Menstrual suppression for adolescents

Laparoscopic Uterine Preservation and Vaginal Reconstruction in a 13-Year-Old Girl with Uterus Didelphys, Bilateral Vesicovaginal Fistulas, and Transverse Vaginal Septum

BACKGROUND

Complex female genital tract malformations account for 1.2% of all female genitourinary malformations. Although exceedingly rare, they can cause severe gynecologic symptoms in young women and lead to fertility problems.

CASE

We present the case of a 13-year-old girl with primary amenorrhea referred for cyclic abdominal lower pain and menouria. Detailed diagnostics revealed uterus didelphys, transverse vaginal septum, and bilateral vesicovaginal fistulas. Laparoscopic left hemi-hysterectomy and salpingectomy were performed. The vesicovaginal fistula on the right side was excised, and the proximal vagina was anastomosed with the distal dimple. Since the operation, the patient has been pain-free and menstruating regularly from the right uterus.

SUMMARY AND CONCLUSION

Preservation of the uterus should be considered in any case of complex female genital tract malformation and, as successful laparoscopic treatment advocates, a minimally invasive approach is feasible.

Norethindrone dosing for adequate menstrual suppression in adolescents

OBJECTIVES

We sought to study factors predictive of achieving menstrual suppression with norethindrone vs. norethindrone acetate in adolescents, as optimal dosing is unknown. Secondary outcomes included analyzing prescriber practices and patient satisfaction.

METHODS

We performed a retrospective chart review of adolescents ages <18 years presenting to an academic medical center from 2010 to 2022. Data collected included demographics, menstrual history, and norethindrone and norethindrone acetate use. Follow-up was measured at one, three, and 12 months. Main outcome measures were starting norethindrone 0.35 mg, continuing norethindrone 0.35 mg, achieving menstrual suppression, and patient satisfaction. Analysis included Chi-square and multivariate logistic regression.

RESULTS

Of 262 adolescents initiating norethindrone or norethindrone acetate, 219 completed ≥1 follow-up. Providers less often started norethindrone 0.35 mg for patients with body mass index ≥25 kg/m2, prolonged bleeding, or younger age at menarche, but more often for patients who were younger, had migraines with aura, or were at risk of venous thromboembolism. Those with prolonged bleeding or older age at menarche were less likely to continue norethindrone 0.35 mg. Obesity, heavy menstrual bleeding, and younger age were negatively associated with achieving menstrual suppression. Patients with disabilities reported greater satisfaction.

CONCLUSIONS

While younger patients more often received norethindrone 0.35 mg vs. norethindrone acetate, they were less likely to achieve menstrual suppression. Patients with obesity or heavy menstrual bleeding may achieve suppression with higher doses of norethindrone acetate. These results reveal opportunities to improve norethindrone and norethindrone acetate prescribing practices for adolescent menstrual suppression.

Menstrual health and genital hygiene status in adolescent girls and young women with cerebral palsy

Menstrual health and genital hygiene behavior in patients with cerebral palsy (CP) is underrecognized, undertreated, and negatively affects quality of life. The aim of this case-control study is to compare menstrual health and genital hygiene behaviors in adolescent girls and young women with CP to a healthy women control group. Participants were invited to study via social media tools between August 2021 and February 2022. The study included 74 adolescent girls and young women with CP and 89 healthy women. Menstrual status with semi-structured questions, menstrual symptoms with "Menstrual Symptom Questionnaire (MSQ)," genital hygiene behavior with "Genital Hygiene Behavior Scale (GHBS)" were evaluated. The control group scored significantly higher on the MSQ sub-dimensions of "negative effects somatic complaints" (r = 0.396; p < .001), "menstrual pain" (r = 0.287; p < .001), "coping methods" (r = 0.291; p < .001), and total score (r = 0.395; p < .001), as well as the GHBS sub-dimensions of "awareness of abnormal findings" (r = 0.270; p = .001) and "menstrual hygiene" (r = 0.495; p < .001) and total score (r = 0.393; p < .001). People with CP had worse genital hygiene behavior, had less menstrual symptoms, and behaved differently about the menstruation symptoms. This study focused on adolescent girls and young women with CP who cannot easily express their own experiences and concerns, emphasized that their needs should be identified by determining their menstrual health and genital hygiene behaviors.Clinical Registration Name, Registration Number, Registration Date: Menstrual Health and Genital Hygiene Status in Cerebral Palsy and NCT04985045, August 2,2021.

