Factors affecting willingness to provide medication abortion among North American Society for Pediatric and Adolescent Gynecology members caring for adolescents and young adults following the Dobbs decision.

STUDY OBJECTIVE: To assess willingness to provide medication abortion among North American Society for Pediatric and Adolescent Gynecology (NASPAG) clinicians caring for adolescents and young adults (AYA) following Dobbs v. Jackson Women's Health Organization DESIGN: Cross-sectional online survey METHODS: Potential participants received an e-mail invitation via the NASPAG listserv. A 43-item questionnaire queried demographics, practice setting, abortion training and practice, willingness to provide medication abortion, potential or real barriers to providing medication abortion, and sentiments of abortion. Descriptive statistics, χ2, and Fisher's exact tests were used. RESULTS: Of the 70 participants, 51% were willing to provide a medication abortion for an adolescent who requested it in their clinical practice. The most common barriers to providing medication abortion were legislative restrictions (47%) and dispensing pills from clinic (33%). Participants' willingness to provide a medication abortion differed by type of practice (p = .001), availability of mifepristone (p = .006), perception of state's abortion policy (p = .001), concern about legislative restrictions (p = .008), experience providing abortion (p = .04), and receipt of medication abortion training (p = .02). Willingness to provide medication abortion also differed based on various sentiments of abortion measured but not on opinion regarding legality of abortion for adolescents (p = .49). CONCLUSIONS: Perception of state's abortion rights and concern about legislative restrictions influenced NASPAG clinicians' willingness to provide medication abortion for adolescents. Interventions to minimize legislative interference with medical care, increase abortion training, and implement medication abortion in pediatric settings may expand AYA medication abortion access.

Surgical Considerations in the Management of Adolescent Endometriosis-An Expert Commentary.

Given the complexities and controversies that exist in diagnosing adult endometriosis, as well as optimizing medical and surgical management, it is not surprising that there is even more ambiguity and inconsistency in the optimal surgical care of endometriosis in the adolescent. This collaborative commentary aimed to provide evidence-based recommendations optimizing the role of surgical interventions for endometriosis in the adolescent patient with input from experts in minimally invasive gynecologic surgery, pediatric and adolescent gynecology, and infertility/reproductive medicine.

Use of the Drospirenone-Only Contraceptive Pill in Adolescents with Endometriosis.

STUDY OBJECTIVE: To evaluate the efficacy and tolerability of a progestin-only pill containing 4 mg drospirenone (DRSP) as a hormonal therapy for the management of endometriosis-associated symptoms in adolescents and young adults. DESIGN: Retrospective cohort study. METHODS: A retrospective chart review was performed of all adolescents who were prescribed DRSP continuously (without placebo) for treatment of endometriosis at a single pediatric tertiary care center between 2019 and 2022. Electronic medical records were reviewed to obtain demographics and clinical characteristics of the patients. Measured outcomes included symptom resolution and medication discontinuation. The study was deemed IRB exempt. RESULTS: A total of 61 patients with endometriosis were prescribed DRSP during the study period, with a median age of 18.9 years (SD 2.3). The majority (97%) were laparoscopically confirmed to have endometriosis, and 85% had stage I disease. Before DRSP use, the most common medications trialed were norethindrone (57%) and norethindrone acetate (68%), and 56% had at least one medical contraindication to receiving estrogen-containing therapy. Of those with follow-up, 52% established an absence of bleeding/spotting, and 67% reported less pain at follow-up. One in 4 patients discontinued DRSP during the study period, most commonly due to breakthrough bleeding. CONCLUSION: DRSP is a well-tolerated and effective option for the treatment of endometriosis-associated symptoms in adolescents and young adults.

Preventive Practices and Knowledge of Human Papillomavirus in Mayer-Rokitansky-Küster-Hauser Syndrome Individuals.

ABSTRACT: Mayer-Rokitansky-Küster-Hauser syndrome is a congenital disorder typified by an underdeveloped female reproductive tract. An exploratory online survey of adults with Mayer-Rokitansky-Küster-Hauser syndrome found that many did not recall receiving the human papillomavirus vaccine, and answers to knowledge questions suggested inadequate human papillomavirus counseling. However, recalled vaccine counseling was associated with improved uptake.

