Abnormal Uterine Bleeding: Current Classification and Clinical Management.

Abnormal uterine bleeding is now classified and categorized according to the International Federation of Gynecology and Obstetrics classification system: PALM-COEIN. This applies to nongravid women during their reproductive years and allows more clear designation of causes, thus aiding clinical care and future research.

The Menopausal Transition.

A clear understanding of the physiology of the menopausal transition, clinical symptoms, and physical changes is essential for individualized patient management, maximizing benefits and minimizing risks for the present and the future. Menopause, defined by amenorrhea for 12 consecutive months, is determined retrospectively and represents a permanent end to menses. Many physical changes occur during the menopausal transition and beyond. Knowledge of symptoms and findings experienced by women undergoing the menopausal transition allow individualized care- improving quality of life and enhancing wellbeing for years to come.

Clinical Recommendation: Labial Adhesions.

Labial adhesions, also known as labial agglutination, are a common finding in prepubertal adolescents. They are defined as fusion of the labia minora in the midline or are termed vulvar adhesions when they occur below the labia minora (inner labia). Patients are often asymptomatic but might present with genitourinary complaints. The decision for treatment is based on symptoms. The mainstay of treatment in asymptomatic patients is conservative, with careful attention to vulvar hygiene and reassurance to parents. In symptomatic patients, topical treatment with estrogen and/or steroid cream is often curative. Less often, corrective surgery is necessary. Recurrence is common until a patient goes through puberty. These recommendations are intended for pediatric and gynecologic health care providers who care for pediatric and adolescent girls to facilitate diagnosis and treatment.

Physical activity during pregnancy is associated with reduced fasting insulin--the Pilot Pregnancy and Active Living Study.

OBJECTIVE: To examine the relationship between physical activity during pregnancy and fasting plasma insulin measured in the second trimester. STUDY DESIGN AND METHODS: We conducted a pilot prospective cohort study of 69 overweight or obese women who were enrolled before 20 weeks of gestation at an obstetric clinic in Columbia, South Carolina in 2006-2007. At 24-28 weeks of gestation, fasting blood samples were collected and physical activity from the 3 months prior to the visit was assessed using a validated Pregnancy Physical Activity Questionnaire. RESULTS: Total energy expenditure (EE) in this population was attributable to sedentary activities (24.4%) and to physical activities of different intensities (light: 44.8%, moderate: 30.2%, and vigorous: 0.6%). By type, total EE mainly came from household/caregiving activities (58.9%) with a small proportion from exercise (3.8%). After adjusting for confounders, the mean fasting insulin values across the quartiles of total EE (least to most) were 17.3, 13.0, 12.1, and 9.6 uIU/ml (P for trend=0.01). CONCLUSION: Our findings suggest that increased total physical activity is associated with reduced fasting insulin levels in overweight or obese pregnant women.

Cervical cytology screening and management of abnormal cytology in adolescents.

The consensus guidelines recognize adolescents as a special group and allow for more conservative follow- up of abnormal cytology and histology. The guidelines recognize the role of high rates of HPV infection and reinfection in teens, along with high rates of clearance of HPV and low rates of invasive cervical cancer. Risks of treatment are balanced with risk for disease progression. The cervical cancer vaccine is now recommended for teens. The approved vaccine protects against HPV related disease caused by four subtypes of HPV 6, 11, 16, and 18. The Food and Drug Administration has approved the vaccine as routine for 11- and 12-year-old girls. The vaccine is most effective prior to HPV exposure or before the sexual debut. In South Carolina only 4.8% of high school girls indicate having sexual intercourse before age 13. Vaccination provides an opportunity to review risky behaviors with adolescent patients and to encourage healthy, safe lifestyles. Vaccination is not protective for sexually transmitted infections and this can be emphasized at vaccination visits as well. The importance of cancer screening can also be reviewed with patients at vaccination visits.

Prepubertal Skene's abscess.

BACKGROUND: Skene's glands are believed to be homologues of the prostate gland derived from the urogenital sinus.(1) Complications of Skene's glands occur most often in the third and fourth decades and are rarely seen in premenarchal females. CASE: A 3-year-old presented to her pediatrician with a 9-day complaint of vulvar pain. Both pediatric and gynecologic office examination revealed an enlarged right labium majus and an erythematous area adjacent to the urethra. Examination under anesthesia revealed a Skene's gland abscess that was treated with incision and drainage. The patient experienced complete resolution of symptoms. CONCLUSION: A Skene's gland abscess is rare among premenarchal girls. An abscess presenting in a patient complaining of pain can be successfully managed with incision and drainage.