Menstrual Suppression in Gender Minority Youth

The purpose of this case series was to evaluate menstrual suppression in sex assigned at birth female adolescents identifying as male or gender non-conforming. A retrospective chart review of four gender minority youth (GMY), age 14-17, was performed for gender identity history, type and success of menstrual suppression, method satisfaction, side effects and improvement in menstrual distress. Menstrual suppression was successful in three patients, one patient discontinued use due to side effects that caused an increase in gender dysphoria. Menstrual distress and bleeding pattern improved in the majority of GMY in this series but side effects, as well as contraindications, may limit their use. In conclusion, menstrual dysphoria can be life-threatening for GMY and it is important that clinicians consider menstrual suppression in GMY with menstrual dysphoria. This series emphasizes the importance of individualized treatment plans.

General Approaches to Medical Management of Menstrual Suppression: ACOG Clinical Consensus No. 3

SUMMARY

The purpose of this document is to review currently available management options, general principles, and counseling approaches for reproductive-aged patients requesting menstrual suppression. It includes considerations for unique populations, including adolescents, patients with physical or cognitive disabilities or both, and those with limited access to health care. Gynecologists should be familiar with the use of hormonal therapy for menstrual suppression (including combined oral contraceptive pills, combined hormonal patches, vaginal rings, progestin-only pills, depot medroxyprogesterone acetate, the levonorgestrel-releasing intrauterine device, and the etonogestrel implant). Approaches to counseling should be individualized based on patient preferences and goals, average treatment effectiveness, and contraindications or risk factors for adverse events. Counseling regarding the choice of hormonal medication for menstrual suppression should be approached with the utmost respect for patient autonomy and be free of coercion. Complete amenorrhea may be difficult to achieve; thus, obstetrician-gynecologists and other clinicians should counsel patients and caregivers, if applicable, about realistic expectations.

Experiences with Menses in Transgender and Gender Nonbinary Adolescents

STUDY OBJECTIVE

To describe menstrual history, associated dysphoria, and desire for menstrual management in transgender male and gender diverse adolescents who were assigned female at birth DESIGN: Retrospective chart review SETTING: Tertiary care children's hospital PARTICIPANTS: All patients seen in a multidisciplinary pediatric gender program from March 2015 through December 2020 who were assigned female at birth, identified as transgender male or gender nonbinary, and had achieved menarche INTERVENTION: None MAIN OUTCOME MEASURES: Patient demographics, menstrual history, interest in and prior experiences with menstrual management, parental support, and concerns about menstrual management RESULTS: Of the 129 included patients, 116 (90%) identified as transgender male and 13 (10%) as gender nonbinary, with an average age of 15 (SD 1.6) years. Almost all (93%) patients reported menstrual-related dysphoria. Most (88%) were interested in menstrual suppression. The most common reasons for desiring suppression were achievement of amenorrhea (97%) and improvement of menstrual-related dysphoria (63%).

CONCLUSIONS

Most gender diverse patients assigned female at birth reported dysphoria associated with menses and desired menstrual suppression. This information can encourage physicians to raise this topic and offer menstrual management for gender diverse patients who experience distress related to menses, especially for those who are not ready for or do not desire gender-affirming hormonal treatment. Future research is needed to better understand patients' experiences with menses and to determine the optimal menstrual management methods. This could be an important intervention to improve outcomes for this vulnerable population.

