Ethical, legal, social, and policy issues of ovarian tissue cryopreservation in prepubertal girls: a critical interpretive review.

PURPOSE: Despite the increasing number of childhood cancer survivors, significant advances in ovarian tissue cryopreservation (OTC) technique and medical societies' recommendations, fertility preservation (FP) and FP discussions are not always offered as a standard of care in the pediatric context. The aim of this literature review is to understand what ethical, legal, social, and policy issues may influence the provision of FP by OTC in prepubertal girls with cancer. METHODS: A critical interpretive review of peer-reviewed papers published between 2000 and January 2023 was conducted, guided by the McDougall's version of the critical interpretive synthesis (Dixon-Woods), to capture recurring concepts, principles, and arguments regarding FP by OTC for prepubertal girls. RESULTS: Of 931 potentially relevant papers, 162 were included in our analysis. Data were grouped into seven thematic categories: (1) risks of the procedure, (2) unique decision-making issues in pediatric oncofertility, (3) counseling, (4) cultural and cost issues, and (5) disposition of cryopreserved reproductive tissue. CONCLUSION: This first literature review focusing on ethical, legal, social, and policy issues surrounding OTC in prepubertal girls highlights concerns in the oncofertility debate. Although OTC is no longer experimental as of December 2019, these issues could limit its availability and the child's future reproductive autonomy. This review concludes that specific actions must be provided to enable the offer of FP, such as supporting families' decision-making in this unique and complex context, and providing pediatric patients universal and full access to free or highly subsidized OTC.

Characteristics of the vaginal microbiomes in prepubertal girls with and without vulvovaginitis.

The present study focused on the characteristics of the vaginal microbiomes in prepubertal girls with and without vulvovaginitis. We collected 24 vaginal samples and 16 fecal samples from 10 girls aged 3-9 years with vulvovaginitis and 16 healthy girls of the same age. The samples were divided into three groups: fecal swabs from healthy controls (HF), vaginal swabs from healthy controls (HVS), and vaginal swabs from girls with vulvovaginitis (VVS). Sequencing of the V3-V4 region of the 16S rDNA gene was performed with the NovaSeq PE250 platform to reveal the vaginal microbial community structure in healthy prepubertal girls and vulvovaginitis-associated microbiota. The intestinal microbiomes of healthy children were also analyzed for comparison. This study revealed that the healthy vaginal tract in prepubertal girls was dominated by Prevotella, Porphyromonas, Ezakiella, and Peptoniphilus species, with a high diversity of microbiota. The vulvovaginitis-associated microbiota were dominated by Streptococcus, Prevotella, Haemophilus, and Granulicatella, with lower diversity than that in healthy girls. Furthermore, the compositions of the vaginal and intestinal microbiomes were completely different. ANOSIM, MRPP, Adonis, and AMOVA were used to analyze the beta diversity, and the results showed that there were significant differences in the microbial communities among the three groups. Lactobacillus deficiency and high bacterial diversity were characteristics of the vaginal microbiome in healthy prepubertal girls; this is inconsistent with that in reproductive-age women. The vulvovaginitis-associated vaginal microbiota differed dramatically from normal microbiota, and the main causative agents were not fecal in origin.

Hormonal response in patients transplanted with cryopreserved ovarian tissue is independent of whether freezing was performed in childhood or adulthood.

PURPOSE: This study evaluated the concentrations of hormones resulting from the transplantation of ovarian tissue (OTT) in relation to whether the tissue was frozen at a time close to puberty or above the age of 19 years. METHODS: Six girls and adolescents (aged 9-14 years) who underwent ovarian tissue cryopreservation (OTC) were followed after transplantation in adulthood. After OTT, the women were followed via regular blood samples to evaluate the concentrations of FSH, LH, oestradiol and AMH. Twenty-three women undergoing OTT (aged 19-36 years at the time of OTC) were included as a reference group. All of the women had postmenopausal levels of gonadotropins at the time of transplantation. RESULTS: The return of FSH and LH to normal premenopausal concentrations in adult women transplanted with ovarian tissue that was frozen at a time close to puberty was similar to the profiles in women from the reference group. Serum AMH levels were below the detection limit (via the Roche Elecsys assay) in many samples, but four out of six young girls showed measurable concentrations. Oestradiol similarly increased in the first 12 weeks following transplantation, after which it tended to be higher in women having frozen tissue in adulthood. CONCLUSIONS: Ovarian tissue that was excised from girls at a time close to puberty, after which it was frozen and transplanted in adulthood, interacts with pituitary tissue in a similar manner to ovarian tissue that is frozen from adult women. Follicles located in the ovarian tissue from young girls are equally sensitive to gonadotropin stimulation as follicles from adult women when exposed to postmenopausal levels of gonadotropins. This result indicates that it is not the ovaries that require maturation to sustain full reproductive potential but rather proper FSH and LH stimulation. Moreover, these results support the continued use of OTC in young women.

