Labial Anatomy Concerns in the Adolescent: A Review.

Labial size concerns are an increasingly common chief complaint by both adolescents and adults despite studies showing a wide variation in sizes of the labia minora in the prepubertal, adolescent, and adult population. A thorough history will elucidate what or whom is driving the concerns, which can then direct management. Educating the patient, caregiver, and referring physician is often all that is needed. Surgery should never be used for cosmetic reasons in a minor.

Recurrence Rates for Pediatric Benign Ovarian Neoplasms.

STUDY OBJECTIVE: To examine the recurrence rates of pediatric benign ovarian neoplasms METHODS: A retrospective review of females up to 21 years of age who underwent surgery for a benign ovarian neoplasm at 8 pediatric hospitals from January 2010 through December 2016 was conducted. Data include primary operation details, follow-up imaging, and reoperation details. RESULTS: Four hundred and twenty-six females were included in our cohort, with a median age of 15 years at the time of the primary operation. Of the patients, 69% had a mature teratoma, 18% had a serous cystadenoma, and 8% had a mucinous cystadenoma. Two-thirds of patients underwent ovarian-sparing surgery. There were 11 pathologically confirmed recurrences (2.6%) at a median follow-up of 12.8 months. The pathologically confirmed recurrence was 10.5 per 100 person-months at 12 months (SE = 5.7) for mucinous cystadenomas and 0.4 months (SE = 0.4) for mature teratomas (P = .001). For half of the patients, the pathologically confirmed recurrences occurred by 12.8 months, and for 75%, they occurred by 23.3 months. There were no differences in reoperation or recurrence on the basis of initial procedure (ovary-sparing surgery vs oophorectomy). CONCLUSION: We measured the pathologically confirmed recurrence rate for pediatric benign ovarian neoplasms in a large cohort. Oophorectomy was not protective against recurrence. Mucinous cystadenomas were at a greater risk of pathologically confirmed recurrence.

Failure of Operative Therapy after Ovarian-Sparing Surgery for Pediatric Benign Ovarian Neoplasms: A Retrospective Review.

STUDY OBJECTIVE: To evaluate failure of initial operative therapy (incomplete tumor removal) of ovarian-sparing surgery for pediatric benign ovarian neoplasms. METHODS: A retrospective review of patients up to 21 years of age who underwent ovarian-sparing surgery for a benign ovarian neoplasm from 2010 to 2016 at 8 pediatric hospitals was conducted. Failure of initial operative therapy is defined as a radiologically suspected or pathologically confirmed ipsilateral lesion with the same pathology as the primary neoplasm within 12 weeks of the initial operation. RESULTS: Forty patients received imaging within 12 weeks of their primary operation. Sixteen (40%) patients had a radiologically identified ovarian abnormality ipsilateral to the primary lesion, and 5 patients were suspected to have the same lesion as their primary neoplasm. Three of the 5 patients (7.5%) underwent reoperation with pathologic confirmation of the same lesion, resulting in a pathologically confirmed failure of therapy rate of 7.5%. The other 2 patients had serial imaging that subsequently demonstrated no recurrence with lesion resolution. Age, race/ethnicity, laparoscopy vs laparotomy, presence of torsion, pathology, size of lesion, and surgeon specialty were not associated with failure of therapy. CONCLUSION: In most patients who received imaging within 12 weeks of the primary operation for resection of a benign ovarian neoplasm, ovarian-sparing surgery was successful in complete tumor removal, with a low failure of therapy rate. Selected patients with suspected failure of therapy on initial imaging could be serially monitored to determine the need for repeat surgical intervention.

Recommendations for Postoperative Surveillance of Pediatric Benign Ovarian Neoplasms.