Medical and Behavioral Aspects of Adolescent Endometriosis: A Review of the Literature

The majority of young women will experience discomfort associated with menstrual cycles and miss out on education and social opportunities. Endometriosis, the presence of endometrial glands and stroma outside of uterus, is the most common cause of secondary dysmenorrhea and characterized by pain despite treatment with nonsteroidal anti-inflammatory drugs and hormonal agents. The true prevalence of adolescent endometriosis is not clear. Delay in diagnosis leads to persistent pain, affects quality of life, and potentially contributes to disease progression and subfertility. A laparoscopic diagnosis is the gold standard, but the surgical appearance may differ from adults, as endometriotic lesions are usually red or clear, making their identification a challenge for gynecologists who are unexperienced with endometriosis in adolescents. A personalized medical–surgical treatment is regarded as the most effective therapeutic strategy to achieve remission of symptoms, suppress disease progression, and protect future fertility. Studies have demonstrated how adolescent endometriosis negatively affects patients’ quality of life and psychosocial functioning. Development of therapeutic interventions targeting psychosocial function and quality of life is imperative for adolescent patients.

Affirming Pediatric Care for Transgender and Gender Expansive Youth

Transgender and gender diverse children and youth experience significant health disparities and adverse health outcomes. Pediatricians have an opportunity to improve those outcomes by practicing gender-affirming care. This includes creating a welcoming environment through changes in office settings, intake forms, communication skills, language used, and support for families. Clinicians should be comfortable discussing social transition, puberty blockers, and gender-affirming hormone therapy with patients as needed. For clinicians caring for teenagers, adaptations in sexual health counseling and fertility counseling are necessary. Clinicians should also be aware of the trauma that has been historically inflicted by the medical and mental health system against people who identify as transgender/nonbinary, and that significant disparities exist even within this group along racial and gender lines. These aspects of caring for gender diverse youth are part of primary care pediatrics, and further education in these areas will improve access to care and health outcomes for these youth. [Pediatr Ann. 2021;50(2):e65-e71.].

Bleeding Patterns among Adolescents Using the Levonorgestrel Intrauterine Device: A Single Institution Review

STUDY OBJECTIVE

To describe the bleeding patterns associated with the use of the levonorgestrel intrauterine device (IUD) in adolescents.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective chart review of postmenarchal adolescent patients ages 8-19 years who had the levonorgestrel IUD inserted at Phoenix Children's Hospital from 2012 to 2018.

INTERVENTIONS

Insertion of the 52-mg and 13.5-mg levonorgestrel IUD.

MAIN OUTCOME MEASURES

The rate of amenorrhea and other bleeding patterns after insertion of the levonorgestrel IUD and the factors that might predict those bleeding patterns.

RESULTS

A total of 260 charts were identified with 221/260 (85.0%) patients choosing the 52-mg IUD and 39/260 (15.0%) patients choosing the 13.5-mg IUD to be inserted. Follow-up data were available for 166 patients. The overall rate of amenorrhea among IUD users was 39.8% (n = 66) with no difference between 52-mg and 13.5-mg IUD users (P = .656). Regularity and flow of menstrual cycle, history of bleeding disorder, history of developmental delay, and current treatment with testosterone for gender dysphoria before IUD insertion did not appear to have a significant effect on the rate of amenorrhea or bleeding patterns post-IUD insertion.

CONCLUSION

The levonorgestrel IUD can be successfully used to control abnormal uterine bleeding and suppress menses in adolescents. Menstrual cycle characteristics pre-IUD insertion did not result in predictable post-IUD bleeding patterns.

Endometriosis in adolescence: Early manifestation of the traditional disease or a unique variant?

