PEDIATRIC & ADOLESCENT GYNECOLOGY
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.
Classification of sexual maturity ratings in girls.
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Table 39–1. Classification of sexual maturity ratings in girls.
|Tanner stage ||Pubic hair ||Breasts |
|1 ||Preadolescent ||Preadolescent |
|2 ||Sparse, lightly pigmented, straight, medial border of labia ||Breast and papilla elevated as small mound; diameter of areola increased. |
|3 ||Darker, beginning to curl, increased amount ||Breast and areola enlarged, no contour separation. |
|4 ||Coarse, curly, abundant, but less than in adult ||Areola and papilla form secondary mound. |
|5 ||Adult feminine triangle, spread to medial surface of thighs ||Mature, nipple projects, areola part of general breast contour. |
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.
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 ...