Labial Anatomy Concerns in the Adolescent: A Review

Labial size concerns are an increasingly common chief complaint by both adolescents and adults despite studies showing a wide variation in sizes of the labia minora in the prepubertal, adolescent, and adult population. A thorough history will elucidate what or whom is driving the concerns, which can then direct management. Educating the patient, caregiver, and referring physician is often all that is needed. Surgery should never be used for cosmetic reasons in a minor.

Recommendations for Postoperative Surveillance of Pediatric Benign Ovarian Neoplasms

STUDY OBJECTIVE

To assess postoperative management of pediatric patients with benign ovarian neoplasms, to develop recommendations for postoperative care.

DESIGN

A retrospective cohort study.

SETTING

Eight pediatric hospitals in the midwestern United States.

PARTICIPANTS

Patients up to 21 years of age who underwent surgery for a benign ovarian neoplasm between January 2010 and December 2016 were included.

INTERVENTIONS

No prospective interventions were evaluated.

MAIN OUTCOME MEASURES

Main outcome measures included postoperative imaging findings, recurrence rates, reoperation rates, and the timing of the aforementioned results.

RESULTS

A total of 427 patients met inclusion criteria. After the index surgery, 155 patients (36%) underwent a routine imaging study. Among those with routine imaging, abnormalities were noted in 48 patients (31%); 7 went on to have reoperation (5%), and no malignant pathologies or torsion were identified. Excluding the 7 patients who went on to have a reoperation as a result of routine imaging, 113 patients developed symptoms postoperatively and underwent imaging as a result (27%, 113/420). Abnormalities were noted in 44 (10%); 15 of these patients underwent reoperation (4%), among them 2 with malignancies and 3 with torsion. Of these 44 patients, 23 had initially undergone routine imaging and subsequently went on to have symptomatic imaging, with 17% (4/23) undergoing reoperation.

CONCLUSIONS

Routine imaging did not identify malignancy; most lesions identified on routine imaging were incidental findings. Although the study was not powered to appreciate a statistically significant difference, patients with malignancy or torsion were identified in the symptomatic group. This suggests no benefit from routine imaging, and supports symptomatic imaging postoperatively to minimize costs and patient/family burden.

Dysgerminoma in a 10-Year Old with 45X/46XY Turner Syndrome Mosaicism

BACKGROUND

Turner syndrome is a genetic disorder resulting from the absence of or structural abnormality of one X chromosome. The presence of Y chromosome material in girls with Turner syndrome confers an increased risk of benign and malignant germ cell tumor and prophylactic bilateral gonadectomy is recommended.

CASE

A 10-year-old Turner mosaic syndrome (45X/46XY) patient underwent prophylactic gonadectomy after unremarkable preoperative pelvic imaging. Histopathology showed a streak right gonad, and left gonad with gonadoblastoma with limited degree of infiltrating germinoma.

SUMMARYAND CONCLUSION

Gonadoblastoma and dysgerminoma have been reported in girls with Turner mosaic who carry Y chromosome material. Prophylactic gonadectomy should be considered in these girls without delay.

Treatment of Prepubertal Labial Adhesions: A Randomized Controlled Trial

STUDY OBJECTIVE

Although various treatment options have been proposed for the treatment of labial adhesions, there are currently no clearly outlined limits on the duration of topical therapy, amount of lateral traction to apply, and methods to decrease the recurrence. This clinical trial was undertaken to assess the need for estrogen for treatment of prepubertal labial adhesions.

DESIGN

Randomized, double-blinded, controlled trial.

SETTING

Pediatric and Adolescent Gynecology Clinic at a children's hospital in a metropolitan area.

PARTICIPANTS

Prepubertal girls ages 3 months to 12 years with labial adhesions.

INTERVENTIONS

Lateral traction with topical estrogen or topical emollient.

MAIN OUTCOME MEASURES

The primary outcome was resolution of labial adhesions. The secondary outcome was the change in severity of labial adhesions over time between the 2 groups.

RESULTS

Forty-three girls were enrolled and 38 (88%) completed the study. The difference in complete resolution between the topical emollient group (19%) and the topical estrogen group (36%) was not statistically significant (P = .21). There was a statistically significant decrease in severity of labial adhesions over time, with the magnitude of improvement favoring the topical estrogen group.

CONCLUSION

Although labial adhesion severity decreased when treated with lateral traction and topical emollient or topical estrogen, the magnitude of the effect was significantly greater for topical estrogen.