The effect of subclinical hypothyroidism on ovarian volume in prepubertal girls.

OBJECTIVE: Enlargement and cystic changes in ovaries of patients with long-standing overt hypothyroidism have been described in numerous case reports. However, there are limited data about the effect of subclinical hypothyroidism (SH) on ovarian volume. The aim of the study is to evaluate the relationship between serum thyroid stimulating hormone (TSH) level and ovarian volume in prepubertal girls with SH. METHODS: Patients who were aged between 6 and 10 years and diagnosed with SH and age-matched healthy euthyroid controls were enrolled in the study. All subjects were prepubertal. RESULTS: Thirty-five children with SH (mean age; 7.6±1.0 years) and 50 euthyroid healthy girls (mean age; 7.7±1.2 years) were enrolled in the study. TSH and LH levels and both ovarian volumes were significantly higher in SH group than controls (p<0.05). In addition, TSH was positively correlated with ovarian volumes and LH in patients with SH (p<0.05). CONCLUSION: The results of this study showed that ovarian volumes of prepubertal girls with SH were significantly greater than those with normal thyroid function. Although ovarian enlargement and cyst formation is well recognized in long-standing overt hypothyroidism, it has been shown for the 1st time in patients with SH.

Effect of topical estrogen cream compared with observation in prepubertal girls with labial adhesions.

BACKGROUND: Topical estrogen treatment has been considered the first-line treatment of labial adhesions in prepubertal girls. However, the effect of topical estrogen cream is different according to studies, and no study compared estrogen cream to observation. OBJECTIVE: This study aims to investigate the efficacy of topical estrogen cream treatment compared with observation in prepubertal girls with labial adhesions. STUDY DESIGN: The medical records of prepubertal girls diagnosed with labial adhesions from April 2005 to June 2019 were retrospectively analyzed. Baseline characteristics such as age at diagnosis and initial symptoms were collected. The primary outcome was the resolution of labial adhesion. Secondary outcomes were recurrence and side effects. RESULTS: A total of 114 patients were enrolled and divided into two groups, topical estrogen cream (n = 94), and observation (n = 20). Girls who were treated with estrogen cream had older age (24.6 ± 19.0 vs. 16.7 ± 15.3 months, p = 0.037) and higher resolution rate than the observation group (100.0% vs. 85.0%, respectively, p = 0.005). Girls younger than 23.3 months showed a significantly higher resolution rate to topical estrogen treatment (100% vs. 86.7%, p = 0.043). Side effects and recurrences occurred exclusively in children treated with topical estrogen therapy without significant differences compared to the observation group. CONCLUSION: Topical estrogen therapy showed a higher resolution rate than observation for the treatment of prepubertal girls with labial adhesions, especially in younger girls.

Squamous Vaginal Papillomatosis in Prepubertal Female Twins: A Case Report.

This is the first case describing vaginal papillomatosis with a fibroepithelial polyp of the vulva in a prepubertal girl and vaginal papillomatosis in her twin sister. Parents contacted pediatric urologist regarding their eight-year-old daughter (twin A), who had a growth next to the external urethral meatus. The girl was referred to a pediatric surgeon. The exophytic 3 cm long structure with necrosis on top was found. After obtaining informed consent from girl parents, pediatric surgeon removed the exophytic structure and perform cystoscopy and vaginoscopy for possible changes in the bladder and vagina. Cystoscopy findings were normal. On vaginoscopy, numerous macroscopic papillomatous structures were identified on the cervix and vaginal walls. Vaginal biopsies were performed on the areas affected by papillomatosis. Histopathologic examination showed a fibroepithelial polyp with a central fibrovascular core covered by squamous epithelium and vaginal squamous papillomatosis. The decision was made to perform vaginoscopy on her twin sister (twin B), too. On vaginoscopy, solitary small vaginal papillomas were also found. In this case manifestation of vaginal papillomatosis in twins might have been influenced by inheritance and the same bacterial and viral environment.

Short-term nitrogen dioxide exposure is associated with the spread of S. pyogenes-induced vulvovaginitis in prepubertal girls in Hangzhou, China.