Continuation rates of hormonal intrauterine devices in adolescents and young adults when placed for contraceptive and non-contraceptive indications.

OBJECTIVE: This study aimed to estimate and compare continuation rates of hormonal intrauterine devices (IUDs) when placed for contraceptive or menstrual management indications in adolescents and young adults. STUDY DESIGN: We conducted a secondary analysis of a prospectively collected database of all hormonal IUD insertions from January 1, 2017 through December 31, 2020, with at least 1-year follow-up, across four Adolescent Medicine practices. IUD insertions without known indication were excluded. RESULTS: A total of 936 IUD insertions were attempted, 45% for contraception only, 18% for menstrual management only, and 37% for both indications. Insertion was successful in 868 (93%) attempts, and success did not differ by indication (p = 0.74). The mean age at insertion was 18.9 years (SD = 2.4 years), with no difference by indication. Of the completed insertions, 650 (75%) had at least one follow-up during the data analysis period. Excluding those without follow-up, the overall continuation rates were 77% at 1 year, 66% at 2 years, and 54% at 3 years. While continuation rates did not differ by indication at 1 year, at 3 years, continuation was highest among those who sought the device for menstrual management only (contraception = 53%, menstrual = 57%, both = 53%, p < 0.01) Malposition was rare (4.0%), as was device expulsion (2.5%), and these did not differ by indication. CONCLUSION: IUD continuation rates were high among adolescents and young adults and did not significantly differ when placed for contraceptive or non-contraceptive indication in the first year of use. IMPLICATIONS: Adolescents and young adults may seek the hormonal IUD for contraception and/or menstrual management. Our study found that IUD continuation rates were high at 1 year regardless of the indication for utilization.

Evaluation and Management of Endometriosis in the Adolescent.

Endometriosis is a chronic condition, with debilitating symptoms affecting all ages. Dysmenorrhea and pelvic pain often begin in adolescence, affecting school, daily activities, and relationships. Despite the profound burden of endometriosis, many adolescents experience suboptimal management and significant delay in diagnosis. The symptomatology and laparoscopic findings of endometriosis in adolescents are often different than in adults, and the medical and surgical treatments for adolescents may differ from those for adults as well. This Narrative Review summarizes the diagnosis, evaluation, and management of endometriosis in adolescents. Given the unique challenges and complexities associated with diagnosing endometriosis in this age group, it is crucial to maintain a heightened level of suspicion and to remain vigilant for signs and symptoms. By maintaining this lower threshold for consideration, we can ensure timely and accurate diagnosis, enabling early intervention and improved management in our adolescent patients.

Treatment of Adolescent Endometriosis Before, During, and After Use of Gonadotropin-Releasing Hormone Agonists: A Retrospective Cohort Study.

OBJECTIVE: To explore the use duration of a gonadotropin-releasing hormone agonists (GnRHa) plus add-back in adolescents with laparoscopically confirmed endometriosis and the treatment course before and after GnRHa therapy. DESIGN: Retrospective cohort study. MATERIALS AND METHODS: We identified 51 subjects with laparoscopically confirmed endometriosis who had participated in a randomized trial of a GnRHa plus add-back as adolescents between 2008 and 2012. Electronic medical records were reviewed to obtain demographic data, clinical characteristics, and treatment outcomes after trial completion. The study was deemed IRB exempt. RESULTS: The average age of participants during trial enrollment was 17.9 ± 1.7 years. Thirty-three participants had stage I endometriosis (65%). The most common treatments trialed before GnRHa therapy were combined oral contraceptives (n = 47, 92%) and progestin-only pills (n = 23, 45%). The average duration of GnRHa use during the trial was 9.5 ± 3.5 months; 34 subjects (67%) completed the 1-year trial. After trial completion, 23 subjects (45%) continued to use a GnRHa with add-back therapy. The mean duration of additional GnRHa use was 31.7 ± 28.6 months, and the longest identified duration was an additional 96 months. Twenty-four subjects switched to other hormonal treatments after trial participation, most commonly oral progestins (n = 15) or combined oral contraceptives (n = 6). Thirteen participants (25%) returned to a therapy that had been trialed before GnRHa use. CONCLUSION: Almost half the participants in this cohort continued to use a GnRHa with add-back for treatment of endometriosis beyond the 12-month recommended duration. Treatment varied widely after discontinuation of GnRHa, with many participants returning to previously trialed medical therapies.

