No. 313-Menstrual Suppression in Special Circumstances.

OBJECTIVE: To provide a Canadian consensus document for health care providers with recommendations for menstrual suppression in patients with physical and/or cognitive challenges or those who are undergoing cancer treatment in whom menstruation may have a deleterious effect on their health. OPTIONS: This document reviews the options available for menstrual suppression, its specific indications, contraindications, and side effects, both immediate and long-term, and the investigations and monitoring necessary throughout suppression. OUTCOMES: Clinicians will be better informed about the options and indications for menstrual suppression in patients with cognitive and/or physical disabilities and patients undergoing chemotherapy, radiation, or other treatments for cancer. EVIDENCE: Published literature was retrieved through searches of Medline, EMBASE, OVID, and the Cochrane Library using appropriate controlled vocabulary and key words (heavy menstrual bleeding, menstrual suppression, chemotherapy/radiation, cognitive disability, physical disability, learning disability). Results were restricted to systematic reviews, randomized controlled trials, observation studies, and pilot studies. There were no language or date restrictions. Searches were updated on a regular basis and new material was incorporated into the guideline until September 2013. Grey (unpublished) literature was identified through searching websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: There is a need for specific guidelines on menstrual suppression in at-risk populations for health care providers.

Review of gynecologic and reproductive care for women with developmental disabilities.

PURPOSE OF REVIEW: Care for women with developmental disabilities requires special consideration for unique needs related to their cognitive and physical abilities. These women and their caregivers require more support and guidance during reproductive health care. We review the literature and provide expert opinion surrounding gynecological issues for women with developmental disabilities to support healthcare providers better understand and care for this population. RECENT FINDINGS: Women with developmental disabilities are more vulnerable to abuse and experience poorer gynecological healthcare outcomes. Many women with developmental disabilities are fertile and participate in sexual activity without adequate knowledge. They are at higher risk of pregnancy and birth complications. They are less likely to receive appropriate preventive screening. SUMMARY: The review highlights important issues and practice suggestions related to the reproductive health care of women with developmental disabilities. Topics include clinic visits, menstruation, sexuality, sexual abuse, sexual health education, contraception, sexually transmitted infections, pregnancy, labor and delivery, and cancer screening/prevention. We emphasize the need for an individualized, comprehensive approach for these patients and review perceived and actual barriers to care. More education is needed on the aforementioned topics for women with developmental disabilities, their caregivers, and their providers.

Menstrual suppression in special circumstances.

OBJECTIVE: To provide a Canadian consensus document for health care providers with recommendations for menstrual suppression in patients with physical and/or cognitive challenges or those who are undergoing cancer treatment in whom menstruation may have a deleterious effect on their health. OPTIONS: This document reviews the options available for menstrual suppression, its specific indications, contraindications, and side effects, both immediate and long-term, and the investigations and monitoring necessary throughout suppression. OUTCOMES: Clinicians will be better informed about the options and indications for menstrual suppression in patients with cognitive and/or physical disabilities and patients undergoing chemotherapy, radiation, or other treatments for cancer. EVIDENCE: Published literature was retrieved through searches of Medline, EMBASE, OVID, and the Cochrane Library using appropriate controlled vocabulary and key words (heavy menstrual bleeding, menstrual suppression, chemotherapy/radiation, cognitive disability, physical disability, learning disability). Results were restricted to systematic reviews, randomized controlled trials, observation studies, and pilot studies. There were no language or date restrictions. Searches were updated on a regular basis and new material was incorporated into the guideline until September 2013. Grey (unpublished) literature was identified through searching websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES: The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS: There is a need for specific guidelines on menstrual suppression in at-risk populations for health care providers. Recommendations 1. Menstrual suppression and therapeutic amenorrhea should be considered safe and viable options for women who need or want to have fewer or no menses. (II-2A) 2. Menstrual suppression should not be initiated in young women with developmental disabilities until after the onset of menses. (II-2B) 3. Combined hormonal or progesterone-only products can be used in an extended or continuous manner to obtain menstrual suppression. (I-A) 4. Gynaecologic consultation should be considered prior to the initiation of treatment in all premenopausal women at risk for abnormal uterine bleeding from chemotherapy. (II-1A) 5. Leuprolide acetate or combined hormonal contraception should be considered highly effective in preventing abnormal uterine bleeding when initiated prior to cancer treatment in premenopausal women at risk for thrombocytopenia. (II-2A).