Patterns of Treatment of Accidental Genital Trauma in Girls

STUDY OBJECTIVE

To evaluate the characteristics of girls with accidental genital trauma (AGT) who can be managed in the emergency department (ED) vs the operating suite (OS).

DESIGN

Retrospective cohort.

SETTING

ED at a children's hospital in a metropolitan area.

PARTICIPANTS

Girls aged 0-18 years with AGT.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Factors associated with need for evaluation and repair of AGT in the OS.

RESULTS

A total of 359 girls were included in the analysis. The mean age was 6 ± 3 years. Most girls presented with pain and bleeding, 321/359 (89%). Straddle injury was the most common mechanism, 258/355 (73%). The most commonly injured site was the labia, 225/358 (63%) and the most common type of injury was laceration, 308/357 (86%). Factors significantly associated with treatment in the OS included older age, transfer from another institution, penetrating injuries, injuries involving the hymen/vagina/urethra/anus, and injuries larger than 3 cm in size. The odds of requiring general anesthesia in the OS were 5.5 times higher for injuries larger than 3 cm (95% confidence interval, 2.8-10.9; P < .0001) and 4.1 times greater if the patient was transferred from another facility (95% confidence interval, 1.3-13.3; P < .02).

CONCLUSION

Most AGT can be managed expectantly. Penetrating injuries, injuries to the hymen/vagina/urethra/anus, and injuries with a maximal size of 3 cm should be considered as indications for management in the OS. With adequate procedural sedation, most girls with minor injuries as a result of AGT can undergo a thorough examination and repair of AGT in the ED.

Menstrual Patterns and Treatment of Heavy Menstrual Bleeding in Adolescents with Bleeding Disorders

STUDY OBJECTIVE

To characterize menstrual bleeding patterns and treatment of heavy menstrual bleeding in adolescents with bleeding disorders.

DESIGN, SETTING, AND PARTICIPANTS

We conducted a retrospective review of female patients aged nine to 21 years with known bleeding disorders who attended a pediatric gynecology, hematology, and comprehensive hematology/gynecology clinic at a children's hospital in a metropolitan area.

MAIN OUTCOME MEASURES

Prevalence of heavy menstrual bleeding at menarche, prolonged menses, and irregular menses among girls with bleeding disorders and patterns of initial and subsequent treatment for heavy menstrual bleeding in girls with bleeding disorders.

RESULTS

Of 115 participants aged nine to 21 years with known bleeding disorders, 102 were included in the final analysis. Of the 69 postmenarcheal girls, almost half (32/69, 46.4%) noted heavy menstrual bleeding at menarche. Girls with von Willebrand disease were more likely to have menses lasting longer than seven days. Only 28% of girls had discussed a treatment plan for heavy menstrual bleeding before menarche. Hormonal therapy was most commonly used as initial treatment of heavy menstrual bleeding. Half (53%) of the girls failed initial treatment. Combination (hormonal and non-hormonal therapy) was more frequently used for subsequent treatment.

CONCLUSIONS

Adolescents with bleeding disorders are at risk of heavy bleeding at and after menarche. Consultation with a pediatric gynecologist and/or hematologist prior to menarche may be helpful to outline abnormal patterns of menstrual bleeding and to discuss options of treatment in the event of heavy menstrual bleeding.

Physician attitudes toward over the counter availability for oral contraceptives

To assess physician attitude towards making oral contraceptives available over the counter in the United States (US). We assessed physician attitudes towards a transition from prescription only to over-the-counter availability (rx-OTC) for oral contraceptive pills by disseminating an electronic survey directed primarily to residents training in Obstetrics and Gynecology (OBGYN) and Family Practice in the US. An overwhelming majority of 638 respondents (71 %) were against an rx-OTC switch for combined oral contraceptives and among this subset of respondents the primary concern was safety (92.3 %). Overall, respondents were evenly divided on the issue of an rx-OTC switch for progestin-only-pills but of those who opposed, 73.2 % cited safety as their primary concern. For progestin-only-pills female respondents were more likely to support OTC availability. Most OBGYN and Family Practice residents opposed to OTC availability for oral contraceptives cite safety as their primary concern. Considering the abundant evidence as to the overall safety of oral contraceptives, especially progestin-only-pills, there appears to be a knowledge deficit among OBGYN and Family Practice residents regarding the safety of oral contraceptives.

Satisfaction with and intention to continue Depo-Provera versus the Mirena IUD among post-partum adolescents through 12 months of follow-up

STUDY OBJECTIVE

No prior study has directly compared satisfaction with Depo-Provera to the Mirena intra-uterine device (IUD) among post-partum parous adolescents. Our aim was to make this comparison among post-partum adolescents at 3, 6, and 12 months of follow-up.

