Decidual cast: a rare cause of genital tract obstruction.

Decidual cast is a little-known entity characterized by sloughing of the endometrium in several large pieces or in one cylindrical or membranous piece retaining the shape of the uterine cavity. Accounts of the diagnosis are sporadic and have not previously appeared in the pediatric imaging literature. We describe a case of a post-menarchal adolescent girl presenting with abnormal uterine bleeding, severe dysmenorrhea, and imaging features of genital tract obstruction, the cause of which was found to be a large decidual cast during examination under anesthesia. While rare, awareness of this phenomenon should be useful to pediatric imagers as the combination of bleeding and obstructive symptoms produces a confusing picture that may lead to a protracted clinical and imaging course.

Factors Predicting Removals of the Levonorgestrel-Releasing Intrauterine System in an Adolescent Cohort.

OBJECTIVE: Use of 52-mg levonorgestrel intrauterine system (LNG-IUS) in adolescents for heavy menstrual bleeding (HMB), dysmenorrhea, and contraception has increased, yet little is known about the factors predicting removal and dissatisfaction in adolescents. The aim of this study was to identify factors predicting LNG-IUS removal in adolescents. METHODS: This was a retrospective cohort study including all adolescents (9-19 years) who underwent LNG-IUS insertion between 2012 and 2021 (n = 536). A medical record review was conducted and data were collated on medical and gynecological history, age, indications for insertion, complications, expulsions, and removals. The data were analyzed using χ2 tests. RESULTS: Indications for LNG-IUS insertions (n = 536) among 517 individual patients (n = 517) included menstrual management (n = 142), HMB alone (n = 118), HMB and pelvic pain/dysmenorrhea (n = 105), dysmenorrhea/pelvic pain alone (n = 47), and contraception (n = 16). Associated diagnoses included intellectual disability (44.29%, 229/517), chronic pain conditions (12.77%, 66/517), and additional mental health concerns (24.37%, 126/517). Patient dissatisfaction with LNG-IUS led to removal in 61 (11.38%), mostly for pain or persistent bleeding. Higher removal rates occurred in those with associated chronic pain conditions (46.97%, χ2 = 55.9, P < .05), mental health concerns (16.67%, χ2 = 5.06, P < .05), and bleeding disorders (26.32%, χ2 = 5.09, P < .05). Among the cohort with an intellectual disability, lower rates of removal occurred (5.7%, χ2 = 11.2, P < .05). Whereas the LNG-IUS removal rate among gender-diverse youth was 23.07%, this was not statistically significant. Younger age was also not associated with a statistically significant increase in removals (13.72%, χ2 = 0.73, P > .05). DISCUSSION: Adolescents have a low dissatisfaction and removal rate (11.38%) of LNG-IUS. Chronic pain, bleeding tendency, and mental health concerns are associated with higher removal rates and intellectual disability with lower rates. These findings are useful in counselling patients and families about LNG-IUS.

Dysmenorrhea in young people: Experiences from a tertiary center with a focus on conservative management.

AIM: To describe the characteristics, management and outcomes of a cohort of young people with dysmenorrhea presenting to a tertiary adolescent gynecology service, managed primarily with medical interventions. METHODS: A retrospective cohort study was conducted at the Royal Children's Hospital in Melbourne, Australia. Data were collected from medical records of patients presenting with dysmenorrhea and/or pelvic pain. RESULTS: Of 154 patients, mean age of presentation was 15.7 years (SD = 2.2) and mean duration of pain was 14.9 months (SD = 10.8). Regular cycles were reported by 64.5%, and heavy menstrual bleeding (HMB) in 67.8%. Patients self-reporting HMB reported less pain on the day prior to menses than those not reporting HMB (P < 0.005). At follow-up, therapeutic interventions included nonsteroidal anti-inflammatory drugs, tranexamic acid and cyclic or continuous combined oral contraceptive pills. Laparoscopies were undertaken in 12 (8.1%) patients, with normal findings in 8 (66.7%). Secondary dysmenorrhea was identified in 10 patients: of these, endometriosis was identified in one patient and unilateral obstructive Müllerian anomalies in six. Overall, 92.2% of patients had improvement in symptoms after treatment. CONCLUSION: Laparoscopy and endometriosis rates in patients presenting to a tertiary center were lower than previously reported, with most patients achieving symptom improvement without laparoscopy.

Dysmenorrhea, Endometriosis and Chronic Pelvic Pain in Adolescents

Most adolescents will experience discomfort during menstruation. Due to normalization of dysmenorrhea, there is delay to diagnosis and treatment. Non-steroidal anti-inflammatories are a first line treatment. Adolescents can safely be offered menstrual suppression with combined hormonal contraception, and progestin-only options. When the above are ineffective, gonadotropin releasing hormone agonists with add back treatment can be considered. Transabdominal ultrasound is indicated when first line treatments do not improve symptoms. Endometriosis should be considered in adolescents who experience ongoing pain despite medical treatment. If laparoscopy is performed and endometriosis visualized, it should be treated with either excision or ablation. Women with endometriosis should be counselled on menstrual suppression until fertility is desired. Management of chronic pain requires the involvement of a multi-disciplinary team.

More than Grapes and Bleeding: An Updated Look at Pelvic Rhabdomyosarcoma in Young Women.

STUDY OBJECTIVE: To review our local experience with urogenital rhabdomyosarcoma (RMS) to determine the most common clinical presentation(s). DESIGN: Retrospective case series of all female patients with urogenital RMS who presented to a tertiary pediatric hospital between 1996 and 2016. All institutional electronic pathology reports were screened for RMS and those that were pelvic in origin and occurred in female patients were included for further analysis. Seventeen cases of urogenital RMS in female patients were identified and reviewed. SETTING: This study was conducted at The Royal Children's Hospital in Melbourne, Australia. This is a tertiary referral center for the state of Victoria and surrounding areas, which services more than 1.5 million pediatric patients. PARTICIPANTS: Female pediatric patients (ages 0-18 years) who presented to The Royal Children's Hospital with eventual pathologic tissue diagnosis of urogenital RMS. MAIN OUTCOME MEASURES: The cases were reviewed for clinical presentation, duration of symptoms before initial presentation, time to tissue diagnosis, and outcomes of treatment. RESULTS: Of the 17 cases reviewed, 5 (29%) presented with perineal mass, 4 (24%) presented with each of abdominal mass and grape-like lesions/hemorrhagic mass at the introitus, 3 (18%) with nonspecific symptoms only, and 1 (6%) with vulvar inflammation. CONCLUSION: The clinical presentation of urogenital RMS in women is heterogeneous, and the classically described presentation of grape-like lesions at the introitus and vaginal bleeding represents only a small proportion of clinical presentations. Awareness of other presentations, which appear to be more common than previously recognized, needs to be increased to ensure timely diagnosis and treatment.