Pregnancy after Essure placement: report of two cases.

OBJECTIVE: To report two cases of pregnancy after placement of Essure micro-inserts. DESIGN: Case report. SETTING: University-based Department of Obstetrics and Gynecology. PATIENT(S): Patient 1, a 38-year-old woman, presented with a positive pregnancy test 7 months after Essure hysteroscopic sterilization. Patient 2, a 35-year-old female, became pregnant approximately 1 year after undergoing the Essure procedure. INTERVENTION(S): Patient 1 received obstetric ultrasounds, a prophylactic cerclage, a cesarean section, and a tubal ligation. Patient 2 underwent a postprocedure hysterosalpingogram, an obstetric ultrasound, pregnancy termination, diagnostic pelvic ultrasound, and a hysterectomy. MAIN OUTCOME MEASURE(S): Documentation of normal progress of pregnancy after Essure placement. RESULT(S): Patient 1 carried an uncomplicated pregnancy to term with an Essure micro-insert in place. Patient 2 became pregnant despite an hysterosalpingogram showing tubal occlusion and was ultimately found to have a micro-insert perforating the uterine wall. CONCLUSION(S): The presence of Essure micro-inserts in the fallopian tubes do not appear to interfere with implantation and pregnancy. Uterine perforation by an Essure micro-insert in proximity to the tubal ostia may mimic proper micro-insert placement and bilateral tubal occlusion on both hysterosalpingogram and saline infusion sonography.

A pure Sertoli cell tumor of the ovary in a 10-year-old female.

STUDY OBJECTIVE: To document an unusual presentation of a pure Sertoli Cell tumor. DESIGN: Case report. RESULTS: We present a 10-year-old female who presented with abdominal pain and diarrhea with no symptoms of puberty. Surgical exploration revealed a metastatic pure Sertoli Cell tumor, which was treated with resection and chemotherapy. CONCLUSION: Sertoli cell tumors are rare occurrences and should be considered in the differential diagnosis for a prepubescent girl with an abdominal mass.

Hair thread tourniquet syndrome in adolescents: a presentation and review of the literature.

Hair thread tourniquet syndrome has been recognized since the 1600s when a strangulating hair was reported around the glans penis. Since that time sporadic reports have appeared in the literature describing strangulation of appendages by human hair. Most often the constriction involves fingers, toes, or the penis. There are several reports of clitoral strangulation. Most cases present to their primary care provider or emergency department. A high index of suspicion is required for diagnosis in order to prevent prolonged devascularization. We describe a hair thread tourniquet syndrome of the labia minora in a 13-year-old. It was successfully treated with exam under anesthesia and resection of the devascularized tissue. We believe this is the oldest patient described as well as the only description of hair tourniquet syndrome of the labia minora. Prompt recognition of this unusual condition is essential for treatment of this potentially serious problem.

Communicating with the adolescent gynecology patient.

Providing health care to adolescents begins with good communication. Teens appreciate providers who are genuine and not parental. Guidelines to facilitate adolescent communication are presented. A good dialogue with teens can initiate a lifetime of care.

Prepubertal labial adhesions: evaluation of a referral population.

OBJECTIVE: The purpose of this study was to assess patient demographics, clinical presentation, response to previous treatment, and current evaluation of prepubertal girls referred for gynecologic care of labial agglutination. STUDY DESIGN: A retrospective chart review of all prepubertal female patients with labial agglutination referred from 1996 through 2001. RESULTS: Twenty-three girls were diagnosed with labial agglutination during the review period. All of the diagnoses were made by a primary care provider. At the time of referral, most patients had received medical therapy, but had not obtained resolution of their labial agglutination with topical estrogen. Twenty-two of the 23 patients required manual separation of the labial adhesions. Findings most frequently revealed a pinpoint opening and thick (3-4 mm) adhesions with >90% of the vestibule adhered in 21 of 23 girls. Nine of 23 girls had recurrence of adhesions. Four girls required a repeat manual separation because of recurrent thick adhesions. One of 4 girls required a third manual separation. Five of the 9 recurrences were treated successfully with topical estrogen. CONCLUSION: Gynecologists who treat patients with labial agglutination frequently may encounter children for whom medical treatment has failed. Patients whose condition does not respond to topical therapy may have thick adhesions and require manual separation.