Little is known about Endometriosis in Adolescents and its prevalence is yet to be estimated. Traditional Endometriosis seems to be, by far, quite different with this unique variant when it comes to clinical presentation, management and course of the disease. Further research needs to be conducted in order to classify these two, phenomenically similar, diseases. Adolescents with a history of dysmenorrhea and chronic pelvic pain (CPP) imply findings suggestive of endometriosis. The severity of the disease is variable, from superficial endometriosis to deep endometriotic lesions or even ovarian endometriomas. The course of the disease also suggests the necessity of a more personalized approach since among adolescents, endometriosis could resolve or even aggravate with no particular pathophysiological pattern. Some studies suggest that appropriate treatment should be based on the understanding of the pathophysiologic mechanisms. Long term course of the disease, as well as, a high recurrence rate pose a difficulty to scientists, deciding conservative over operative surgery. Some believe that early operation on superficial forms of endometriosis could potentially prevent deep endometriotic lesions in the long-run. Others find medication such as, combined oral contraceptive pills (COCPs), progestins, levonorgestrel intrauterine device or gonadotrophin releasing hormone analogues (GnRHa), more appropriate for this age group. Last but not least, operation with post-operative hormonal treatment remains the most common treatment approach. Nevertheless, our limited understanding of the disease, as well as, particular factors needed to be taken into consideration, for instance, bone formation in this age group, underline the necessity of further studies, needed to be appointed, in order to determine the best diagnostic and therapeutic approach.

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.

Medical Options for Care of Gender Diverse and Transgender Youth

Increasing numbers of transgender and gender diverse (TGD) youth are presenting for medical care, including seeking more information and access to services from gynecologic and reproductive health experts. Such experts are well positioned to provide affirming, comprehensive services, including education, hormonal interventions, menstrual management, contraception, and various gynecological procedures. Early medical guidance and support for the TGD community has been associated with long-term positive emotional and physical health outcomes. In this article medical interventions that reproductive health experts can offer to their TGD patients are discussed.

Diagnosis and Management of Heavy Menstrual Bleeding and Bleeding Disorders in Adolescents

IMPORTANCE

Heavy menstrual bleeding is a common cause of anemia and reduced quality of life in adolescents. There is a higher prevalence of bleeding disorders in girls with heavy menstrual bleeding than in the general population. Pediatricians should be comfortable with the initial evaluation of heavy menstrual bleeding and the indications for referral to subspecialty care.

OBSERVATIONS

The most common cause of heavy menstrual bleeding in adolescents is ovulatory dysfunction, followed by coagulopathies. The most common inherited bleeding disorder is von Willebrand disease, and its incidence in adolescents with heavy menstrual bleeding is high. Distinguishing the etiology of heavy menstrual bleeding will guide treatment, which can include hemostatic medications, hormonal agents, or a combination of both. Among hormonal agents, the 52-mg levonogestrel intrauterine device has been shown to be superior in its effect on heavy menstrual bleeding and is safe and effective in adolescents with bleeding disorders.

CONCLUSIONS AND RELEVANCE

Anemia, need for transfusion of blood products, and hospitalization may be avoided with prompt recognition, diagnosis, and treatment of heavy menstrual bleeding, especially when in the setting of bleeding disorders. Safe and effective treatment methods are available and can greatly improve quality of life for affected adolescents. A multidisciplinary approach to the treatment of girls with bleeding disorders and history of heavy menstrual bleeding is optimal.

A Clinical Approach to Catamenial Epilepsy: A Review

IMPORTANCE

Catamenial epilepsy (CE) is exacerbated by hormonal fluctuations during the menstrual cycle. Approximately 1.7 million women have epilepsy in the United States. CE affects more than 40% of women with epilepsy. There is a paucity of literature addressing this condition from a clinical standpoint, and the literature that does exist is limited to the neurological community. This article reviews the diagnosis and management of CE for the non-neurologist. Women with CE have early touch points in their care with numerous health care providers before ever consulting with a specialist, including OB/GYNs, pediatricians, emergency department physicians, and family medicine providers. In addition, women affected by CE have seizures that are more recalcitrant to traditional epilepsy treatment regimens. To optimize management in patients affected by CE, menstrual physiology must be understood, individualized hormonal contraception treatment considered, and adjustments and interactions with antiepileptic drugs addressed.

