Diagnostic Performance of Magnetic Resonance Imaging for Pediatric Ovarian Neoplasms: A Multi-Institutional Review

STUDY OBJECTIVE

To assess the diagnostic performance of MRI to predict ovarian malignancy alone and compared with other diagnostic studies.

METHODS

A retrospective analysis was conducted of patients aged 2-21 years who underwent ovarian mass resection between 2009 and 2021 at 11 pediatric hospitals. Sociodemographic information, clinical and imaging findings, tumor markers, and operative and pathology details were collected. Diagnostic performance for detecting malignancy was assessed by calculating sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for MRI with other diagnostic modalities.

RESULTS

One thousand and fifty-three patients, with a median age of 14.6 years, underwent resection of an ovarian mass; 10% (110/1053) had malignant disease on pathology, and 13% (136/1053) underwent preoperative MRI. MRI sensitivity, specificity, PPV, and NPV were 60%, 94%, 60%, and 94%. Ultrasound sensitivity, specificity, PPV, and NPV were 31%, 99%, 73%, and 95%. Tumor marker sensitivity, specificity, PPV, and NPV were 90%, 46%, 22%, and 96%. MRI and ultrasound concordance was 88%, with sensitivity, specificity, PPV, and NPV of 33%, 99%, 75%, and 94%. MRI sensitivity in ultrasound-discordant cases was 100%. MRI and tumor marker concordance was 88% with sensitivity, specificity, PPV, and NPV of 100%, 86%, 64%, and 100%. MRI specificity in tumor marker-discordant cases was 100%.

CONCLUSION

Diagnostic modalities used to assess ovarian neoplasms in pediatric patients typically agree. In cases of disagreement, MRI is more sensitive for malignancy than ultrasound and more specific than tumor markers. Selective use of MRI with preoperative ultrasound and tumor markers may be beneficial when the risk of malignancy is uncertain.

CONCISE ABSTRACT

This retrospective review of 1053 patients aged 2-21 years who underwent ovarian mass resection between 2009 and 2021 at 11 pediatric hospitals found that ultrasound, tumor markers, and MRI tend to agree on benign vs malignant, but in cases of disagreement, MRI is more sensitive for malignancy than ultrasound.

Multi-Institutional Review of the Preoperative Diagnostic Accuracy for Pediatric Ovarian Mature Cystic Teratomas

STUDY OBJECTIVE

To assess the preoperative imaging impression and surgeon diagnostic accuracy for pediatric ovarian mature cystic teratomas (MCTs) DESIGN: Retrospective review SETTING: Eleven pediatric hospitals PARTICIPANTS: Patients ages 2 to 21 who underwent surgical management of an ovarian neoplasm or adnexal torsion with an associated ovarian lesion INTERVENTION: None MAIN OUTCOME MEASURES: Preoperative imaging impression, surgeon diagnosis, tumor markers, and pathology RESULTS: Our cohort included 946 females. Final pathology identified 422 (45%) MCTs, 405 (43%) other benign pathologies, and 119 (12%) malignancies. Preoperative imaging impression for MCTs had a 70% sensitivity, 92% specificity, 88% positive predictive value (PPV), and 79% negative predictive value (NPV). For the preoperative surgeon diagnosis, sensitivity was 59%, specificity 96%, PPV 92%, and NPV 74%. Some measures of diagnostic accuracy were affected by the presence of torsion, size of the lesion on imaging, imaging modality, and surgeon specialty. Of the 352 masses preoperatively thought to be MCTs, 14 were malignancies (4%). Eleven patients with inaccurately diagnosed malignancies had tumor markers evaluated and 82% had at least 1 elevated tumor marker, compared with 49% of those with MCTs.

CONCLUSIONS

Diagnostic accuracy for the preoperative imaging impression and surgeon diagnosis is lower than expected for pediatric ovarian MCTs. For all ovarian neoplasms, preoperative risk assessment including a panel of tumor markers and a multidisciplinary review is recommended. This process could minimize the risk of misdiagnosis and improve operative planning to maximize the use of ovarian-sparing surgery for benign lesions and allow for appropriate resection and staging for lesions suspected to be malignant.

Laparoscopy versus laparotomy for pediatric ovarian dermoids

BACKGROUND

With increased surgeon comfort using laparoscopy, we hypothesized resection of pediatric ovarian dermoids using laparoscopy would yield a shorter length of stay and no increase in morbidity or recurrence compared to laparotomy.

METHODS

A retrospective review was performed amongst eleven pediatric hospitals. Patients aged 2 to 21 who underwent resection of an ovarian dermoid from 2010 to 2020 were included. Patient characteristics, operative details, and outcomes by approach were evaluated using Chi-squared and Wilcoxon-Mann tests.

