Adolescent Gynecology

The effect of gonadoliberin analog treatment in precocious puberty on polycystic ovarian syndrome prevalence in adulthood

Precocious puberty is diagnosed when pubertal characteristics appear before the age of 8 years in females. The most common form is gonadotropin-dependent, called axial. The primary method of treatment is administration of gonadotrophin-releasing hormone analogues (GnRHa). The aim of the study was to verify hypothesis that GnRHa therapy in the childhood may be of additive risk factor for polycystic ovary syndrome (PCOS) in adulthood.

Material and Methods

The study group consists of 24 women (median age 22 88 years, median BMI 23.5) treated with GnRHa for central precocious puberty in childhood. The control group includes 40 women (median age 23 years, median BMI 25.6) diagnosed with isolated premature thelarche and not using GnRHa in the childhood. Anthropometric measurements, ultrasound examination of minor pelvis and hormonal profile were performed. PCOS diagnosis was based on Rotterdam criteria.

Results

The study confirmed a higher prevalence of PCOS in the study group (50%) than in the control group (10%); p=0.0006. Significant, linear correlation between free testosterone levels and ovarian size was found in the study group (R=0.45 p= 0.03).

Conclusions

GnRHa therapy during childhood may have a potential influence on incidence of PCOS in the adulthood. Therefore, in this group of patients long-term follow-up focused on screening for PCOS would seem beneficial.

Peculiar Aspects of Endometriosis in Adolescents

Although documented rates of endometriosis in adolescent patients undergoing laparoscopy for chronic pelvic pain range from about 25% to 45%, adolescent endometriosis has received limited attention in terms of research activity and follow-up studies. In this manuscript, distinctive characteristics of adolescent and young endometriosis have been considered in order to define pathogenetic and scientific concepts that might be useful in clarifying some aspects of the adult disease as well. Some highlights relative to the cellular origin of the disease can be derived from reported cases before menarche, from the appearance of endometriotic lesions in teenagers (mostly stage I-II endometriosis), and from the relative infrequency of ovarian endometriotic cysts in this population. Adolescents and young patients might be also particularly useful for studying the natural course of the disease. To this end, clinical manifestations and recurrence patterns of the disease in adolescent patients need to be elucidated. Differences in clinical aspects of the disease between the adult and young populations are presented. Risk of recurrence and potential risk factors involved in the reappearance of the disease in teenagers are completely unknown. (Journal of Endometriosis 2010; 2: 19–25)

Assessment of the menstrual cycle, eating disorders and self-esteem of Polish adolescents

INTRODUCTION

Eating disorders are an important factor in menstrual cycle disorders in girls. Moreover, low self-esteem among adolescent girls may be a risk factor for eating disorders. The aim of the study was to assess the menstrual cycle, eating habits and self-esteem of Polish adolescents.

METHODS

The study was conducted from January 2014 to March 2015 and included 623 girls, aged 15-19, from randomly selected junior high schools in Silesia, Poland, in which their menstrual cycle, risk of eating disorders and self-esteem were evaluated. A five-part questionnaire was used to assess basic demographic data, lifestyle and physical activity, gynecological history, as well as Rosenberg Self-Esteem Scale (SES) and Eating Attitude Test (EAT-26).

RESULTS

Irregular menstrual cycles were observed in 236 (37.88%) girls; 5.20% presented secondary amenorrhea. Based on the EAT-26 test, 101 (16.21%) girls were indicated being at risk for an eating disorder. Low self-esteem was observed in 340 (54.57%) study girls on the base of SES.

DISCUSSION

Girls with irregular menses had higher scores on the EAT-26 test in subscales: EAT-overall score, EAT-diet and EAT-bulimia, while lower scores on the SES. In our study, we did not observe a significant relationship between exercise intensity, body mass, BMI and menstrual cycle regularity. Low self-esteem among adolescent girls may be a risk factor for eating disorders which could interrupt the menstrual cycle.

Effectiveness of the Association N-Palmitoylethanolamine and Transpolydatin in the Treatment of Primary Dysmenorrhea

STUDY OBJECTIVE

To evaluate the effectiveness and safety of the combination of N-palmitoylethanolamine (PEA) and transpolydatin vs placebo in the treatment of primary dysmenorrhea in adolescents and young women.

DESIGN, SETTING, AND PARTICIPANTS

Randomized treatment and follow-up of 220 cases of primary dysmenorrhea in the Department of Medicine and Health Sciences, Institute of Gynecology and Obstetrics, University of Molise, Italy.

