TEXTBOOK OF PEDIATRIC GYNECOLOGY - 2013

Chapter 2. ORGANIZATION OF SPECIALIZED GYNECOLOGICAL CARE FOR ADOLESCENT GIRLS IN UKRAINE

In Ukraine, the health of girls as future mothers is monitored across all stages and Phases of the female body's development. To this end, specialized gynecological care for girls and adolescents has been in operation and continuously improved since 1957, taking into account their age-specific characteristics. In accordance with Order No. 114 of the Ministry of Health of Ukraine dated June 22, 1995, the specialty of PEDIATRIC AND ADOLESCENT obstetrician-gynecologist was officially included in the relevant nomenclature of medical specialties. Training in this field is conducted pursuant to Order No. 143 of the Ministry of Health of Ukraine dated June 22, 1993, with further enhancements regulated by Order No. 391 of the Ministry of Health of Ukraine dated December 27, 1996, "On the Improvement of the Pediatric and Adolescent Gynecology Service."

Methodological, therapeutic, and diagnostic work in pediatric gynecology is spearheaded by two primary centers in Ukraine that prioritize girls' reproductive health from early childhood at the state level. These are the Ukrainian Center for Pediatric and Adolescent Gynecology at the Institute of Pediatrics, Obstetrics, and Gynecology of the National Academy of Medical Sciences of Ukraine, and the Kharkiv Research Institute for the Protection of Children's and Adolescents' Health of the Ministry of Health of Ukraine, as outlined in the National Programs "Children of Ukraine," "Family Planning," and "Reproductive Health of the Nation 2006-2011."

Specialized offices for pediatric and adolescent gynecology operate within regional centers, while in certain regions, pediatric and adolescent gynecologists are available in every district center. Many of these facilities feature specialized gynecological examination tables or dedicated inpatient units for adolescent girls.

The dynamic monitoring system for girls and adolescents comprises a three-tier healthcare delivery framework.

The first tier involves routine preventive screenings of girls and adolescents in preschools, schools, and vocational colleges. To safeguard the reproductive health of girls and adolescents and prepare them for future motherhood, this stage must also incorporate health education on sex education.

Girls of preschool and early school age undergo preventive examinations by the pediatrician of the children's institution to rule out sexual development disorders and gynecological conditions. District pediatricians monitor girls' development from birth to the age of 15 using standard assessment Methods, which include clinical anthropometry and evaluation of secondary sexual characteristics. If a girl exhibits symptoms or objective signs indicative of pathology, she is referred for a specialized consultation—specifically, a pediatric and adolescent gynecology office—where clinical, instrumental, recto-abdominal, and supplementary diagnostic methods are performed.

A crucial component of the first tier is the Organization of targeted screenings among school and college students to detect gynecological pathology or developmental disorders, conducted by a pediatric and adolescent gynecologist. Preventive check-ups for adolescent girls are recommended starting at age 12.

In accordance with child rights protection provisions in the context of bioethics and the Convention on Human Rights and Biomedicine adopted by the Parliamentary Assembly of the Council of Europe (1997), preventive screenings for early Reproductive System disorders in girls must be preceded by explanatory work. Schoolgirls should be informed that the examination is performed exclusively to protect each individual girl's health and requires the consent of the girl herself or her parents/guardians.

The second tier involves the provision of outpatient care in specialized pediatric and adolescent gynecology offices.

The third tier entails the delivery of medical care in specialized inpatient hospitals or gynecological departments.

This three-tier specialized gynecological care system for girls facilitates the effective Prevention of generative function disorders and helps reduce morbidity rates.

DEONTOLOGY AND MEDICAL ETHICS IN PEDIATRIC GYNECOLOGY

The work of a pediatric gynecologist requires exceptional professional and personal qualities. Because young women and girls are inherently vulnerable, every word spoken by the physician must be carefully weighed and considered.

Deontology in pediatric gynecology has A number of unique features, particularly because providing medical care often requires the physician to delve into the most intimate aspects of a girl's life. This involves taking a detailed medical history as well as performing gynecological examinations, which are frequently conducted in the presence of other medical staff. Given the heightened sense of modesty in adolescents—especially between the ages of 5 and 8—a pediatric gynecologist must exercise exceptional tact and employ a specialized approach during examinations.

When a child is brought to a gynecologist, the physician must first establish rapport with the parents. While parents may initially hesitate regarding a gynecological examination, it is precisely during the pre-pubertal years that various conditions can arise requiring professional medical intervention.

Interviewing a young patient requires considerable professional skill and should never be conducted in a hospital ward in the presence of other patients or physicians. Appropriate conditions must be arranged in an office or examination room. While taking the medical history, it is best to converse with the mother while asking tactful and delicate questions. Special attention should be paid to the girl's emotional sphere and personality traits. It is essential to remember that an accurate Diagnosis and effective Treatment depend directly on a properly gathered medical history.

For girls, a gynecological examination is an emotionally stressful event, and the physician must find an individualized approach for each patient.

The gynecologist should inform the girl and her parents about the possibility of gynecological conditions at various ages, emphasize the necessity of the examination, and reassure them of its safety and critical importance for establishing an accurate diagnosis and timely treatment. Parents are encouraged to prepare the girl for the examination in advance to prevent any psychological trauma.

A specialized gynecological examination—like any other medical Procedure—must under no circumstances cause psychological trauma to the child. This can be achieved by adhering to the following ethical guidelines:

— first, it is essential to reassure the mother and convince her that the examination will cause no harm to the girl, that her reproductive Organs will remain undamaged, and that the instruments used are specifically designed for pediatric gynecological examinations;

— the girl must be assured that the procedure will be painless, and that the physician will stop immediately if she experiences any pain or discomfort.