STUDY OBJECTIVE: To assess postoperative management of pediatric patients with benign ovarian neoplasms, to develop recommendations for postoperative care. DESIGN: A retrospective cohort study. SETTING: Eight pediatric hospitals in the midwestern United States. PARTICIPANTS: Patients up to 21 years of age who underwent surgery for a benign ovarian neoplasm between January 2010 and December 2016 were included. INTERVENTIONS: No prospective interventions were evaluated. MAIN OUTCOME MEASURES: Main outcome measures included postoperative imaging findings, recurrence rates, reoperation rates, and the timing of the aforementioned results. RESULTS: A total of 427 patients met inclusion criteria. After the index surgery, 155 patients (36%) underwent a routine imaging study. Among those with routine imaging, abnormalities were noted in 48 patients (31%); 7 went on to have reoperation (5%), and no malignant pathologies or torsion were identified. Excluding the 7 patients who went on to have a reoperation as a result of routine imaging, 113 patients developed symptoms postoperatively and underwent imaging as a result (27%, 113/420). Abnormalities were noted in 44 (10%); 15 of these patients underwent reoperation (4%), among them 2 with malignancies and 3 with torsion. Of these 44 patients, 23 had initially undergone routine imaging and subsequently went on to have symptomatic imaging, with 17% (4/23) undergoing reoperation. CONCLUSIONS: Routine imaging did not identify malignancy; most lesions identified on routine imaging were incidental findings. Although the study was not powered to appreciate a statistically significant difference, patients with malignancy or torsion were identified in the symptomatic group. This suggests no benefit from routine imaging, and supports symptomatic imaging postoperatively to minimize costs and patient/family burden.

Dysgerminoma in a 10-Year Old with 45X/46XY Turner Syndrome Mosaicism.

BACKGROUND: Turner syndrome is a genetic disorder resulting from the absence of or structural abnormality of one X chromosome. The presence of Y chromosome material in girls with Turner syndrome confers an increased risk of benign and malignant germ cell tumor and prophylactic bilateral gonadectomy is recommended. CASE: A 10-year-old Turner mosaic syndrome (45X/46XY) patient underwent prophylactic gonadectomy after unremarkable preoperative pelvic imaging. Histopathology showed a streak right gonad, and left gonad with gonadoblastoma with limited degree of infiltrating germinoma. SUMMARYAND CONCLUSION: Gonadoblastoma and dysgerminoma have been reported in girls with Turner mosaic who carry Y chromosome material. Prophylactic gonadectomy should be considered in these girls without delay.

Treatment of Prepubertal Labial Adhesions: A Randomized Controlled Trial.

STUDY OBJECTIVE: Although various treatment options have been proposed for the treatment of labial adhesions, there are currently no clearly outlined limits on the duration of topical therapy, amount of lateral traction to apply, and methods to decrease the recurrence. This clinical trial was undertaken to assess the need for estrogen for treatment of prepubertal labial adhesions. DESIGN: Randomized, double-blinded, controlled trial. SETTING: Pediatric and Adolescent Gynecology Clinic at a children's hospital in a metropolitan area. PARTICIPANTS: Prepubertal girls ages 3 months to 12 years with labial adhesions. INTERVENTIONS: Lateral traction with topical estrogen or topical emollient. MAIN OUTCOME MEASURES: The primary outcome was resolution of labial adhesions. The secondary outcome was the change in severity of labial adhesions over time between the 2 groups. RESULTS: Forty-three girls were enrolled and 38 (88%) completed the study. The difference in complete resolution between the topical emollient group (19%) and the topical estrogen group (36%) was not statistically significant (P = .21). There was a statistically significant decrease in severity of labial adhesions over time, with the magnitude of improvement favoring the topical estrogen group. CONCLUSION: Although labial adhesion severity decreased when treated with lateral traction and topical emollient or topical estrogen, the magnitude of the effect was significantly greater for topical estrogen.

Patterns of Treatment of Accidental Genital Trauma in Girls.