METHODS

Between February 2013 and February 2014, we treated 220 young women aged 16 to 24 years who had primary dysmenorrhea: 110 patients were treated with the oral combination of PEA-transpolydatin: 400 mg + 40 mg (1 tablet a day for 10 days from the 24th day of cycle) and 110 patients with placebo (1 tablet a day for 10 days from the 24th day of cycle). A follow-up was performed after treatment, and all girls were seen at this time. A 10-point visual analog scale was used to measure the improvement of pelvic pain. For categorical variables, the χ(2) test and analysis of variance were performed to value the significance of differences between groups. A value of P < .05 was considered statistically significant.

RESULTS

An improvement of pelvic pain was seen in 98.18% (95% confidence interval 97.64% to 98.60%) of cases in group 1 vs 56.36% (95% confidence interval 48.62% to 63.81%) in group 2 (P < .001). The combination of PEA and transpolydatin was more effective than placebo (P < .001).

CONCLUSION

The combination of PEA and transpolydatin shows promise as a valid adjuvant therapy in the medical treatment of primary dysmenorrhea in adolescents and young women.

Menstrual Cycle and the Prevalence of Premenstrual Syndrome/Premenstrual Dysphoric Disorder in Adolescent Athletes

STUDY OBJECTIVE

The purpose of this study was to assess the menstrual cycle, menstrual disorders and premenstrual syndrome/premenstrual dysphoric disorder (PMS/PMDD) in girls and young women participating in competitive sports. The impact of PMS/PMDD symptoms on the quality of life was also analyzed.

DESIGN

The prospective study encompassed 125 girls and young women with the aim to determine the presence of menstrual disorders and the prevalence of PMS/PMDD.

PARTICIPANTS

The studied group was composed of 75 female athletes aged 16 to 22 years. The control group included 50 healthy girls and young women who did not practice competitive sports.

SETTING

The studied athletes and the controls prospectively evaluated their 2 consecutive menstrual cycles by using a questionnaire.

INTERVENTIONS

The research tools were a purpose-built questionnaire, a daily log of PMS symptoms according to the American College of Obstetricians and Gynecologists' guidelines, and a daily log of PMDD symptoms based on the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, diagnostic criteria.

MAIN OUTCOME MEASURES

To determine the impact of competitive sports on the menstrual cycle, menstrual disorders, and the prevalence of PMS/PMDD in girls and young women.

RESULTS

Intensive physical exercise delayed menarche. PMDD was diagnosed in 8% and PMS in 42.4% of all respondents. The prevalence of PMDD did not differ significantly between the groups (9.33% versus 6.00%). PMS was significantly more frequent among athletes than among controls (49.33% versus 32%, P = .045). The prevalence of PMS correlated significantly with mean age (P = .00001) and age at menarche (P = .03) in athletes. PMS was more frequent in older athletes and in girls with older age at menarche.

CONCLUSION

Competitive sports, older mean age, older age at menarche, length of sporting career, and intensity of training are conducive to PMS. The prevalence of PMS increases with the duration and intensification of competitive exercises.

Exploring clinician confidence in the management of adolescent menstrual and reproductive health problems

PURPOSE

A high incidence of menstrual problems is reported in adolescent girls, with significant attendant morbidity. The majority are likely to be seen and managed by doctors other than specialist gynaecologists. This study aimed to survey the practice of doctors other than gynaecologists, to establish their chosen therapeutic options and confidence levels and to explore knowledge, using clinically challenging scenarios.

METHODS

A questionnaire designed to fulfil the above aims was distributed to a wide range of clinicians across paediatric disciplines and primary care.

RESULTS

The questionnaire was returned by 306 clinicians. General practitioners and paediatric endocrinologists were more confident in management and were more likely to self-manage patients (p < 0.01). The oral contraceptive pill was the most frequently chosen first-line therapy by all clinicians, followed by transdermal oestrogen/progesterone, etonorgestrel implant, progesterone-only pills, levonorgestrel-intrauterine system and depot medroxyprogesterone acetate injections. General, community and subspecialist paediatricians were more likely to choose suboptimal management strategies for each of five clinical scenarios.

CONCLUSIONS

Low confidence levels, suboptimal therapy choices and high referral rates are common among general paediatricians, community paediatricians and subspecialists for adolescents with menstrual and reproductive health concerns. Targeted education for these clinician groups, towards optimizing management for these patients, would enhance care.

Contraceptive need, counseling, and provision at the time of human papillomavirus vaccination on a catch-up schedule

STUDY OBJECTIVE

Human papillomavirus vaccination may be given on a catch-up schedule to individuals between 13-26 years of age. Young women receiving human papillomavirus (HPV) vaccination during this time of adolescence and young adulthood may be at risk for pregnancy. We aimed to describe contraceptive need and contraceptive care for females at the time of HPV vaccination on a catch-up schedule.