Objectif : Offrir, aux fournisseurs de soins de santé, un document de consensus canadien comptant des recommandations pour ce qui est de la suppression menstruelle chez les patientes qui font face à des obstacles physiques et/ou cognitifs ou chez les patientes qui font l'objet d'un traitement contre le cancer et pour lesquelles les règles pourraient exercer un effet délétère sur la santé. Options : Le présent document analyse les options disponibles aux fins de la suppression menstruelle, les indications, les contre-indications et les effets indésirables (tant immédiats qu'à long terme) propres à cette dernière, et les explorations et le monitorage nécessaires tout au long de la suppression. Issues : Les cliniciens seront mieux renseignés au sujet des options et des indications propres à la suppression menstruelle chez les patientes qui présentent des déficiences cognitives et/ou physiques et chez les patientes qui font l'objet d'une chimiothérapie, d'une radiothérapie ou d'autres traitements contre le cancer. Résultats : La littérature publiée a été récupérée par l'intermédiaire de recherches menées dans Medline, EMBASE, OVID et The Cochrane Library au moyen d'un vocabulaire contrôlé et de mots clés appropriés (p. ex. « heavy menstrual bleeding ¼, « menstrual suppression ¼, « chemotherapy/radiation ¼, « cognitive disability ¼, « physical disability ¼, « learning disability ¼). Les résultats ont été restreints aux analyses systématiques, aux essais comparatifs randomisés, aux études observationnelles et aux études pilotes. Aucune restriction n'a été imposée en matière de langue ou de date. Les recherches ont été mises à jour de façon régulière et du nouveau matériel a été intégré à la directive clinique jusqu'en septembre 2013. La littérature grise (non publiée) a été identifiée par l'intermédiaire de recherches menées dans les sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, dans des registres d'essais cliniques et auprès de sociétés de spécialité médicale nationales et internationales. Valeurs : La qualité des résultats est évaluée au moyen des critères décrits dans le rapport du Groupe d'étude canadien sur les soins de santé préventifs (Tableau). Avantages, désavantages et coûts : La rédaction (à l'intention des fournisseurs de soins de santé) de lignes directrices traitant particulièrement de la suppression menstruelle au sein des populations exposées à des risques s'avère nécessaire. Recommandations 1. La suppression menstruelle et l'aménorrhée thérapeutique devraient être considérées comme étant des options sûres et viables pour les femmes qui doivent ou qui souhaitent obtenir une atténuation ou l'élimination de leurs règles. (II-2A) 2. Chez les jeunes femmes qui présentent des déficiences sur le plan du développement, la suppression menstruelle ne devrait être mise en œuvre qu'après l'apparition des premières règles. (II-2B) 3. Des agents hormonaux combinés ou ne contenant que de la progestérone peuvent être utilisés de façon prolongée ou continue aux fins de l'obtention d'une suppression menstruelle. (I-A) 4. La tenue d'une consultation en gynécologie devrait être envisagée avant la mise en œuvre d'un traitement chez toutes les femmes préménopausées qui sont exposées au risque de connaître des saignements utérins anormaux attribuables à la chimiothérapie. (II-1A) 5. L'acétate de leuprolide ou la contraception hormonale combinée devraient être considérés comme des moyens grandement efficaces d'assurer la prévention des saignements utérins anormaux, lorsqu'ils sont mis en œuvre avant l'administration d'un traitement anticancéreux chez des femmes préménopausées exposées à un risque de thrombocytopénie. (II-2A).

Can paediatric and adolescent gynecological care be delivered via Telehealth?

