Practical Pediatric and Adolescent Gynecology

Pediatric and Adolescent Gynecology



Edited by

Paula J Adams Hillard, MD, Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford,
CA, USA



The gynecologic needs of younger patients are variable and complex

Clinicians are often uncomfortable with the gynecologic concerns of young girls and developing women. How can I put
the patient at ease? What are the rights of the patient and her parents? How do I ask the questions in a way that
allows her to trust me so that I can better understand her medical and social situation?



In Pediatric and Adolescent Gynecology, Dr Hillard has designed a new textbook that puts the patient at the center. It
follows the patient’s life and her changing needs as she matures. An emphasis on effective, patient-friendly
encounters is the prelude to a sensitive clinical approach to intimate, potentially awkward, clinical challenges.
Short, practical chapters provide guidance on the issues rather than an academic treatise.



This ‘in the office’ guide to effective patient care is informed by evidence-based practice and backed by a wealth of
practical features:



Algorithms and guidelines to most effective approaches
‘Tips and Tricks’ boxes so you can improve you clinical outcomes
‘Caution’ warning boxes so you can avoid complications
‘Science Revisited’ boxes give a quick reminder of the basic science principles


Dr Hillard has assembled an expert group of authors to provide straightforward guidance to caring for and reassuring
your younger patients and their parents. If you provide clinical care to girls and young women then Pediatric and
Adolescent Gynecology is designed for you.


