Women's Corner
Women's Corner
· Priorities :
- Rule out life threatening diseases e.g. tumors
- Exclude isolated non-endocrinal causes of vaginal bleeding e.g. F.B.
- Define whether the process is progressing or stationary
· History :
1. Confrim precocious puberty : Age
2. Type of precocious puberty : complete or incomple and iso- or heterosexual
3. Etiology :
a. Central : - Family history for consititutional cases
- Symptoms of increased intracranial tension
- History suggestive of hypothyroidism
- Past history of skull injury, rickets or meningitis
b. Peripheral : - History of drug intake
- Rapidly growing abdominal mass
-Manifestations of Albright syndrome
· Examination :
1. General :
- Weight, height and span : normally the span is 5 cm from the height. If the difference is greater this means premature closure of the epiphysis . Upper/lower body segments is 1.7 at birth , 1 on adults and 0.9 in negros .
- Ocular : fundus and field examination for increased intracranial tension
- Thyroid : for goiter - Breast : for galactorrhea and Tanner staging
- Skin : Axillary hair , skin pigmentation and manifestations of virilization
- Bone cysts
2. Abdominal :
- Abdominal masses
- Pubic hair for Tanner staging .
3. Pelvic :
- Estrogenic manifestation of the vulva and vaginal mucosa
- Exclude local causes of vaginal bleeding
- Bimanual abdominorectal examination for adenxal masses and uterine size .
· Investigation (Novak) :
1. Confirm precocious puberty and its type :
a. Hormonal assays : Basal gonadotropin is the first step :
- High or normal levels points out to a central cause . Occasionally high gonadotropins may be present with an ectopic-gonadotropin secreting tumor
- Low gonadotropin indicates a peripheral cause which needs to determine the estradiol levels in isosexual cases and androgens levels in heterosexual cases .
b. Imaging X-ray for estimation of the bone age :
- Advanced : denotes complete precocity (a central or peripheral cause)
- Normal : incomplete precocious puberty
N.B. bone age may be retarded in hypothyroidism
2. To reach an etiology :
a. Hormonal studies :
1. Estradiol levels : if increased suggests an estrogen secreting ovarian neoplasm
2. Androgen levels :
- Testosterone : points to a a virilizing ovarian tumor
- DHAS : points to an adrenal cause
- 17 hydroxylase : high in CAH
3. Thyroid functions
b. Imaging :
Head CT or MRI and US on the abdomen
dr. Hisham Al-Inany Lecturer in Obstetrics and Gynecology Department, Cairo University, Egypt Dr. Amr Hussein Lecturer in Obstetrics and Gynecology Department, Cairo University, Egypt