RESULTS

466 patients were included, with a median age of 14.4 and median follow-up of 4.0 months. 279 patients underwent laparoscopy (60%), 139 laparotomy (30%), and 48 laparoscopy converted to laparotomy (10%). There were no differences in rates of tumor spillage by approach (p = 0.15). 65% underwent ovarian-sparing surgery and 35% underwent oophorectomy. Length of stay was significantly shorter amongst patients who underwent laparoscopy (1 day versus 2 days for laparotomy and converted, p<0.0001). There were no differences in rates of suspected recurrence or reoperation (p = 0.19 and p = 0.57, respectively).

CONCLUSION

Patients who underwent laparoscopy experienced no differences in the rates of tumor spillage, recurrence, or reoperation and had a shorter length of stay compared to laparotomy. Laparoscopy is an acceptable approach for resection of pediatric ovarian dermoids.

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.

Factors Associated With Management of Pediatric Ovarian Neoplasms

BACKGROUND

Available evidence supports ovary-sparing surgery for benign ovarian neoplasms; however, preoperative risk stratification of pediatric ovarian masses can be difficult. Our objective of this study was to characterize the surgical management of pediatric ovarian neoplasms across 10 children's hospitals and to identify factors that could potentially aid in the preoperative risk stratification of these lesions.

METHODS

A retrospective review of girls and women aged 2 to 21 years who underwent surgery for an ovarian neoplasm between 2010 and 2016 at 10 children's hospitals was performed. Multivariable logistic regression was used to examine the relationships between the preoperative cohort characteristics, procedure performed, and risk of malignancy.

RESULTS

Among 819 girls and women undergoing surgery for an ovarian neoplasm, malignant lesions were identified in 11%. The overall oophorectomy rate for benign disease was 33% (range: 15%-49%) across institutions. Oophorectomy for benign lesions was independently associated with provider specialty (P = .002: adult gynecologist, 45%; pediatric surgeon, 32%; pediatric gynecologist, 18%), premenarchal status (P = .02), preoperative suspicion for malignancy (P < .0001), larger lesion size (P < .0001), and presence of solid components (P < .0001). Preoperative findings independently associated with malignancy included increasing size (P < .0001), solid components (P = .003), and age (P < .0001).

CONCLUSIONS

The rate of oophorectomy for benign ovarian disease remains high within the pediatric population. Identification of factors associated with the choice of procedure and the risk of malignancy may allow for improved preoperative risk stratification and fewer unnecessary oophorectomies. These results have been used to develop and validate a multidisciplinary preoperative risk stratification algorithm that is currently being studied prospectively across 10 institutions.

Challenges and Opportunities in Adolescent Gynecology Patients with Surgically-Treated Congenital and Acquired Anomalies: Transition of Care from Pediatric to Adult Surgery

The transition from adolescence to young adulthood in patients with reproductive health care needs such as disorders of sexual development and congenital anomalies is a complex process that occurs over several years. The transition process for these patients is still poorly understood. The patients with disorders of sexual development and reproductive issues have specific and unique issues regarding timing of disclosure of diagnosis, genital examinations, gonadectomy, vaginal treatments, surgical procedures, hormone replacement therapy, use of long-term medication, and potential cancer screening. The purpose of this review is to briefly describe complex genital malformations and their associated anomalies with long-term concerns and then provide an overview of what has been published at this time regarding the transition of care to provide some guidance for providers who care for those patients.

A multicenter survey of contraceptive knowledge among adolescents in North America

STUDY OBJECTIVE

To assess knowledge about contraceptive efficacy and side effects in an adolescent population seen in Pediatric and Adolescent Gynecology referral centers.

DESIGN

This is a multisite cross-sectional survey study. A 23-question survey assessing knowledge of contraception and demographic information was administered. Data analysis was performed using descriptive statistics, simple paired t tests, and chi-square analyses using SAS 9.3.

SETTING

Pediatric and Adolescent Gynecology clinics in 4 tertiary care centers. The study was conducted in 3 institutions in the United States and 1 institution in Canada.

PARTICIPANTS

A convenience sample of 354 female patients aged 10-24 y seeking reproductive healthcare at participating institutions.

INTERVENTIONS

None

MAIN OUTCOME MEASURES

The percentage of correct answers to questions assessing general knowledge about contraception, familiarity with different contraceptive methods, and comparison of results between study sites.

RESULTS

The mean percentage of correct answers among all participants was 55.8% ± 17%. Younger participants (age 10-13 years) scored significantly lower than their older counterparts (49%, 55%, and 60% respectively, P < .05). There was no correlation between score and ethnicity or location of the participating site. Subjects reporting the internet as a source of information, those who were sexually active, and those familiar with long acting reversible contraceptives scored significantly higher. Of all contraceptive methods, participants were least likely to have heard of etonogestrel implants (18%), rhythm method/natural family planning (28%), and IUDs (32%).

