Journal of Pediatric and Adolescent Gynecology

Published by Elsevier
Print ISSN: 1083-3188
Publications
To compare in a regular non-clinical trial experience the efficacy, acceptability, and continuation rates of an injectable contraceptive containing 50 mg norethisterone enanthate plus 5mg estradiol valerate (IC) and an oral contraceptive containing 0.15 mg levonorgestrel plus 0.03 mg ethinyl estradiol (OC), among adolescent users. A total of 251 adolescents ages 14-19 were followed during 12 months. The IC group (124 subjects) was studied for 1044 cycles and the OC group (127 subjects) was studied for 1368 cycles. The users were not assigned in a random selection. Information was collected from clinical records. Groups were compared using Pearson chi-square, odds ratio (95% confidence interval), t-test, and proportion difference test. The IC group had significant differences in baseline social risk, confidence, psychiatric problems, consumption of alcohol, and number of sexual partners. At 12 months, the IC group showed significant decrease in weight and increase in hypermenorrhea. In the OC group, dysmenorrhea decreased, and hypomenorrhea and regular cycles were significantly more frequent. One pregnancy occurred in the OC group (Pearl Index: 0.88). Final continuation rates at 12 months were 41.9% and 37.8% for IC and OC, respectively. The monthly injectable is a recommended contraceptive option for adolescents, especially for those facing psychosocial risk factors.
 
Unlike varicosities, which result from venous insufficiency, vascular malformations are developmental errors that do not regress. While these lesions are challenging to treat in most anatomic locations, genital venous malformations are particularly difficult problems for the gynecologist, urologist, or primary care physician who may identify them. The risk of surgical treatment has led to investigation of new therapeutic options for these vascular lesions. We describe an 11-year-old premenarchal female with bilateral, symptomatic vulvar venous malformations. These lesions were successfully treated with Doppler ultrasound-guided direct injection venography and ethanol sclerotherapy. Direct injection venography with ethanol sclerotherapy is an attractive diagnostic and therapeutic option for management of vulvar venous malformations.
 
Background: To date, a limited number of endometriosis cases occurring before or around the time of menarche have been documented. Case: An 11-year-old adolescent underwent an emergency operation for left ovarian endometrioma. Her menarche occurred spontaneously 6 months after surgery. Results and conclusions: We discuss the above mentioned case and consider data published in the literature. Endometrioma should be considered even in premenarcheal girls with ovarian cysts, regardless of their size.
 
Ovarian tumors are the most common gynecologic malignancy occurring in childhood, with germ cell tumors being most frequent. This contrasts with adults where epithelial tumors account for most ovarian neoplasms. Tumor markers are an integral part of the work-up and may guide management. A 6-year-old girl with a persistent adnexal mass was found to have a highly elevated CA-125. Other tumor markers were normal. Laparoscopy revealed an enlarged, adherent ovary. A minilaparotomy revealed an ovary filled with necrotic material. This necrotic material was excised and the ovary was spared. The pathology was consistent with necrosis. Follow-up ultrasonography and CA-125 were normal. This case demonstrates for the first time the association of an elevated CA-125 and ovarian torsion in a pediatric patient. This benign finding allowed attempting a conservative ovary-sparing approach during the surgery even in the presence of a highly elevated CA-125. However, in general, for children CA-125 is of limited utility, as it will not affect the indication for surgical exploration of persistent masses and elevations in CA-125 may discourage ovarian conservation.
 
Meigs syndrome is rare in women under 30 years of age and even more if associated with an elevated CA-125. In this case, malignancy was suspected and raised concerns about fertility preservation. A 13-year-old girl presented with a 4-month amenorrhea, abdominal enlargement and dyspnea. Ultrasonography showed a 14-cm solid mass with ascites, bilateral pleural effusion and, analytically, elevated serum CA-125. Unilateral salpingo-oophorectomy was performed, with a 19 × 15 × 12 cm mass being disclosed from the right ovary. Final pathology diagnosed a mitotically active cellular ovarian fibroma (MACF), with no significant nuclear atypia. MACF is a recent histopathologic entity. Despite the high count of mitotic figures, it is not associated with atypia, which contributes to favorable outcome. Although initial suspicions of malignancy, a conservative surgical intervention allowed fertility preservation. This was clinically appropriate and with no implications on survival and prognosis of these patients.
 
Mucinous cystadenoma of the ovary constitutes about 15% of ovarian tumors. It is more common in women between 20 and 40, but is rare in teenagers and exceptional in pre-menstrual girls. Malignant transformation is possible in 5-10% of cases. Spontaneous or iatrogenic breaks are more common. It makes the different diagnosis of pseudomixoma peritonei more difficult. A 13-year-old girl came to the National Cancer Institute "Regina Elena" of Rome, with increasing abdominal distension over 2 months. The abdominal mass was removed and a left salpingo-oophorectomy was performed. Histological examination of the mass revealed a 40-cm diameter mucinous cystadenoma of the ovary. The rapid enlargement of the ovarian mass, the young age and the difficulty of certain pre-operative diagnosis, make this case interesting. Management of this pathology and fertility-conserving treatment need careful follow-up because of the possibility of recurrence in the remaining ovary.
 
