O&G · Gynaecological health — paediatric and adolescent
Paediatric and adolescent gynaecology: Tanner staging verbatim, labial adhesions, prepubertal vulvovaginitis, precocious puberty, adolescent menstrual concerns and the safeguarding framework
Also known as Paediatric gynaecology · Adolescent gynaecology · Tanner staging · Labial adhesions · Prepubertal vulvovaginitis · Precocious puberty · Adolescent heavy menstrual bleeding · HEEADSSS
Exam-exhaustive FRANZCOG fellowship topic on paediatric and adolescent gynaecology: the Marshall and Tanner 1969 staging reproduced verbatim; the common prepubertal gynaecological concerns (labial adhesions, vulvovaginitis in prepubertal girls, the differential of vaginal discharge); the definition and workup of precocious puberty; adolescent menstrual concerns (dysmenorrhoea, heavy menstrual bleeding, primary and secondary amenorrhoea); the safeguarding and mandatory reporting framework; and the HEEADSSS adolescent consultation approach. RANZCOG-primary with ACOG and ESPE deltas.
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Target exams
Red flags
- Any STI in a prepubertal child triggers an urgent specialist and child-protection discussion — perinatally acquired chlamydia can persist for 2 to 3 years but sexually acquired infection must be considered
- A genital finding suggestive of trauma, laceration, bruising or scarring in a child warrants immediate safeguarding referral — examination by a forensic-trained clinician, never repeat the examination
- Precocious puberty (under 8 in girls) needs a same-visit MRI brain to exclude a CNS lesion — central causes are not all benign
- Adolescent heavy menstrual bleeding since menarche — screen for von Willebrand disease before any surgery; the FIGO bleeding-disorder screen is about 90% sensitive
- An adolescent with primary amenorrhoea and cyclic pelvic pain has a menstrual outflow obstruction (imperforate hymen, transverse vaginal septum, obstructed hemi-vagina) until proven otherwise — urgent imaging
- Mood or suicidality disclosed in a HEEADSSS interview is a same-visit mental-health response, not a follow-up appointment
A worried mother brings her 4-year-old to clinic: "She's been holding her wee and crying when she goes." A 7-year-old has breast buds that started at 6. A 14-year-old has cyclic pelvic pain but no period. Paediatric and adolescent gynaecology is built on three things — knowing what normal puberty looks like, recognising the few true emergencies, and applying a trauma-informed, safeguarding-aware consultation framework to every encounter. This topic walks the examiner through the canonical examinable questions.[1][11][13]
Why this matters — the numbers
Tanner staging — the verbatim reference
Puberty in girls follows a predictable sequence: thelarche (breast bud) → adrenarche (pubic and axillary hair) → peak height velocity → menarche. Marshall and Tanner described the staging in their 1969 cohort study, and it has been the global standard for over 50 years.[1]
Breast stages (B1 to B5), reproduced from Marshall and Tanner 1969
These are the verbatim stage descriptions.[1]
- Stage 1 (B1) — prepubertal. Elevation of the papilla only. No glandular tissue; the areola conforms to the general contour of the chest wall.
- Stage 2 (B2) — breast bud stage. Elevation of the breast and papilla as a small mound; enlargement of the areolar diameter. Glandular tissue is palpable.
- Stage 3 (B3). Further enlargement of the breast and areola with no separation of their contours; the breast and areola form a single smooth mound.
- Stage 4 (B4). The areola and papilla project above the level of the rest of the breast to form a secondary mound.
- Stage 5 (B5) — mature stage. The areola has receded to the general contour of the breast, with only the papilla projecting; the secondary mound of stage 4 is no longer present.[1]
Pubic hair stages (PH1 to PH5), reproduced from Marshall and Tanner 1969
- Stage 1 (PH1) — prepubertal. No true pubic hair; the vellus hair over the pubes is not further developed than that on the anterior abdominal wall.
- Stage 2 (PH2). Sparse growth of long, slightly pigmented, downy hair, chiefly along the labia.
