Most common cause is recurrent vulvovaginitis, common age 2-7 yrs.

Simple non-invasive inspection of the vulvovaginal area.

Empirical antibiotic or thrush treatment is not indicated.

Swabs rarely indicated unless sexually active. Prepubertal hymen is very sensitive so perineum surface swab only if there is visible discharge or skin changes suggestive of infection.

Consider threadworms, empirical treatment may be appropriate.

Exclude UTI and constipation which can exacerbate vulval irritation.

Most respond to reassurance and simple hygiene advice ( BritSPAG information leaflet)

Treat confirmed bacterial infection only with antibiotics.

Candida infection (thrush) is rare in prepubertal girls; a confirmed infection on swab should raise the possibility of other medical conditions (e.g. diabetes, immunosuppression) or Child Sexual Abuse (CSA).

Recurrent symptoms or those not responding to general advice should be referred to gynaecology.

The range of normal vaginal discharge patterns is wide.

White/yellow, non-offensive vaginal discharge is normal in young girls and increases as they become oestrogenised, often with cyclical variation.

Discoloured or offensive discharge may indicate bacterial vulvovaginitis as above. Swab the discharge. Treat any confirmed bacterial infection.

Copious, green or offensive discharge. Consider sexually transmitted disease (STD) or foreign body. Suspicion of foreign body should be discussed with the paediatric gynaecology service or on call gynaecology team. Suspicion of STD in girls who are sexually active should be referred to GUM clinic. If there are any concerns regarding non-consensual sexual activity or other forms of CSA this should be discussed first with G4S.

If acute, severe menstrual bleeding refer to on call gynaecology team.

Presentation of genital bleeding in premenarcheal girls is rare. Establish source of bleeding e.g. anal (common with constipation), vulval skin, vaginal

Possible causes of vaginal bleeding:

• Neonatal hormonal withdrawal bleeding (self-limiting)
• Trauma (see below)
• Hormonal causes (precocious puberty, exogenous oestrogen)
• Genital tract malignancies (suspect in girls under 3 years, refer)

Many teenage girls are concerned about the appearance of their labia. Asymmetry and protrusion is common until pubertal development is complete. Range of normality is wide and sociocultural expectations are usually the issue (see BRITSPAG leaflet on normal appearances). Do not refer for cosmetic reasons only.

Labial adhesions in young girls are common and most do not require treatment. Natural history is spontaneous resolution. Referral to gynaecology clinic appropriate if confirmation of diagnosis and management needed. ( BritSPAG leaflet)

The most common skin change in vulval area is lichen sclerosis, a pearly, translucent appearance around vulva and anus +/- itching, soreness and bleeding. Treatment is with topical steroid ointments on a variable dosing schedule over a period of weeks. Referral to gynaecology clinic for confirmation of diagnosis and treatment advice would be appropriate.

Any other abnormal anatomical appearance that you cannot explain please refer.

Chapter 7 Obstetrics, gynaecology, and urinary-tract disorders

Primary amenorrhea with normal pubertal progress of secondary sexual characteristics (no menstruation by age 16 years)

Most common cause is constitutional delay or low BMI/over exercise.

If any concerns regarding eating disorder refer to eating disorder service.

All others should be referred to gynaecology for further investigation and advice.

Please arrange to accompany referral:

• Pelvic ultrasound scan
• Bloods
  • Luteinizing hormone (LH)
  • Follicle-stimulating hormone (FSH)
  • Prolactin
  • Oestradiol

Secondary amenorrhea (menstruation stopped for 6 consecutive months)

There are a number of causes of secondary amenorrhea. Always consider whether there has been rapid weight loss, low BMI, or over exercise as referral of these cases would be more appropriately into the eating disorder clinic.

Girls with suspected polycystic ovarian syndrome (PCOS) should be referred to the endocrine service if they are obese and/or have other endocrine complications of obesity. Otherwise referral to gynaecology is appropriate for advice and management.

Please arrange to accompany referral:

• Luteinizing hormone (LH)

• Follicle-stimulating hormone (FSH)

• Prolactin

• Oestradiol

Simple period problems are best managed in primary care.

Refer to gynaecology where they are significantly disruptive to schooling and/or extracurricular activities, not responding to primary care management or complicated by a medical or physical/learning disability.

Dysmenorrhea

Topical treatments e.g. heat, wheat bags

Ibuprofen in addition to paracetamol is often the most useful combination of simple analgesics.

There is insufficient evidence to indicate whether any one NSAID is more effective than another for the treatment of dysmenorrhoea. If considering using an alternative NSAID to ibuprofen prescribers should consider using the most appropriate cost effective alternative.

Menorrhagia

Tranexamic acid (1g tds for up to 4 days), decreases blood loss by up to 50% and can be used in combination with analgesics.

Full Blood Count (FBC) and clotting studies in severe cases.

Hormonal treatment

Use of hormonal preparations to manage menstrual problems is best managed in primary care or family planning clinics.

Once completed pubertal development (usually 2 years post menarche) the most effective menstrual management is the combined oral contraceptive pill (OCP).

The contraceptive implant can render many young people amenorrheic but this is not predictable and therefore should only be preferred if reliable contraception is the greater need.

Depot injection should be reserved for contraception.

Rarely hormone patches or the Mirena coil may be indicated but usually reserved for young people with physical/learning disabilities and should be managed through gynaecology.

Chapter 7 Obstetrics, gynaecology, and urinary-tract disorders

Pelvic/lower abdominal pain in girls is common.

Full medical assessment to exclude other causes

If concerns re a gynaecological cause then arrange for pelvic USS and refer.

Approach as with any unusual injury in children.

Accidental injuries do occur e.g. straddle falls, bike handle bars, scooters etc.

Inspect injury to assess need for and urgency of medical intervention.

Contact on call gynaecology (+/- paediatric) team to review if concerned.

If there are any concerns re CSA contact G4S team to discuss.

Referral Criteria

Acute haematocolpos – refer urgently to on call gynaecology

Appropriate referrals to Gynaecology:

• Vulvovaginal complaints e.g. itching, soreness, discharge
• Abnormal vulvovaginal appearances e.g. labial adhesions, tags, skin changes
• Primary amenorrhea with normal progress of secondary sexual characteristics (no menstruation by age 16 years)
• Secondary amenorrhea (menstruation stopped for 6 consecutive months)
• Menstrual problems e.g. menorrhagia, dysmenorrhea, irregular periods, not responding to primary care management or complicated by a medical or physical/learning disability.
• Vaginal bleeding in pre menarchal children (if no concerns re CSA)

Referral Instructions

e-Referral Service

• Specialty: Child & Adolescent Services
• Clinic Type: Gynaecology/Endocrinology
• Service: DRSS-Northern-Child & Adolescent Services- Devon CCG - 15N

Referral Forms

DRSS referral form

Patient Information

For patient/parent information leaflets on common gynaecological conditions referred to above visit: www.britspag.org

Devon Sexual Health

Pathway Group

This guideline has been signed off by the Northern Locality on behalf of NEW Devon CCG.

Publication date: June 2017