Female athlete triad.

PURPOSE OF REVIEW: The obstetrician/gynecologist (ob/gyn) may be the first provider to have the opportunity to recognize and diagnose female athlete triad. This review will help the ob/gyn to understand the female athlete triad and what is new on this topic, how to screen and diagnose the condition and the ob/gyn's role in treatment. RECENT FINDINGS: Female athlete triad, also known as relative energy deficiency in sports, involves an interrelationship among energy availability, menstrual function and low bone density. When these components are not balanced, the health of the athlete is at risk. By using menstrual cycle as a vital sign, a careful medical history may alert you to this condition. The mainstay of treatment is achieving optimal energy balance and resumption of menses. This may involve dietary invention by increasing caloric intake or activity modification by limiting or restricting participation in sports. A multidisciplinary team, including the ob/gyn, athlete, coach, parents, sport nutritionist and sometimes psychiatrist/psychologist, is optimal for management. Medication may supplement but not replace treating the underlying condition. SUMMARY: The female athlete triad is an important disorder to identify, as early diagnosis and intervention may prevent long-term consequences, some of which may not be reversible if not diagnosed and treated.

Teen pregnancy: an update.

PURPOSE OF REVIEW: To provide clinicians with a review of recent research and clinically applicable tools regarding teen pregnancy. RECENT FINDINGS: Teen pregnancy rates have declined but still remain a significant problem in the USA. Teen pregnancy prevention was identified by Centers for Disease Control and Prevention as one of its top six priorities, which is increasing research and intervention data. Long-acting contraceptive methods are acceptable to teens and have been shown to reduce teen birth rates. Pregnant teens need special attention to counseling on pregnancy options and reducing risk during pregnancy with regular prenatal care. Postpartum teens should be encouraged and supported to breastfeed, monitored for depression, and have access to reliable contraception to avoid repeat undesired pregnancy. SUMMARY: This review highlights important issues for all providers caring for female adolescents and those who may encounter teen pregnancy. Foremost prevention of teen pregnancy by comprehensive sexual education and access to contraception is the priority. Educating patients and healthcare providers about safety and efficacy of long-acting reversible contraception is a good step to reducing undesired teen pregnancies. Rates of postpartum depression are greater in adolescents than in adults, and adolescent mothers need to be screened and monitored for depression. Strategies to avoid another undesired pregnancy shortly after delivery should be implemented.

Screening for coagulation disorders in adolescents with abnormal uterine bleeding.

STUDY OBJECTIVE: To determine if screening for coagulation disorders was routinely performed during the evaluation of adolescents with abnormal uterine bleeding. DESIGN: A retrospective chart review. Data were analyzed using the chi-square test. P < 0.05 was considered significant. SETTING: Outpatient clinics of an academic center. PARTICIPANTS: Eligible charts of patients age eighteen years and under with abnormal uterine bleeding who were evaluated either by pediatric gynecologists, gynecologists, or pediatricians. INTERVENTIONS: A chart review. MAIN OUTCOME MEASURES: Data on provider type, documented patient history and laboratory tests ordered. RESULTS: In our review, 43% (n= 36) of patients were evaluated by gynecologists, 38% (n=32) by pediatricians and 19% (n=16) by pediatric gynecologists. The mean age of patients whose charts were reviewed was 15 years. Overall 36.6% (n=30) of providers indicated that they screened for a bleeding disorder by documenting at least one screening question in the patient's history. There was a significant difference among providers with 68.8% (n=11) of pediatric gynecologists documenting at least one screening question, compared to 31.4% (n=11) of gynecologists and 25.8% (n=8) of pediatricians (P < 0.05). Overall 14.6% (n=12) of subjects were screened for a coagulation disorder with laboratory testing. CONCLUSIONS: The majority of adolescents with abnormal uterine bleeding were not screened for bleeding disorders. The frequency of evaluation for blood dyscrasias varied by specialty.

Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology.

Vulvovaginitis is one of the most common gynecological complaints presenting in the pediatric and adolescent female. The common causes of vulvovaginitis in the pediatric patient differ than that considered in adolescent females. When a child present with vulvar itching, burning and irritation the most common etiology is non-specific and hygiene measures are recommended. However these symptoms can mimic more serious etiologies including infection, labial adhesion, lichen sclerosis, pinworms and foreign body must be considered. Yeast infection is rare in the pediatric population but common in the adolescent. In the adolescent patient infections are more common. Yeast and bacterial vaginosis are commonly seen but due to the higher rate of sexual activity in this population sexually transmitted infections must also be considered.