OBJECTIVE: Paediatric and adolescent gynecology (PAG) is an evolving subspecialty, with patients often having to travel large distances to access care. The goal of the present study was to assess whether Telehealth (TH) would be appropriate for PAG services in a tertiary care centre and to determine patient/family interest. METHODS: The present study was a prospective observational study of patients who attended PAG clinics over the course of one year. Patient data collected on each visit included postal code, diagnosis, availability of a local hospital with TH, patient appropriateness for TH and patient/family reasons for accepting TH. Visits were stratified by diagnosis to determine if certain conditions were more amenable to TH. RESULTS: From the total visits through the year (July 15, 2008 to July 15, 2009), 1541 (79.6%) patients were approached for participation; 8 (0.5%) declined. The final sample size was 1533 patient visits. Four hundred sixty-nine visits (30.6%) were potentially appropriate for TH based on geography. According to clinic physicians, only 51 of these 469 visits (10.9%) were appropriate for TH. The main reasons for being inappropriate were the need for physical examination (n=238, 57.0%), imaging (n=57, 13.6%), or issues regarding sexuality/privacy (n=45, 10.8%). Of the 51 appropriate visits, 28 patients/families (55.0%) expressed interest in TH. Of those not interested in TH, the main reasons included the desire for a face-to-face encounter and the need to coordinate with other health care appointments. CONCLUSION: Of the patient visits considered for TH (based on the fact that patients lived a considerable distance from the hospital), 10.9% were deemed appropriate for TH by the PAG team, but 45.0% of families/patients in this group said they would prefer a traditional clinic visit. Currently, TH appears to be appropriate for only a small subset of patients/families.

OBJECTIF : La gynécologie pour les enfants et les adolescentes (GEA) est une surspécialité en évolution, et les patientes doivent souvent parcourir de longues distances pour accéder aux soins. La présente étude visait à évaluer si la télésanté (TS) peut convenir pour prodiguer des services de GEA dans un centre de soins tertiaires et pour déterminer l'intérêt des patientes et de la famille. MÉTHODOLOGIE : La présente étude d'observation prospective portait sur des patientes qui avaient fréquenté des cliniques de GEA pendant un an. Les données sur les patientes colligées à chaque visite incluaient le code postal, le diagnostic, l'accès à un hôpital local doté de la TS, l'applicabilité des patientes à la TS et les raisons pour que la patiente et sa famille acceptent la TS. Les visites étaient stratifiées selon le diagnostic afin de déterminer si certaines maladies étaient plus acceptables pour la télésanté. RÉSULTATS : D'après le nombre total de visites tout au long de l'année (du 15 juillet 2008 au 15 juillet 2009), les chercheurs ont demandé à 1 541 patientes (79,6 %) de participer, mais huit (0,5 %) ont refusé. La dimension définitive de l'échantillon était de 1 533 visites-patients. Quatre cent soixante-neuf visites (30,6 %) avaient le potentiel de convenir à la TS d'après le facteur géographique. Selon les médecins de la clinique, seulement 51 de ces 469 visites (10,9 %) convenaient à la TS. Les principales raisons des rejets étaient la nécessité de procéder à un examen physique (n=238, 57,0 %) ou à une imagerie (n=57, 13,6 %) ou les questions relatives à la sexualité ou au respect de la vie privée (n=45, 10,8 %). Des 51 visites pertinentes, 28 patientes ou familles (55,0 %) ont exprimé leur intérêt envers la TS. Parmi les personnes qui n'y étaient pas intéressées, les principales raisons invoquées étaient le souhait d'une rencontre en personne et la nécessité de coordonner avec d'autres rendez-vous de santé. CONCLUSION : Parmi les visites de patientes envisagées pour la TS (parce que les patientes vivaient très loin de l'hôpital), 11 % étaient réputées convenir selon l'équipe de GEA, mais 45,0 % des familles et des patientes de ce groupe affirmaient préférer une visite classique en clinique. Pour l'instant, la TS semble convenir seulement à un petit sous-groupe de patientes et de familles.