OBSERVATIONS

CE is a unique subset of seizure disorders affected by menstrual fluctuations of progesterone and estrogen. The diagnosis of CE has been refined and clarified. There is an ever-increasing understanding of the importance and variety of options of hormonal contraception available to help manage CE. Furthermore, antiepileptic drugs and contraception can interact, so attention must be directed to optimizing both regimens to prevent uncontrolled seizures and pregnancy.

CONCLUSION AND RELEVANCE

CE can be diagnosed with charting of menstrual cycles and seizure activity. Hormonal treatments that induce amenorrhea have been shown to reduce CE. Optimizing antiepileptic drug dosing and contraceptive methods also can minimize unplanned pregnancies in women affected by CE.

Management of Menstrual and Gynecologic Concerns in Girls with Special Needs

For girls with physical and developmental disabilities and their families/caregivers, puberty and menstruation can present significant problems such as vulnerability, abuse risk, unintended pregnancies, difficulties with managing menstrual hygiene, abnormal uterine bleeding, dysmenorrhea, behavioral difficulties/mood concerns or changes in seizure pattern. Healthcare providers may have an important and positive impact for both the adolescents and their families/caregivers during this stage of life. Whether menstrual manipulation is indicated should be decided after a detailed history is taken from both the patient and the caregivers to determine the impact of current problems on quality of life. It should be explained that complete amenorrhea is difficult to achieve and realistic expectations should be addressed. The goals for the management of menstrual concerns should be a reduction in the amount and total days of menstrual flow, reduction of menstrual pain and suppression of ovulatory or cyclic symptoms, depending on each individual patient’s needs. Advantages and disadvantages of available treatment methods should also be discussed.

The myth of menstruation: how menstrual regulation and suppression impact contraceptive choice

BACKGROUND

Women in the US have access to various hormonal contraceptive methods that can regulate menstruation. This study examined the attitudes and perceptions of reproductive-aged women toward contraceptive methods, including how menstrual regulation and suppression preferences influenced contraceptive choice.

METHODS

Data collection used a mixed-methods approach, including 6 focus groups (n = 61), individual interviews (n = 18), and a web-based survey (n = 547).

RESULTS

Participants described contraceptive method preferences that allowed monthly bleeding and daily control, expressing concerns about long-acting reversible contraception (LARC) because of decreased user involvement. Some participants noted LARC improved their menstrual control. Many participants felt menstruation was healthy, whereas suppression was abnormal and resulted in negative health outcomes. Though participants indicated LARC as beneficial (M = 4.99 ± 1.66), convenient (M = 5.43 ± 1.68), and healthy (M = 4.62 ± 1.69), they chose combined oral contraceptives due to convenience.

CONCLUSIONS

Findings suggest women need more information about menstrual regulation and suppression before selecting a contraceptive method, specifically in relation to LARC versus combined oral contraception. Framing menstrual suppression as healthy and natural may improve perceptions of long-term health consequences related to LARC. Providers should discuss menstrual suppression safety to ensure selection of contraceptive options aligning with women's preferences and needs.

Menstrual Suppression in Pediatric and Adolescent Patients with Disabilities Ranging from Developmental to Acquired Conditions: A Population Study in an Australian Quaternary Pediatric and Adolescent Gynecology Service from January 2005 to December 2015

STUDY OBJECTIVE

The aim of this study was to review the efficacy of different medical modalities for menstrual suppression in the cohort of patients with disabilities who presented to the Queensland Paediatric and Adolescent Gynaecology (PAG) Service between January 2005 and December 2015. Menstrual suppression in adolescents with disabilities is an important aspect of care to support the patient and their carers in managing the complexities of menstrual hygiene, pain, and other discomfort associated with menses. It is important for general practitioners, pediatricians, and gynecologists to establish the right modality of suppression for each individual adolescent. DESIGN, SETTINGS, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: The study was a retrospective case notes review of 68 adolescents who presented to the Queensland PAG Service, Brisbane, Australia with a request for menstrual suppression. The medical interventions included treatment with either combined oral hormonal contraceptive, oral medroxyprogesterone, depot medroxyprogesterone, or the levonorgestrel intrauterine system (Mirena, Bayer). The primary outcome measure was success of menstrual suppression from commencement of medical intervention to achievement of complete amenorrhea or very light bleeding described as spotting, for each medical modality. Secondary outcomes were length of time from first treatment to first observed menstrual suppression, and the number of outpatient appointments taken to achieve menstrual suppression.