Creation and Dissemination of a Multispecialty Graduate Medical Education Curriculum in Pediatric and Adolescent Gynecology: The North American Society for Pediatric and Adolescent Gynecology Resident Education Committee Experiences.

STUDY OBJECTIVE: The goal was to develop a multispecialty committee to address deficiencies in pediatric and adolescent gynecology (PAG) resident education through curricular development under the auspices of the North American Society for Pediatric and Adolescent Gynecology. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: A multispecialty North American committee was organized to develop short as well as long curricula in PAG through a combination of conference calls and face-to-face meetings. Content was guided by objectives of national accrediting organizations. The curricula used print as well as interactive electronic resources. RESULTS: After publication of the short and long curricula, a dissemination strategy was developed to present the information at national meetings. A curricular study was performed after introduction of the curriculum to evaluate its efficacy. Long-term plans for further curricular components and expansion of educational tools are ongoing. CONCLUSION: We gathered a diverse multispecialty group of doctors to collaborate on a unified educational goal. This committee developed and disseminated resident PAG curricula using a variety of learning tools. This curricular development and implementation can occur with a minimal financial burden.

Primary and preventive healthcare in obstetrics and gynecology: a study of practice patterns in the mid-atlantic region.

OBJECTIVES: To assess the current perspective of regional obstetrician/gynecologists on providing primary/preventive healthcare, including their desire to provide primary care in their practices and whether or not they are adequately trained as primary care providers. METHODS: A self-administered survey with a Likert scale that included demographic information and questions about the practice of primary healthcare was mailed to regional obstetrician/gynecologists both in practice and in residency training. RESULTS: One hundred thirty-nine physicians responded to the survey (33% response rate). Respondents were divided (48% agreed vs. 52% disagreed) when asked if obstetrician/gynecologists should be considered primary healthcare providers. When asked if they viewed themselves as specialists who also provide primary care for women, the majority of physicians (62%) agreed. The majority of physicians (64%) disagreed when asked if they wanted to include primary care in their practice. When asked if they thought that they were adequately trained to provide primary healthcare, respondents were divided (47% agreed vs. 53% disagreed). However, a significant gender difference was found between respondents, with male physicians being more likely than female physicians to agree (55% vs. 33%, p < 0.05) when asked if they were adequately trained to provide primary care. CONCLUSIONS: In this regional study of obstetrician/gynecologists, physician opinions were divided regarding their status as primary care providers, but the majority of respondents did not want to include primary healthcare in their practice. A significant gender difference exists between physicians with regard to the question of adequate training for primary care, with male obstetrician/gynecologists being more likely as to agree that they are adequately trained to provide primary care.

Tethered Cord Syndrome in the Pediatric-Adolescent Gynecologic Patient.

STUDY OBJECTIVE: To describe how pediatric and adolescent patients present to the gynecologist when they have tethered cord syndrome (TCS). DESIGN: We conducted a retrospective chart review on all patients suspected by the gynecologist of having TCS. SETTING: Single pediatric and adolescent gynecology clinic in a mid-sized city in the midwest. PARTICIPANTS: Thirty-two patients, first seen between 2005 and 2012, suspected of having TCS and for whom follow-up information was available. INTERVENTIONS AND MAIN OUTCOME MEASURES: Patient characteristics, including patient history, gynecologic clinical indicators, clinical outcomes, indications for surgery, and postoperative resolution of symptoms, were reviewed. RESULTS: The initial review of systems indicated stress urinary incontinence, back pain, and constipation as common markers in the 32 patients who were suspected of having TCS. All 32 patients underwent lumbar magnetic resonance imaging without contrast and evaluation by neurosurgery. Of the 32 patients with suspected TCS, 18 were later confirmed and 14 were shown to not have TCS. Of the 18 patients with sufficient information to justify a detethering procedure, 14 patients were followed and 93% (13 patients) had complete resolution of symptoms. Final diagnosis in the non-TCS group varied, including vulvovaginitis, enuresis, chronic constipation, and lichen sclerosis. Symptoms improved with the treatment of each primary condition. CONCLUSIONS: TCS symptoms overlap with gynecologic conditions; therefore, patients with TCS may present initially to the gynecologist. In pediatric/adolescent patients, TCS should be considered when stress urinary incontinence, back pain, and constipation are discovered in the review of systems. Because possible irreversible ischemic and neurologic changes are believed to be involved, early diagnosis and surgery are crucial for resolution. Providers should be aware of TCS in these pediatric and adolescent settings, because quick assessment may result in complete resolution of a chronic progressive disease.

Resident education curriculum in pediatric and adolescent gynecology: the short curriculum.