To review the main sonographic and magnetic resonance imaging manifestations of Herlyn-Werner-Wunderlich syndrome, characterized by uterus didelphys, obstructed hemivagina, and ipsilateral renal agenesis, and to discuss the value of techniques for its diagnosis and treatment. Thirteen patients with Herlyn-Werner-Wunderlich syndrome referred to our department with acute abdomen were identified for the period from 2009-2012. Retrospective chart review. Two tertiary academic centers. None. The evaluation of the clinical features, ultrasonography and magnetic resonance imaging findings, and the treatment protocols. Ultrasonographic evaluation of didelphic or double uterus in 10 and bicornuate-bicollis uterus in 3 patients with hematocolpos or hematometrocolpos associated with agenesis of the ipsilateral kidney revealed the diagnosis. In 10 patients, magnetic resonance imaging provided extra information. In 1 patient, a 25-week pregnancy was additionally detected and follow-up was suggested. Seven patients underwent surgical excision of the septum and drainage of the obstructed vagina. Total hysterectomy and hemicolpectomy were performed in 1 patient with 2 children suffering from severe chronic pelvic pain due to pelvic inflammatory disease. Despite its rarity, accurate diagnosis and morphologic description of Herlyn-Werner-Wunderlich syndrome with radiologic modalities are of importance in relieving the clinical complaints by enabling the suitable surgical treatment to be identified. Copyright © 2014 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.
 
Isolated absence of the clitoris is a rare entity with medical and sexual implications for patients. As part of an examination for alleged sexual abuse, a 13-year-old female was noted to have an apparent absence of the clitoris. Congenital absence of the clitoris was felt to be the most likely diagnosis. The differential diagnosis and medical implications are reviewed. Isolated absence of the clitoris is a rare entity. When faced with the finding, a detailed medical evaluation should be performed to clarify the nature of the finding, rule out other potential anomalies and help in the counseling of the patient.
 
Juvenile granulosa cell tumor (JGCT) of the ovary has been reported to occur rarely in conjunction with Ollier's disease. We report a case of a 13-year-old girl who was noted to have a large abdominal mass at the time of excision of a symptomatic enchondroma of the right femur. Subsequent laparotomy at a tertiary care children's medical center identified a JGCT confined to the right ovary. Review of the literature reveals eight previous cases of JGCT in patients with Ollier's disease. The pathophysiology and possible common causes of both disorders is discussed.
 
Superficial epithelial ovarian tumors are unusual in adolescent girls (when compared with adult women) and extremely rare before menarche. Mucinous cystadenoma (MCA) in children that is a rare form of epithelial tumor is a benign cystic ovarian neoplasm. To our knowledge, there are only eight cases of mucinous cystadenoma, three of borderline mucinous cystadenoma, and three of mucinous cystadenocarcinoma reported in the English-language literature. We present a 14-year-old premenarchal girl with a giant ovarian mucinous cystadenoma. This review is supported by the finding that epithelial ovarian neoplasms are extremely rare prior to puberty and that only 14 mucinous tumors have been reported prior to menarche.
 
Inflammatory bowel disease is a relatively common condition that may present in a myriad of fashions, from the more frequently seen symptoms of diarrhea and abdominal pain to the less likely presentations with fistulas and abscesses. A 14-year-old female with a presumed diagnosis of a Bartholin's gland cyst was treated for over 1 year with both medical and surgical interventions without her symptoms ever completely resolving. It was later found that these recurring vulvar abscesses were a manifestation of Crohn's disease. While the patient's history and physical are both very important in determining cause for pathology, we must also realize the importance of re-examining and broadening our differential diagnosis when faced with a patient who has failed multiple avenues of care.
 
Pelvic inflammatory disease in prepubertal and non-sexually active adolescents is rare and poorly understood. Various organisms have been named as causative agents in adolescent pelvic infections. Early diagnosis and treatment of pelvic inflammatory disease in young girls is imperative to future fertility and long term sequela. We present a 14-year-old, menarchal, non-sexually active female with a 3-week history of abdominal pain and fever. Surgical exploration and cultures revealed Stage IV pelvic inflammatory disease caused by Beta Streptococcus Group F. Various organisms including Streptococcal infections should be considered in the differential diagnosis of pelvic inflammatory disease in young girls without risk factors.
 
Background: Numerous cutaneous abnormalities have been described in adolescent girls who have been sexually abused. These include bruising, bite marks, cuts, scratches, abrasions, edema, hematomas or other evidence of struggle. Victims frequently shower or bathe excessively in an effort to cleanse their skin following such an unwanted encounter. However, there is a paucity of information in the literature regarding the association of sexual abuse and removal of the superficial layers of the skin as a more desperate attempt by teenagers to rid themselves of the perpetrator. The purpose of this paper is to heighten awareness among practitioners that self-induced cutting and carving of the forearms with scarification may occur as a manifestation of sexual abuse in young women. Methods: A 14-year-old girl was seen in an adolescent medicine consultation setting during the spring of 1999 for evaluation of an anxiety disorder. During the interview the girl related that she had been under considerable stress and that she was having difficulty sleeping. She also had worsening of facial tics that had been previously noted in association with obsessive compulsive behaviors. She had been receiving psychotherapy and was being treated with fluoxetine, but the symptoms were becoming more severe. On examination she appeared very anxious and demonstrated numerous involuntary, repetitive facial grimaces. Similar twitching movements of the neck were also noted. In addition, she had several well healed scars over both forearms. The lesions were linear with a range of one half to one inch in width and three to four inches in length. The remainder of the general physical examination was entirely unremarkable. Results: The etiology of the scars was initially unknown. Upon further questioning the patient was asked directly about what had caused these marks. At that point she broke down and cried as she related that had been sexually assaulted several months earlier. She stated that she carved out tatoos on her arms to get rid of the skin that the perpetrator had touched when he forcibly held her down and raped her. She believed that the scars were “clean” as they were covered with newly regenerated skin. Her gynecologic exam was normal. Further psychiatric intervention was then obtained as it became very apparent that the patient had numerous unresolved emotional conflicts stemming from the attack. Conclusions: This paper documents that carving and scarification of the forearms may be due to self-induced injury in adolescent girls who have been the victims of a sexual assault. Clinicians who care for teens should be aware of this finding as it appears to be an important dermatologic manifestation of sexual abuse. Early recognition of this sign and prompt treatment of the underlying psychiatric issues are essential to an optimal outcome so that any further complications following such a traumatic event can be minimized.
 