STUDY OBJECTIVE: To evaluate the characteristics of girls with accidental genital trauma (AGT) who can be managed in the emergency department (ED) vs the operating suite (OS). DESIGN: Retrospective cohort. SETTING: ED at a children's hospital in a metropolitan area. PARTICIPANTS: Girls aged 0-18 years with AGT. INTERVENTIONS AND MAIN OUTCOME MEASURES: Factors associated with need for evaluation and repair of AGT in the OS. RESULTS: A total of 359 girls were included in the analysis. The mean age was 6 ± 3 years. Most girls presented with pain and bleeding, 321/359 (89%). Straddle injury was the most common mechanism, 258/355 (73%). The most commonly injured site was the labia, 225/358 (63%) and the most common type of injury was laceration, 308/357 (86%). Factors significantly associated with treatment in the OS included older age, transfer from another institution, penetrating injuries, injuries involving the hymen/vagina/urethra/anus, and injuries larger than 3 cm in size. The odds of requiring general anesthesia in the OS were 5.5 times higher for injuries larger than 3 cm (95% confidence interval, 2.8-10.9; P < .0001) and 4.1 times greater if the patient was transferred from another facility (95% confidence interval, 1.3-13.3; P < .02). CONCLUSION: Most AGT can be managed expectantly. Penetrating injuries, injuries to the hymen/vagina/urethra/anus, and injuries with a maximal size of 3 cm should be considered as indications for management in the OS. With adequate procedural sedation, most girls with minor injuries as a result of AGT can undergo a thorough examination and repair of AGT in the ED.

Endometriosis in adolescents.

PURPOSE OF REVIEW: The current article addresses recent literature regarding the diagnosis and management of endometriosis in adolescents. RECENT FINDINGS: An increasing body of literature suggests that advanced-stage endometriosis (revised scoring system of the American Society for Reproductive Medicine Stage III or IV) and deeply invasive endometriosis are relatively common in adolescents. There remains limited data on the efficacy of postoperative hormonal management of endometriosis in the adolescent population. SUMMARY: Strong consideration should be made for surgical diagnosis of endometriosis in adolescents with pelvic pain, including noncyclic pain, with a concurrent family history of endometriosis and personal history of atopic disease. More research is needed regarding the benefits of the routine use of hypoestrogenic and other hormonal agents in the prevention of disease progression and long-term sequela in adolescents with endometriosis.

Menstrual Patterns and Treatment of Heavy Menstrual Bleeding in Adolescents with Bleeding Disorders.

STUDY OBJECTIVE: To characterize menstrual bleeding patterns and treatment of heavy menstrual bleeding in adolescents with bleeding disorders. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective review of female patients aged nine to 21 years with known bleeding disorders who attended a pediatric gynecology, hematology, and comprehensive hematology/gynecology clinic at a children's hospital in a metropolitan area. MAIN OUTCOME MEASURES: Prevalence of heavy menstrual bleeding at menarche, prolonged menses, and irregular menses among girls with bleeding disorders and patterns of initial and subsequent treatment for heavy menstrual bleeding in girls with bleeding disorders. RESULTS: Of 115 participants aged nine to 21 years with known bleeding disorders, 102 were included in the final analysis. Of the 69 postmenarcheal girls, almost half (32/69, 46.4%) noted heavy menstrual bleeding at menarche. Girls with von Willebrand disease were more likely to have menses lasting longer than seven days. Only 28% of girls had discussed a treatment plan for heavy menstrual bleeding before menarche. Hormonal therapy was most commonly used as initial treatment of heavy menstrual bleeding. Half (53%) of the girls failed initial treatment. Combination (hormonal and non-hormonal therapy) was more frequently used for subsequent treatment. CONCLUSIONS: Adolescents with bleeding disorders are at risk of heavy bleeding at and after menarche. Consultation with a pediatric gynecologist and/or hematologist prior to menarche may be helpful to outline abnormal patterns of menstrual bleeding and to discuss options of treatment in the event of heavy menstrual bleeding.

Satisfaction with and intention to continue Depo-Provera versus the Mirena IUD among post-partum adolescents through 12 months of follow-up.