Preface, xi

Contributors, xiii

SECTION 1 PREPUBERTAL GIRLS, 1

Part 1 Introduction

1 Initial assessment, 3
Maureen Lynch

Part 2 Prepubertal Girls: Symptoms and Signs

2 Ambiguous genitalia in the neonate and infant, 6
Sejal Shah and Avni C. Shah

3 Vaginal discharge and odor, 14
Corinne Bazella and Majorie Greenfield

4 Vaginal bleeding, 18
Valerie S. Ratts

5 Ovarian masses, 22
Julie L. Strickland and Anne-Marie Priebe

Part 3 Prepubertal Girls: Gynecologic Conditions

6 Labial adhesions, 29
Jane E. D. Broecker

7 Pediatric vulvovaginitis, 33
Sari Kives

8 Sexual abuse, 38
Nancy D. Kellogg and James L. Lukefahr

SECTION 2 CONCERNS IN PREPUBERTAL GIRLS AND IN ADOLESCENTS, 43

Part 1 External Genitalia

9 Normal hymen and hymenal variations, 45
Amy D. DiVasta and Estherann Grace

10 Vulvar signs and symptoms, 49

10.1 Overview of vulvar signs and symptoms, 49
Paula J. Adams Hillard

10.2 Vulvar ulcers and aphthosis, 57
Helen R. Deitch

10.3 Vulvar tumors, cysts, and masses, 60
Meredith Loveless

10.4 Vulvar abscesses, 64
Jennie Yoost and S. Paige Hertweck

11 Vulvar lichen sclerosus, 69
Paula J. Adams Hillard

12 Accidental trauma, 72
Mariel A. Focseneanu and Diane F. Merritt

13 Female genital mutilation, 76
Katherine A. Zakhour and Comfort Momoh

Part 2 Puberty

14 Normal puberty, 80
Jennifer C. Kelley and Frank M. Biro

15 Precocious puberty, 87
Paul B. Kaplowitz

16 Delayed puberty, 91
Sara E. Watson, Peter A. Lee and Christopher P. Houk

SECTION 3 ADOLESCENT GIRLS, 97

Part 1 Adolescent Health

17 Initial assessment: consultation with an adolescent girl, 99
Paula J. Adams Hillard

18 Confidentiality, 103
Janice Bacon and Jennifer A. Greene

19 Legal issues, 108
Rebecca Gudeman and Abigail English

20 Adolescent sexuality, 114
Linda M. Kollar

21 Adolescent preventive care for healthy teens, 119
Kristin L. Kaltenstadler and Corinne Lehmann

22 Weight, 125

22.1 Overweight and obesity and gynecologic conditions, 125
Stephanie Crewe and Maria Trent

22.2 Eating disorders, 131
Anne Hsii and Neville H. Golden

23 The female athlete, 138
James R. Ebert

24 Immunizations, 142
Amy B. Middleman

25 Substance abuse: screening and brief intervention, 146
Patricia Schram and Sharon Levy

26 Suicidal ideation and self-harm: screening, 151
Matthew B. Wintersteen and Christopher V. Chambers

27 Healthcare for lesbian, bisexual, and transgender adolescents, 154
Elizabeth B. Erbaugh and Margaret J. Blythe

28 Developmental delay, 158
Lisa Allen and Melanie Ornstein

29 Menstrual health, 163

29.1 Tampons and menstrual hygiene products, 163
Stephanie Stockburger and Hatim A. Omar

29.2 Normal menses, 166
Paula J. Adams Hillard

29.3 Menstrual suppression, 169
Kelly Kantartzis and Gina Sucato

30 The gynecologic exam, 174

30.1 When and how to perform a gynecologic exam, 174
Paula J. Adams Hillard

30.2 Cervical cytology screening, 180
Paula J. Adams Hillard

31 Sexually-transmitted disease screening, 183
Michael G. Spigarelli

Part 2 Pregnancy Prevention and Options

32 Unintended pregnancy: options and counseling, 187
Kaiyti Duffy and Rachael Phelps

33 Contraceptive counseling, 192

33.1 Contraceptive counseling for healthy teens, 192
Stephanie B. Teal

33.2 Contraceptive counseling for teens with medical illness, 197
Melissa Gilliam and Amy Whitaker

34 Contraception, 205

34.1 Barrier methods, 205
Uri Belkind and Susan M. Coupey

34.2 Oral contraception, 210
Emily M. Godfrey and Melissa Kottke

34.3 Transdermal and vaginal combination methods, 217
Sherine Patterson-Rose and Paula Braverman

34.4 Intrauterine devices, 222
Sophia Yen

34.5 Progestin-only contraception, 226
Michelle M. Isley and Andrew M. Kaunitz

34.6 Emergency contraception, 230
Kaiyti Duffy and Melanie A. Gold

Part 3 Adolescent Girls: Symptoms and Signs

35 Hirsutism, 234
Dianne Deplewski and Robert L. Rosenfield

36 The breast, 241

36.1 Breast concerns, 241
Kaylene J. Logan and Eduardo Lara-Torre

36.2 Breast discharge, 246
Donald E. Greydanus and Colleen Bryzik Dodich

37 Vaginal discharge, 249
Seema Menon, Mandakini Sadhir, and Susan Jay

38 Pelvic masses, 254
Noam Smorgick-Rosenbaum and Elisabeth H. Quint

39 Gynecologic pain, 260

39.1 Pelvic and abdominal pain, 260
Geri D. Hewitt

39.2 Myofascial (musculoskeletal) pain, 266
John Jarrell

40 Amenorrhea, 269
Melanie Nathan and Andrea L. Zuckerman

41 Abnormal uterine bleeding, 275
Jennifer E. Dietrich and Jennifer L. Bercaw-Pratt

42 Premenstrual syndrome/premenstrual dysphoric disorder and mood disorders, 281
Michael Dobbs and Paula Braverman

Part 4 Adolescent Girls: Gynecologic Conditions

43 Vulvovaginal conditions, 285

43.1 Yeast/candida, 285
Sofya Maslyanskaya and Elizabeth Alderman

43.2 Bacterial vaginosis, 289
Jennifer Louis-Jacques and Rebecca Flynn O’Brien

44 Sexually-transmitted diseases, 293

44.1 Genital herpes, 293
Terri Warren

44.2 Human papillomavirus and condyloma, 297
Lea E. Widdice and Jessica A. Kahn

44.3 Chlamydia, 302
Taraneh Shafii and Gale R. Burstein

44.4 Gonorrhea, 307
Bree Weaver and J. Dennis Fortenberry

44.5 Trichomonas, 312
Samantha E. Montgomery and Jill S. Huppert

44.6 HIV, 315
Anita Radix and Donna Futterman

44.7 Other sexually-transmitted diseases, 318
Ellen S. Rome

45 Dysmenorrhea, 325
Michelle Forcier and Zeev Harel

46 Congenital anomalies, 330
Amy M. Vallerie and Lesley L. Breech

47 Ectopic pregnancy, 339
Michelle Vichnin

48 The ovaries, 342

48.1 Ovarian cysts, 342
Paula J. Adams Hillard

48.2 Ovarian germ cell tumors, 348
Claire Templeman

49 Endometriosis, 351
Mary Anne Jamieson

50 Polycystic ovary syndrome, 355
Samantha M. Pfeifer

51 Pelvic infl ammatory disease, 361
Colleen McNicholas and Jeffrey F. Peipert

52 Gonadal dysgenesis, 366
Courtney A. Marsh and Yolanda R. Smith

53 Sexual assault and date rape, 371
Beth L. Emerson and Kirsten Bechtel

Appendix 1 Essential information, 375

Appendix 2 Useful web resources for adolescents, their parents/caregivers, and clinicians, 389

Index, 391