Effects of Ovarian Tissue Cryopreservation on Primary Ovarian Insufficiency in Girls Undergoing Bone Marrow Transplantation.

OBJECTIVE: To determine if removing an ovary for ovarian tissue cryopreservation (OTC) increased rates of primary ovarian insufficiency (POI) in girls undergoing bone marrow transplantation (BMT). Institutional review board approval was obtained from all 3 clinical sites. DESIGN: Multicenter retrospective cohort study SETTING: Academic children's hospitals PATIENTS: Females aged 2-21 who underwent BMT with or without OTC from 2010 to 2017. INTERVENTIONS: None MAIN OUTCOME MEASURES: Rates of POI in girls who underwent OTC vs those who underwent BMT alone as determined by serum markers, presence of menses, or clinical diagnosis. RESULTS: A total of 142 patients were identified, 43 who had OTC and 99 with BMT alone. The rate of POI in girls undergoing OTC was 65% vs 41.8% in those who underwent BMT alone (P = .26). CONCLUSIONS: Although this study was not powered to detect a lack of difference, it is reassuring that there does not seem to be a clinically significant increase in POI in patients undergoing OTC.

Postoperative Vaginal Bleeding Concerns after Gender-Affirming Hysterectomy in Transgender Adolescents and Young Adults on Testosterone.

STUDY OBJECTIVE: This study aimed to characterize the incidence and management of postoperative vaginal bleeding concerns experienced by transgender adolescents and young adults (AYA) on testosterone hormone therapy after gender-affirming hysterectomy (GAH). METHODS: This was a retrospective cohort of transgender AYA, 18 years and older, using testosterone therapy who underwent a GAH between July 2020 and September 2021 at a tertiary care children's hospital. The incidence of patient-reported postoperative vaginal bleeding concerns and management of bleeding are described. RESULTS: Patient ages ranged between 18 and 33 years. Among 25 patients who met the inclusion criteria, 13 (52.0%) reported vaginal bleeding concerns. No modifiable patient or operative characteristics reached statistical significance in association with postoperative bleeding concerns. Among patients with bleeding concerns, 10 (76.9%) experienced such concerns during the first 2 weeks after surgery, and 6 (46.2%) had resolution of bleeding without intervention. Among 11 patients who underwent an exam for evaluation of bleeding, findings included granulation tissue (n = 5, 45.5%), vaginal atrophy (n = 4, 36.4%), bleeding vessel (n = 1, 9.1%), mucosal separation (n = 1, 9.1%), or no cause of bleeding identified (n = 4, 36.4%). CONCLUSIONS: Over half of transgender AYA on testosterone therapy in this cohort reported postoperative vaginal bleeding concerns that were most often secondary to atrophy and granulation tissue, suggesting possible susceptibility to vaginal tissue trauma at the time of GAH and granulation-susceptible healing in patients on testosterone. As vaginal bleeding could worsen gender dysphoria, these findings support the need for patient counseling on postoperative bleeding expectations and identification of interventions to reduce vaginal bleeding after GAH.

The Association between Immediate Postpartum Depot Medroxyprogesterone Acetate Use and Postpartum Depressive Symptoms.