Uterine leiomyomas are rarely seen in adolescent and to date nine leiomyoma cases have been reported under age 17. Eight of these have been treated surgically via laparotomic myomectomy. A 16-year-old girl presented with a painless, lobulated necrotic mass protruding through the introitus. The mass originated from posterior uterine wall resected using hysteroscopy. Final pathology report revealed a submucous uterine leiomyoma. Submucous uterine leiomyomas may present as a vaginal mass in adolescents and can be safely treated using hysteroscopy.
 
Vaginal bleeding in premenarchal girls is always abnormal and its source must be identified for appropriate management. Examination under anesthesia and vaginoscopy are commonly employed for evaluation of the vagina as a source of bleeding, and the examination may occasionally reveal vaginal pathology. A 16-month-old otherwise healthy girl presented with spotting. Exam under general anesthesia and vaginoscopy revealed a 1-cm polypoid-like lesion overlying the posterior vaginal wall which was excised using the hysteroscope. Pathology revealed a benign Müllerian cyst. Vaginal findings of causes of premenarchal bleeding such as Mullerian cysts may be diagnosed and treated with the vaginoscopic approach.
 
Demographic Characteristics and Pregnancy Outcomes of GDM þ GIGT Cases
The aim of this study was to determine the prevalence of gestational diabetes mellitus (GDM) and gestational impaired glucose tolerance (GIGT) in adolescent pregnancies, associated risk factors, and pregnancy complications. Retrospective study. Community-based teaching hospital. Results of 1653 pregnant women age ≤ 19 years in 2005-2007 were reviewed. All pregnant women screened with 50-g glucose challenge test (GCT) and patients with a GCT result ≥ 140 mg/dl underwent a 3-hour 100-g oral glucose tolerance test (OGTT). GDM was diagnosed with at least two abnormal results and GIGT was diagnosed with one abnormal result. GDM and GIGT cases were evaluated for the presence of any associated risk factors and effects of presence of risk factors on pregnancy outcomes. The prevalence of GDM was 0.85% (95% CI, 0.41-1.29), GIGT was 0.5% (95% CI, 0.15-0.81) and GDM+GIGT was 1.35% (95% CI, 0.78-1.88) by Carpenter and Coustan criteria. 68% of patients had at least one of the risk factors including body mass index ≥ 25, family history of diabetes and polycystic ovary syndrome (PCOS). Only 9.1% (n = 2) of them required insulin for glucose regulation during pregnancy with 9.1% (n = 2) macrosomia rate. All patients were primiparous and cesarean delivery rate was 27.3% (n = 6). We could not find any effect of presence of risk factors on pregnancy outcomes in GDM and GIGT cases. We demonstrated that GDM and GIGT are strongly associated with high BMI before pregnancy, PCOS, and family history of diabetes. Since GDM is a state of prediabetes, it is important to diagnose in adolescent pregnancies considering their life expectancy to take preventive measures to avoid diabetes mellitus.
 
17α-hydroxlyase/17, 20-lyase deficiency (17OHD) is a rare phenotype of congenital adrenal hyperplasia that can cause primary amenorrhea. Three phenotypically female siblings visited the adolescent gynecologic clinic complaining of primary amenorrhea and absence of secondary sexual developments. All had constant high blood pressure and showed a hypergonadotropic hypogonadal state with high progesterone and low testosterone levels. Two were genotypically females and one was genotypically a male; all were confirmed to have 17OHD, and estrogen replacement, glucocorticoids, and antihypertensive drugs were Prescribed to the patients. Identifying a 17OHD patient complaining of primary amenorrhea in a gynecologic clinic is important for proper management.
 
Anaplastic carcinoma arising within a mucinous ovarian neoplasm is rare, with only about 30 reported cases. Reported cases have given a broad age range, ranging from 17 to 72 years of age, but occurrence in adolescents is exceptional, with only a few cases reported. We report a case of anaplastic carcinoma arising in a mucinous cystadenocarcinoma in a 17-year-old female who presented with severe abdominal pain, an unusual symptom for an ovarian malignancy in the postmenopausal patient, but not in the adolescent. The patient had widespread metastases at the time of presentation, consistent with the aggressive behavior of this neoplasm. This case illustrates that, although rare, epithelial ovarian malignancy is in the differential diagnosis of abdominal pain in an adolescent.
 