CONCLUSION

Adolescents and young adults performed poorly overall demonstrating both the lack of overall knowledge regarding methods of contraception and misinformation about side effects.

Health care decision making by mothers for their adolescent daughters regarding the quadrivalent HPV vaccine

STUDY OBJECTIVE

In this study we sought to understand the predictors of a mother's decision (behavior) to vaccinate her daughter with the initial dose of the HPV vaccine.

DESIGN

This prospective, cross sectional study involved a convenience sample of 68 mother-daughter dyads recruited to test the hypothesis that the Theory of Planned Behavior (TPB) variables (attitudes toward vaccine, perception of others' opinions, and perceived difficulty in obtaining vaccine) would explain a mother's decision to consent for her daughter to receive the first dose of the HPV vaccine.

MAIN OUTCOME MEASURES

Mothers and daughters independently completed survey instruments that measure the variables of the TPB (attitude, subjective norms, and perceived behavioral control). Instruments also included measures of parenting style and conflict.

RESULTS

The mother's intention to vaccinate was predicted by her attitude (β = .41, P < .001), subjective norms (β = .33, P = .002), and perceived behavioral control (β = .24, P = .005). The pathway connecting intention to the decision (yes or no) to vaccinate was significant (β = .41, P < .001). Squared multiple correlations for intention and decision, respectively, were .68 and .12. The mothers who chose to vaccinate their daughter did not differ on any of the demographic variables from those who chose not to vaccinate but had significantly different scores on attitude, subjective norms, and intention but not perceived behavioral control.

CONCLUSIONS

The TPB model demonstrates potential influences on a mother's intention to choose to initiate the HPV vaccination series for her daughter. Influences of attitude, subjective norms and perceived control are potential targets for interventions and tailored social marketing to improve vaccine acceptance.

Ferriman-Gallwey scores, serum androgen and mullerian inhibiting substance levels in hirstute adolescent girls

OBJECTIVE

To study Ferriman-Gallwey (FG) scoring in adolescents with an aim to correlate these scores with serum androgens and mullerian inhibiting substance (MIS).

DESIGN

Cross sectional study.

SETTING

Pediatric and Adolescent Gynecology Clinic of a university hospital.

PATIENTS

Twenty-four hirsute adolescent girls age 12-19 with a FG score of 6 or greater.

INTERVENTIONS

FG examination and collection of serum levels of MIS, total testosterone, free testosterone, follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, cortisol, and androstenedione.

MAIN OUTCOME MEASURES

Correlation between FG scores in adolescents and serum androgens and MIS.

RESULTS

Weak correlations were seen between FG score and FSH, free-testosterone, total testosterone, and cortisol. Increasing FG scores correlated with an increase in cortisol. As FG score increased, FSH, free-testosterone, and total testosterone decreased. There was no statistical relationship between FG score and LH, androstenedione, prolactin, and MIS. There were weak positive correlations between MIS levels and FSH, total testosterone, and androstenedione. There was no evidence for a linear relationship between MIS levels and LH, free testosterone, cortisol, prolactin, and FG score.

CONCLUSIONS

The utility of FG scoring in adolescents is unknown. There were no direct correlations found with MIS levels and FG score. MIS was not found to be a predictor of hirsutism. A larger study is needed to assess the clinical relevance of FG scoring and presence of underlying causes of hirsutism in adolescents.

Retrospective review of intrauterine device in adolescent and young women

STUDY OBJECTIVE

To examine our experience with intrauterine device (IUD) use in adolescents and young women.

DESIGN

Retrospective descriptive study evaluating outcomes after IUD insertion for patients 21 years or less over an 8-year period.

SETTING

Three sites including a Pediatric and Adolescent gynecology private practice, a Title X clinic, and community based, grant funded clinic serving a high risk teen population.

PARTICIPANTS

Females from menarche to age 21.

MAIN OUTCOMES MEASURED

The probability of IUD retention, differences in IUD retention probabilities between two age groups, and risk factors for IUD removal, expulsion, and infection were evaluated.

RESULTS

233 records showed 50% of the <18-year-old age group and 71.5% of the 18-21-year-old group had their IUD in place at 5 years. Age was found to be a significant factor for removal (P < 0.001), with under 18-year-olds at greater risk of removal/expulsion (hazard ratio (HR) = 2.85). Parity (RR = 5.6 for nulliparous vs multiparous patients, P < 0.001) and prior STI (RR = 5.5, P < 0.001) were significant risk factors for infection. Nulliparous patients were at higher risk of expulsion (P = 0.045), though age was not a statistically significant risk factor.

CONCLUSIONS

The rate of continuation was lower in adolescents under 18 compared to 18-21-year-olds, but was still higher than for other hormonal contraceptives. Despite this groups' high risk for STI the IUD did not increase the risk of infection and may offer some degree of protection. IUDs appear to be a safe option in young adolescents (<18 years old) and nulliparous women.