As a cause of vulvovaginitis in prepubertal girls, Streptococcus pyogenes (S. pyogenes) is commonly isolated from vaginal introitus swabs. Studies have identified several risk factors, but have not focused on the correlation between ambient air pollutants and S. pyogenes-induced vulvovaginitis in prepubertal girls. This study was conducted to determine whether ambient air pollutants were associated with S. pyogenes-induced vulvovaginitis in prepubertal girls. Daily data about S. pyogenes-induced vulvovaginitis in prepubertal girls from the outpatient department of Children's Hospital at the Zhejiang University School of Medicine in Hangzhou City between January 1, 2015, and December 31, 2018, were retrospectively reviewed. Ambient air pollutants in Hangzhou were measured daily. A generalized additive model (GAM) was utilized to assess the associations between daily air pollutants and S. pyogenes isolates obtained from vaginal introitus swabs of prepubertal girls. The mean daily concentration of nitrogen dioxide (NO2) in Hangzhou City during the study period was 44.6 µg/m3 (25th-75th percentiles, 32.0-56.0 µg/m3). The GAM showed that the largest estimate effects in S. pyogenes-induced vulvovaginitis in prepubertal girls were found in NO2 with a moving (accumulative) average on day 3. The excess risk of NO2 in terms of the daily number of S. pyogenes isolates obtained from the vaginal introitus swabs was 14.91% (95% confidence interval [CI]: 4.85-25.94%) in the single-pollutant model. The multipollutant model revealed that an increase of 10 µg/m3 in NO2 exposure was associated with an 18.33% increased risk for acquiring S. pyogenes-induced vulvovaginitis in prepubertal girls (95% CI: 1.21-38.35%; P < 0.05). In conclusion, short-term NO2 exposure was strongly associated with the spread of S. pyogenes-induced vulvovaginitis in prepubertal girls.

Clinical and Microbiological Findings of Vulvovaginitis in Prepubertal Girls.

STUDY OBJECTIVE: To evaluate genital microbiological findings in prepubertal girls with vulvovaginitis and in healthy controls. DESIGN: Prospective case-control study. SETTING: Pediatric Outpatient unit of the Department of Pediatrics of the Hospital of the Lithuanian University of Health Sciences Kauno Klinikos from November 2014 to May 2017. PARTICIPANTS: Fifty-two prepubertal girls aged 1-9 years diagnosed with vulvovaginitis, and 42 age-matched healthy controls. INTERVENTIONS AND MAIN OUTCOME MEASURES: Samples for microbiological culture were collected using sterile cotton swabs from the introitus and the lower third of the vagina from all study participants. Microbiological findings were analyzed according to bacteria type and intensity of growth. RESULTS: Most of the vaginal microbiological swab results were positive for bacterial growth: 47 (90.4%) and 34 (80.9%) were similar in the study and control groups, respectively (P = .24). Sixteen (30.8%) and 9 (21.4%) of the microbiological traits results in the case and control groups, respectively, were regarded as potential causative agents (P = .27). Streptococcus pyogenes was the most frequent pathogen in the study group (P = .03); all other microorganisms detected as either a pure or dominant growth in the control group, were considered opportunistic. CONCLUSIONS: Vaginal bacterial culture results were positive in prepubertal girls with vulvovaginitis and in healthy controls. Nonspecific vulvovaginitis without a dominant/isolated pathogen was seen to be more common than vulvovaginitis with a potential causative agent. Clinical symptoms were more frequent among girls when the potential infectious agent was identified.

Personal Hygiene and Vulvovaginitis in Prepubertal Children.

STUDY OBJECTIVE: To determine and compare clinical and microbiological features of vulvovaginitis in prepubertal girls. Vulvovaginitis is the most common gynecological problem of childhood. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This study involved 45 girls from 2-12 (5.38 ± 2.9) years old; and 26 girls from 3-12 (5.72 ± 3.1) years old as a control group. Anamnesis and physical examination were followed by vaginal smear, urine culture, and stool analyses from both groups, and the personal hygiene status and education level of the mother were determined. RESULTS: The most common symptoms among the patients were vaginal discharge (44.4%, vulvar erythema (37.8%), and vaginal itch (24.4%). Microorganisms, isolated from vaginal smears, were detected in 48.9% of the patients. Escherichia coli was shown in the urine culture of 3 patients with vulvovaginitis (6.70%). In microscopic stool analysis parasites were detected (45.9%). We found some relevant personal hygiene factors, such as wiping back to front (42.9%), cleaning by herself after defecation (89.3%), using toilet paper (60.7%) and wet wipes (21.4%), and bathing standing (14.3%) and sitting (46.4%) among patients. The questionnaire also showed that the children wore tight clothing (35.7%). CONCLUSION: Our findings suggest that vulvovaginitis in prepubertal girls is related not only to microorganisms but also poor personal hygiene, the educational status of mothers, and specific irritants.

