IUD Insertion Under Conscious Sedation: Patient Characteristics with Clinical Decisions.

STUDY OBJECTIVE: Uptake of intrauterine devices (IUDs) in the adolescent population may be limited by anxiety and pain anticipated during the insertion procedure. Our institution offers conscious sedation for IUD insertion to mitigate this concern. The objective of this study was to identify characteristics and outcomes of teens choosing between two types of conscious sedation for insertion of a levonorgestrel IUD. METHODS: This was a single-site, retrospective cohort study over a one year period, reviewing the electronic medical records of patients who had undergone an attempted IUD insertion using conscious sedation. Conscious sedation included nitrous gas (termed "light" sedation) or intravenous midazolam and fentanyl (termed "moderate" sedation). Patient demographic characteristics and medical and gynecological histories were analyzed. RESULTS: There were 69 attempted IUD insertions during the study period. Most patients (75.36%) were placed under light sedation, and 92.75% were successfully inserted. The only significant factor associated with choice in the type of conscious sedation was previous sexual activity, which increased the odds by 10.0 that the patient would choose light sedation (95% CI, 1.23-81.34; P = 0.031). Differences between other factors (age, history of sexual assault, tampon use, and gender identity) were not statistically significant between successful and failed insertions. CONCLUSION: In conclusion, history of sexual activity significantly differed between patients in our cohort who selected light sedation over moderate sedation. No other factors influenced the choice in sedative or success of IUD insertion. Knowing the characteristics of patients who choose nitrous versus intravenous sedation, and how it relates to successful insertion, may help guide pre-procedural counseling for patients regarding sedation for IUD insertion.

Selective Venous Sampling Prompting Unilateral Oophorectomy in an Adolescent With PCOS and Markedly Elevated Testosterone.

BACKGROUND: For adolescents with suspected polycystic ovary syndrome (PCOS) and severely elevated testosterone concentrations, imaging is recommended to assess for neoplasm. Selective venous sampling (SVS) can be considered when imaging is nondiagnostic. CASE: An adolescent female treated for PCOS had a peak testosterone of 344 ng/dL (11.9 nmol/L). Imaging did not localize a mass. SVS implicated the right ovary as the source of hyperandrogenism. Following laparoscopic right oophorectomy, pathology excluded a neoplasm and confirmed PCOS. She subsequently had rapid and persistent improvement in her hyperandrogenism. SUMMARY AND CONCLUSION: Striking testosterone elevation can occur with adolescent PCOS. SVS is a tool for localizing the source of severe hyperandrogenism, yet unilaterality is not always diagnostic of a neoplasm. Unilateral oophorectomy could nonetheless be therapeutic for severe PCOS.

Unique Evaluation and Management Considerations for Adolescents with Late Gynecologic and Colorectal Issues in the Setting of Anorectal Malformations.

STUDY OBJECTIVE: There is little guidance for managing pubertally identified Mullerian anomalies in patients with anorectal malformations (ARMs). We sought to assess these unique issues. DESIGN: Retrospective review SETTING: Single-institution study PARTICIPANTS: Natal female patients aged 10-25, with an ARM, cloaca, or exstrophy, who presented from 2009 to 2019 with a gynecologic concern were included. INTERVENTION: Data collection was performed and included the presenting problem, psychological evaluation, fertility and sexuality concerns, and management strategies for these problems. MAIN OUTCOME MEASURES: The main outcome was unique needs that had to be addressed in the young adult population and the type of colorectal and gynecological procedures needed on representation. RESULTS: Twelve patients were identified; all had gynecologic concerns. Ten had ARMs, including cloaca (n = 3) and cloacal exstrophy (n = 5). Median age at representation was 14.6 years (IQR = 12.7, 15.3). Colorectal revisions included posterior sagittal anorectoplasty (n = 1), resection of bowel attached to urogenital sinus (n = 1), and appendicostomy revision (n = 1). Gynecologic issues included dysmenorrhea (n = 8), obstructed Mullerian anomaly (n = 6), and introital stenosis (n = 5). Behavioral health concerns (n = 9) and fertility/sexuality concerns (n = 4) were identified. Median time from first visit to reconstruction was 1.5 years (IQR = 0.5, 1.5), providing multiple visits to achieve consensus among patients and providers before intervention, including vaginal or introital repair (n = 5) and hysterectomy of obstructed uterine horns (n = 3). CONCLUSIONS: Goal-directed follow-up is required before surgical management to identify psychological and reproductive issues in patients with ARMs who have gynecologic concerns. Patient input and psychologic consultation are helpful for patients requiring staged reconstruction.