(A) Transabdominal sonography of dysgerminoma with adnexal torsion. Presence of homogeneous solid mass measuring 7 cm in diameter is noted in the lower abdomen. (B) Laparoscopic finding of twisted adnexa with ovarian dysgerminoma. Neither adhesion nor capsule rupture was noted. (C) After untwisting, left adnexal tissue was excised by LigaSure Atlas. (D) Excised tissue was retrieved in an endobag and extracted through the 12-mm port. 
Histological findings of dysgerminoma with adnexal torsion. (A) Large aggregates of uniform, round cells existed with infiltrating channels of lymphocytes admixed with connective tissue stroma. (Hematoxylin-Eosin staining, scale bar: 200 m m) (B) Presence of placental alkaline phosphatase-positive cells was shown by immunohistochemical staining. (Scale bar: 200 m m). 
Ovarian dysgerminoma cases very rarely present with acute abdomen due to adnexal torsion and the successful laparoscopic management of such a case has not been reported previously. A 17-year-old sexually inactive high school girl presenting with acute abdomen was referred to our emergency department. Transabdominal ultrasonography showed the presence of homogeneous tumor in the lower abdomen. Emergency laparoscopic surgery was performed and left ovarian tumor with adnexal torsion was identified. Left salpingo-oophorectomy was performed carefully to avoid damaging the tumor capsule and the excised tissue was removed after retrieval in an endobag. The histopathological diagnosis was pure ovarian dysgerminoma. The postoperative course was uneventful. Laparoscopic management with careful postoperative follow-up to monitor recurrence could be a treatment option in a young girl with dysgerminoma, if the disease condition is detected in the early stage.
 
To assess the level of HPV knowledge among low income, minority mothers with a child between the ages of 9-17 y. Women who sought care at a university-based clinic and had at least 1 child aged 9 to 17 years were approached. A total of 638 mothers were recruited. Only those who had heard of HPV were included in the correlation analyses (n = 468). HPV knowledge was assessed utilizing a self-administered questionnaire consisting of 20 questions. There were differences between those who had heard of HPV and those who had not. More of those who had not heard of HPV were Hispanic (63%), low-income (89%), and did not graduate high school (59%). Of those who had heard of HPV, the majority did not answer 50% of questions correctly. Few knew the vaccine could prevent genital warts (19.7%). Factors independently associated with HPV knowledge included age, personal history of HPV, cervical dysplasia or cervical cancer, acquiring knowledge from ≥2 sources, having known someone with HPV or cervical cancer, having seen a brochure on the vaccine, and having seen an advertisement for the vaccine. Knowledge regarding HPV is low among low-income women with children in the target age range for HPV vaccination. Increased awareness should focus on genital warts and other cancers, since this population has virtually no knowledge of other health outcomes related to HPV infection. Educational programs tailored to this population need to be developed to increase vaccination. Copyright © 2014 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.
 
Study objective: To analyze all cases of congenital rectovestibular and rectoperineal fistulas diagnosed and treated later in life, and to describe presenting complaints, treatment, and outcome. Design: Retrospective cohort study. Setting: Pediatric surgery departments of 3 major referral centers in the US and Europe. Participants: Seventeen women with untreated or inadequately treated rectovestibular or rectoperineal fistulas. Interventions: Analyses of all eligible patients: charts were analyzed for the classification of the malformation, main complaints, continence, sexual function, indications for surgery, associated anomalies, surgical procedure, complications, and outcome. Main outcome measures: Patients' complaints, continence, constipation, and sexual function. Results: Major complaints at time of diagnosis were fecal incontinence, and concerns for hygiene and cosmesis. All patients were repaired by a posterior sagittal approach. In all but 1 patient the complaints disappeared or improved after surgery. Conclusions: Anorectal malformations in females are congenital malformations mostly seen and treated in early childhood. If unrepaired or inadequately repaired the patient, when reaching adulthood, can suffer from significant morbidity. Surgical treatment is similar as in childhood and has an excellent clinical outcome.
 
To determine whether mutations occur in the 17 alpha-hydroxylase/17,20-lyase (CYP17) gene in patients with mild hyperandrogenism. Clinical and molecular genetic study. Pediatric endocrine outpatient clinic in an academic research environment. Girls (n = 11) referred for evaluation of premature pubic hair and adolescent girls (n = 16) referred for evaluation of hirsutism and/or oligomenorrhea. None. Mutation detection analysis of the coding regions and intron/exon boundary regions of the CYP17 gene. Two polymorphic nucleotides were identified in the CYP17 gene. No mutations were detected in the 27 subjects. Mutation detection studies presented herein exclude CYP17 as a candidate gene for premature pubic hair and adolescent hyperandrogenism.
 
17 beta-Hydroxysteroid dehydrogenase deficiency is an uncommon inherited disorder characterized by genital ambiguity and progressive pubertal virilization. We describe the clinical and biochemical features in a 13-year-old 46, XY individual who presented with progressive pubertal virilization.
 
Cervical clear cell carcinoma is one of the rare subtypes of cervical adenocarcinomas. Few cases of cervical clear cell carcinoma have been reported in adolescents. We present here a case of a 14-year-old adolescent female diagnosed with a stage II cervical clear cell carcinoma. The patient had no sexual history or diethylstilbestrol-exposure in utero. Polymerase chain reaction identified in the tumor the presence of human papillomavirus type 18, a high-risk genotype for cervical cancer development. The ovaries were retained during surgery and the patient was still alive without recurrence after 9 years. Positivity of HPV18 nucleic acids suggests an association between high risk HPV infection and cervical clear cell carcinoma in the case. Furthermore, in the treatment of young patients with cervical carcinoma, the risks associated with loss of ovarian function should be weighed against that of potential ovarian metastasis.
 
Disseminated peritoneal leiomyomatosis (DPL) is a rare hormone-dependent disease entity occurring primarily in women of reproductive age group subjected to an altered hormonal milieu. The lesion is characterized by numerous subperitoneal nodules of benign smooth muscle proliferations which usually mimic the macroscopic appearance of metastatic malignancy. In 70% of cases, the underlying cause of hormonal alteration is pregnancy and in the remaining cases, the causes are oral contraceptives or hormone-secreting tumors. This indicates that endocrine factors are of importance in the development of this condition. This is an unusual case, hitherto unreported, of DPL with multiple uterine leiomyoma, occurring in a 18-year-old girl, who had previously undergone several laparoscopic surgical resections of uterine leiyomyomas. Her disease was unrelated to pregnancy or to any other obvious sources of hormonal elevation.
 
