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Transient precocious puberty may occur in response to a functional ovarian cyst, and vaginal bleeding may be triggered by the spontaneous resolution of the cyst. Exogenous hormonal exposure should be considered because children have been known to ingest birth control pills. Ovarian tumors resulting in pseudoprecocious puberty should be ruled out. Vulvovaginitis is common but is a diagnosis of exclusion. When bleeding is present, it is necessary to assess the vagina and to rule out a foreign body or vaginal tumor.

In such cases, there should be supportive ­evidence of a hormonal effect, such as the presence of breast ­ tissue and pale, engorged vaginal epithelium. Bleeding ­ disorders are uncommon in this age group but should be considered. Vitamin K is routinely given to the newborn, but some patients may refuse the medication. Precocious puberty (see Chapter 31) may present with vaginal bleeding, although most commonly other evidence of maturation will have preceded the bleeding and will be evident on examination.

The presence of a pleural effusion may be indicative of a disseminated malignancy, particularly ovarian­ cancer. Abdomen Examination of the abdomen is critical in the evaluation of the gynecologic patient. The contour, whether flat, scaphoid, or protuberant, should be noted. The latter appearance may suggest ascites. The presence and distribution of hair, especially in the area of the escutcheon, should be recorded, as should the presence of striae or operative scars. Abdominal tenderness must be determined by placing one hand flat against the abdomen in the nonpainful areas initially, then gently and gradually exerting pressure with the fingers of the other hand (Figure 2-1).