Paediatric and adolescent gynaecology — structured SAQ (15 marks)

(a) Tanner staging verbatim (4 marks)

Two marks for the definition and the sequence; one mark each for the breast stage 1 and pubic hair stage 1 verbatim descriptions. ^[1]

• Tanner staging is the standardised five-stage classification of pubertal development described by Marshall and Tanner in 1969; the sequence in girls is thelarche, adrenarche, peak height velocity, then menarche.^[1]
• This 6-year-old is Tanner breast stage 1 and pubic hair stage 1 (prepubertal) because she has no breast development and no clitoral enlargement.
• Breast stage 1 (verbatim): "Elevation of the papilla only. No glandular tissue; the areola conforms to the general contour of the chest wall."
• Pubic hair stage 1 (verbatim): "No true pubic hair; the vellus hair over the pubes is not further developed than that on the anterior abdominal wall."^[1]

(b) Labial adhesion management (4 marks)

One mark per point, maximum four. ^[2][3][4]

• Diagnosis: labial adhesions — fusion of the labia minora across the midline, leaving a small opening, in a prepubertal hypo-oestrogenic girl.
• Mild, minimally symptomatic: observation alone is reasonable; the Kim SW 2023 randomised study showed observation was non-inferior to topical estrogen for asymptomatic adhesions, and the Norris 2018 cohort confirmed substantial spontaneous resolution.^[3][4]
• Symptomatic (dribbling, UTI): first-line is topical estrogen cream applied nightly to the fusion line for 2 weeks, repeated up to 6 weeks if incomplete; the Dowlut-McElroy 2019 RCT confirmed efficacy. Counsel the parents about transient local hyperpigmentation and breast budding that resolves on cessation.^[2]
• Surgical separation (manual or sharp) is reserved for severe urinary obstruction or failed medical therapy; recurrence is common without post-procedure estrogen maintenance. Adhesions typically resolve permanently at puberty.^[2]

(c) Natural history and prognosis (3 marks)

One mark per point. ^[2][3][4]

• Labial adhesions are common in prepubertal girls because the skin is thin and low in estrogen; they are not caused by anything the parents did wrong.
• They resolve spontaneously in a substantial proportion; topical estrogen works in most; recurrence is common until puberty establishes endogenous estrogenisation.
• There is no impact on future fertility or sexual function; adhesions typically resolve permanently once puberty starts.^[3][4]

(d) Cyclic pain with amenorrhoea — differential and first investigation (4 marks)

Two marks for a complete differential; one mark for the diagnosis most likely; one mark for the first investigation. ^[5]

• Differential: menstrual outflow obstruction — imperforate hymen, transverse vaginal septum, obstructed hemi-vagina (often with a didelphys uterus), vaginal or cervical atresia.^[5]
• Less likely but to consider: hypothalamic or pituitary causes of secondary amenorrhoea, pregnancy (mandatory to exclude), Müllerian agenesis (no cyclic pain because no endometrial tissue).
• Most likely in this 11-year-old with cyclic pain, Tanner stage 4 breast development and absent menses: an outflow tract obstruction — classically imperforate hymen or a transverse vaginal septum.
• First investigation: a pregnancy test to exclude pregnancy, then a pelvic ultrasound to assess the uterus, vagina, and any haematocolpos or haematometra. Pelvic MRI if ultrasound is equivocal. Examination under anaesthesia with planned hymenotomy or vaginoplasty if a structural obstruction is confirmed.^[5]