Pediatric vulvovaginal disorders: a diagnostic approach and review of the literature.

Vulvovaginal complaints in the prepubertal child are a common reason for referral to the health care provider. The Cochrane Library and Medline databases were searched for articles published in English from 1980 to December 2004 relating to vulvovaginal conditions in girls. The following search terms were used: vulvovaginitis, prepubertal, pediatric, lichen sclerosis, labial fusion, labial adhesion, genital ulcers, urethral prolapse, psoriasis, and straddle injuries. The objectives of this article are to review the normal vulvovaginal anatomy, describe how to perform an age-appropriate examination, and discuss common vulvovaginal disorders and their management in young girls.

Retrospective review of unintentional female genital trauma at a pediatric referral center.

UNLABELLED: Unintentional female genital trauma is a complaint commonly seen and managed through the emergency department. The purpose of this study was to review all unintentional female genital trauma evaluated at The Hospital for Sick Children for 3.5 years to determine the factors associated with gynecologic consultation and need for operative repair. METHODS: One hundred five patients were identified by health record coding. Data were extracted to study factors associated with gynecologic consultation and operative repair. Statistical analyses were performed to evaluate the significance of these associations. Surgical choices were also evaluated. RESULTS: Mean age was 5.60 years. Mean time to presentation was 7.05 hours. Straddle injury was the most common mechanism (81.90%), and only 4.76% injuries were penetrating. Of the 105 patients, 48.57% consulted the gynecology section, 19.05% were taken to the operating room, and 6.66% were treated under conscious sedation. Overall, 20.95% required surgical repair. The most common complication was dysuria. Six patients had other injuries, the most common of which were pelvic fractures related to trauma.Factors significantly associated with gynecologic consultation and operative management included older age, transfer to our institution, shorter time to presentation, laceration-type injury, hymenal injury, and larger size of injury. Straddle injuries were significantly less likely to be taken to the operating room. When cases were stratified by a surgeon, there were no significant differences in management. CONCLUSIONS: Unintentional female pediatric genital traumas most commonly result from straddle injuries. Most injuries are minor, and in this cohort, only 48.57% received gynecologic consultation and 19.05% required operative management. Future prospective studies would be useful to better evaluate the efficacy of surgical choices.

Vaginal laceration from a high-pressure water jet in a prepubescent girl.

OBJECTIVE: To document an unusual case of water douche injury in a prepubescent girl. DESIGN: Case report. RESULTS: After sitting atop a high-pressure water jet in a public fountain, a 9-year-old girl experienced pain and vaginal bleeding. She sustained a laceration high in her vaginal vault with an estimated total blood loss of 750 mL. Examination and vaginal packing were done under general anesthesia resulting in cessation of bleeding. CONCLUSIONS: High-pressure water douche is recognized as producing serious vaginal injury in adult women but is not well reported as a cause of genital trauma in the pediatric population. Although not well documented, the prepubescent vagina is capable of receiving significant trauma due to highly pressurized water. Initial trauma management should be implemented with subsequent repair of the laceration, if possible. The prepubescent genital anatomy must be taken into account during examination and postoperative care.

Menstrual and contraceptive issues among young women with developmental delay: a retrospective review of cases at the Hospital for Sick Children, Toronto.

OBJECTIVES: To define the clinical characteristics of, and management options offered to, young women with developmental delay referred to The Hospital for Sick Children gynecology clinic in Toronto for menstrual suppression and contraception. To review the primary caregiver concerns and preferences with regards to menstruation and contraception. METHODS: A retrospective chart review of hospital records of young women with developmental delay referred to the gynecology clinic at The Hospital for Sick Children, Toronto from 1998 to 2003. RESULTS: A total of 72 charts were reviewed from clinic visits between 1998 to 2003. Ages range from 8 to 17 years with an unknown cause of their cognitive disability in 44% and medium to high support needs in the majority. Forty-three percent were still premenarcheal when first brought to the gynecology clinic by their families or caregivers. The main reason for consult was menstrual-related in 90%, with concerns related to hygiene and problems coping. CONCLUSIONS: Caregivers often approach physicians for menstrual suppression prior to menarche with a primary concern of personal hygiene. Medical suppression of menstruation can be successfully achieved. Depo-Provera was the most commonly prescribed and accepted method of menstrual suppression within our population.