PARTICIPANTS

Post-partum/parous adolescents (aged 20 and younger) choosing either Depo-Provera or the Mirena IUD as their method of contraception.

DESIGN

Prospective longitudinal survey.

SETTING

The adolescent clinic at the Truman Medical Center, Kansas City Missouri.

MAIN OUTCOME MEASURE

Satisfaction with and intention to continue the chosen method at 3, 6, and 12 months of follow-up.

INTERVENTIONS

None.

RESULTS

Sixty-six post-partum/parous adolescents were recruited, 37 choosing the Mirena IUD and 29 choosing Depo-Provera for contraception. The 2 groups had similar baseline characteristics. There was no statistically significant difference in overall satisfaction with Depo-Provera versus the Mirena IUD at 3, 6, or 12 months of follow-up. For both contraceptive methods, unpredictable bleeding was most unacceptable at 6 months of follow-up but the trend was only statistically significant for Depo-Provera. For Depo-Provera, there was a significantly lower proportion of participants actually continuing the method at 12 months (42.9%) relative to the proportion who at 6 months had expressed an intention to continue (80.0%; P = .01). This trend was not seen for the Mirena IUD.

CONCLUSION

Among post-partum/parous adolescents, overall subjective satisfaction with Depo-Provera and the Mirena IUD is similarly high over 12 months of follow-up. With Depo-Provera, however, there appears to be a disconnect between intention to continue at 6 months and actual continuation at 12 months.

Virilizing ovarian dermoid cyst with leydig cells

BACKGROUND

The clinical observation of virilization is a rare finding that has a number of possible explanations. Overall, ovarian tumors causing virilization are exceedingly rare and mostly occur in post-menopausal women. In fact, there are no reported cases of virilization from a testosterone-producing ovarian dermoid in the adolescent female age group. The most frequent germ cell tumor derived from the ovaries is the benign cystic teratoma (dermoid) which accounts for 25% of all ovarian neoplasms. Teratomas consist of tissues that recapitulate the ectoderm, endoderm, and mesoderm. Usually the tumors are asymptomatic, but they occasionally can cause severe pain if there is torsion or if sebaceous material perforates the cyst wall, leading to reactive peritonitis.

CASE

A 12-year-old female was found to have a large 3 5 x 19 x 12 cm ovarian mature cystic teratoma arising from her right ovary. The patient also displayed evidence of masculinization demonstrated by a deepening voice and clitoromegaly. The dermoid was producing large amounts of testosterone from a nest of Leydig cells found pathologically in the mass.

CONCLUSION

Benign cystic teratomas can produce active hormones, albeit rarely. This is a finding important to consider when ovarian cystectomy is performed for removal of a benign cystic teratoma.

Contraceptive Choices for Chronically Ill Adolescents

Ten percent of teenagers have chronic medical illness and need effective contraception for pregnancy prevention. There are available safe and effective methods; however, the selection of a contraceptive may be challenging because of the complexity of the underlying medical illness. This article offers options for contraception for girls with various chronic medical conditions. Considerations of some of the newer contraception methods are discussed as future options for these girls.

Recurrent Mature Cystic Ovarian Teratoma in Adolescence: Atypical Case of the Growing Teratoma Syndrome

BACKGROUND

A primary mature cystic ovarian teratoma was diagnosed in an adolescent female. She was followed up after initial exploration with computed tomography, pelvic ultrasonography, and serum tumor markers. Recurrent tumor, consisting solely of mature teratomatous elements, was confirmed with 2 subsequent laparotomies.

CASE

This is a report of the growing teratoma syndrome in a young woman with a primary diagnosis of a mature cystic ovarian teratoma not treated with adjuvant chemotherapy.

CONCLUSION

The growing teratoma syndrome is an uncommon condition. Surgical resection of recurrent lesions is necessary to reduce potential complications of abdominopelvic organ compression and obstruction and to evaluate for the presence of malignant degeneration.

Beta hemolytic streptococcus group f causing pelvic inflammatory disease in a 14-year-old girl

BACKGROUND

Pelvic inflammatory disease in prepubertal and non-sexually active adolescents is rare and poorly understood. Various organisms have been named as causative agents in adolescent pelvic infections. Early diagnosis and treatment of pelvic inflammatory disease in young girls is imperative to future fertility and long term sequela.

CASE

We present a 14-year-old, menarchal, non-sexually active female with a 3-week history of abdominal pain and fever. Surgical exploration and cultures revealed Stage IV pelvic inflammatory disease caused by Beta Streptococcus Group F.

