Hair-thread tourniquet syndrome of labia minor.

BACKGROUND: Several organs may be damaged by strangulation by hair or strings that cause ischemia and necrosis. There have been sporadic case reports of such events. Injuries to the hands, feet, and fingers, as well as penile(1-5) and clitoral injuries(6-8) have been reported. CASES: Three cases of labia minor strangulation by hair are described. A review of the relevant literature is included. CONCLUSIONS: Pediatricians, gynecologists, and family physicians must be aware of labial tourniquet syndrome. If the diagnosis is missed or remains without immediate attention, the hair or string may cause necrosis and the resulting amputation of the vital body part.

A simulated patient-based program for training gynecologists in communication with adolescent girls presenting with gynecological problems.

Most gynecologists lack the unique skills required for communication with female adolescent patients and with their parents. Years of clinical experience are required to develop communication skills that would facilitate the confidence of the young patient already during the first visit. Simulation-based medical education at the Israel Center for Medical Simulation (MSR) has become a powerful force in quality-care training for healthcare providers using empirical educational modalities, enabling controlled proactive experiential exposure to both regular and complex scenarios. Among the various MSR programs, for various medical sectors, training programs have been developed to improve the skills of physicians communicating with adolescents, including primary care physicians and school doctors. This paper describes the first reported simulated patient-based MSR training program for gynecologists in communication with adolescents who present with common complaints encountered in gynecology clinics. Twenty gynecologists participated in eight individual simulated scenarios conducted at simulated physicians' offices, equipped with audio-visual recording cameras and one-way mirrors for observation. Three physicians experienced in debriefing and in facilitating group discussions led the debriefing sessions, using the video recording of the simulated scenario following the simulation exercises. These discussions focused on communication techniques when facing adolescent patients with or without their parents, hidden agendas disclosed by using systematic physical and psychosocial reviews, the emotional load often associated with clinical problems, and the non-judgmental and supportive approach to adolescent patients. The clear recommendation that emerged from the high satisfaction of the program participants was to expand simulated patient-based programs for gynecologists and to include it as an integrated part of the training curriculum in pediatric and adolescent gynecology.

Postmyomectomy sonographic imaging: uterus remodeling and scar repair.

PURPOSE: Description and evaluation of the sonographic changes at the site of the myomectomy and follow-up of the healing process. METHODS: Twelve patients with intramural fibroids underwent myomectomy. Pre- and postoperative ultrasound examinations included measurements of uterine volume and the largest diameters of the largest fibroid and the myomectomy scar. RESULTS: The mean uterine preoperative volume was 773 cm(3) (range 271-1,343) (SD 285). It decreased postoperatively to 318 cm(3) (range 98-756) (SD 192) and 185 cm(3) (range 78-420) (SD 96) in the immediate and late scans, respectively. The mean size of the largest diameter of the largest fibroid was 10 cm (range 7-15) (SD 2.3). The largest diameter of the immediate postoperative myomectomy site was 4.5 cm (range 2.2-8) (SD 1.8) decreasing later to 2.4 cm (range 0-6) (SD 1.6). CONCLUSION: The postoperative sonographic findings following myomectomy demonstrates a solid finding that may mistakenly be interpreted as the remaining fibroid that shrinks gradually. The finding is probably the result of changes in hyperplastic myometrial tissue, focal small hematomata and suture material.

[Extended cycle oral contraceptives].

Oral contraceptive pills are conventionally prescribed in a manner that causes monthly withdrawal uterine bleeding (lunar month). The reasons for this are historical without an inherent medical need. According to our literature search, there are patients' demands for less frequent menstrual cycles. We have learned from patients who were given the pill continuously for long periods due to medical or social indications that continuous administration of the contraceptive pill is feasible and safe. In the current review, the authors have searched the literature regarding extended cycle oral contraception for periods of time up to one year. This way of administration of the pill is not compromising the efficacy of pregnancy prevention, nor is it detrimental in terms of cardiovascular and hemostatic complications or endometrial malignancy. It is known that there is a slightly increased risk of breast cancer in users of oral contraceptives up to 10 years, regardless of the mode of administration. From a few studies of hormone replacement therapy in postmenopausal women, there is concern that continuous treatment may be deleterious, while sequential is not. Extended cycle contraceptive treatment has a few side effects, mainly increased breakthrough bleeding but decreased withdrawal bleeding. Other side effects were less prevalent than in conventional administration.

