has yeast
vulvovaginitis, consider systemic therapy rather than intravaginal antifungal (difficult)
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| Noninfectious causes: lichen sclerosis et atrophicus—thin pale white tissue; does not extend past midline of
labia majora; tends to spare vulvar mucosa; also seen in postmenopausal women; bimodal distribution;
bleeding seen if subepithelial hemorrhages present; painful defecation causes stool withholding and urinary
retention; secondary bacterial infection of vulva (because of tissue breakdown); usually resolves by
puberty because of endogenous steroid production; management in preschool and early grade school
years challenging; manage to point of control (not cure); adult women cured with high-potency topical
steroids, but no data to show effectiveness in children (limited clinical experience); clobetasol used in
adults (use judiciously and selectively in children); urethral prolapse—treated with estrogen cream; often
presents as dysuria and blood in underwear; fusion of labia minora—most common vulvar condition; asymptomatic;
resolves on its own; treat only if patient symptomatic (eg, obstructed urination, persistent
vulvar infection); tends to recur; treat judiciously (sufficient to avoid symptoms) with topical estrogen
cream; 2 small studies using topical steroids but more data needed; technique critical (apply gentle pressure
where adhesion located); extra strand—either hymenal strand or vaginal septum; crucial to diagnose
and treat before problems develop; may cause painful intercourse with excessive bleeding; 2 schools of
thought on when management best begun (at time of diagnosis or later, when surgical field bigger);
speaker thinks ideal time just before menarche (heals better or may have resolved by then); imperforate
hymen—causes abdominal pain; vaginal cysts—perform US to ensure no extensive cyst formation;
should be left untouched (resolve or child grows into them); vulvar cyst—mucosal surface; no treatment
necessary
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Suggested Reading
American Academy of Family Physicians: Information from your family doctor. Amenorrhea: what you
should know. Am Fam Physician 73:1387, 2006; Joishy M et al: Do we need to treat vulvovaginitis in prepubertal
girls? BMJ 330:186, 2005; Loucks AB et al: Essay: The female athlete triad. Lancet 366 Suppl
1:S49, 2005; Master-Hunter T et al: Amenorrhea: evaluation and treatment. Am Fam Physician 73:1374,
2006; Quint EH et al: Primary amenorrhea in a teenager. Obstet Gynecol 107:414, 2006; Rickenlund A et
al: Oral contraceptives improve endothelial function in amenorrheic athletes. J Clin Endocrinol Metab
90:3162, 2005; Epub 2005 Mar 15. Stricker T et al: Vulvovaginitis in prepubertal girls. Arch Dis Child
88:324, 2003.
Educational Objectives
| The goal of this program is to improve the evaluation and management of amenorrhea in adolescents, and
of vulvovaginal conditions in prepubertal girls. After hearing and assimilating this program, the clinician
will be better able to:
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 | 1. Recognize the common causes of amenorrhea and its differential diagnosis.
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| 2. Determine which laboratory tests to perform to confirm the cause of amenorrhea.
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| 3. Recommend treatment to prevent the consequences of amenorrhea in adolescents.
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| 4. Advise parents and patients on how to prevent vulvovaginitis.
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| 5. Recognize other common vulvovaginal conditions in children.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to
disclose relevant financial relationships within the past 12 months that might create any personal conflicts
of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality
in health care and not a proprietary business or commercial interest. For this program, the faculty reported
nothing to disclose.
Acknowledgements
Dr. Simmons was recorded at Pediatrics for the Primary Care Physician, held June 29 to July 1, 2007, at Amelia
Island, FL, and sponsored by Nemours. The Audio-Digest Foundation thanks Dr. Simmons and Nemours
for their cooperation in the production of this program.
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