CONCLUSION

Various organisms including Streptococcal infections should be considered in the differential diagnosis of pelvic inflammatory disease in young girls without risk factors.

Vulvar venous malformations in an 11-year-old girl: a case report

BACKGROUND

Unlike varicosities, which result from venous insufficiency, vascular malformations are developmental errors that do not regress. While these lesions are challenging to treat in most anatomic locations, genital venous malformations are particularly difficult problems for the gynecologist, urologist, or primary care physician who may identify them. The risk of surgical treatment has led to investigation of new therapeutic options for these vascular lesions.

CASE

We describe an 11-year-old premenarchal female with bilateral, symptomatic vulvar venous malformations. These lesions were successfully treated with Doppler ultrasound-guided direct injection venography and ethanol sclerotherapy.

CONCLUSION

Direct injection venography with ethanol sclerotherapy is an attractive diagnostic and therapeutic option for management of vulvar venous malformations.

Female circumcision/female genital mutilation

Female circumcision/female genital mutilation (FC/FGM) refers to any alteration of the genitalia by excision or covering of the introitus done for nonmedical reasons. This procedure is widely prevalent in sub-Saharan Africa and is traditionally performed on children and young adolescents. FC/FGM is associated with acute and long-term genitourinary and reproductive disorders that may require medical intervention. Due to turbulent economic and political immigration patterns, Western physicians may be called upon to care for children or adolescents from this part of the world. This review explains the procedure and the resultant physical alterations as well as the cultural and historic basis of this ancient tradition. Emphasis is also placed on the elements of culturally competent and compassionate care for young women who have undergone FC/FGM.

A randomized controlled trial to evaluate the use of the endocervical brush after endocervical curettage

OBJECTIVE

To determine if using the endocervical brush after curetting the endocervix will increase the yield of endocervical tissue retrieved for an endocervical curettage (ECC) specimen.

METHODS

Between March 1, 1995, and June 30, 1996, we recruited for participation patients with abnormal Papanicolaou smears referred for colposcopy. Exclusion criteria were pregnancy, previous hysterectomy, and a history of diethylstilbestrol exposure. Colposcopy and biopsies were performed by residents under direct supervision of the attending staff. Endocervical curettages were performed using the Kevorkian endocervical curette. The subjects were then assigned randomly to one of two ways of collecting the ECC tissue: with either a curette or an endocervical brush. Specimens were reviewed by pathologists, who were blinded to the method of ECC collection.

RESULTS

During the study period, 124 patients agreed to participate; 62 were assigned to the control group, and 62 to the study group. Six subjects had missing data, leaving 118 patients available for analysis. In the control group, six of the 58 ECC samples obtained contained insufficient endocervical tissue for pathologic diagnosis. None of the 60 samples from the endocervical brush group was insufficient. The difference between the two groups was statistically significant (P = .01).

CONCLUSION

The addition of the endocervical brush to endocervical tissue sampling at colposcopy in the study decreased the number of insufficient samples. The endocervical brush method of collection of an ECC specimen from the canal after the Kevorkian curette is used is a valuable addition to this diagnostic tool. We recommend its use in obtaining an ECC specimen.

Irradiation-induced atherosclerosis: a factor in therapeutic planning

Early primary head and neck cancers (stages I and II) and occult metastatic neck disease have caused debate regarding the choice between surgery and irradiation. The arguments for each are reviewed with a new consideration: the acceleration and/or induction of carotid atherosclerosis in irradiated patients. We present clinical case reports (n = 9), a retrospective clinical evaluation for the occurrence of carotid atherosclerosis in irradiated head and neck cancer patients (n = 57) and a comparison study of the extent and distribution of atherosclerosis in irradiated (n = 29) and nonirradiated head and neck cancer patients controlled for age, blood pressure, and tobacco use. The results show that carotid atherosclerosis is found in a wider anatomic distribution and to a greater extent in irradiated than in nonirradiated patients. We conclude that carotid atherosclerosis is induced and/or accelerated by neck irradiation. The implications as they relate to choice of treatment, to pretreatment evaluations, and to long-term follow-up are discussed.

Cesarean hysterectomy: a procedure for modern obstetrics?

The indications for emergency and elective cesarean hysterectomy have remained controversial throughout modern obstetric history. In an attempt to clarify the role of cesarean hysterectomy in today's practice, we retrospectively studied 216 peripartum hysterectomies done at our institution from 1956 to 1988. We analyzed indications, surgical procedures, and intraoperative and postoperative complications in an attempt to illustrate evolving obstetric trends.