Perinatal outcome of teenage pregnancies in a selected group of patients.

STUDY OBJECTIVE: To explore the effect of young age on the outcome of teenage pregnancies by studying teenage deliveries in our unique population. DESIGN, SETTING, AND PARTICIPANTS: Retrospective chart review of teenage gravidas (age 19 and younger), who had delivered in our hospital. OUTCOME MEASURES: Mode of delivery, gestational age at delivery, newborn's weight and Apgar scores and maternal and neonatal complications. RESULTS: We recruited 565 teenage delivery cases from the hospital's computerized database. Mean maternal age was 18 (14-19). Most (96%) were married. Fifty-one percent were Jewish and 44% were Muslim. Most of the girls were nulligravidas. Mean gestational age at delivery was 39 weeks (33-44 weeks). A normal vaginal delivery ensued in 72.7%, while 9% had a cesarean section and 17.4% instrumental deliveries (compared to 85.75%, 10% and 4.25% in our adult population, respectively) and 1% underwent vaginal breech delivery. Mean birth weight was 3108 g (1450-4980 g). Apgar score of 9 at 5 minutes was recorded in 97.8% of the newborns. Prenatal care included a mean of 6 prenatal visits with a range of 1-18. The main complication was anemia; 41% had hemoglobin levels of less than 11 g/dL. The rate of other complications was low. CONCLUSIONS: In our homogenous group of teenagers, there was a similar complication rate as in the adult population. The only significant complication was anemia (less than 11 g/dL). There was a higher rate of instrumental deliveries and the cesarean delivery rate was slightly lower than in our adult population. Teenage pregnancy should not be considered as a high-risk situation as long as it is planned and followed with the normal routines of prenatal care.

Combination of endometrial thickness and time since menopause in predicting endometrial cancer in women with postmenopausal bleeding.

PURPOSE: This study was conducted to assess the combination of endometrial thickness, as measured by transvaginal sonography, and time since menopause, in predicting the presence of endometrial cancer in women with postmenopausal bleeding. METHODS: The study group consisted of 95 women with postmenopausal bleeding who underwent sonographic measurement of endometrial thickness followed by endometrial biopsy. No patient had ever received hormone replacement therapy. RESULTS: The mean endometrial thickness was significantly lower in the absence of endometrial carcinoma (6.9 +/- 4.3 mm) than in its presence (13.5 +/- 7.7 mm) (p < 0.005). The incidence of endometrial carcinoma increased with increases in endometrial thickness and the number of years since menopause. No patient had carcinoma when the endometrium was less than 5 mm thick, but 18.5% did when the thickness exceeded 9 mm. The incidence of cancer was 2.6% in women who had undergone menopause less than 5 years earlier but was 21.4% in women who had undergone menopause more than 15 years prior. Multiple logistic regression analysis showed that time since menopause and endometrial thickness were statistically significant predictors of endometrial carcinoma. CONCLUSIONS: Time since menopause and endometrial thickness together define cutoff points for the diagnostic biopsy of tissue samples for endometrial carcinoma; that is, within a particular time interval, sampling should not be performed if the thickness is below a given value. When using cutoff points of 6 mm of endometrial thickness for women experiencing menopause 5-15 years prior and 5 mm in those going through menopause 15 or more years prior, approximately 60% of invasive procedures may be avoided. In addition, models derived by multiple logistic regression can be used to calculate a patient's risk of cancer based on her age and endometrial thickness.

Contribution of sonographic measurement of ovarian volume to diagnosing ovarian tumors in postmenopausal women.