Diagnosis and treatment of interstitial cystitis in adolescents

Interstitial cystitis (IC), or painful bladder syndrome, is characterized by irritative voiding symptoms and can be a challenging problem that affects children and adolescents. Diagnosis and management in children and adolescents is challenging because of strict diagnostic criteria and the paucity of investigations focusing on this age group, which often can lead to delayed or missed diagnosis. Clinical features suggestive of IC include bladder pain, urgency, frequency, nocturia, and pressure. Symptoms may wax and wane and often are exacerbated by menstruation, intercourse, dietary triggers, and stress. Diagnosis can be made by history, physical exam findings such as suprapubic tenderness, voiding diaries, and exclusion of other etiologies. Some diagnostic tests such as the potassium sensitivity test and cystoscopy are invasive and often impractical in younger patients. Treatment of IC consists of a multimodal approach that should be tailored to the individual needs of the patient. Therapies for younger patients include oral medication, intravesical therapy, cystoscopy with hydrodistention, and conservative measures such as dietary modification. This review of the literature focuses on diagnosing IC in younger patients and on what treatment modalities are appropriate and effective for this age group.

Laparoscopically assisted creation of a neovagina using the Louisville modification

OBJECTIVE

To report a modification of the laparoscopic Davydov method for creation of a neovagina.

DESIGN

Case study.

SETTING

University gynecology practice.

PATIENT(S)

Female with vaginal agenesis.

INTERVENTION(S)

Laparoscopically assisted creation of a neovagina using a modified technique to improve both structural and functional capacity.

MAIN OUTCOME MEASURE(S)

Patient morbidity and satisfaction.

RESULT(S)

The patient satisfactorily underwent creation of a neovagina using the laparoscopic modification of the Davydov technique via the Louisville method.

CONCLUSION(S)

This laparoscopic modification allows for structural maintenance and functional capacity without increasing postoperative morbidity.

Secondary amenorrhea resulting from traumatic separation of the cervix from the uterine corpus

BACKGROUND

Amenorrhea resulting from crushing trauma of the pelvis is exceptionally rare. The purpose of this case report is to describe the diagnosis of and successful surgical correction of traumatic separation of the cervix from the uterine corpus.

CASE

A nulligravida presented with a complaint of secondary amenorrhea after a motor vehicle accident in which she sustained a crush-type injury to the pelvis. Ultrasonography and laparotomy revealed a complete separation of the uterine corpus from the cervix. The uterine corpus was approximated to the cervix with circumferentially placed sutures to establish a patent outflow tract from the endometrial cavity to the cervical canal.

CONCLUSION

This case demonstrates the successful surgical correction of secondary amenorrhea resulting from traumatic separation of the uterine corpus from the cervix. Normal menstruation resumed 6 weeks after surgery.

Efficacy of family history in determining thrombophilia risk

STUDY OBJECTIVE

This retrospective study sought to examine the importance of family history of cardiovascular disease (CVD) or venous thromboembolism (VTE) in predicting risk for an inherited thrombophilia.

DESIGN/METHODS

A cohort of 88 adolescent females who had a thrombophilia panel in the last three years was identified for this retrospective chart review. Family history data of CVD or VTE were collected in addition to laboratory results from the thrombophilia screen.

SETTING

Adolescent patients who had a thrombophilia screen within the last three years at University OB-GYN Associates, Louisville, KY.

RESULTS

Within the cohort (n=88), 21% of patients were found to have a documented thrombophilia. At least 47% of individuals diagnosed with thrombophilia had more than one screening abnormality. A family history of VTE was noted to have a positive predictive value (PPV) of 40% and a negative predictive value (NPV) of 88% for detection of thrombophilia. Patients with a family history of CVD alone carried a PPV of 24% and NPV of 100%. Finally, among individuals with both family history risk factors, PPV was strengthened at 52% while NPV remained unchanged.

CONCLUSIONS

Within the last decade, inherited thrombophilias have gained more clinical interest. While thrombophilia disease prevalence data is available for the adult population, there remains a paucity of data in adolescents. Our results reinforce the importance for screening adolescent females, prior to contraceptive administration, if family history risk factors exist.

Undescended ovaries: a clinical review

Undescended ovaries are frequently seen in conjunction with uterine malformations and are typically found during the course of an infertility evaluation. Other important clinical signs may prompt evaluation in an adolescent patient, though this may also be an incidental finding. An understanding of embryologic features is critical for management. It is additionally important to explain to patients and families that this is a normal developmental variant of the ovary that does not require removal in the absence of concerning pathology.

