Pelvic pain. A SAFE approach.

The efficacy of a multidisciplinary approach for the treatment of chronic pain has been well documented. A recent randomized prospective trial by Peters and co-workers confirmed that multidisciplinary management of chronic pelvic pain resulted in greater improvement in pain severity, increased employment, and improved functional health scores when compared with a traditional medical approach. Unfortunately, many gynecologists do not have the luxury of working in these types of settings. The SAFE approach allows the busy practitioner to evaluate the nonorganic and organic nature of pelvic pain simultaneously to manage these difficult patients better. Initially, it is important to set up regular weekly visits with a prespecified time limit. During these sessions, one should focus on compliance to treatment recommendations. Components of management that have led to pain reduction should be defined. Over time, these short visits can be spaced to bimonthly and monthly intervals; however, this strategy should not be rushed. If possible, the gynecologist should coordinate the care of difficult patients with a physical therapist and mental health provider who can work in tandem on pain reduction strategies and focused psychotherapy. The gynecologist should focus the patient's attention on improvements in pain reports and in functioning at school or work and reinforce the consistent use of medications, even if the recommended dose is low. Small improvements in health beget larger improvements in daily functioning.

Ovarian masses.

All types of ovarian tumors seen in the adult population can also be seen in children and adolescents. However, the relative incidence of each entity varies considerably with age. Functional non-neoplastic cysts and masses are much more frequent in the adolescent. Furthermore, in the adolescent age group, neoplasms are more likely to be germ cell rather than epithelial in origin. Fortunately, in children and adolescents only 10% of ovarian tumors are malignant. In diagnostic evaluation of ovarian masses, a complete history and physical examination are of utmost importance. Whenever an ovarian mass, be it physiologic or neoplastic, benign or malignant, is diagnosed in an adolescent female or prepubertal child, every effort must be made to preserve the reproductive function in that female in order to ensure future childbearing.

Telomeric fusion and chromosome instability in multiple tissues of a patient with mosaic Ullrich-Turner syndrome.

We describe the cytogenetic evolution of multiple cell lines in the gonadal tissue of a 10-year-old girl with mosaic Ullrich-Turner syndrome (UTS) involving clonal telomeric associations (tas) of the Y chromosome. G-band analysis of all tissues showed at least 2 cell lines; 45, X and 46,X,tas(Y;21)(q12;p13). However, analysis of left gonadal tissue of this patient showed the evolution of 2 additional cell lines, one designated 45,X,tas(Y;21)(q12;p13),-22 and the other 46,X,tas(Y;21)(q12;p13),+tas(Y;14)(q12;p13), -22. Fluorescence in situ hybridization (FISH) analysis of interphase nuclei from uncultured gonadal tissue confirmed the findings of aneuploidy in the left gonadal tissue and extended the findings of aneuploidy to the tissue of the right gonad. The chromosome findings in the gonadal tissue of this patient suggest a preneoplastic karyotype relating to several distinct tumor associations. The clonal evolution of telomeric fusions indicates chromosomes instability and suggests the extra copy of the Y chromosome may have resulted from a fusion-related malsegregation. In addition, the extra Y suggests low-level amplification of a putative gonadoblastoma gene, while the loss of chromosome 22 suggests the loss of heterozygosity for genes on chromosome 22. This case demonstrates the utility of the study of gonadal tissue in 45,X/46XY UTS patients, and provides evidence that clonal telomeric fusions may, in rare cases, be associated with chromosome malsegregation and with the subsequent evolution of unstable karyotypes.

High prevalence of adeno-associated virus (AAV) type 2 rep DNA in cervical materials: AAV may be sexually transmitted.

Adeno-associated virus (AAV) is a human parvovirus that in laboratory and animal models has the ability to suppress the oncogenic phenotype of a variety of viruses and cellular derived oncogenes. The inhibitory effects of AAV have been mapped to its rap gene (Rep78 protein). Furthermore, seroepidemiologic data indicate that AAV infection is linked to reduced cervical cancer rates in humans. Because of AAV's inverse relationship with cervical cancer, we attempted to identify AAV rep sequences within DNA derived from cervical brushings taken from nondiseased middle class patients at a Little Rock clinic. Polymerase chain reaction (PCR) amplification was carried out with primers designed to amplify a specific segment of the endogenous human beta-globin gene or the AAV rep gene. Of those cervical samples that were positive for beta-globin DNA, 50% were also found to be positive for AAV rep DNA when analyzed by either ethidium bromide staining or dot-blot hybridization with an internal probe. These data strongly suggest that AAV is commonly carried in the genital region and further raise the possibility that AAV can be sexually transmitted.

Maternal influence on the decision to adopt Norplant.

PURPOSE: To examine maternal influence and related variables on adolescents' decision to adopt Norplant. METHODS: A prospective study of 121 adolescent females who received Norplant through a hospital-based outpatient adolescent gynecology service. Each patient completed self-report questionnaires about her decision process, sexual behaviors and standardized measures of depression and anxiety at their insertion appointment or first-follow-up appointment. RESULTS: Almost 40% of the sample reported that their mother significantly influenced their decision to use Norplant and 61% of all patients stated that they had informed their mother of their choice of this contraceptive method. Through logistic regression, six variables were found to be significantly associated with mother as the most important decision source. These included: obtaining information about Norplant from a parent, maintaining the same sexual partner, past pill use, and not knowing other adolescents who boast about using the Norplant system. CONCLUSION: These data suggest that when parental consent is not required, adolescent females disclose sensitive information regarding choice-making to their mothers when they decided to adopt Norplant.