RESULTS

Of the 68 adolescents, 59/68 (86.8%) successfully achieved menstrual suppression, with 9/68 (13.2%) having ongoing treatment or loss to follow-up at the time of conclusion of the study; 39/68 (57.4%) were menstrually suppressed with their chosen medical modality after their initial appointment.

CONCLUSION

Medical modalities are highly effective in achieving menstrual suppression and no young women at this institution required a hysterectomy. Depot medroxyprogesterone was the most successful modality used to achieve menstrual suppression followed by the levonorgestrel intrauterine system. The combined oral hormonal contraceptive was the least successful medical treatment in achieving menstrual suppression.

Contraceptive Practices and Reproductive Health Considerations for Adolescent and Adult Women with Intellectual and Developmental Disabilities: A Review of the Literature

Whereas progress has been made on increasing access to comprehensive healthcare for individuals with intellectual and developmental disabilities (I/DD), disparities continue in health outcomes, including those related to the reproductive health of adolescent and adult women with I/DD. This review summarizes reproductive care considerations for adolescent and adult women with I/DD and current practices regarding the delivery of contraceptive services to these women. Forty-seven (47) articles based on research conducted in the US between 1999 and 2019 were selected for inclusion in the review. Primary themes discussed include (1) common reproductive health concerns for adolescent and adult women with I/DD, other than pregnancy prevention; (2) contraceptive methods and disability-related concerns; (3) informed consent and reproductive decision-making; and (4) provider knowledge and education. The management of menses and hormonal dysregulation were identified as concerns that providers encounter among patients with I/DD and their families. Disability-related concerns with regard to use of contraception in general and considerations regarding certain methods in particular include challenges with prescription adherence, physical effects of hormonal therapies, drug interactions for individuals with additional health conditions, and legal and ethical concerns involved with decision-making and consent. The results of this review also suggest that focused efforts in partnership with health care providers may be needed to address barriers that adolescent and adult women with I/DD face when trying to obtain quality reproductive health services and contraceptive guidance.

Hormonal Contraceptives, Intrauterine Devices, Gonadotropin-releasing Hormone Analogues and Testosterone: Menstrual Suppression in Special Adolescent Populations

Menstrual suppression (the use of hormonal contraceptive methods to eliminate or significantly decrease the frequency of menstrual cycles) is frequently used in the adolescent population for the management of menstrual symptoms such as heavy or painful periods, premenstrual syndrome, menstrual migraines, or even for patient preference. However, in cases of menstrual suppression in special populations additional risks and benefits need to be considered. The purpose of this article is to review the options and medical considerations for menstrual suppression in patients undergoing chemotherapy who might be at risk of abnormal uterine bleeding, those with intellectual or physical disability, and transgender and gender nonbinary individuals.

Experiences of Gender Minority Youth With the Intrauterine System

PURPOSE

The aim of the study was to evaluate the experience of menstruating adolescents identifying as male or gender nonconforming with the levonorgestrel-releasing intrauterine system (LNG-IUS) as a method of menstrual suppression and compare to that of cisgender youth (CGY) using the LNG-IUS for noncontraceptive indications.

METHODS

A retrospective chart review of gender minority youth (GMY), aged 12-22 years, who self-selected the 52 mg LNG-IUS for menstrual suppression between June 2014 and January 2018. GMY were then matched for age and time of insertion with CGY. Subjects were contacted by telephone to further explore LNG-IUS experience such as if the device was still in place, method satisfaction, current bleeding patterns, and for GMY improvement in menstrual distress.