Premenarchal recurrent periclitoral abscess: a case report

BACKGROUND

Periclitoral abscesses in premenarchal girls is a serious condition and can have negative implications for future reproductive health. Recurrent periclitoral abscess in premenarchal girls is rare.

CASE

An 11-year-old, premenarchal girl presented complaining of dysuria, vulvar swelling, pain and erythema of the clitoral hood and a similar episode 12 months previously. Intravenous antibiotics and local measures resulted in spontaneous drainage of the abscess. On day 3 the area was healing, and the patient was discharged on oral antibiotics and sitz baths. At her 6-month follow-up, she had a normal clitoral hood without tenderness or erythema.

CONCLUSION

Broad-spectrum antibiotics and local measures may prevent surgical treatment and potential associated reproductive morbidity.

Bone mineral density in adolescent females using depot medroxyprogesterone acetate

STUDY OBJECTIVE

To examine bone mineral density (BMD) on a semi-annual basis among control subjects and adolescent females receiving depot medroxyprogesterone acetate (DMPA) injection or oral contraceptives.

DESIGN

Non-randomized prospective study.

SETTING

Teenage pregnancy prevention intervention clinic.

PARTICIPANTS

Adolescent females who were new users of DMPA injection (N=58, age 12-21) or the oral contraceptive pill (N=71, age 11-19) and normal menstruating girls (N=19, age 15-18).

INTERVENTIONS

Baseline and 6-monthly measures of lumbar vertebral BMD using dual-energy X-ray absorptiometry over a 2-year period.

MAIN OUTCOME MEASURES

comparison of percent change on BMD over time between DMPA users, pill users, and normal menstruating girls.

RESULTS

There was no difference on group characteristics at baseline except for the ethnicity between the controls and the DMPA group. There was a statistically significant decrease in BMD between DMPA users and controls at 6 months (-3.02% change, P=0.014) 12 months (-3.38% change, P=0.001) 18 months (-4.81% change, P<0.001) and 24 months (-6.81% change, P=0.010). There was no statistical difference between pill users and controls.

CONCLUSION

There is a relationship between DMPA use and a decrease in BMD compared to normal menstruating controls that seems to persist up to 24 months.

Is there a seasonal variation in gonorrhea and chlamydia in adolescents?

STUDY OBJECTIVE

To determine if a seasonal variation exists in gonorrhea and chlamydia in female adolescents. DESIGN, SETTING, PARTICIPASNTS: We conducted a retrospective chart review of 604 sexually active adolescent females 21 years of age and younger in a teen pregnancy prevention clinic in a small Midwestern city. Positive gonorrhea and chlamydia tests were evaluated for seasonal variation. Chi-square, odds ratios, and 95% confidence intervals were calculated.

RESULTS

A greater percentage of tests were positive in the fall than in other seasons (P = 0.028), and there was a trend towards more cases in the summer than winter and spring.

CONCLUSIONS

Increased emphasis should be placed on prevention and screening during summer and fall.

Managing mature cystic teratomas of the ovary

Mature cystic teratomas (MCT), commonly called dermoid cysts, are the most common benign germ cell tumors of the ovary in women of reproductive age. Future fertility is of major concern among these women; therefore, the surgical management must focus on preserving ovarian tissue and minimizing adhesion formation. Patients requiring surgery should be appropriately counseled about the risks and benefits of laparoscopy and laparotomy, the risks of intraoperative MCT spillage and adhesion formation. In addition, the risks of recurrence and malignant transformation should be discussed. The parents of children with MCTs have the same concerns as older women and a similar discussion should take place. The goal of this article is to review these issues and provide the physician with the information to counsel their patients preoperatively.

The management of mature cystic teratomas in children and adolescents: a retrospective analysis

Mature cystic teratomas (MCT) are the most common ovarian tumours seen in children and adolescents. Fifty-two patients <21 years of age had surgical removal of an MCT, 14 of whom were approached laparoscopically. Compared with laparotomy, those patients managed laparoscopically had a significantly shorter hospital stay. Intra-operative tumour spillage occurred in 27 (52%) patients; there were no cases of chemical peritonitis. Available follow-up data on 34 (65%) patients revealed seven pregnancies occurring at a median of 70 months (46-123) postoperatively, including four in patients with intraoperative MCT spill. There were no cases of tumour recurrence during the follow-up period among the 27 (52%) patients managed with ovarian cystectomy. These results demonstrate that some of the conclusions regarding the contemporary management of MCT in adults are applicable to children and adolescents.

Use of laparoscopically mobilized peritoneum in the creation of a neovagina

OBJECTIVE

To present an alternative technique for the creation of a neovagina.

DESIGN

Case study.

SETTING

Academic university gynecology clinic.

PATIENT(S)

A patient diagnosed with müllerian agenesis.

INTERVENTION(S)

Laparoscopically assisted creation of a neovagina by using peritoneum.