The degree of exposure to Pediatric and Adolescent Gynecology (PAG) varies across academic programs in Obstetrics and Gynecology, Pediatrics, and Adolescent Medicine. Nevertheless, these programs are responsible to train residents and provide opportunities within their training programs to fulfill PAG learning objectives. To that end, North American Society for Pediatric and Adolescent Gynecology has taken a leadership role in PAG resident education by disseminating the Short Curriculum with specific learning objectives and list of essential resources where key concepts in PAG can be covered.

Update on adolescent gynecology.

Adolescent gynecology is an important part of clinical care of adolescent females. This discussion provides a basic review of current issues in adolescent gynecology, including consideration of current pubertal concepts with attention also given to delayed and precocious puberty. Causes of breast masses are reviewed, including discussion of the ANDI classification. It is recommended that physicians provide sexuality education to their adolescent patients, in addition to the community, to reduce the high rates of unintended adolescent pregnancy and STIs in teens that continue in the United States. Finally, attention is provided to ovarian masses and their management. Adolescent medicine physicians may have to work with a variety of specialists in their care of adolescents and the many gynecologic conditions that may arise.

Use of the levonorgestrel intrauterine system in adolescents with endometriosis.

STUDY OBJECTIVE: The purpose of this study was to evaluate our adolescent patient population who had received a levonorgestrel intrauterine system (LNG-IUS) at or after the time of endometriosis diagnosis, and determine efficacy of the LNG-IUS in regards to pain and bleeding on follow-up exam. DESIGN: Retrospective cohort study. SETTING: Pediatric Adolescent Gynecology Clinic and Children's Hospital in a metropolitan area. PARTICIPANTS: Adolescent patients age 14-22 with pathology-proven endometriosis who had the LNG-IUS placed during the course of their treatment for this disease. Patients were divided into LNG-IUS placement at the time of surgical diagnosis versus placement some time after diagnosis. MAIN OUTCOME MEASURES: Pain and bleeding were assessed by follow-up exam. Pain was classified at each follow-up visit as either none, minimal, moderate, or severe. Bleeding was classified as none, irregular spotting, irregular bleeding, or daily bleeding. RESULTS: The majority of patients (67%) required additional hormonal therapy for pain and bleeding suppression. Time to bleeding suppression and pain suppression was sooner in the group with interval time between surgical diagnosis and LNG-IUS placement, compared to LNG-IUS placement at the time of surgery (2.4 months vs 5.3 months until bleeding suppression, and 3.8 months vs 4.8 months until pain suppression), although statistical significance was not achieved. CONCLUSIONS: The LNG-IUS is an option for treatment of endometriosis in adolescents. As pain is the main problem associated with endometriosis, LNG-IUS placement is beneficial at the time of surgery when it is diagnosed. A prospective study is needed for further assessment of outcomes.

Retrospective review of intrauterine device in adolescent and young women.

STUDY OBJECTIVE: To examine our experience with intrauterine device (IUD) use in adolescents and young women. DESIGN: Retrospective descriptive study evaluating outcomes after IUD insertion for patients 21 years or less over an 8-year period. SETTING: Three sites including a Pediatric and Adolescent gynecology private practice, a Title X clinic, and community based, grant funded clinic serving a high risk teen population. PARTICIPANTS: Females from menarche to age 21. MAIN OUTCOMES MEASURED: The probability of IUD retention, differences in IUD retention probabilities between two age groups, and risk factors for IUD removal, expulsion, and infection were evaluated. RESULTS: 233 records showed 50% of the <18-year-old age group and 71.5% of the 18-21-year-old group had their IUD in place at 5 years. Age was found to be a significant factor for removal (P < 0.001), with under 18-year-olds at greater risk of removal/expulsion (hazard ratio (HR) = 2.85). Parity (RR = 5.6 for nulliparous vs multiparous patients, P < 0.001) and prior STI (RR = 5.5, P < 0.001) were significant risk factors for infection. Nulliparous patients were at higher risk of expulsion (P = 0.045), though age was not a statistically significant risk factor. CONCLUSIONS: The rate of continuation was lower in adolescents under 18 compared to 18-21-year-olds, but was still higher than for other hormonal contraceptives. Despite this groups' high risk for STI the IUD did not increase the risk of infection and may offer some degree of protection. IUDs appear to be a safe option in young adolescents (<18 years old) and nulliparous women.

Coexistence of gonadoblastoma and dysgerminoma in a dysgenetic gonad on touch preparation: a case report.

