25.3 Contemporary Issues & Pediatric and Adolescent Gynecology: Violence Against Women, Sexual Assault Care, Breast Disorders, Ethics of Maternal-Fetal Conflict, and Gynecologic Problems of Children and Adolescents

Why these areas matter

TOS area T asks you to explain:

• the psychological aspects of obstetrics and gynecology;
• domestic violence and sexual assault;
• the gynecologist's role in screening for and diagnosing breast disorders;
• the ethics of therapeutic abortion and other situations where helping one patient may harm the other.

TOS area U covers:

• the anatomy and physiology of the reproductive system in children;
• examination techniques;
• common problems;
• sensitivity to possible abuse.

Violence against women and children is common and underreported in the Philippines, and physicians are often the first to see its effects.

Psychological aspects of OB-GYN

• Pregnancy loss, stillbirth, infertility, gynecologic cancer, hysterectomy and menopause carry grief and anxiety, and sometimes depression. Perinatal depression affects mother, infant and family.
• Address these issues with:
  • empathic communication;
  • screening (for example the Edinburgh Postnatal Depression Scale);
  • support for bereaved parents, such as seeing and holding the baby and memory-making;
  • referral to mental health services.
• Sexual dysfunction (low desire, dyspareunia, vaginismus) is common after childbirth, cancer treatment and menopause, and should be asked about.

Domestic violence and sexual assault

• Philippine laws:
  • RA 9262 (Anti-Violence Against Women and Their Children Act of 2004) covers physical, sexual, psychological and economic violence by a husband, former partner or dating partner. It provides protection orders (Barangay, Temporary and Permanent).
  • RA 8353 (Anti-Rape Law), as amended by RA 11648 (age of sexual consent 16).
  • RA 7610 (child abuse).
  • RA 11313 (Safe Spaces Act).
• Clues to abuse:
  • injuries that do not match the history, or delays in seeking care;
  • injuries in pregnancy, especially to the abdomen, breasts and genitals;
  • repeated visits, depression, substance use;
  • a controlling partner who will not leave the room.
  • Abuse often begins or worsens in pregnancy and is linked to abruption, preterm birth and maternal death.
• Response:
  • ask privately and without judgment;
  • document injuries carefully (with diagrams and photos);
  • assess immediate safety;
  • refer to the hospital Women and Children Protection Unit (WCPU), social workers, police women's desks and legal aid.
• Care after sexual assault:
  • informed consent and a medicolegal examination with chain of custody, done promptly and ideally before bathing;
  • treat injuries;
  • emergency contraception (levonorgestrel or a copper IUD);
  • HIV post-exposure prophylaxis within 72 hours;
  • presumptive treatment of gonorrhea, chlamydia and trichomoniasis;
  • hepatitis B vaccination (with HBIG if indicated) and tetanus as needed;
  • pregnancy testing, follow-up testing for syphilis and HIV;
  • psychological first aid and counseling.
  • The medicolegal aspects are covered in Legal Medicine.

The gynecologist and breast disorders

• Breast cancer is the most common cancer among Filipino women. Every gynecologic consultation is a chance for clinical breast examination and risk assessment.
• Mammography: WHO recommends organized screening every 2 years for women aged 50 to 69 where resources allow, and many guidelines begin at 40.
• Breast awareness: women should know how their breasts normally look and feel and report changes promptly.
• Triple assessment of a lump: clinical examination, imaging (ultrasound under 30 to 35, mammography in older women) and tissue diagnosis (core needle biopsy).

Benign breast conditions:

• Fibroadenoma: a firm, mobile, rubbery, painless lump in young women ("breast mouse").
• Fibrocystic changes: cyclic tenderness and lumpiness before menses.
• Intraductal papilloma: bloody discharge from a single duct.
• Duct ectasia: in perimenopausal women, with thick discharge.
• Mastitis and abscess: see postpartum care.
• Galactorrhea: check prolactin and TSH, and review drugs.

Red flags:

• a hard, fixed lump;
• skin dimpling or peau d'orange;
• nipple retraction;
• bloody discharge;
• axillary nodes.

Ethics: therapeutic abortion and maternal-fetal conflict

• Legal position: the 1987 Constitution protects "the life of the mother and the life of the unborn from conception", and the Revised Penal Code punishes abortion. There is no law permitting therapeutic abortion.
• The principle of double effect is widely applied. An act aimed directly at treating a serious condition in the mother may be performed even if fetal death is a foreseen but unintended consequence, if there is a proportionate reason. Examples are:
  • salpingectomy for a tubal ectopic pregnancy;
  • hysterectomy for cervical cancer in pregnancy;
  • chemotherapy for maternal cancer;
  • delivery for severe preeclampsia or chorioamnionitis, even before viability.
• Other ethical issues:
  • informed consent and refusal of treatment, such as cesarean or blood transfusion;
  • conscientious objection, in which the provider must still give emergency care and information;
  • confidentiality for adolescents within the law;
  • assisted reproduction and surrogacy, which are not specifically regulated in the Philippines.
• Always provide humane, nonjudgmental care for complications of abortion (DOH AO 2016-0041).

Pediatric and adolescent gynecology

• Physiology:
  • in the newborn, maternal estrogen causes breast buds, a whitish discharge and sometimes withdrawal bleeding in the first weeks, which is normal;
  • in childhood, the vulvar skin is thin and unestrogenized, the vagina is alkaline and the labia minora are small, which explains vulvovaginitis and labial adhesions.
• Examination:
  • a parent present;
  • explanation in words the child understands;
  • frog-leg or knee-chest position;
  • labial separation and traction;
  • no speculum: use an otoscope, saline irrigation, or vaginoscopy under anesthesia if needed;
  • never force an examination.

Note: most children who are sexually abused have normal genital examinations, so a child's disclosure is taken seriously even when there are no findings.