OBJECTIVE: While postpartum depot medroxyprogesterone acetate (DMPA) is a highly effective form of contraception, some data suggest an association with depressive symptoms. Our objective was to evaluate the relationship between receipt of DMPA in the immediate postpartum period and postpartum depressive symptoms. STUDY DESIGN: This retrospective cohort study included all women who received prenatal and postpartum care at academic obstetric clinics affiliated with a tertiary care institution between January 1, 2008 and December 31, 2014. All women were counseled on contraception prior to hospital discharge. DMPA was available in the hospital pharmacy, and its utilization was documented in the electronic health record. The Patient Health Questionnaire 9 (PHQ-9) was used to screen for postpartum depression for all women at all postpartum visits. A score of 10 or greater was categorized as positive. Bivariable and multivariable analyses were used to identify the association between immediate postpartum DMPA use and a positive postpartum depression screen. RESULTS: Of the 5,073 women who met inclusion criteria, 410 (8.1%) received DMPA prior to hospital discharge. Compared with women who did not receive DMPA, women who received DMPA prior to hospital discharge were younger, more likely to identify as Black race or Latinx ethnicity, and more likely to be publicly insured. Clinical characteristics also differed. Women who received DMPA were more likely to be obese and to have experienced prenatal depressive symptoms, been diagnosed with a hypertensive disorder of pregnancy, delivered preterm, and delivered vaginally. Receipt of immediate postpartum DMPA was not associated with having a positive screen for postpartum depression in bivariable (5.4 vs. 6.0%, p = 0.29) or multivariable (adjusted odds ratio 0.94, confidence interval 0.53-1.68) analyses. CONCLUSION: Receipt of postpartum DMPA is not associated with a positive postpartum PHQ-9 screen. Concerns about precipitating postpartum depression should not preclude the utilization of DMPA as a contraceptive agent. KEY POINTS: · Contraception is an important issue for obstetricians to address with postpartum patients.. · Concerns have been raised over the relationship between DMPA and depression.. · Our study shows that DMPA is not associated with a positive postpartum depression screen..

Evaluating Provider Self-Disclosure in Adolescent Contraception Counseling.

STUDY OBJECTIVE: This study aimed to assess the prevalence of provider self-disclosure (PSD) of intrauterine device (IUD) usage with adolescent patients and identify the content and context of their PSD. DESIGN AND SETTING: A cross-sectional study PARTICIPANTS: Providers sex-assigned female at birth who counsel adolescents or young adults on contraception INTERVENTION: Participants were asked to voluntarily complete a web-based survey disseminated through the North American Society for Pediatric and Adolescent Gynecology listserve. MAIN OUTCOME MEASURES: PSD in relation to IUD use (IUD-PSD) and other contraception use RESULTS: Eighty-five respondents completed the survey. Thirty-one (36%) reported that PSD of contraception usage to adolescents is usually or always appropriate, 32 (38%) as neither appropriate nor inappropriate, and 22 (26%) as usually or always inappropriate. Regarding IUDs, 61 respondents have used or are currently using an IUD. Forty-four (72%) IUD users have self-disclosed IUD use to an adolescent by choice, 6 (10%) have only by patient request, and 9 (15%) have never self-disclosed use. Out of 52 IUD users, 32 (62%) stated that IUD-PSD most often occurs when the patient has decided on the IUD but has questions, 25 (48%) when the patient was debating between fewer methods, and 14 (27%) when discussing all contraceptive options with the patient. Respondents who choose to self-disclose IUD use are more likely to disclose other contraceptive use compared with those who do not self-disclose IUD use (P < 0.001) and are also more likely to disclose personal family aspects (P < 0.001). CONCLUSION: Self-disclosure of IUD usage is relatively common among study respondents and occurs most often after a patient has decided on an IUD.

The Use of Telemedicine in Pediatric and Adolescent Gynecology.

