Chapter 39

#### NORMAL DEVELOPMENT

An important aspect of the pediatric and adolescent gynecologic examination is an understanding of the various stages of development and when each would typically occur. The Tanner stages, known as sexual maturity ratings, classify the progression of boys and girls through pubertal development. Table 39–1 presents the classification of sexual maturity ­ratings in girls.

Table 39–1.Classification of sexual maturity ratings in girls.

Normal age of onset of puberty in girls is considered to be between 8 and 13 years of age. Puberty involves thelarche, (onset of breast development), pubarche, (onset of pubic hair development), and menarche (onset of menses). The sequence of puberty progression usually begins with thelarche, then pubarche, followed by menarche. Thelarche occurs about 1 year earlier in non-Hispanic African American and Hispanic American girls. The trend toward earlier age of puberty onset in girls has continued over the past several decades and, as a result, there is uncertainty about the current range of normal. Obesity decreases the age of onset by approximately 0.5 years.

#### EXAMINATION

Gynecologic examination of the female pediatric patient is a procedure that some physicians are uncomfortable performing. This may be due to the fact that some of the examination involves a nulliparous patient who may also be prepubertal. It can be a challenging situation caused by anxiety of the parent and patient. It is best to develop a strategy for approaching the examination beforehand in order to improve success.

Genital anatomy of the prepubertal girl differs from that of the adult woman. The pediatric vulva is more susceptible to irritants and trauma due to its inherent anatomy and lack of estrogenization. Prior to puberty, the pediatric vulva is hairless and has very little subcutaneous fat. The labia minora lack pigmentation and have an atrophic appearance. The distance from the vestibule to the anus is shorter, which places the vulva at an increased risk of irritation. The vagina is proportionally smaller in length and diameter and has very little distensibility. The vaginal mucosa will be red, thin, and moist. The vestibule and vagina are not glycogenated or estrogenized, and the glans clitoris may appear relatively more prominent due to the flat appearance of the labia in the prepubertal patient. The cervix is either flush ...

Sign in to your MyAccess profile while you are actively authenticated on this site via your institution (you will be able to verify this by looking at the top right corner of the screen - if you see your institution's name, you are authenticated). Once logged in to your MyAccess profile, you will be able to access your institution's subscription for 90 days from any location. You must be logged in while authenticated at least once every 90 days to maintain this remote access.

Ok

## Subscription Options

### AccessPediatrics Full Site: One-Year Subscription

Connect to the full suite of AccessPediatrics content and resources including 20+ textbooks such as Rudolph’s Pediatrics and The Pediatric Practice series, high-quality procedural videos, images, and animations, interactive board review, an integrated pediatric drug database, and more.