DESIGN

We performed a cross-sectional study of adolescents and young women who received HPV vaccination between June 2006 and May 2010.

SETTING

University of Illinois Health Sciences Center.

PARTICIPANTS

Females aged 13-26 years.

MAIN OUTCOME MEASURES

Proportion of females receiving contraception counseling and provision at time of catch-up HPV vaccination. We used descriptive and chi-square statistics for analysis.

RESULTS

507 females, mean age 22 years, received HPV vaccination in the study period. Initiation of heterosexual activity was documented for 472 (94%). Of those who were currently sexually active, 316 (80%) were using contraception. The majority of all subjects (76%) were counseled on contraception at vaccination. Sexually active females were more likely to be counseled than those who had not initiated sexual activity (77% vs 54%, P = .002). Those vaccinated in primary care clinics were more likely to be counseled than in colposcopy clinics (87% vs 36%, P < .001).

CONCLUSION

Young women presenting for HPV vaccination are often at risk of pregnancy. Onset of sexual activity and clinical site were associated with contraceptive care. HPV vaccination represents an opportunity to improve access to contraceptive care.

Neighborhood disadvantage, racial concentration and the birthweight of infants born to adolescent mothers

To study the relationship between neighborhood demographic characteristics (disadvantage, racial concentration) and the birthweight of infants born to adolescent mothers, potentially as mediated by smoking, prenatal care use, or perceptions of neighborhood safety. Data from Waves I and IV of the National Longitudinal Survey of Adolescent Health were analyzed. Birthweight (continuous) and low birthweight (<2.5 kg) of singleton infants born to non-Hispanic Black and non-Hispanic White adolescent mothers (<20 years) after Wave I were examined as outcomes. Neighborhood demographic characteristics included Census Block Group socioeconomic disadvantage and Black racial concentration. Possible mediators (smoking during pregnancy, early initiation of prenatal care, and perceptions of safety) were also examined. Controls for adolescent baseline age, age at pregnancy, body mass index (BMI) and parental education were included. Analyses were run stratified on race. Baseline continuous birthweight, BMI and neighborhood demographics varied significantly between non-Hispanic Black and White adolescent mothers, with Black adolescent mothers evidencing lower birthweight and higher BMI, neighborhood disadvantage and Black racial concentration. In multivariable analyses among Black adolescent mothers, Black racial concentration was positively associated with birthweight, and negatively associated with low birthweight; no mediators were supported. Neighborhood disadvantage and Black racial concentration were unassociated with birthweight outcomes among White adolescent mothers. Infants born to Black adolescent mothers evidenced higher birthweight with increasing Black neighborhood concentration. Further exploration of mechanisms by which Black racial concentration may positively impact birthweight is warranted.

Clinical characteristics of adolescent endometrioma

STUDY OBJECTIVE

To evaluate the clinical characteristics of endometrioma in adolescent women compared to women of other age groups.

DESIGN

Cross-sectional study.

SETTING

A university hospital.

PARTICIPANTS

Three-hundred seventy-six women.

INTERVENTION

Women of reproductive age who underwent surgery for the treatment of endometrioma were classified into 4 groups according to age (group 1, ≤20 years; group 2, 21-30 years; group 3, 31-40 years; group 4, 41-45 years), and compared.

MAIN OUTCOME MEASURE

Clinical characteristics including demographic factors, menstrual patterns, and characteristics of endometriosis.

RESULTS

Group 1 (adolescent females) experienced menarche at earlier age compared to other groups (P < .005 for all comparisons). In group 1, main symptom was pain (77%) and the proportion of incidental detection (23%) was low, similar to findings for group 2. However, the proportions of incidental detection (45%) and infertility (10%) were increased in group 3, and the proportion of incidental detection (60%) was even higher than that of pain (40%) in group 4 showing that the distributions of presenting symptoms differed from those of group 1. There were no differences in menstrual pattern among groups. In addition, except for the absence of coexisting gynecologic problems such as myoma or adenomyosis in group 1, other characteristics of endometrioma did not differ among groups.

CONCLUSION

Adolescents with endometrioma experience more frequent pain, but other clinical characteristics are similar to adults.