STUDY OBJECTIVE: To study the feasibility of virtual visits for ambulatory encounters in pediatric and adolescent gynecology DESIGN: A retrospective review SETTING: Boston Children's Hospital PARTICIPANTS: Patients who were seen virtually through the Division of Gynecology between January 1, 2020 and June 1, 2020 MAIN OUTCOME MEASURE(S): Patient demographics, visit diagnoses, and operational characteristics of the completed visits RESULTS: There were a total of 654 virtual visits for 614 patients. Ninety-one percent (n=558) of patients were in-state, and the median age of patients was 17 years (range 0 - 37 years). The majority were return visits (n=502, 76.8%), 115 (17.6%) were new patient visits, and 32 (4.89%) were post-operative visits. The median virtual visit duration was 12 minutes and 39 seconds (range 5 minutes to over 1 hour). The most common gynecologic diagnoses were dysmenorrhea/endometriosis (n=485, 74.2%), abnormal uterine bleeding (n=225, 34.4%), and pelvic pain (n=82, 12.5%). The percentage of virtual visits which required an in-person follow-up visit within 90 days was low (n=14, 2.1%). Five of these were within 30 days from the initial virtual visit, 6 were within 60 days, and 3 were within 90 days. CONCLUSION: Telemedicine is a feasible method for expanding access to, and healthcare delivery for, pediatric and adolescent gynecology, with low rates of short interval in-person follow-up required. Virtual visits can be conducted for a range of patients with a variety of gynecologic conditions, upon initial presentation and follow-up.

Interdisciplinary Management of Malignant Ovarian Tumors in the Pediatric and Adolescent Age Group.

Malignant ovarian neoplasms are uncommon in the pediatric and adolescent population. Imaging and tumor markers help to guide the preoperative risk/benefit analysis for planned surgical management, which is the mainstay of therapy. An interdisciplinary approach should be taken in the management of this vulnerable population from diagnosis through post-treatment surveillance. In this review, the initial evaluation, risk stratification, and management of various types of malignant ovarian masses will be addressed, with a special focus on how to optimize an interdisciplinary approach to ovarian masses.

A 13-Year-Old Girl with Primary Amenorrhea.

A 13-Year-Old Girl with Primary AmenorrheaA 13-year-old girl presented for evaluation of intermittent lower abdominal pain and absence of menarche. How do you approach the evaluation, and what is the diagnosis?

Breakthrough Bleeding in Transgender and Gender Diverse Adolescents and Young Adults on Long-Term Testosterone.

STUDY OBJECTIVE: Amenorrhea is a goal of many transgender and gender diverse adolescent and young adult (TGD AYA) patients on testosterone gender-affirming hormone therapy (T-GAHT). Breakthrough bleeding can contribute to worsening gender dysphoria. Our objective was to evaluate breakthrough bleeding in TGD AYA on T-GAHT. DESIGN: Institutional review board-approved retrospective cohort. SETTING: Tertiary-care children's hospital. PARTICIPANTS: TGD AYA on T-GAHT >1 year. INTERVENTIONS: None; observational. MAIN OUTCOME MEASURES: Presence of, and risk factors for, breakthrough bleeding. RESULTS: Of the 232 patients who met inclusion criteria, one-fourth (n = 58) had 1 or more episodes of breakthrough bleeding, defined as bleeding after more than 1 year on T-GAHT. In comparing patients with breakthrough bleeding to those without, there were no significant differences between age of initiation, body mass index (BMI), race/ethnicity, testosterone type used, use of additional menstrual suppression, serum testosterone, or estradiol levels. Patients with breakthrough bleeding patients were on T-GAHT longer (37.3 ± 17.0 vs 28.5 ± 14.6 months, P < .001) and were more likely to have endometriosis (P = .049). Breakthrough bleeding began at a mean of 24.3 ± 17.2 months after T-GAHT initiation. Of those with breakthrough bleeding, 46 (79.3%) had no known cause, 10 (17.2%) bled only with missed T-GAHT doses, and 2 (3.4%) bled only when withdrawing from concomitant menstrual suppression. No breakthrough bleeding management method was found to be superior. CONCLUSION: Breakthrough bleeding is relatively common (25%) on T-GAHT despite early amenorrhea. Most cases do not have an identifiable cause. Our data did not show superiority of any 1 method for managing breakthrough bleeding on T-GAHT.

The Association between Positive Antenatal Depression Screening and Breastfeeding Initiation and Continuation.