PIP: A prospective study of 121 Norplant acceptors 12-21 years old recruited from a hospital-based adolescent gynecology service in Arkansas confirmed the importance of maternal influence on the acceptance process, even when state law does not mandate parental consent. These adolescents completed a questionnaire indicating the relative roles of various significant others in providing information about Norplant and influencing the decision-making process. The adolescent's mother was cited as the most important decision source by 45 (37%) young women; another 33 (27%) identified a health care provider. Although Arkansas does not require parental notification, 74 (63%) had told their mother of their decision to use Norplant. Maternally influenced adolescents were significantly more likely than those who identified health care professionals, girlfriends, and boyfriends as decisive to have obtained specific information about Norplant from their mother, to be former oral contraceptive users, and to have a consistent sexual partner. Overall, 99 (82%) adolescents reported they intended to use Norplant for at least two years. Although 44 (36%) expressed concerns about Norplant's cost, only two indicated this was a factor in their decision. The findings of this study offer reassurance to health care providers who seek to protect patient confidentiality yet encourage parent-teen communication about reproductive health.

Adolescents and Norplant: preliminary findings of side effects.

PURPOSE: The purpose of this study was to investigate side effects such as menstrual irregularities, weight gain, and blood pressure changes among adolescent females who had been implanted with Norplant eight or more months. METHOD: A retrospective chart review was completed on adolescents who received care through an outpatient adolescent gynecology service. Subjects (n = 110) with an average age of 17.2 years were implanted with Norplant between March 1991 and February 1992. The mean length of time since implantation was 12.7 months and 64% were African-American. Data collected included: dates of all medical visits; presence of acne, mood changes, and menstrual patterns following implantation. Measurements of blood pressure and weight were taken at implantation and at all subsequent visits. RESULTS: Weights for Caucasian females at the last visit were significantly higher than at baseline (P < .02). With regard to the African-American females' weight, significant differences were found between baseline weight and each follow-up visit. Although we could not determine the bleeding patterns in 22% of our study sample, almost 40% of the adolescent females followed reported their bleeding to be light as well as regular and cyclic. CONCLUSION: Weight gain was the most frequently observed side-effect of Norplant in adolescents in this study.

PIP: To learn more about the side effects associated with Norplant use in adolescence, the charts of 110 women 13-21 years of age (average, 17.2 years) who received the implants through hospital-based adolescent gynecology clinics in Arkansas were reviewed. The implants were inserted between March 1991 and February 1993; the mean length of time since insertion was 12.7 months (range, 8-19 months). 64% of Norplant acceptors were African-American. Weight and blood pressure measurements were obtained at baseline and at three follow-up periods: 1-4 months, 5-7 months, and 8 or more months. Overall, the average weight gain was 3.3 kg, but there were significant racial differences. At follow-up one, African-American females showed an average weight gain of 1.4 kg compared to no gain among White females. At follow-up three, the mean weight gain was 5.4 kg for African Americans and 2.6 kg for White youth. 37% of all participants reported no change in menstrual patterns, 28% experienced irregular (mainly light) bleeding, and 13% were amenorrheic; no data were available for the remaining 22%. There were no significant changes over time in blood pressure, and acne and depression were each recorded in only one chart. Three women requested Norplant removal during the study period. Overall, the findings of this study suggest that Norplant-related side effects may be less severe among adolescents than adult women, most notably the incidence of bleeding irregularities (82% in adult Norplant acceptors). To ensure Norplant continuation, however, adolescents should be counseled about the possibility of slight weight gain and light bleeding.

Adolescents and colposcopy: the use of different procedures to reduce anxiety.

OBJECTIVE: Two consecutively occurring studies examined whether using a video colposcope to view this procedure or allowing the female adolescent to watch music videos would reduce anxiety and related body movements. STUDY DESIGN: Female adolescents who underwent colposcopy were randomly assigned to one of two groups, experimental and control. In study 1, 27 female adolescents were randomly assigned either to view the procedure on a television monitor or to be part of a control group (no visual distraction). In study 2, 30 female adolescents were randomly assigned either to a music video group or to a control group. Studies were completed in a consecutive manner and used the same measures, colposcopic equipment, and professional staff, including physician. Multiple measures of anxiety were used (heart rate, behavior observation, and paper and pencil) before, during, and after the procedure. During each colposcopy the subject's behavior across 10 dimensions was observed and coded. Data were analyzed by chi 2, analysis of variance, and Student t tests. RESULTS: Study 1 found no significant differences in body movements and anxiety ratings between the video colposcope group and controls. In study 2, subjects who were allowed to watch the music videos demonstrated significantly fewer body movements indicative of pain, required less physician reassurance, and received fewer procedural explanations (p < 0.05). CONCLUSION: Results suggest that allowing a female adolescent to watch music videos during a colposcopic examination appears to decrease body movements associated with discomfort.

Prenatal diagnosis of abdominal cystic hygroma.

We present a case of fetal abdominal cystic hygroma that presented at 19 weeks of gestation. Ultrasonographic evaluation of the fetus revealed soft tissue enlargement of the left leg and a retroperitoneal mass in the left pelvis and abdomen. This represents the first reported case of prenatal diagnosis of abdominal cystic hygroma.