Genital HPV in Children and Adolescents: Does Sexual Activity Make a Difference?

STUDY OBJECTIVE: To compare the prevalence of human papillomavirus (HPV) genital infection among prepubertal children, sexually active and not sexually active adolescents, and assess potential risk factors for transmission. DESIGN: Prospective study. SETTING: Outpatient adolescent health clinic. PARTICIPANTS: Ninety-five girls aged 2-21 years; 38 sexually active adolescents (group A), 28 not sexually active adolescents (group B), and 29 prepubertal children (group C). INTERVENTIONS: Participants' vaginal or cervical specimens were tested for HPV with the CLART HPV 2 assay (Clinical Array Technology, Genomica, Madrid, Spain) and for cytological abnormalities with liquid-based cytology. MAIN OUTCOME MEASURES: Differences in prevalence of low- and high-risk HPV infections among the 3 groups. RESULTS: Genital HPV was detected in 37.9% (36/95) of all participants; 47.4% (18/38) of group A, 28.6% (8/28) of group B, and 34.5% (10/29)of group C (P = .27). Multiple HPV infection was detected in 26.3% (10/38), 10.7% (3/28), and 13.8% (4/29) of groups A, B, and C, respectively (P = .21). High-risk genotypes were detected in 47.4% (18/38), 28.6% (8/28), and 24.1% (7/29) of groups A, B, and C, respectively (P = .10). Main high-risk genotypes were HPV 16 (27%, 10/37), HPV 31 (21.6%, 8/37 ), HPV 35 (13.5%, 5/37), HPV 53 (13.5%, 5/37), and low-risk HPV 6 (18.9%, 7/37). Sexual activity was associated with increased risk for genital high-risk HPV infection (odds ratio = 3.41; 95% confidence interval, 1.19-9.78); specifically with HPV 33 and HPV 51. Forty percent of sexually active adolescents with normal cervical cytology were infected with high-risk HPV types. Family history of skin HPV was positively associated with genital HPV in the sexually active group (odds ratio = 2.01; 95% confidence interval, 1.17-3.46). CONCLUSION: Timeline and target population for HPV vaccination might need to be reappraised, in view of significant nonsexual transmission of genital HPV so early in childhood.

Updates in preserving reproductive potential of prepubertal girls with cancer: Systematic review.

INTRODUCTION: With increasing numbers of adult female survivors of childhood cancers due to advances in early diagnosis and treatment, the issue of preserving the reproductive potential of prepubertal girls undergoing gonadotoxic treatments has gained greater attention. METHODS: According to PRISMA guidelines, a systematic review of the literature was performed for all relevant full-text articles published in PubMed in English throughout the past 15 years to explore the significant updates in preserving the reproductive potential of prepubertal girls with cancer. RESULTS: The two established fertility preservation options, embryo freezing and egg freezing, cannot be offered routinely to prepubertal girls as these options necessitate prior ovarian stimulation and subsequent mature oocytes retrieval that are contraindicated or infeasible before puberty. Therefore, the most suitable fertility preservation options to prepubertal girls are (1) ovarian tissue freezing and autotransplantation, (2) in vitro maturation, and (3) ovarian protection techniques. In this review, we discuss in detail those options as well as their success rates, advantages, disadvantages and future directions. We also suggest a new integrated strategy to preserve the reproductive potential of prepubertal girls with cancer. CONCLUSION: Although experimental, ovarian tissue slow freezing and orthotopic autotransplantation may be the most feasible option to preserve the reproductive potential of prepubertal girls with cancer. However, this technique has two major and serious disadvantages: (1) the risk of reintroducing malignant cells, and (2) the relatively short lifespan of ovarian tissue transplants. Several medical and ethical considerations should be taken into account before applying this technique to prepubertal girls with cancer.

A new surgical approach of temporary ovarian transposition for children undergoing brachytherapy: technical assessment and dose evaluation.