MAIN OUTCOME MEASURE(S)

Patient morbidity and satisfactory intercourse.

RESULT(S)

The patient underwent the procedure satisfactorily and was discharged within 24 hours. She had no perioperative or postoperative complications, and she became satisfactorily sexually active.

CONCLUSION(S)

The use of laparoscopically mobilized peritoneum in the creation of a neovagina provided the patient with a functional vagina, allowing satisfactory intercourse.

The clinical course of unresected ovarian torsion

The authors report the clinical course of a young girl with ovarian torsion who was treated conservatively. This case shows that detorsion of the ovary may be associated with immediate postoperative febrile morbidity and slow resolution of ovarian enlargement. The authors emphasize that these signs can be associated with viable ovarian tissue and are not necessarily an indication for oophorectomy.

Laparoscopic management of neonatal ovarian cysts

A laparoscopic approach was used in four infants with antenatally diagnosed ovarian cysts requiring surgical intervention. Operating time ranged from 60 to 90 minutes, there were no intraoperative or postoperative complications, and all infants were discharged within 23 hours after surgery. If performed by experienced practitioners, microendoscopy is an alternative to laparotomy in neonates requiring surgical intervention for ovarian cysts.

Noninflammatory ovarian masses in girls and young women

OBJECTIVE

We reviewed the presentation, treatment, and pathologic diagnoses of girls and young women less than 21 years old with noninflammatory ovarian masses that required surgery and established whether treatment had changed over time.

METHODS

We retrospectively reviewed charts of all girls and young women under 21 years old with International Classification of Diseases, 9th Revision (ICD-9) codes specific for noninflammatory ovarian masses treated at our institution from June 1980 to July 1998 (n = 140).

RESULTS

The median age at surgery was 15 years (range 2 days-21 years). Ovarian cysts occurred in 57.9% (81 of 140) of patients, benign tumors (including mature cystic teratomas) in 30% (42 of 140), malignant tumors in 7.9% (11 of 104), and torsed but normal ovaries in 4.3% (six of 140) of the study sample. Patients older than 15 years were more likely to have ovarian cysts and benign tumors than younger patients (P =.019). There were no malignancies among girls with neonatal cysts. The incidence of ovarian torsion was 17.8% (25 of 140). Patients with ovarian cysts, mature cystic teratomas, and normal ovaries were more likely to have torsion than those with other benign or malignant tumors (P <.001). Operative approach and surgical procedure were compared before and after July 1, 1989. Laparoscopy was performed more commonly after July 1, 1989 (P =.009). However, patient age (P <.001) rather than time of surgery (P =.83) was the most important predictive factor in a multivariate analysis for use of laparoscopy. In addition, multivariate analysis revealed that patient age (P =.02) rather than time of surgery (P =.79) was also predictive of surgeon type (gynecologist or pediatric surgeon).

CONCLUSION

The most frequent cause of an ovarian mass requiring surgery in a girl or young woman under 21 years of age is an ovarian cyst, which justifies consideration of a laparoscopic approach. Patient age rather than time of surgery predicted operative approach and surgeon type. Caution should be exercised in patients over age 12 months with a complex mass on ultrasound and clinical evidence of hormonal activity, as these masses are usually malignant.

Vaginal agenesis: an opinion on the surgical management

The management of vaginal agenesis-Mayer-Rokitanksy-Kuster-Hauser syndrome-has always been a controversial topic. Initially, the arguments centered on whether to do surgery or try passive dilation as well as at what age to intervene. As surgical techniques have recently become refined, the question is, if surgery is selected, what type of tissue should one use (bowel vs. skin graft) and, if skin graft, from what area to select. Now we are faced with new surgical techniques from the realm of pelviscopy and ask the question: Is one of these better than the other, and is this approach superior to previously established surgical techniques? Drs. Claire Templeman and S. Paige Hertweck from the University of Louisville School of Medicine, Department of Obstetrics and Gynecology here present a concise discussion of these diverse issues.

Postpartum contraceptive use among adolescent mothers

OBJECTIVE

To compare the incidence of repeat pregnancy and method continuation rate at 12 months postpartum in young women who chose either depot medroxyprogesterone acetate or oral contraceptives (OCs) as contraception.

METHODS

We conducted a prospective cohort study of 122 postpartum women younger than 18 years of age who delivered between January 8, 1997 and December 31, 1997. Patients choosing depot medroxyprogesterone acetate (n = 76) and OCs (n = 46) were accrued for 12 months and were followed-up for a minimum of 12 months. Main outcome measures were median contraceptive method continuation and the incidence of repeat pregnancy at 12 months postpartum.