STUDY OBJECTIVE: No prior study has directly compared satisfaction with Depo-Provera to the Mirena intra-uterine device (IUD) among post-partum parous adolescents. Our aim was to make this comparison among post-partum adolescents at 3, 6, and 12 months of follow-up. PARTICIPANTS: Post-partum/parous adolescents (aged 20 and younger) choosing either Depo-Provera or the Mirena IUD as their method of contraception. DESIGN: Prospective longitudinal survey. SETTING: The adolescent clinic at the Truman Medical Center, Kansas City Missouri. MAIN OUTCOME MEASURE: Satisfaction with and intention to continue the chosen method at 3, 6, and 12 months of follow-up. INTERVENTIONS: None. RESULTS: Sixty-six post-partum/parous adolescents were recruited, 37 choosing the Mirena IUD and 29 choosing Depo-Provera for contraception. The 2 groups had similar baseline characteristics. There was no statistically significant difference in overall satisfaction with Depo-Provera versus the Mirena IUD at 3, 6, or 12 months of follow-up. For both contraceptive methods, unpredictable bleeding was most unacceptable at 6 months of follow-up but the trend was only statistically significant for Depo-Provera. For Depo-Provera, there was a significantly lower proportion of participants actually continuing the method at 12 months (42.9%) relative to the proportion who at 6 months had expressed an intention to continue (80.0%; P = .01). This trend was not seen for the Mirena IUD. CONCLUSION: Among post-partum/parous adolescents, overall subjective satisfaction with Depo-Provera and the Mirena IUD is similarly high over 12 months of follow-up. With Depo-Provera, however, there appears to be a disconnect between intention to continue at 6 months and actual continuation at 12 months.

Physician attitudes toward over the counter availability for oral contraceptives.

To assess physician attitude towards making oral contraceptives available over the counter in the United States (US). We assessed physician attitudes towards a transition from prescription only to over-the-counter availability (rx-OTC) for oral contraceptive pills by disseminating an electronic survey directed primarily to residents training in Obstetrics and Gynecology (OBGYN) and Family Practice in the US. An overwhelming majority of 638 respondents (71 %) were against an rx-OTC switch for combined oral contraceptives and among this subset of respondents the primary concern was safety (92.3 %). Overall, respondents were evenly divided on the issue of an rx-OTC switch for progestin-only-pills but of those who opposed, 73.2 % cited safety as their primary concern. For progestin-only-pills female respondents were more likely to support OTC availability. Most OBGYN and Family Practice residents opposed to OTC availability for oral contraceptives cite safety as their primary concern. Considering the abundant evidence as to the overall safety of oral contraceptives, especially progestin-only-pills, there appears to be a knowledge deficit among OBGYN and Family Practice residents regarding the safety of oral contraceptives.

What are the factors predictive of hysterosalpingogram compliance after female sterilization by the Essure procedure in a publicly insured population?

To determine what factors are predictive of post-Essure hysterosalpingogram (HSG) compliance. We conducted a retrospective chart review of all patients who underwent the Essure procedure at the two campuses of the Truman Medical Center, Kansas City, Missouri, from January 1, 2005 through December 31, 2010. Our study population consisted primarily of women who were publicly insured (89.0 %) and unmarried (76.7 %). Of 132 patients referred for HSG, 70 (53.0 %) complied. In adjusted analyses women 35 years and older had an almost fourfold higher odds of HSG compliance (OR = 3.72, 95 % CI 1.35-10.23) and women with 3 or more living children had a 64 % lower odds of HSG compliance (OR = 0.36, 95 % CI 0.16-0.82). Women younger than 35 who had 3 or more children had the lowest compliance rate (36.4 %) suggesting an interaction between age and parity. Women undergoing the Essure procedure at the campus with a dedicated protocol to ensure compliance had an almost fourfold higher odds of HSG compliance (OR = 3.67, 95 % CI 1.01-13.40). In a population consisting largely of publicly insured, unmarried women, several factors are predictive of post-Essure HSG compliance. These include age, parity and the presence or absence of an institutional protocol to keep track of patients after their Essure procedure.