Trends in menstrual concerns and suppression in adolescents with developmental disabilities.

PURPOSE: Demonstrate changes in methods of menstrual suppression in adolescents with developmental disabilities in a recent 5-year cohort compared with an historical cohort at the same hospital. METHODS: Retrospective cohort study of patients with physical and cognitive challenges presenting for menstrual concerns at an Adolescent Gynecology Clinic between 2006 and 2011 compared with a previous published cohort (1998 to 2003). RESULTS: Three hundred patients with developmental disabilities aged 7.3 to 18.5 years (mean 12.1 ± 1.6) were analyzed. Caregiver concerns included menstrual suppression, hygiene, caregiver burden, and menstrual symptoms. Ninety-five percent of patients had cognitive disabilities, 4.4% had only physical impairments. Thirty-two (31.7) percent of patients presented premenarchally. The most commonly selected initial method of suppression was extended or continuous oral contraceptive pill (OCP) (42.3%) followed by patch (20%), expectant management (14.9%), depot medroxyprogesterone acetate (DMPA) (11.6%), and levonorgestrel intrauterine system (LNG-IUS) (2.8%). Published data from 1998 to 2003 indicated a preference for DMPA in 59% and OCP in 17% of patients. The average number of methods to reach caregiver satisfaction was 1.5. Sixty-five percent of initial methods were continued. The most common reasons for discontinuation were breakthrough bleeding, decreased bone mineral density, or difficulties with patch adherence. Second-choice selections included OCP (42.5%), LNG-IUS inserted under general anesthesia (19.2%), DMPA (17.8%), and patch (13.7%). CONCLUSIONS: Since identification of decreased bone mineral density with DMPA and emergence of new contraceptive options, use of extended OCP or patch has surpassed DMPA for menstrual suppression in our patient population. LNG-IUS is an accepted, successful second-line option in adolescents with developmental disabilities.

Videoconferencing for resident teaching of subspecialty topics: the pediatric and adolescent gynecology experience at the Hospital for Sick Children.

STUDY OBJECTIVE: Videoconferencing enables distance learning and subspecialty teaching. The objective of this study is to describe and evaluate a 3-hour teaching session on Pediatric and Adolescent Gynecology held by videoconferencing from the Hospital for Sick Children and broadcast to 8 other Canadian universities. DESIGN: Evaluation forms were completed by attendees on the clinical applicability, content quality, delivery quality, meeting of objectives and overall assessment of each session. Further evaluations asked whether presentations were received clearly, material could be followed, method of videoconferencing seemed too impersonal, and whether there were any technical problems. Presenters were asked for a qualitative assessment of their experience. SETTING: The teaching session was broadcast from Toronto. Local residents attended and 8 other centers were connected by videoconferencing. PARTICIPANTS: Participants were residents at the 9 involved Canadian centers. INTERVENTION: PowerPoint presentations were shown at each location with rotating views of the 4 presenters. Monitors enabled each location to view fellow participants. After participating in a videoconferenced teaching session, participants were asked to fill out evaluations. Presenters were asked for a qualitative assessment of their experience providing the session. MAIN OUTCOME MEASURE: Successful use of videoconferencing as a means of subspecialty resident education. RESULTS AND CONCLUSIONS: There were at most 61 responses to evaluation questions. Presentations were well received; 98.6% of responses were "excellent," "very good," or "good." Comments indicated significant variability in video quality received at different centers. Presenters felt the experience was positive but that there was a lack of connection with the distant audience. Videoconferencing offers opportunities for expanding medical subspecialty education to geographical areas without subspecialty representation. Overall, this experience was positive but recommendations to ensure equal levels of technology at all centers and to enhance the interactive nature of the presentation would be made for future experiences.