Paediatric and adolescent gynaecology — structured oral station (12 minutes)

Opening prompt — "Describe your examination findings using the standard staging system."

Model response: ^[1]

• "I am staging puberty using the Marshall and Tanner 1969 system. This 7-year-old has breast stage 2 (B2) — the breast bud stage, with elevation of the breast and papilla as a small mound and enlargement of the areolar diameter; glandular tissue is palpable. Her pubic hair stage is 1 (PH1) — no true pubic hair, only vellus."
• "On the sequence thelarche → adrenarche → peak height velocity → menarche, she is at the start of thelarche, which is pathologically early at age 7 — below the threshold of 8 for the diagnosis of central precocious puberty in girls."^[1]

Probe 1 — "What is your differential?"

• "The two big divisions are central (GnRH-dependent) precocious puberty and peripheral (GnRH-independent) precocious puberty. Central is idiopathic in about 90 per cent of girls; a minority have CNS tumours (hypothalamic hamartoma, astrocytoma), CNS injury, or severe hypothyroidism. Peripheral causes include ovarian cysts or tumours (granulosa cell), adrenal tumours, McCune-Albright, exogenous oestrogen."
• "The premature thelarche variant is isolated breast development with no other signs, no growth spurt, no bone age advance, and normal GnRH testing — and it is benign. The premature adrenarche variant is isolated pubic hair with no breast development; it is often benign but warrants workup for non-classic CAH. Her age 7 with growth spurt and breast bud points to true central precocity, not a variant."^[2]

Probe 2 — "Outline your workup."

• "Bone age radiograph of the left hand and wrist; basal LH and FSH with a GnRH analogue stimulation test (or GnRH agonist stimulation) — a basal LH above 0.3 IU/L supports central activation; pelvic ultrasound for uterine and ovarian size, endometrial thickness and to exclude an ovarian tumour."
• "MRI brain and pituitary is mandatory in any girl with confirmed central precocious puberty, particularly under age 6 or with neurological signs, to exclude a CNS lesion."^[2]

Probe 3 — "Her 14-year-old sister is also in clinic for HMB since menarche. How do you approach her?"

Communication and respect domains — demonstrate the HEEADSSS interview out loud: ^[3]

• "I establish confidentiality first: 'What we discuss is confidential. The exceptions are if I am worried about your safety or someone else's safety, or if the law requires me to report something — in which case I will discuss it with you first.'"
• "I then walk the HEEADSSS domains — Home, Education/Employment, Eating, Activities, Drugs, Sexuality, Suicide/Mood. The HMB itself I treat as a vital sign: I take a FIGO bleeding-disorder screen because HMB since menarche has up to a 20 per cent yield for von Willebrand disease."
• "I treat her HMB with a levonorgestrel intrauterine system as first-line hormonal therapy, screen for iron deficiency, and replete ferritin."^[3]

Probe 4 — "The mother asks whether the 7-year-old will need treatment."

• "The Carel 2009 consensus established the framework. The indications for GnRH analogue therapy in central precocious puberty are rapidly progressive puberty with likely impact on final height, or significant psychosocial distress. The aims are to halt progression of secondary sexual characteristics, preserve final adult height, and address psychosocial distress. Therapy is typically discontinued at the physiological age of puberty (around 11 in girls)."
• "I would discuss the workup results first — if a CNS lesion is identified, that drives the management plan and a neurosurgical referral."^[2]

Probe 5 — "Suppose, instead, this were a 4-year-old with a confirmed STI. What would change?"

• "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. I would examine the child once, by a clinician trained in forensic paediatric examination, with a chaperone and parental consent and child assent, with documented photography and chain-of-custody swabs. The Adams 2018 update remains the reference for the interpretation of medical findings in child sexual abuse. Mandatory reporting applies."^[4]