To investigate the impact of operating surgeon specialty on rates of ovarian preservation, and to explore differences in surgical management when malignant lesions are identified. Retrospective study. Education and research hospitals. Between January 1, 2003 and January 1, 2009, all female patients ≤ 20 years of age undergoing surgery with pathologically confirmed ovarian or fallopian tube tissues removed were evaluated. Demographic, operative, and pathologic data were abstracted. Rates of ovarian preservation with benign lesions, and rates of appropriate surgical staging when malignant lesions were identified. The mean age was 11.9 ± 4.4 years. Malignant lesions were larger than benign masses, 17.3 ± 7.1 cm versus 8.8 ± 7.1 cm respectively (P < .001). Torsion was associated with oophorectomy with a relative risk (RR) of 1.86 and 95% confidence interval (CI) of 1.35-2.57 (P = 0.033). Postmenarchal patients were less likely to undergo ovarian sacrificing procedures (RR 0.62, 95% CI 0.45-0.84, P < .001). The relative risk of incomplete surgical staging with malignant lesions was reduced in the presence of a gynecologic oncologist (RR 0.14, 95% CI 0.02-0.89, P = .003). Ovarian conservation should be prioritized in cases with benign lesions, whereas complete and accurate surgical staging is imperative when malignancy is identified.
 
Background: HEDIS 2000 measure includes chlamydia screening in women which is designed to assess the percentage of sexually active women 15 to 25 years who have received at least one screening test for chlamydia during the reporting year. This study is being undertaken to determine feasibility of implementing a population-level intervention within HMOs to promote chlamydia screening. This abstract presents preliminary findings from the Birmingham project of this multicenter study.Methods: In partnerships with two HMOs, series of outreach methods were used in a stepwise fashion to determine potential barriers and enabling factors for the implementation of chlamydia HEDIS measure in a conservative social environment. Mail outreach was sequentially combined with newspaper, TV, radio advertisements and poster displays. Both qualitative and quantitative impact of the outreach efforts were measured across the timeline. The measures included reporting for chlamydia screening (urine LCR) and infection rate, monitoring chlamydia hotline and staffed phoneline use, and assessment of untoward effects and cost-analysis of the chlamydia outreach campaign.Results: The key findings are: the benefit of chlamydia screening is not understood by general public, letters send by Health Plans to their members are not read by many subscribers, and there are wide gaps between adolescents and their parents, in knowledge, attitudes, beliefs in regard to obtaining information and accessing the screening services (teens prefer hotline, brochure in an envelop addressed to teens, incentives for reporting to the clinic for screening, vs. parents prefer staffed phone consults, "exposed" brochure addressed to parents, and no incentives). A month of sustained and repeat multi-media campaign resulted in 330 hotline calls, 83 phone calls and only 17 subjects being tested (3 were positive) though many more intended to come. Cumulative effects and cost of various outreach efforts are being monitored. Informational chlamydia brochures and free test cards mailed to the homes generated no negative response from the subscribers, contrary to the concerns of the HMOs. Conclusion: To be effective, investment in public education campaign and social marketing strategies must be integrated in population-level intervention for the implementation of the chlamydia HEDIS 2000 measure.
 
To investigate the knowledge, attitude, and behavior of secondary (high) school students concerning HIV/AIDS as a way of assessing the need for inclusion of reproductive health education in the school curriculum. A questionnaire was constructed to expose depth of knowledge and attitude of respondents concerning HIV/AIDS. This was a workshop venue, a civic center, outside a school compound. Three hundred and sixty students were randomly selected from 5 secondary (high) schools in Enugu, Nigeria. The questionnaire was administered just before the commencement of a workshop. All the students responded to the questionnaire but none responded to all the questions. The students had a defective knowledge of the disease. They were aware and afraid of the disease as being deadly but not sure of the cause, nature, or modes of transmission and prevention, except that illicit sexual activity should be avoided. Their attitude and behavior were consequently defective. Their main source of information was the media. There is need to provide students with correct, detailed, and broad-based information on reproductive health as part of the school curriculum to help them acquire adequate knowledge and develop appropriate attitude and behavior towards HIV/AIDS and other STDs.
 
Adolescent pregnancy constitutes a multidimensional social problem in modern Greece. The purpose of this study was to investigate the trends of teenage childbearing and to determine the relationship between the incidence of teenage pregnancy and immigrant status of the mother. This is a retrospective correlational study. The birth registry of the hospital was examined for a 6-year period, from January 2000 to December 2005. Information about the age and nationality of the mothers was collected. The hospital under investigation is Tzaneio Hospital, a public general hospital that provides health services to the residents of Piraeus, a large municipality next to Athens. During the study period 4628 women gave birth at Tzaneio Hospital, among which 349 (7.54%) were under the age of 19. The study hypothesis, that adolescent childbearing prevails among immigrant population, was confirmed (P < 0.01). Teenage pregnancy rate remains high among some subsamples of the population, such as immigrants. The Greek government, health professionals, and sexuality educators should all work together in order to confront this problem.
 