RESULTS

Thirty GMY had the LNG-IUS inserted during the study period, and 20 GMY were matched with CGY for age and time of insertion. GMY were significantly more likely to receive sedation for LNG-IUS insertion (50% vs. 15%, p = .04). Otherwise, the LNG-IUS experience was similar between groups, including mean number of telephone/office visit encounters for an LNG-IUS concern, expulsion and reinsertion rates, and need for additional medications to control bleeding. On average, the mean months of use was 14.5 ± 8.6 months in GMY and 14.6±11.5 in CGY (p = .97). LNG-IUS removal was documented in three (15%) of GMY and five (25%) of CGY. Improvement in menstrual distress was reported by 80% of GMY after the insertion of the LNG-IUS.

CONCLUSIONS

Overall experience with the LNG-IUS was similar for GMY and CGY, and menstrual distress and bleeding pattern improved in the majority of GMY who self-selected this method for menstrual suppression.

When more is not better: 10 'don'ts' in endometriosis management. An ETIC * position statement

A network of endometriosis experts from 16 Italian academic departments and teaching hospitals distributed all over the country made a critical appraisal of the available evidence and definition of 10 suggestions regarding measures to be de-implemented. Strong suggestions were made only when high-quality evidence was available. The aim was to select 10 low-value medical interventions, characterized by an unfavorable balance between potential benefits, potential harms, and costs, which should be discouraged in women with endometriosis. The following suggestions were agreed by all experts: do not suggest laparoscopy to detect and treat superficial peritoneal endometriosis in infertile women without pelvic pain symptoms; do not recommend controlled ovarian stimulation and IUI in infertile women with endometriosis at any stage; do not remove small ovarian endometriomas (diameter <4 cm) with the sole objective of improving the likelihood of conception in infertile patients scheduled for IVF; do not remove uncomplicated deep endometriotic lesions in asymptomatic women, and also in symptomatic women not seeking conception when medical treatment is effective and well tolerated; do not systematically request second-level diagnostic investigations in women with known or suspected non-subocclusive colorectal endometriosis or with symptoms responding to medical treatment; do not recommend repeated follow-up serum CA-125 (or other currently available biomarkers) measurements in women successfully using medical treatments for uncomplicated endometriosis in the absence of suspicious ovarian cysts; do not leave women undergoing surgery for ovarian endometriomas and not seeking immediate conception without post-operative long-term treatment with estrogen-progestins or progestins; do not perform laparoscopy in adolescent women (<20 years) with moderate-severe dysmenorrhea and clinically suspected early endometriosis without prior attempting to relieve symptoms with estrogen-progestins or progestins; do not prescribe drugs that cannot be used for prolonged periods of time because of safety or cost issues as first-line medical treatment, unless estrogen-progestins or progestins have been proven ineffective, not tolerated, or contraindicated; do not use robotic-assisted laparoscopic surgery for endometriosis outside research settings. Our proposal is to better address medical and surgical approaches to endometriosis de-implementing low-value interventions, with the aim to prevent unnecessary morbidity, limit psychological distress, and reduce the burden of treatment avoiding medical overuse and allowing a more equitable distribution of healthcare resources.

Gender-Affirming Pharmacological Interventions for Youth With Gender Dysphoria: When Treatment Guidelines Are Not Enough

Youth with gender dysphoria, also known as transgender youth, are increasingly presenting to multidisciplinary clinics within academic pediatric centers across the United States. Gender-affirming pharmacological interventions for adolescents with gender dysphoria may be used to promote positive psychological well-being and mental health outcomes. Interventions range from completely reversible to partially irreversible, based on the age and sexual maturity of the adolescent. For each intervention, dilemmas and controversies exist regarding age at treatment initiation, treatment duration, safety, and cost. Pharmacists' awareness of these considerations and interventions is important when providing evidence-based gender-affirming care to this underserved population.