RESULTS

There was no difference in mean age at delivery (P =.47), parity (P =.84), or gravidity (P =.78) between depot medroxyprogesterone acetate and OC users. At 12 months postpartum, 27.4% of OC users and 55.3% of depot medroxyprogesterone acetate users were still using contraception. Median time to contraceptive discontinuation was longer for those choosing depot medroxyprogesterone acetate compared with OCs (17.8 vs 7.4 months, respectively, P =.002). The overall incidence of repeat pregnancy at 12 months postpartum was 10.6%. Among OC and depot medroxyprogesterone acetate users, respectively, 24% and 2.6% became pregnant again, producing a relative risk (RR) of 9.09 (95% confidence interval [CI] 2.1, 39.2) for repeat pregnancy among OC users. The mean time to repeat pregnancy (this was reported instead of the median time whenever the pregnancy rate had not reached 50% at the end of the follow-up period) was longer for depot medroxyprogesterone acetate compared with OC users (17.1 months vs 13.2 months, respectively, P <.001).

CONCLUSION

Adolescent mothers using depot medroxyprogesterone acetate injection for contraception have a higher method continuation rate and a lower incidence of repeat pregnancy at 12 months postpartum than those selecting OCs during the same period.

Breast disorders in the pediatric and adolescent patient

Despite the wide range of breast abnormalities that affect patients in the pediatric and adolescent populations, some conclusions can be drawn. Breast self-examination in the adolescent population is controversial but is recommended for girls who carry the BRCA1 or BRCA2 gene beginning at age 18 to 21 years. All girls with a disorder of breast size or symmetry should be given the opportunity of consultation with a plastic surgeon to discuss reconstructive options. Ultrasound is the most appropriate initial investigation in any adolescent patient with a breast mass owing to the dense nature of breast tissue in this age group. Although it is extremely rare in this population, breast cancer must always be included in the differential diagnosis of a breast mass, particularly in the patient with a prior history of childhood malignancy or chest irradiation.

An unusual presentation of Tourette's syndrome

STUDY OBJECTIVE

To report an unusual complex motor tic as the presenting symptom in a patient diagnosed with Tourette's syndrome.

METHODS

This case report was compiled via interview with a 9-year-old white female who presented to the private gynecologic practice of the senior author. Additional history was gained from the patient's mother and follow up information was obtained from written and verbal communication with neurology colleagues.

MAIN OUTCOME MEASURES

Referral to neurology. Diagnosis of persistent perineal touching.

RESULTS

Diagnosis of Tourette's syndrome.

CONCLUSION

In young patients with nonspecific vulval symptoms, Tourette's syndrome should be considered in the differential diagnosis particularly if persistent self touching is a feature of the complaint. Referral to a physician experienced with the syndrome is important since the diagnosis is made on the basis of the clinical symptoms and signs.

Correlation between glycemic control and menstruation in diabetic adolescents

OBJECTIVE

To determine if a correlation exists between the degree of glycemic control in insulin-dependent diabetic adolescents and menstrual regulation.

STUDY DESIGN

A retrospective review of charts of diabetic girls aged 10-18 was performed. Office visits were scheduled every three to six months, at which time pubertal development, menstrual function, growth and diabetic control, including hemoglobin (Hgb) A1C, and complications were assessed. Forty-six patients were eligible for data analysis. Descriptive and inferential statistics, including chi 2 and Student t tests, were applied.

RESULTS

Thirty-seven (81%) patients had regular menstrual cycles, and nine (19%) had menstrual disturbances, including secondary amenorrhea (one), oligomenorrhea (seven) and primary amenorrhea followed by oligomenorrhea (one). There were two pregnancies. Six patients used hormonal contraception but none for menstrual regulation. There was a statistically significant difference (P < .05) in mean Hgb A1C concentrations between those with menstrual disturbances (11.4) and those with regular menses (9.7). As Hgb A1C values increased, the percent of patients with menstrual disturbances increased, becoming statistically significant when the Hgb A1C was > 10 (odds ratio 7.3, 95% confidence interval 1.5-35.6). There was no difference (P > .05) between the two groups with respect to age at menarche (156 vs. 152 months), age at onset of diabetes (144 vs. 108 months) and interval between diabetes onset and menarche (54 vs. 41 months). There were no patients in either group with diabetic retinopathy or nephropathy. Four patients were hypertensive, but there was no statistically significant difference (P > .05) between groups.

CONCLUSION

Tighter glycemic control, as measured by Hgb A1C concentrations, corresponded to improved menstrual regulation in adolescent insulin-dependent diabetics.

Surgical management of vaginal agenesis

Vaginal agenesis is a rare anomaly that may result from a variety of different underlying diagnoses. The most important aspects of the surgical management of this condition are: correct diagnosis of both the underlying abnormality and its anatomy, documentation of any associated renal or skeletal anomalies, and proper psychological preparation of the young woman for any anticipated corrective surgery. Over the years, there have been many different techniques devised in an attempt to provide these women with a functioning vagina that approximates normal anatomy. The purpose of this article is to review the surgical options for the management of this anomaly.