To investigate the prescribing trend of contraceptives in adolescent girls aged 12-18 years and to compare prescribing patterns of the most frequently used contraceptives among this population in Germany in 2007 and 2011. A retrospective cohort study was conducted to analyze contraceptive prescriptions written by gynecologists in 2007 and 2011 in Germany by using the IMS Disease Analyzer database (IMS HEALTH). All adolescent girls aged 12-18 years with at least 1 prescription of a contraceptive drug in 2007 or 2011 were identified. The prevalence of contraceptive prescriptions was calculated and the types of contraceptive substances prescribed were examined. A total of 21,026 teenage girls in 2007 and 18,969 in 2011 received contraceptive prescriptions. The prevalence of contraceptive prescribing rose significantly between 2007 and 2011 (P < .001). The percentage of teen girls who received prescriptions of levonorgestrel and chlormadinone pills was significantly higher in 2011 compared to 2007 (P < .001). However, the portion of contraceptive pills containing drospirenone or desogestrel significantly decreased in 2011 compared to 2007 (P < .01). There was a significant increase in contraceptive prescription usage among adolescent girls between 2007 and 2011 in Germany. However, the prescription behavior of doctors also changed; they consequently prescribed contraceptives with more evidence. Further research is needed to better understand the various factors associated with contraceptive use among this population.
 
Gynecologists and sexologists should define having sex/making love, the situation in which orgasm happens in both partners with or without vaginal intercourse: a definition for all human beings.
 
To compare the outcomes of women aged 15-21 yr to those of older women in a multicenter case series of early medical abortion. We enrolled 1973 women at 34 outpatient Planned Parenthood sites in a case series for medical abortion in the first seven weeks of pregnancy. We used methotrexate (50 mg/m(2)) and misoprostol (800 mg vaginally, repeated as needed). We compared women who started the abortion prior to their 22(nd) birthday to older women. Outcomes of abortion were classified as documented or presumed complete medical abortion, and documented or presumed suction curettage. During the first half of the study, we did an exit interview assessing patient satisfaction. A total of 330 women were under 22 yr and 1641 women over 21 yr. Younger women presented for abortion at the same gestational ages. Overall, younger women had a higher rate of complete medical abortion than did older women (89.4% vs 83%). However, the multiple regression model demonstrated a significant adverse effect of prior live birth (P = 0.006), but not patient age, on outcome. Younger women were less likely to have had prior live births. Younger women were more likely to return for follow-up (96.4% vs 92.9%); the regression model demonstrated a significant effect (P = 0.001) of prior birth on rates of follow-up. Side effects and satisfaction were similar for older and younger women. Younger women having medical abortion with methotrexate and misoprostol have better outcomes and similar satisfaction levels as do older women.
 
To quantify the number of adolescent females < age 21 years with pre-cancerous cervical lesions (cervical intraepithelial neoplasia grade 2 or higher (CIN 2+) or adenocarcinoma in situ (AIS)) in Connecticut in the time period before new cervical screening recommendations went into effect and identify any demographic associations with a diagnosis of CIN 3. Descriptive analysis, surveillance. CIN 2+/AIS precancerous cervical lesions have been reportable conditions in Connecticut since 2008 for the purpose of public health surveillance. All women < 21 years old with pre-cancerous cervical lesions diagnosed between 2008 and 2010 (N = 681). Of the 681 reports, 478 (70.2%) women had CIN 2, 92 had CIN 2/3 (13.5%), and 110 (16.2%) had CIN 3. CIN 3 occurred at an average rate statewide of 19/100,000 per year for women ages 13-20. The majority of adolescents with pre-cancerous cervical lesions CIN 2+/AIS (70%) were 19 and 20 years of age. CIN 3 vs CIN 2 is not found to be associated with age, insurance status, specimen collection year, or living in a non-urban vs urban county. The majority of cases of pre-cancerous cervical lesions in adolescents diagnosed before new screening recommendations were in effect are CIN 2 and therefore, likely to regress. CIN 3 has been infrequently found in adolescent females under age 19 years; however, under the new screening guidelines, 110 cases of CIN 3 including 77 in women 19-20 years could have been missed in the adolescent female in Connecticut from 2008-2010 (54.4 per 100,000 per year for 19-20 year olds). Based upon these findings, it is necessary that clinicians educate adolescents and parents about the new screening guidelines and the importance of establishing regular cervical cancer screening beginning at age 21.
 
Study objective: To evaluate the outcomes of treatment with minimal invasive surgery in children with benign ovarian cysts. Design: Retrospective chart review. Settings: Maternity and children hospital. Patients: Between May 2007 and May 2011, 21 children were treated by laparoscopic method for ovarian cysts at our clinic. The age, symptoms, ultrasonographic findings, operation records and follow-up times were retrospectively evaluated. Results: The mean age was 13.2 years. One patient presented with findings of torsion and another presented with findings of rupture; both were urgently operated on. The other patients presented with intermittent abdominal pain and were operated on under elective basis. The mean cyst size was 8.4 cm (5-13 cm). One patient with necrotic ovary and salpinx due to torsion underwent salpingo-oophorectomy while the others were administered ovary-preserving cystectomy. Only 4 patients required iv paracetamol as an analgesic in the postoperative period. Two patients were discharged on the second postoperative day while the remaining 19 patients were discharged on the first postoperative day. During a mean follow-up of 14 months, no recurrence was seen in this period. Cosmetic appearance was good in all patients. Conclusion: The authors demonstrated that laparoscopic cystectomy was a technically feasible and safe method in the treatment of benign ovarian cysts, associated with short hospitalization, minimal analgesic requirement, and a good cosmetic appearance.
 