Swyer syndrome is known as pure gonadal dysgenesis. Individuals with Swyer syndrome are phenotypically female with unambiguously female genital appearance at birth, and normal Mullerian structures. The condition usually first becomes apparent in adolescence with delayed puberty and amenorrhea due to the fact that the gonads have no hormonal or reproductive potential. These individuals are characterized by 46XY karyotype, primary amenorrhea, tall stature, female external genitalia and normal but hypoestrogenised vagina and cervix. A high incidence of gonadoblastoma and germ cell malignancies has been reported in dysgenetic gonads, and therefore, the current practice is to proceed to a gonadectomy once the diagnosis is made. Herein, we report a case of gonadoblastoma and dysgerminoma diagnosed on touch preparation in a dysgenetic gonad of a 16-year-old patient with Swyer syndrome.

Van wyk and grumbach syndrome: an unusual case and review of the literature.

BACKGROUND: The syndrome consisting of primary hypothyroidism, precocious puberty, and massive ovarian cysts was termed Van Wyk and Grumbach syndrome in 1960. Little is known about the effect of the cysts on ovarian tumor markers. CASE: A 12-year-old Caucasian female presented with headaches and fatigue. Imaging to evaluate her headaches revealed a pituitary macroadenoma. Soon after her macroadenoma was discovered, she presented to the emergency room with abdominal pain. Imaging at that time revealed massive bilateral ovarian masses with the left measuring 17 × 13 × 8.5 cm and the right measuring 18 × 11 × 10 cm. Ovarian tumor markers were drawn at this time, most of which were highly elevated. Subsequent evaluation revealed extreme hypothyroidism. Given these findings of a pituitary macroadenoma, bilateral ovarian masses, and severe hypothyroidism, the patient was diagnosed with Van Wyk and Grumbach syndrome. We followed the cyst conservatively and the ovaries and tumor markers returned to normal after adequate thyroid replacement. COMMENTS: This case supports conservative treatment as the first-line approach to massive ovarian cysts caused by hypothyroidism. In addition this case shows that tumor markers can be abnormal in the absence of a malignancy in this setting. Before proceeding with surgical evaluation, exclusion of hypothyroidism to exclude this rare but treatable syndrome should be undertaken. The most important diagnostic clue that the cyst may be caused by an endocrine source is the finding of bilateral ovarian cysts rather than one ovary affected as seen in most ovarian malignancies in this age group.

A simulation program for teaching obstetrics and gynecology residents the pediatric gynecology examination and procedures.

STUDY OBJECTIVE: To assess the use of a pelvic simulation curriculum to teach obstetrics and gynecologic residents the pediatric gynecology examination and procedures. DESIGN: Residents in obstetrics and gynecology participated in a simulation curriculum using a modified pelvic hemimodel to simulate a pediatric pelvis. PARTICIPANTS: 19 obstetrics and gynecology residents completed the study protocol. INTERVENTIONS: Digitally recorded encounters with a standardized patient scenario using the simulator were utilized. After the initial encounter the trainees participated in a formal lecture and demonstration using the model. The trainees were then reassessed at least four weeks after the initial encounter; results were reviewed by a blinded evaluator. Scores were analyzed using the two-sided t-test and Wilcoxon signed-rank test. MAIN OUTCOME MEASURES: Scores from before to after the simulation training. RESULTS: A total of 19 residents completed the study protocol and demonstrated significant improvement in scores from before to after the simulation training. Scores improved from a pre-training mean of 6.1 to post-training mean of 16.7 (P = 0.0001). Improvement was seen at all levels of residency training. Specific skill sets included in the Council for Resident Education in Obstetrics and Gynecology (CREOG) Educational objectives (1) were improved including: pediatric gynecologic examination, collection of microbial cultures, vaginal lavage and vaginoscopy. CONCLUSIONS: This teaching program using a simulation model was found to be an effective tool to improve resident knowledge and performance of the skills needed to accomplish the pediatric gynecology examination.

Supernumerary nipple presenting as a vulvar mass in an adolescent: case report and literature review.

BACKGROUND: Ectopic breast tissues can be found along the embryonic mammary ridges and can occur in the vulva. While ectopic breast tissue is not uncommon, functional breast with overlying nipple located within the vulva is exceedingly rare. CASE: A 17-year-old with undiagnosed hypothyroidism presents with vulvar mass draining milky white fluid. A small lesion with appearance similar to a skin tag is noted and milky fluid expressed. Biopsy and excision of this mass confirmed the presence of a functional supernumerary nipple. SUMMARY AND CONCLUSIONS: This appears to be the first reported case of a supernumerary nipple with symptomatic lactation in a non-pregnant adolescent. Supernumerary nipple should be considered in the differential diagnosis of a vulvar mass. Ectopic breast tissue in the vulva can undergo malignant transformation, therefore excision of this tissue is generally recommended.