Sexuality and Disability in Adolescents

Healthy sexual development is important for adolescents with and without disabilities, yet the topic of sexuality is often ignored in the disabled population. Adolescents with mild or moderate degrees of disability have rates of sexual activity and reproductive health needs comparable to their typically developing peers. Their need for support, risk reduction, and education in sexual health may exceed that of their peers. The medical provider may support healthy sexual development through education, anticipatory guidance, menstrual and contraceptive management, and by expanding the notion of sexuality to include a broader conceptualization of sexual behavior and expression.

Adolescents with Special Needs: Clinical Challenges in Reproductive Health Care

Adolescents with special needs have unique reproductive health care needs related to their physical and cognitive issues. This review discusses some of the most common concerns that are encountered in clinical practice, as the clinician will partner with the adolescent and her family to guide her through the pubertal transition and to help navigate the risks and rights of reproduction. Families often seek anticipatory guidance before menarche on menstrual hygiene, abuse risk and sexuality and can be reassured that most teens with special needs do very well with menstruation. The clinician needs to evaluate the teenager's reproductive knowledge as well her risk for abuse and coercion and her ability to consent to sexual activity, if she requests contraception. Menstrual management is mostly based on the impact of the menstrual cycles on the teenager's life and activities. The adolescents may have a decreased ability to tolerate menses or pain, or experience changes in seizure pattern or altered mood. Hormonal treatment is often used to assist with menstrual hygiene, cyclical mood changes or dysmenorrhea. The goal of treatment can be complete amenorrhea, alleviate pain or regulate and decrease menstrual flow. The unique risks and benefits of hormonal treatment for this special population are highlighted.

Monthly Periods--Are They Necessary?

Menstrual suppression--the use of hormones to delay or eliminate menses--is often used in adolescents to manage conditions associated with the menstrual cycle and to accommodate lifestyle preferences. Reducing the frequency of menstrual bleeding does not cause any known physiologic harm and has potential short-term and long-term advantages. Different methods used for menstrual suppression, however, have associated risks and side effects that need to be weighed against the benefits of controlling menses. This article reviews the advantages and disadvantages of menstrual suppression and the different methods available for adolescents.

Prevalence of endometriosis among adolescent school girls with severe dysmenorrhea: A cross sectional prospective study

OBJECTIVES

To determine the prevalence of endometriosis among adolescent school girls with severe dysmenorrhea.

METHODOLOGY

Data was collected via interviewed questionnaire. Patients with symptoms and signs suggestive of endometriosis were further evaluated by abdominal ultrasonography (AUS), serum cancer antigen 125 (CA125). Laparoscopy was done for confirmation in those who agreed. Those who declined laparoscopy were offered magnetic resonance imaging (MRI).

RESULTS

A total number of 654 adolescents were interviewed. Their mean age was 15.2 ± 3.53 SD years. The mean duration of cycles and flow days was 29 ± 8.4 SD and 4 ± 2.8 SD respectively. The age of menarche in years was 13 ± 1.2 SD. Cycles were regular in 77.4 % (n=506) while irregular in 22.6 % (n=148). Of all studied girls, 48.9% (n=320) had menstrual pain of varying degree of severity. Severe dysmenorrhea was reported in 68.8 % (n=220/320) of them. Fifty six of these cases (25.5 %) had ultrasound findings suggestive of endometriosis. CA125 was elevated in 41.5 % (n= 27/56) of them. Patients accepted laparoscopic confirmations were 34, of them 79.4%, (n=27) had positive histo-pathological evidence of endometriosis. MRI was offered to those declined laparoscopy (n=22). Endometriosis was suggested in 77.3% of them.

CONCLUSION

The study concluded the prevalence of endometriosis in adolescents with severe dysmenorrhea was 12.3 % despite some declined laparoscopy. The unacceptability of laparoscopy and unfeasibility of local examination and trans-vaginal ultrasound add more to the difficulty of diagnosis.