Ovarian follicular cyst producing estradiol is a rare cause of isosexual pseudoprecocious puberty. Intense pigmentation of breast papillae, areolae, and labia minora is also rarely reported in the literature. We describe a 2(1/2) year old girl presenting with signs of precocious puberty and advanced bone age due to a large follicular cyst. Estradiol and Dehydro-epiandrosterone sulfate (DHEAS) levels were remarkably elevated. Hyperpigmentation was also noted. Salpingoophorectomy resulted in regression of precocity and depigmentation, but DHEAS serum levels remained elevated. High levels of circulating estradiol due to an ovarian follicle can induce precocious puberty and pigmentation of the skin which regresses after surgical removal of the cyst. Elevated DHEAS levels may be the initiating event causing the formation of the large follicular cyst.
 
The injuries of sexually abused and assaulted girls seldom require surgical repair, and genital and anal injuries due to other causes appear to require repair uncommonly. We sought to determine the causes of genital and anorectal injuries requiring surgical repair in relation to such variables as injury sites and severity. Retrospective study A large tertiary care children's hospital Forty-four girls less than 21 years of age who required surgical repair of genital injuries between June 1986 and April 2007 were identified. Information collected included the victims' ages, trauma mechanisms, and sites and severity of injuries. Injuries requiring repair of the genital and anal areas were uncommon in the 20 year period of this study. Although most injuries were due to straddle and impalement mechanisms, sexual abuse or assault was identified in 25% of the girls. The remaining 11% were victims of motor vehicle accidents. Straddle/impalement injuries involved only the external genitalia, vestibule, perineum, or posterior fourchette of 21 of the 28 girls (76%) with those injuries. The injuries of 9 of the 11 sexually abused/assaulted girls (82%) also involved the hymen, vagina, anus, or rectum. Injuries due to sexual abuse/assault and motor vehicle accidents (MVA) had average severity scores of 2.1 and 2.2, respectively, while straddle injuries had an average severity score of 1.4. (Exact Pearson chi-square P < 0.003.) The ages of the girls were unrelated to the severity of their injuries. Although straddle/impalement was the most commonly found mechanism of genital and anorectal injury requiring surgical repair, sexual abuse or assault was identified in 25% of the girls. Sexual abuse and assault should always be considered and assessed appropriately when such injuries are found. Consultation of a social worker or child abuse specialist may be appropriate, especially when injuries clearly not due to an MVA involve the vagina or anorectum. A suspicion of sexual abuse or assault should be reported to the legally mandated state agency in accordance with the laws of state.
 
Several studies have noted contemporary girls are undergoing pubertal maturation at younger ages. During this same time period many Western nations have experienced an obesity epidemic, prompting investigators and public health officials to consider the association of these 2 events, and if other exposures might impact this relationship. There are several potential mechanisms that could impact the relationship of pubertal timing in girls with greater body mass, including direct effects of obesity on pubertal timing as well underlying exposures that impact body mass as well as timing of pubertal maturation. These underlying conditions include chemical compounds that could impact synthesis or action of sex hormones, called endocrine disrupting chemicals (EDs). We examine the decline in the age of breast development and potential genetic and environmental influences, the obesity epidemic in the US and other nations, and potential mechanisms to explain the relationship between greater body mass index with earlier puberty in girls.
 
To investigate the effects of 4-month treatment of medroxyprogesterone acetate (MPA) and Diane-35 on the clinical and biochemical features of hyperandrogenism and quality of life of adolescent girls with polycystic ovarian syndrome (PCOS). A prospective, randomized, cross-over study. An accredited pediatric and adolescent gynecology clinic of a university-affiliated tertiary hospital. 76 adolescents girls aged 14 to 19 years old with PCOS were recruited from July 2007 to July 2010. Girls were randomized into 2 groups. Group 1 received oral MPA for 4 months, followed by a washout period of 4 months, and then Diane-35 for another 4 months. Group 2 received the same combination but in the reverse order. Clinical and biochemical features of hyperandrogenism and quality of life were assessed. There was no significant difference between the 2 groups at baseline. No significant difference was found in the clinical and biochemical parameters of hyperandrogenism before and after treatment with MPA. Significant reduction of the acne score, LH/FSH ratio, and testosterone level was seen after taking Diane-35. Hirsutism was also improved but it did not reach statistical significant. When comparing post-MPA and post-Diane-35, the post-Diane-35 group had significantly improved acne score and LH/FSH ratio. No significant difference was found on quality of life between both groups after treatment. Diane-35 may be a more suitable treatment option in adolescent girls diagnosed with PCOS when compared to MPA.
 
Pregnancy in young adolescents is often understudied. The objective of our study was to evaluate the effect of young maternal age on adverse obstetrical and neonatal outcomes. We conducted a population-based cohort study using the Center for Disease Control and Prevention's Linked Birth-Infant Death and Fetal Death data on all births in the US between 1995 and 2004. We excluded all births of gestational age under 24 weeks and those with reported congenital malformations or chromosomal abnormalities. Maternal age was obtained from the birth certificate and relative risks estimating its effect on obstetrical and neonatal outcomes were computed using unconditional logistic regression analysis. 37,504,230 births met study criteria of which 300,627 were in women aged <15 years with decreasing rates from 11/1,000 to 6/1,000 over a 10-year period. As compared to women 15 years and older, women <15 were more likely to be black and Hispanic, less likely to have adequate prenatal care, and more likely to not have had any prenatal care. In adjusted analysis, births to women <15 were more likely to be IUGR, born under 28, 32, and 37 weeks' gestation and to result in stillbirths and infant deaths. Prenatal care was protective against infant deaths in women < 15 years of age. Although public health initiatives have been successful in decreasing rates of young adolescent pregnancies, these remain high risk pregnancies that may benefit from centers capable of ensuring adequate prenatal care.
 