OBJECTIVE: This study was aimed to determine the association between antenatal depression and breastfeeding initiation and continuation at 6 weeks postpartum. STUDY DESIGN: This retrospective cohort study included all live-born deliveries after 24weeks' gestation at a single tertiary care institution between 2009 and 2014 with a documented antenatal depression screen using the Patient Health Questionnaire-9 (PHQ-9). During the study period, it was recommended that routine screening occur during both the first and third trimesters. A positive screen was defined as a PHQ-9 score ≥ 10. Breastfeeding initiation and continuation until 6 weeks' postpartum were compared between women with and without a positive screen using bivariable analyses. Stepwise backward elimination regressions were used to identify whether a positive screen was independently associated with breastfeeding rates after controlling for confounders. RESULTS: Among the 2,871 women meeting inclusion criteria, 302 (10.5%) were screened positive for antenatal depression. After adjusting for confounders, there were no differences in breastfeeding initiation (adjusted odds ratio [aOR] = 0.78, 95% confidence interval [CI]: 0.52-1.16), but women with a positive antenatal depression screen were significantly less likely to continue breastfeeding at 6 weeks' postpartum (aOR= 0.67, 95% CI: 0.48-0.96). CONCLUSION: A positive antenatal depression, screened in the first or third trimester, is a significant risk factor for early breastfeeding cessation.

Spontaneous Cervicovaginal Fistula in Obstructed Hemivagina and Ipsilateral Renal Anomaly Syndrome: A Case Report.

BACKGROUND: Obstructed hemivagina and ipsilateral renal anomaly (OHVIRA) syndrome is a rare diagnosis; patients classically present with dysmenorrhea and increasing pelvic pain. Unusual manifestations of OHVIRA syndrome might occur as a result of patient anatomy and the rupture or relief of the obstructed hemivagina. CASE: We present a 15-year-old patient with OHVIRA syndrome who developed a spontaneous cervicovaginal fistula and subsequently underwent hemihysterectomy.

Dysmenorrhea and Endometriosis in Transgender Adolescents.

STUDY OBJECTIVE: To study the presentation of dysmenorrhea and endometriosis in transmasculine adolescents and review their treatment outcomes. DESIGN: A retrospective review. SETTING: Boston Children's Hospital. PARTICIPANTS: Transmasculine persons younger than 26 years old who were diagnosed with dysmenorrhea and treated between January 1, 2000 and March 1, 2020. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: An electronic medical record review of the clinical characteristics, transition-related care, and treatment outcomes. RESULTS: Dysmenorrhea was diagnosed in 35 transmasculine persons. Mean age was 14.9 years ± 1.9 years. Twenty-nine (82.9%) were diagnosed after social transition. Twenty-three of 35 (65.7%) were first treated with combined oral contraceptives, but 14/23 (61%) discontinued or transitioned to alternative therapy. Twelve patients with dysmenorrhea alone initiated testosterone treatment, and 4/12 (33.3%) experienced persistent symptoms. Seven of 35 patients with dysmenorrhea (20.0%) were laparoscopically evaluated for endometriosis, and it was confirmed in all seven. Six had stage I disease, and one had stage II. Three of the 7 (42.9%) were diagnosed after social transition, with one diagnosed 20 months after initiating testosterone treatment. Their endometriosis was treated with combined oral contraceptives, danazol, or progestins; four experienced suboptimal response during treatment with these therapies alone. Two of those with suboptimal response subsequently resolved their dysmenorrhea when using testosterone. Five patients with endometriosis initiated testosterone treatment, and of the 5 (40%) experienced persistent symptomatology with combined testosterone and progestin therapies. CONCLUSION: To our knowledge, this is the first study to characterize endometriosis in transmasculine persons. Evaluation for endometriosis was underutilized in transmasculine persons with dysmenorrhea, despite those who underwent laparoscopic evaluation and had disease confirmation. Although testosterone treatment can resolve symptoms in some, others might require additional suppression. Endometriosis should be considered in transmasculine persons with symptoms even when they are using testosterone.

Adolescent Endometriosis: An Update.

Endometriosis is the leading pathologic cause of dysmenorrhea and chronic pelvic pain among adolescents. The appearance of endometriosis in adolescents may be different from that in female adults, resulting in delayed recognition and intervention. This article addresses the epidemiology, pathophysiology, clinical presentation, diagnosis, and management of endometriosis in the adolescent.