Predictors of birth weight and gestational age among adolescents

Although pregnant adolescents are at high risk of poor birth outcomes, the majority of adolescents go on to have full-term, healthy babies. Data from the National Longitudinal Study of Adolescent Health, a longitudinal study of a nationally representative sample of adolescents in grades 7-12 in the United States who were surveyed from 1994-1995 through 2008, were used to examine the epidemiology of preterm birth and low birth weight within this population. Outcomes of pregnancies were reported by participants in the fourth wave of data collection (when participants were 24-32 years of age); data were compared between female participants who reported a first singleton livebirth at less than 20 years of age (n = 1,101) and those who were 20 years of age or older (n = 2,846). Multivariable modeling was used to model outcomes; predictors included demographic characteristics and maternal health and behavior. Among black adolescents, low parental educational levels and older age at pregnancy were associated with higher birth weight, whereas low parental educational levels and being on birth control when one got pregnant were associated with higher gestational age. In nonblack adolescents, lower body mass index was associated with lower birth weight, whereas being unmarried was associated with lower gestational age. Predictors of birth outcomes may differ by age group and social context.

Sexual and reproductive health education: contrasting teachers', health partners' and former students' perspectives

CONTEXT

National guidelines recommend that Canadian sexual and reproductive health (SRH) education promote access to SRH services and effectively target SRH information to adolescents prior to their leaving secondary school. Within the context of rapidly changing health technologies (HPV vaccine, contraception innovations), SRH education can be an essential health promotion strategy targeting Canada's youth. SRH education in publicly funded Catholic and secular ("public") secondary schools in the National Capital Region, Canada was evaluated to determine whether it meets the standards of health promotion.

METHODS

SRH strategies were collected by semi-structured interviews with 44 SRH educators: 15 public school teachers, 15 Catholic school teachers and 14 referent health partners and 31 young adults. Interview transcripts were subjected to deductive content analysis using the Information, Motivation, Behavioural Skills (IMB) model.

RESULTS

Student uptake of SRH classroom themes (reproductive anatomy, contraceptive/condom use and risk prevention) was fairly consistent with teacher self-report. Students were encouraged to abstain from sexual activity by both public and Catholic teachers. SRH skill-building activities included relationship scenarios and facilitated access to SRH services by teachers from both Catholic and public schools, however only public schools provided condom demonstrations. Students recommended a more sex-positive education as sex was presented as an inherently negative and risky activity.

CONCLUSIONS

SRH education, framed by the IMB model and in the context of school-community health partnerships, is an effective tool for health promotion. Knowledge transfer of biomedical SRH information is effective; however improvements can be made in the promotion of SRH self-efficacy.

Menorrhagia in adolescents with inherited bleeding disorders

STUDY OBJECTIVES

We reviewed the management and treatment outcomes of menorrhagia in adolescents with inherited bleeding disorders and assessed the impact of menorrhagia on their quality of life.

DESIGN

Retrospective review of case notes and a questionnaire study.

SETTING

Comprehensive-care hemophilia treatment center.

PARTICIPANTS

Adolescents with inherited bleeding disorders who had registered at the center and were attending the multidisciplinary hemophilia and gynecology clinic for management of menorrhagia.

INTERVENTIONS

Review of medical records and assessment of menstrual blood loss using the pictorial blood assessment chart and quality of life measurements during menstruation using a questionnaire.

MAIN OUTCOME MEASURES

Scores on pictorial blood assessment charts and quality of life measurements before and after treatment.

RESULTS

Of 153 girls aged 12 to 19 years who had registered at the center and had an inherited bleeding disorder, 42 (27%) attended the multidisciplinary clinic for management of menorrhagia. The majority (38/42; 90%) had experienced menorrhagia since menarche. Of the group, 5 (12%) required hospital admission for acute menorrhagia and severe anemia. Treatment options for menorrhagia included tranexamic acid, desmopressin, combined oral contraceptive pills, clotting factor concentrate, and the levonorgestrel intrauterine system. These treatment modalities, alone or in combination, were associated with a reduction in menstrual blood loss (median pre- and posttreatment pictorial blood assessment chart scores were 215 and 88, respectively) and improvement in quality of life scores (median pre- and posttreatment were 26 and 44, respectively).

CONCLUSIONS

Menorrhagia is a common symptom in adolescents with inherited bleeding disorders. It can present acutely, and it adversely affects quality of life. Treatment options include hemostatic and/or hormonal therapies and can improve the quality of life of affected girls.

Foreign body sexual assault complicated by rectovaginal fistula

A case is discussed of an adolescent presenting with a rectovaginal fistula secondary to a sexual assault 2 years earlier. The fistula resulted from a retained foreign body (bottle cap) inserted into the vagina during the assault. The adolescent did not disclose the presence of the foreign body at the initial examination.