Chromosomally competent ovarian failure at adolescence.

Three female adolescents are presented with delayed or incomplete secondary sexual development due to primary ovarian failure. All three patients had normal blood leukocyte and ovarian tissue karyotypes. The importance of performing a diagnostic laparoscopy with ovarian biopsy in the setting of chromosome competent ovarian failure (CCOF) is emphasized.

PIP: The cases are described of 3 female adolescents evaluated at the Cincinnati Adolescent Clinic for delayed or incomplete secondary sexual development due to primary ovarian failure. All 3 patients had normal blood leukocyte and ovarian tissue karyotypes. The clinical, laboratory, and pathological findings are discussed with emphasis on distinguishing chromosome incompetent ovarian failure (CIOF-Turner's syndrome) from chromosome competent ovarian failure (CCOF). The patients included a 15 1/2 year old black female who sought evaluation of obesity and lethargy, a 17 1/2 year old white female with secondary amenorrhea in whom oral provera failed to induce menstrual flow, and a 17 1/2 year old black female with scanty, infrequent menses who achieved a normal amount and duration of menstrual flow with Norinyl 1 + 80. Hypoestrogenization should be suspected in cases of incomplete breast development for age, thin vaginal mucosa with a prepubertal pattern of the vaginal cytology, scant cervical mucus without ferning, and lack of withdrawal bleeding after progesterone administration. If any decrease in ovarian steroid production is clinically suspected in an adolescent with primary or secondary amenorrhea associated with delayed or incomplete puberty, serum gonadotropin levels should be measured. A single elevated follicle stimulating hormone (FSH) level in the menopausal range is diagnostic of primary ovarian failure in an adolescent. If the FSH is low or normal, hypothalamic or pituitary disease would be suspected. A blood leukocyte karyotype is the next diagnostic procedure for patients with primary ovarian failure to distinguish between CCOF and CIOF. If the blood karyotype is XO or a variant without a Y cell line, no further cytogenic workup or visualization of the gonads is needed, but girls with blood karyotype of XX or a mosaic pattern with 1 cell line with a Y chromosome should undergo laparoscopy and gonadal biopsy. A unilateral testis should be removed to avoid malignant changes in later years. Patients with CCOF may have other endocrine dysfunction, particularly autoimmune disease. Other possible diagnoses include resistant ovary syndrome, pure gonadal dysgenesis, premature menopause, or infectious, chemical, or other causes of ovarian failure. The incidence of CIOF is greater than that of CCOF among patients with primary ovarian failure. Optimal treatment requires medical and psychosocial intervention.

Experience with the copper 7 intrauterine device in an adolescent population.

A retrospective study was conducted of 120 consecutive patients who received a Cu-7 IUD at the Cincinnati Adolescent Clinic during a four-year period from July, 1974, through June, 1978. Follow-up was obtained in 116 (97%) of the initial patient population. Mean age at initial Cu-7 insertion was 16.8 years; 81% of the patients were nulliparous. An experience of 149.7 women years was accumulated; the pregnancy rate at the conclusion of the study was 2.0/100 women years. Continuation rate was 83% at six months, 70% at 12 months, 49% at 24 months, and 39% at 36 months. Patient expulsion rate was 18% overall, with a total of 17 expulsion events/100 woman years. Subjective satisfaction with the IUD as a contraceptive method was expressed by 72% of these patients. The Cu-7 has proven to be a safe, effective, well-tolerated contraceptive method in the adolescent female.

PIP: Over the July 1974 through June 1978 period a retrospective study was conducted of 120 consecutive patients between the ages of 13 and 22 years who received a copper 7 IUD at the Cincinnatti Adolescent Clinic. The patient population was 58% black and 42% white, generally urban, and predominantly from lower socioeconomic areas. At the time of the initial Cu-7 insertion, 81% of the patients were nulliparous, 16% were primiparous, and 3% multiparous. Follow-up was obtained in 116 (97%) of the initial population. At the conclusion of the study the combined duration of Cu-7 retention was 149.7 woman years. The cumulative patient continuation rate was 96/116 or 83% at 6 months, 63/90 or 70% at 12 months, 27/55 or 49% at 24 months, and 12/31 or 39% at 36 months. 3 pregnancies occured, yielding a rate of 2.0/100 woman years of IUD retention. A survey of contraceptive methods used before Cu-7 insertion showed that 47% of the patients had used oral contraception, whereas 38% had no previous contraceptive experience. Partial spontaneous expulsion of the Cu-7 was noted in 18% of the patient population, with a total of 26 expulsions or 17/100 woman years. Most side-effects reported by patients were self-limited and resolved within 2-3 months following insertion. Documented episodes of sexually transmitted disease occurred in 60/116 (51%) of the patients during the period of IUD retention. The Cu-7 was removed from 64 patients (55%) at some point during the period studied. Subjective reasons for removal predominated. Almost 2/3 of the patients chose an alternative contraceptive following IUD removal.