PURPOSE: We developed a new technique of temporary ovarian transposition (OT) for prepubertal girls undergoing brachytherapy. The aim of this study was to describe it, assess its feasibility and safety and calculate the dose delivered to the ovary in order to prove its efficacy. METHODS: Sixteen prepubertal patients underwent temporary OT for brachytherapy at our center from March 2001 to December 2012. OT was done either by laparotomy or by laparoscopy. In all patients, the ovaries were grasped with an atraumatic forceps and mobilized above the iliac crest level as high as possible without any dissection or division of the ovarian ligaments or of the fallopian tube. They were sutured to the anterior abdominal wall by a transfixing stitch of non-dissolvable suture knotted on the outside of the patient on a pledget. RESULTS: Median age at surgery was 3 years (range: 2-9 years). The integrity of the fallopian tube was respected and not a single ligament was dissected or divided. None of the patients had intraoperative or postoperative complications. The stitches were retrieved after completion of irradiation and the ovaries in all the patients fell back into the pelvis. The calculated median radiation dose to the ovary was 1.4 Gy (range: 0.4-2.4 Gy). CONCLUSIONS: This surgical technique is simple and safe, either by laparotomy or by laparoscopy. It meets the radiation and physical constraints in prepubertal girls with vaginal or bladder RMS. However, longer follow-up is required to assess the ovarian function.

Hormonal profile and androgen receptor study in prepubertal girls with hypertrichosis.

BACKGROUND: Prepubertal hypertrichosis is a reportedly benign condition characterized by an excessive growth of vellous hair in non-androgen dependent areas of the body compared to the amount usually present in normal subjects of the same age, race and sex. Although this condition is usually considered idiopathic and regarded as benign, it may be very disturbing cosmetically, causing significant patient and parental anxiety. METHOD: We performed a hormonal and androgen receptor study in 42 prepubertal girls with hypertrichosis and 29 control girls from 2 to 8 years of age. Both groups underwent a determination of basal LH, FSH, 17OH progesterone, androstenedione, testosterone, estradiol and SHBG, abdominal ultrasound to assess ovarian morphology, and the number of androgen receptor CAG/GGC repeats in DNA obtained from peripheral leukocytes. RESULTS: The hypertrichosis score was higher in the cases compared to controls. Serum gonadotropins and sex steroids were similar in both groups, but SHBG was significantly lower in the girls with hypertrichosis (71.1 ± 2.9 vs 81.9 ± 3.0 nmol/L, p < 0.02). The distribution of shorter, larger and total alleles was not statistically different between cases and controls. The combined analysis of CAG/GGC, however, showed a significantly higher prevalence of the most androgen-sensitive haplotypes (1-2: <22CAG + 17/17GGC- < 14CAG + 17/18GGC) in girls with hypertrichosis compared to controls. CONCLUSIONS: We conclude that girls with hypertrychosis exhibit AR(s) with enhanced sensitivity, which may facilitate the growth of their body hair.

Effect of oligofructose-enriched inulin on bone metabolism in girls with low calcium intakes

In the present clinical study, the effect of oligofructose-enriched inulin was studied on bone metabolism in girls from 9 to 12 years old, with low habitual calcium intakes, who attended public schools. Two calcium-enriched formulations, supplemented with oligofructose-enriched inulin (test drink) or without (standard drink) were made. Sixty pre-pubertal girls were randomized into a double-blind and crossover design, divided into three groups and received one daily portion of either the standard drink (group 1) or test drink (group 2) during 11 weeks, followed by a three-week washout period. Group control did not receive any supplementation. Biochemical evaluations of serum calcium, intact parathyroid hormone - iPTH - and bone alkaline phosphatase - BAP - were performed at baseline and after 4, 8 and 11 weeks of each intervention period. In group 1, a significant increase in serum calcium and BAP and a reduction of iPTH were observed after consumption of the test drink.

No presente ensaio clínico, o efeito de oligofrutose enriquecida com inulina foi estudado no metabolismo ósseo de meninas de 9 a 12 anos com baixa ingestão habitual de cálcio, matriculadas em escolas públicas. Duas formulações foram suplementadas ou não (bebida padrão) com oligofrutose enriquecida com inulina (bebida teste). Sessenta meninas pré-púberes foram aleatorizadas em estudo duplo cego crossover e divididas em três grupos e receberam uma porção diária da bebida padrão (grupo 1) ou teste (grupo 2) durante 11 semanas, seguidos por um período de intervalo de três semanas. O grupo controle não recebeu nenhuma suplementação. As avaliações bioquímicas de cálcio sérico, paratormônio intacto - PTHi e fosfatase alcalina fração óssea - FAO foram executadas ao início e após 4, 8 e 11 semanas de cada período de intervenção. No grupo 1, um aumento significante no cálcio sérico e FAO e uma redução no PTHi foram observadas após o consumo da bebida teste.