Use of intraoperative fluoroscopy during laparotomy to identify fragments of retained Essure microinserts: case report.

In previous case-reports of Essure microinsert perforation, the microinsert was successfully removed at laparoscopy. Herein is discussed the scenario of persistent pelvic pain over several years after an apparently successful laparoscopic retrieval of a perforating right-sided microinsert. In the interim, the patient underwent 2 unsuccessful exploratory laparotomy procedures in an attempt to retrieve additional microinsert fragments that had perforated the uterus. Successful management of Essure microinsert perforation in this patient ultimately required use of intraoperative fluoroscopy. Surgeons performing laparoscopy or laparotomy to retrieve Essure microinserts that have perforated should be aware that these are not always visible to the naked eye, and there should be a low threshold to use intraoperative fluoroscopy to ensure that all perforating fragments have been removed.

Virilizing ovarian dermoid cyst with leydig cells.

BACKGROUND: The clinical observation of virilization is a rare finding that has a number of possible explanations. Overall, ovarian tumors causing virilization are exceedingly rare and mostly occur in post-menopausal women. In fact, there are no reported cases of virilization from a testosterone-producing ovarian dermoid in the adolescent female age group. The most frequent germ cell tumor derived from the ovaries is the benign cystic teratoma (dermoid) which accounts for 25% of all ovarian neoplasms. Teratomas consist of tissues that recapitulate the ectoderm, endoderm, and mesoderm. Usually the tumors are asymptomatic, but they occasionally can cause severe pain if there is torsion or if sebaceous material perforates the cyst wall, leading to reactive peritonitis. CASE: A 12-year-old female was found to have a large 3 5 x 19 x 12 cm ovarian mature cystic teratoma arising from her right ovary. The patient also displayed evidence of masculinization demonstrated by a deepening voice and clitoromegaly. The dermoid was producing large amounts of testosterone from a nest of Leydig cells found pathologically in the mass. CONCLUSION: Benign cystic teratomas can produce active hormones, albeit rarely. This is a finding important to consider when ovarian cystectomy is performed for removal of a benign cystic teratoma.

Contraceptive choices for chronically ill adolescents.

Ten percent of teenagers have chronic medical illness and need effective contraception for pregnancy prevention. There are available safe and effective methods; however, the selection of a contraceptive may be challenging because of the complexity of the underlying medical illness. This article offers options for contraception for girls with various chronic medical conditions. Considerations of some of the newer contraception methods are discussed as future options for these girls.

Beta hemolytic streptococcus group f causing pelvic inflammatory disease in a 14-year-old girl.

BACKGROUND: 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. CASE: 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. CONCLUSION: Various organisms including Streptococcal infections should be considered in the differential diagnosis of pelvic inflammatory disease in young girls without risk factors.

Recurrent mature cystic ovarian teratoma in adolescence: atypical case of the growing teratoma syndrome.

BACKGROUND: A primary mature cystic ovarian teratoma was diagnosed in an adolescent female. She was followed up after initial exploration with computed tomography, pelvic ultrasonography, and serum tumor markers. Recurrent tumor, consisting solely of mature teratomatous elements, was confirmed with 2 subsequent laparotomies. CASE: This is a report of the growing teratoma syndrome in a young woman with a primary diagnosis of a mature cystic ovarian teratoma not treated with adjuvant chemotherapy. CONCLUSION: The growing teratoma syndrome is an uncommon condition. Surgical resection of recurrent lesions is necessary to reduce potential complications of abdominopelvic organ compression and obstruction and to evaluate for the presence of malignant degeneration.

Vulvar venous malformations in an 11-year-old girl: a case report.

BACKGROUND: 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. CASE: 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. CONCLUSION: Direct injection venography with ethanol sclerotherapy is an attractive diagnostic and therapeutic option for management of vulvar venous malformations.