Chicago Classification of Causes of Disorders of Sex Development (DSDs)
Diagnostic Spectrum of 46,XX DSD 
Characteristics of CAH Patients 
Characteristics of 2 Patients, Suggested P450 POR Gen Deficiency (PORD) 
The aim of our study was to determine the etiologic distribution of 46,XX disorder of sexual development (DSD) according to the new DSD classification system and to evaluate the clinical features of this DSD subgroup in our patient cohort. The evaluation criteria and clinical findings of 95 46,XX patients were described by clinical presentation, gonadal morphology, genital anatomy, associated dysmorphic features, presence during prenatal period with/without postnatal virilization, hormonal characteristics, and presence or absence of steroidogenic defects among 319 patients with DSD. Types and ratios of each presentation of our 95 patients with 46,XX DSD were as follows: 82 had androgen excess (86.3%): (74 had classical congenital adrenal hyperplasia, 2 had CAH variant possibility of P450-oxidoreductase gene defect), 6 had disorders of ovarian development (6.3%): (1 patient had gonadal dysgenesis with virilization at birth with bilateral streak gonad, 4 patients had complete gonadal dysgenesis, and 1 patient had ovotesticular DSD) and 7 had other 46,XX DSD. Two sisters, who had 46,XX complete gonadal dysgenesis,were diagnosed with Perrault Syndrome with ovarian failure due to streak gonads and associated with sensorineural deafness. 46,XX DSD are usually derived from intrauterine virilization and CAH is the most common cause of 46,XX DSD due to fetal androgen exposure. Copyright © 2014 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.
 
We report on a phenotypically normal girl with a deletion of the distal long arm of one X chromosome at Xq22, and spontaneous pubertal development including menarche. This suggests that the distal long arm of the X chromosome is not crucial for ovarian development. Cytogenetic and polymerase chain reaction (PCR) amplification methods both showed preferential inactivation of the deleted X chromosome. The PCR-based assay has the additional advantage of identifying the paternal origin of the deleted X chromosome.
 
Steroidogenic factor-1 (SF-1) gene (NR5A1) mutations cause disorders of sexual development due to gonadal dysgenesis, particularly in 46,XY individuals. In cases exhibiting this mutation, the phenotype is heterogeneous, and it may vary within a spectrum ranging from complete female appearance to an infertile male. Virilization observed in some cases in the pubertal age group may lead to diagnostic difficulties. The present case report describes the clinical, histopathologic, and genetic characteristics of a 46,XY case, who was born with a female phenotype and raised as a girl, presented with findings of virilization in the pubertal period. She had no germ cells and very few Leydig cells with atrophic testis on biopsy and in whom a novel heterozygous mutation in the SF-1 gene (a heterozygous 7-bp deletion mutation in exon 7 [c.1308-1314del7bp] causing frameshift) was identified. Although the gonads are very dysgentic in patient with SF-1 mutations, sufficient androgen synthesis can cause severe virilization during puberty.
 
The growing use of prenatal investigations allows an early detection of several inborn disorders, including disorders of sexual development. The management of these conditions is an arising problem. 46,XY karyotype and female phenotype were detected in a fetus; 5α-reductase and androgen receptor gene analysis on chorionic villi revealed no relevant mutation. The newborn was assigned to female sex. The diagnosis of 17β-hydroxysteroid dehydrogenase-3 β-OL deficiency was reached at four months of age, by means of a low testosterone/Δ 4-androstenedione ratio after HCG test and HSD17B3 gene analysis. A 46,XY fetus with female external genitalia suggests different conditions, some very rare. Specific genetic investigations should be performed prenatally when possible. A complete evaluation is mandatory after delivery to reach a correct diagnosis.
 
To understand the timing and factors affecting diagnosis of phenotypically female 46XY children. We studied all phenotypically female 46XY children who attended our multidisciplinary disorders of sexual differentiation (DSD) clinic in Nottingham England in a 3-year period since its inception. Case notes from a prospectively maintained database were reviewed and data were analyzed on the age at presentation, family history, findings on genital examination, and underlying endocrine abnormality. Eleven children were studied, all of whom were being raised as girls. The median age of presentation was 18 months (range birth-15 years). Although the newborn examination detected the possibility of DSD in only 3 cases; 10 of 11 children had at least one significant abnormality in their external genitalia at presentation. Careful neonatal genital examination can identify children with DSD. However, not all children with these conditions are identified early. Early diagnosis, when possible, is important, as it has the potential to make the management of this difficult condition more straightforward.
 
Premature ovarian failure (POF) may be idiopathic or may be associated with genetic or autoimmune disorders. The 47,XXX karyotype has been associated with POF and other genitourinary anomalies. A 17-year-old woman with a history of immune thrombocytopenic purpura was referred to the adolescent medicine clinic for evaluation of oligomenorrhea with secondary amenorrhea. Evaluation revealed hypergonadotrophic premature ovarian failure, a positive antinuclear antibody, and the 47,XXX karyotype. She has since developed a positive anti-cardiolipin antibody but does not meet diagnostic criteria for systemic lupus erythematosis. The presence of known autoimmune disease in a woman with POF should not dissuade the clinician from evaluating for a potential genetic cause.
 
Top-cited authors
Marc R Laufer
  • Harvard Medical School
Joyce Ann Adams
Nancy Kellogg
  • University of Texas Health Science Center at San Antonio
Zeev Harel
  • Lifespan
Paula Hillard
  • Stanford University