Emergency contraception: lack of awareness among patients presenting for pregnancy termination

STUDY OBJECTIVE

Emergency contraception, otherwise known as postcoital contraception, refers to a group of birth control modalities that, when used after unprotected intercourse within defined time constraints, can markedly reduce the risk of a resultant unintended pregnancy. The English literature, using British and American awareness data, consistently claims that these contraceptive options are underutilized in the United States because of a lack of patient and physician awareness of their existence. The objective of this study was to determine the level of awareness of postcoital contraceptive techniques in a population of American women who were presenting for pregnancy termination. The secondary goal was to calculate (theoretically) how many of these surgical terminations could have been prevented through the use of postcoital contraception.

METHODS

A questionnaire was administered to patients presenting to an abortion clinic. It was intended to anonymously identify patient demographics and knowledge of the various emergency contraceptive options and, in hindsight, to determine what percentage of these women would have been willing candidates for one of these medical modalities. On completing the questionnaire, all patients received an emergency contraceptive information sheet for future consideration.

RESULTS

Eighty-three patients completed the study. They ranged in age from 15 to 44 years (mean, 24 years). Forty-six percent of the patients were 21 years of age or younger. A total of 71% of all patients had no real knowledge of the existence of emergency contraceptive options; 26% had some limited knowledge, and only 3% had somewhat complete and valuable information. Fifty-one percent of the patients would have been appropriate, realistic, and willing candidates for at least the emergency contraceptive pill. Assuming at least a 75% effectiveness rate for the emergency contraceptive pill, 38% of the surgical pregnancy terminations performed on this population of women could have been avoided.

CONCLUSION

Our data confirm that emergency contraceptive options are underutilized because of a lack of patient awareness. Contraception education, especially directed toward adolescents, should include disseminating enhanced information about postcoital contraception options.

Late follow-up and functional outcome after traumatic reproductive tract injuries in women

The aim of this study was to assess female reproductive tract injuries and late effects on sexual and reproductive function. This was a review of women presenting to a Level I trauma center with reproductive tract injuries over 12 years. Thirty-one women (average age, 30 years) were divided into coital (19) and noncoital (12) injury groups. One-third of coital trauma presented late, one-fourth was abuse related, and seven women presented in shock. All had vaginal lacerations, and 15 required repair. Follow-up in 6 of 19 (32%) women averaged 4.5 years. Noncoital injuries resulted primarily from vehicular trauma, and two-thirds had associated abdominal injuries. Interventions included: vaginal laceration irrigation/repair (4), salpingectomy (2), ovariectomy (2), repair uterine perforation (1), and emergency cesarean section (2). The average Injury Severity Score was 25, with two deaths. Follow-up in 6 of 10 (60%) survivors averaged 6.1 years. The combined group has had seven subsequent pregnancies, and two women have minor dyspareunia after pelvic fracture. Women with coital injuries may develop shock, requiring rapid resuscitation and operative repair. Noncoital injuries are often associated with multiple severe injuries and require operative intervention. Late sequelae are minimal in both groups, and even severe injuries do not preclude normal pregnancy and sexual function.

Anorexia nervosa: issues for the obstetrician and gynecologist

Anorexia nervosa, primarily a disorder in adolescent and young women, is not only a psychiatric illness; the disorder can have serious gynecologic and medical ramifications. As obstetricians and gynecologists assume a broader role in preventative medicine and health maintenance, an awareness is needed in the latest issues regarding this relatively common disorder. These issues include the newly recognized effects on the neuroendocrine system and the possible implications for treatment, the relationship of anorexia nervosa with a history of childhood sexual abuse and the possible implications of maternal anorexia nervosa on infant development.

Dysfunctional uterine bleeding

DUB is a common adolescent problem usually related to HPO axis immaturity and anovulation. Modern hormonal and other medical therapies enable physicians to treat DUB effectively, regardless of the cause. The evaluation provides the physician with an opportunity to offer confidential education, reassurance, treatment, and appropriate intervention in cases in which a systemic or coagulation disorder may be the underlying pathophysiology involved.

Tensile characteristics of PTFE sutures

The tensile strength load to failure and knotting characteristics of the six gauges of a new PTFE suture have been studied. In its unstressed state, the suture comprises 50% by volume of air but this diminishes upon stretching so that its diameter appears to be very large and the tensile strength low. The low surface-surface friction necessitates fairly complex knotting regimens (3 = 1 = 3 = 2 or 3 = 1 = 3 = 3) to ensure stable knot configurations, i.e. failure of the loop before knot failure. However, the relatively simple 2 = 1 = 1 = 1 configuration was found to have an adequate tensile strength.