Spotlight on … adolescent gynaecology

Abstract

Adolescents present with a variety of symptoms to the gynaecology clinic. A common gynaecological condition is heavy menstrual bleeding and usually this will be managed in primary care. However, patients who do not respond to first-line management or who have co-morbidities will be referred to the gynaecologist. Other common presentations are dysmenorrhea, menstrual irregularities primary and secondary amenorrhoea. Many of these symptoms are common during puberty and adolescence and usually are amenable to expectant management or simple therapies. Nevertheless, as they are common they also run the risk of delayed diagnosis and treatment. Delayed diagnosis of endometriosis in adolescence illustrates this problem. Research articles, review articles and guidelines serve to increase awareness and emphasise the need to keep a degree of suspicion regarding different pathologies, for timely diagnosis and treatment. The 2017 National Institute for Health and Care Excellence (NICE) guidance on the diagnosis and management of endometriosis (http://www.nice.org.uk/guidance/ng73) emphasises the need to suspect endometriosis in women (including young women aged 17 years and under) presenting with one or more of the following signs or symptoms: chronic pelvic pain; period-related pain (dysmenorrhoea) affecting daily activities and quality of life; deep pain during or after sexual intercourse; period-related or cyclical gastrointestinal symptoms, in particular, painful bowel movements; and period-related or cyclical urinary symptoms. Different causes of menstrual obstruction should also be borne in mind in evaluating pain. The Obstetrician and Gynaecologist (TOG) has attempted to maintain the presence of adolescent gynaecology in its contents. Two articles published in the last 2 years were centred on adolescent gynaecology and are highlighted below. A section of an article on polycystic ovary syndrome (PCOS) featured adolescents specifically and has therefore been included in this ‘Spotlight’. Genital outflow tract anomalies, management of menstrual disturbances, contraception in the under 16s have featured between 2011 and 2013 and updates on these topics are due. In the July 2017 issue of TOG, Dr Katherine Gilmore and colleagues aimed to increase awareness of child sexual exploitation and safeguarding among obstetricians and gynaecologists (TOG 2017;19:205–10). A helpful ‘spotting the signs’ pro forma was presented. Questions that would facilitate exploration of possibility of sexual abuse include whether someone is in a relationship, whether the relationship going well, and how she feels about herself. Several risk factors that should alert clinicians are enumerated in tables which are easy to read and act as memory aids. Emily Gelson and colleagues wrote about the assessment and care of female survivors of childhood cancer in the October edition of 2016 (TOG 2016;18:315–22). With increased survival in childhood cancers, there are increasing consequences such as premature ovarian insufficiency (POI). The authors have highlighted that in survivors who continue to have menstrual cycles, an assessment of ovarian reserve should be made because of the risk of POI. The authors presented evidence that anti-müllerian hormone (AMH) is a good marker of ovarian reserve and can be used to identify those at risk of POI. The care of survivors who go through menopause include counselling and hormone replacement therapy. Options for fertility and fertility preservation are also discussed in the paper. An update on PCOS by Professor Adam Balen was published in January 2017 (TOG 2017;19:119–29). The article included a section on the condition in adolescence. The problems of applying the Rotterdam criteria in adolescence were discussed. Many symptoms of PCOS, such as irregularity of menstrual cycles and acne, are common in adolescence. A pragmatic approach of treating symptoms, excluding other pathology and following up for evolution of symptoms with time are recommended. Paediatric and adolescent gynaecology is a vital component of obstetrics and gynaecology. However, this subspecialty has not been proportionately represented in TOG content. Updates on the management of heavy menstrual bleeding in adolescents and children, pelvic pain, primary amenorrhoea and ovarian cysts would be welcome. An online collection of all TOG articles on adolescent gynaecology is available at onlinetog.org.