Incidence of venous thromboembolic disease in nonpregnant women of childbearing age.

Data from 12 Cincinnati hospitals were examined to determine the incidence of venous thromboembolic disease in nonpregnant women of reproductive age. The incidence of superficial and deep vein thromboembolic disease in women age 15 to 44 was 1.09 cases per 1,000 women per year; for women age 20 to 44 the incidence was 1.3 cases for 1,000 women per year. These figures include idiopathic and non-idiopathic cases and thus are representative of the general population of nonpregnant women of reproductive age. The incidence of pulmonary embolism was approximately 1 case per 5,000 women age 20 to 44. There were two deaths from pulmonary embolism, giving a mortality rate of 11.3 deaths per million women age 15 to 44.

Gorlin's syndrome: ovarian fibromas at adolescence.

An adolescent with bilateral ovarian fibromas associated with Gorlin's or the multiple nevoid basal cell carcinoma syndrome is described. The syndrome should be considered and looked for when bilateral solid ovarian masses are found in young women.

Contraception for the teenager.

PIP: Although adolescents are now fecund at an earlier age, they are not ready for parenthood financially, educationally, or socially until a much later time. More and more states directly or indirectly permit minors to consent for their own contraceptive needs, a trend that must be applauded. Studies of adolescent attitudes, knowledge, and use of contraceptives indicate a woeful ignorance and lack of use, even among college students. From a medical and practical point of view, the IUD is considered the most suitable contraceptive for the teen-ager. A well-established menstrual cycle of at least 2 years should be be present if oral contraceptives are used. Abstience, although medically ideal, must be initiated by the patient; otherwise, the failure rate is high. The failure rate for the condom, diaphragm, and spermicidal foam is high, except when 2 methods are used at the same time. Coitus interruptus, douche, and rhythm have no application for adolescents. Girls who have had an abortion should receive contraceptive counseling immediately following the abortion. Sterilization must be considered very cautiously for this age group.^ieng

Problems with contraception in adolescents. The successful use of an intrauterine device.

PIP: The use of intrauterine contraceptive devices to prevent out-of-wedlock pregnancies among 155 adolescents at the Adolecent Clinic of the University of Cincinnati Medical Center is described. The girls participating in the program from 1965 to 1971 were predominantly black, ranging in age from 11-20 years. Patients and parents were counselled about contraceptive methods, and if the IUD was chosen, its function and use were explained. An IUD was usually recommended for those patients who had a medical contraindication to oral contraceptives, in cases of other method failure, or in cases of lack of motivation or ability to follow instructions. Of 91 insertions of the Lippes loop IUD, there were 50 spontaneous expulsions. The high expulsion rate was a serious deterrent to proper patient motivation. In 1968 the program began using the Majzlin Spring, a stainless steel accordion-like device. 60 insertions were performed with this device and only 3 expulsions have been reported in follow-up ranging from 5 to 18 months. 1 uterine perforation occurred, believed due to problems with early postpartum insertion. 17 removals for infection or bleeding were necessary with the Lippes loop, and 8 with the Majzlin Spring. The pregnancy failure rate for the loop was 2.2% and 1.6% for the spring. The Majzlin device was also noticeably well retained by patients who had expelled other IUDs, but one-third of the patients with the spring device experienced significant postinsertion bleeding. The Majzlin Spring appears to be a highly acceptable contraceptive method for adolescents who fail to handle other means of preventing pregnancy, provided careful clinic observations are maintained.^ieng