The purpose of this review article is to evaluate the current method of sonographic measurement of ovarian volume as a means of diagnosing ovarian tumors in postmenopausal women, in whom an ovarian volume greater than 10 ml is generally considered abnormal. After reviewing the general medical literature, we propose a nomogram of ovarian volume that may be used to determine whether an ovary is abnormal. Furthermore, on the basis of our previous results, we recommend that a cutoff point for ovarian volume that is adjusted to patient age be used to determine whether an ovary is abnormal. We recommend the use of such nomograms in routine clinical practice to assist physicians in identifying abnormality of the ovaries during sonographic examination.

[The adolescent breast--normal and abnormal development, diseases and tumors].

BACKGROUND: The possible problems of an adolescent breast include a large spectrum of phenomena such as changes which may cause aesthetic problems, infectious diseases and in rare cases, malignant tumors. Young adolescents and their mothers tend to consult with a gynecologist usually due to developmental abnormalities of the growing breast such as asymmetry of the breast, agenesis or hypoplasia of one breast. Cysts and tumors are usually worrisome and warrant attention and precise diagnosis. PURPOSE: The aim of this paper is to review the recent studies and data concerning breast diseases in adolescents and to summarize by presenting symptoms, diagnostic procedures and the most up-to-date treatment modalities. METHOD: A comprehensive and updated literature review. RESULTS AND CONCLUSIONS: A large variety of abnormal phenomena in the breast during adolescence have been described. Abnormal breast development in adolescents may present themselves as an aesthetic problem only, but other symptoms such as breast tumors or cysts may arouse suspicion of malignancy of the breast. These findings may be the initiative for the first clinical visit to a gynecologist, initiated by the patient herself or by her parent. Malignancy of the breast in adolescence is very rare, especially when there are no risk factors such as family history or previous X-ray radiation to the breast region. In any case, detailed medical history should be recorded and meticulous physical examination performed in order to rule out any breast pathology that may necessitate prompt treatment. Usually, breast problems in adolescents are benign disorders and only require follow-up without additional treatment. In any aesthetic problem or developmental abnormality, surgery should be postponed until the breast has completed the adolescent stage.

Exercise training, menstrual irregularities and bone development in children and adolescents.

Weight bearing physical activity plays an important role in bone development. This is particularly important in children and adolescents since bone mineral density reaches about 90% of its peak by the end of the second decade, and because about one quarter of adult bone is accumulated during the two years surrounding the peak bone growth velocity. Recent studies suggested that the exercise-induced increase in bone mineralization is maturity dependent, and that there is a "window of opportunity" and a critical period for bone response to weight bearing exercise during early puberty and premenarchal years. This supports the idea that increase in physical activity during childhood and adolescence can prevent bone disorders (like osteoporosis) later in life. In contrast, strenuous physical activity may affect the female reproductive system and lead to "athletic amenorrhea". The prevalence of "athletic amenorrhea" is 4-20 times higher than the general population. As a consequence, bone demineralization may develop with increased risk of skeletal fragility, fractures, vertebral instability, and curvature. Menstrual abnormalities in the female athlete result from hypothalamic suppression of the spontaneous pulsatile secretion of gonadotropin releasing hormone. Recent studies suggested that reduced energy availability (increased energy expenditure with inadequate caloric intake) is the main cause of the central suppression of the hypothalamic pituitary-gonadal axis. Therefore, effort should be made to optimize the nutritional state of female athletes, and if not successful, to reduce the training load in order to prevent menstrual abnormalities, and deleterious bone effects in particular during the critical period of rapid bone growth.

Extrauterine mislocated IUD: is surgical removal mandatory?

The incidence of intrauterine device perforation is 0.87 per 1000 insertions. An intrauterine device (IUD) may perforate through the uterine wall into the pelvic or abdominal cavity or into adjacent organs. The accepted treatment for displaced IUDs is surgical removal because of the putative risk of adhesion formation or of damage to the intestine or urinary bladder. The purpose of this article is to present three cases of IUD perforation where surgical removal may not have been necessary. In all three cases, the IUD was removed by laparoscopy. No adhesions were found in any of the patients. Criteria for the surgical removal of a displaced IUD, as a result of uterine perforation, should be re-evaluated. Whilst surgical procedures to remove a misplaced IUD must be performed on symptomatic patients, asymptomatic patients, under certain circumstances, may benefit from conservative management.