- Stage 3 (PH3). The hair becomes darker, coarser and curlier; it spreads sparsely over the junction of the pubes.
- Stage 4 (PH4). The hair is adult in type but covers a smaller area than in most adults; there is no spread to the medial surfaces of the thighs.
- Stage 5 (PH5). Adult in type and quantity, distributed as an inverse triangle; the hair spreads classically to the medial surfaces of the thighs.[1]
Premature thelarche
- Isolated breast development before age 8 with no other signs of puberty
- Benign; observe with serial exams every 6 to 12 months
- Normal growth velocity and bone age
- Distinguish from central precocious puberty: no pubic hair, no growth spurt, normal GnRH testing
Premature adrenarche
- Isolated pubic/axillary hair before age 8
- Often benign but warrants workup for non-classic CAH and androgen tumour
- Bone age often advanced
- Risk marker for later PCOS and metabolic syndrome
Central precocious puberty
- Activation of the HPO axis before age 8 in girls
- GnRH-dependent; idiopathic in 90 per cent of girls
- MRI brain to exclude CNS tumour or hamartoma
- Treat with GnRH analogues to preserve final height
References13ShowHide
- [1]Marshall WA, Tanner JM Variations in pattern of pubertal changes in girls. Arch Dis Child, 1969.PMID 5785179
- [2]Biro FM, Greenspan LC, Galvez MP, Pinney SM, Teitelbaum A, Windham GC, Deardorff J, Herrick RL, Succop PA, Hiatt RA, Kushi LH, Wolff MS Onset of breast development in a longitudinal cohort. Pediatrics, 2013.PMID 24190685
- [3]Herman-Giddens ME, Slora EJ, Wasserman RC, Bourdony CJ, Bhapkar MV, Koch GG, Hasemeier CM Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings network. Pediatrics, 1997.PMID 9093289
- [4]Kaplowitz PB, Slora EJ, Wasserman RC, Pedlow SE, Herman-Giddens ME Earlier onset of puberty in girls: relation to increased body mass index and race. Pediatrics, 2001.PMID 11483799
- [5]Carel JC, Eugster EA, Rogol A, et al. Consensus statement on the use of gonadotropin-releasing hormone analogs in children. Pediatrics, 2009.PMID 19332438
- [6]Dowlut-McElroy T, Higgins J, Williams KB, Strickland JL Treatment of Prepubertal Labial Adhesions: A Randomized Controlled Trial. J Pediatr Adolesc Gynecol, 2019.PMID 30385397
- [7]Kim SW, Han JY, Han SJ, Kim H, Ku SY Effect of topical estrogen cream compared with observation in prepubertal girls with labial adhesions. J Pediatr Urol, 2023.PMID 37179197
- [8]Norris JE, Elder CV, Dunford AM, Rampal D, Cheung C Spontaneous resolution of labial adhesions in pre-pubertal girls. J Paediatr Child Health, 2018.PMID 29436045
- [9]Nurzia MJ, Eickhorst KM, Ankem MK, Barone JG The surgical treatment of labial adhesions in pre-pubertal girls. J Pediatr Adolesc Gynecol, 2003.PMID 12604141
- [10]Lanis A, Talib HJ, Dodson N Prepubertal and Adolescent Vulvovaginitis: What to Do When a Girl Reports Vaginal Discharge. Pediatr Ann, 2020.PMID 32275761
- [11]Adams JA Understanding Medical Findings in Child Sexual Abuse: An Update For 2018. Acad Forensic Pathol, 2018.PMID 31240081
- [12]American College of Obstetricians and Gynecologists ACOG Committee Opinion No. 760: Dysmenorrhea and Endometriosis in the Adolescent. Obstet Gynecol, 2018.PMID 30461694
- [13]American College of Obstetricians and Gynecologists ACOG Committee Opinion No. 651: Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign. Obstet Gynecol, 2015.PMID 26595586