Most girls readily agree to the examination once the physician convinces them of its necessity.

The success of the examination depends largely on the trust that both the mother and the girl place in the physician. A child's behavior often reflects her mother's mood and anxieties; therefore, the physician must cultivate a calm, welcoming atmosphere and explain every step of the procedure.

The gynecological examination is performed after psychologically preparing the child, in a separate room, away from outsiders or behind a screen. It is advisable that the mother or legal guardian be present during the examination. However, in certain cases—such as suspected adolescent Pregnancy—it is preferable to conduct the examination in the presence of a nurse. Throughout the examination, the physician should continue talking to the girl to distract her attention.

Adhering to the principles of medical deontology sometimes necessitates examining a child under anesthesia. If the physician fails to overcome the girl's fear and resistance, forceful examination is counterproductive, as it will cause psychological trauma. In such cases, the examination must be performed under anesthesia.

Upon completion of the procedure, the child should be thanked for her cooperation and informed of the results.

To clarify the diagnosis, Additional Diagnostic Methods are often required. Their use must be clinically justified and must not cause undue distress. The procedure should be minimally painful and non-traumatic. Before taking swabs for suspected genital inflammatory conditions, both the mother and the older girl should be reassured that swab collection is a safe and painless procedure necessary for selecting appropriate therapy.

Vaginoscopy often causes anxiety among parents due to the potential risk of damaging the hymen. Parents must be briefed on the technique of this manipulation, which completely rules out the possibility of injury. In some cases, vaginoscopy is performed under anesthesia in an inpatient Setting.

Inflammatory Diseases of the genitalia are the most common pathology in young girls. In such cases, the physician informs the mother about the potential causes of the inflammatory process, its chronic forms, and complications, noting that chronic inflammation is often sustained or exacerbated by reinfection via shared personal items or bed linen. It is also important for the mother to understand that effective treatment takes time and its final outcome depends on strict adherence to all medical recommendations.

In cases of menstrual irregularities in girls, special attention is paid to the medical history, living conditions, daily routine, dietary habits, and previous chronic illnesses. It is essential to carefully ascertain the girl's dietary habits, specifically whether she is restricting food intake to achieve a "fashionable figure." This conversation should be conducted in a trusting, confidential manner, as it often touches upon intimate aspects of the girl's life (such as parental Separation, family alcoholism, etc.). Parents are informed of their responsibilities regarding the condition, the necessity of hospitalization, and the rationale behind treatment methods. When discussing treatment options, the potential and success of hormone therapy should be highlighted. Treatment success largely depends on the parents' and the girl's understanding of the therapeutic goals.

When providing care to a child with genital trauma, the physician must assess the severity and Nature of the injury, and then reassure the parents by explaining that accidental injuries to the genitalia are typically mild and do not impair future reproductive function. During the Structure/133.html">Discussion with parents, the physician outlines The Nature of the planned procedure and emphasizes that modern surgical techniques allow for the complete correction of most traumatic injuries.

Traumatic injuries resulting from violence require the physician's utmost attention toward both the injured child and her parents. It is essential to thoroughly investigate the circumstances of the incident, and to accurately document and describe the nature of the physical injuries. Parents must be advised on proper behavior to minimize the child's emotional stress. They should be informed about The Nature and severity of the injuries, surgical management options, and the necessity of taking vaginal swabs and performing Blood tests for the Wassermann reaction. Assault-related injuries generally attract public attention and publicity. In such cases, the physician must respond tactfully to inquiries and, at times, recommend changing the child's place of residence, school, or childcare facility to prevent further psychological trauma.

Genital tumors are a rare pathology in children and typically run an asymptomatic course. Parents rarely anticipate the possibility of a neoplastic process in young girls. When a genital tumor is detected, parents must be informed of the necessity of hospitalization, while every effort is made to ensure the hospitalization process does not traumatize the child. When justifying The Need for surgery, the physician should reassure the parents that the operation will not harm the child's health and that every effort will be made to preserve the function of the affected organ.

Deontological issues concerning Congenital Malformations of the female genitalia in girls present unique challenges. First and foremost, the physician must assess the severity and nature of the anomaly, and subsequently inform the parents about the possibilities of surgical and hormonal correction.

In gynecological inpatient departments, children are accommodated in wards grouped by age. Ward rounds are of particular significance. In such settings, every young patient in the ward listens carefully to everything the physicians say. Therefore, information regarding a patient's condition must be precise, comprehensive, but not excessive. Sensitive matters concerning individual girls should be discussed privately, without outsiders present. Medical staff should ensure equal attention is given to all patients and avoid examining girls in the presence of other children.

When performing surgical interventions on the genitalia of older girls, it is generally inadvisable to inform them of the exact scope of the surgery. The patient should be reassured of a favorable outcome and made to understand that her recovery depends on adhering to a proper daily routine and diet. It is crucial that the child does not receive contradictory information from various sources (parents, staff, physicians).

Medical professionals must strictly maintain medical confidentiality and refrain from disclosing any details regarding the patient's condition to outsiders or to the girl herself.

Adhering to medical ethics and the core principles of deontology in pediatric gynecology is a mandatory prerequisite for the successful practice of a pediatric gynecologist and plays a pivotal role in the effective treatment and prevention of gynecological disorders in girls.