Incidence of Abnormal Findings During Pelvic Examinations in Women Aged 21-35 Years.

To describe the incidence of abnormal gynecologic examination findings in asymptomatic compared with symptomatic patients during preventive visits, we conducted a retrospective study of 1,121 visits for patients between the ages of 21 and 35 years from January 2017 to March 2017. Only 1.2% (95% CI, 0.5%,1.9%) of asymptomatic patients had abnormal findings on pelvic examination, compared with 32.4% (95% CI, 27.0%, 37.8%) of those with symptoms ( P ≤.001). In symptomatic patients, the most common symptoms were vaginal discharge (25.1%), pelvic pain (16.4%), and vaginal bleeding (15.7%). In asymptomatic patients, the most common findings were bacterial vaginosis and Candida infection. Asymptomatic patients presenting for a routine preventive visit have low rates of abnormalities detected on examination, and routine pelvic examinations should be re-considered.

Levels of Gynecologic Care: A Task Force Consensus Statement.

Systems of care have been established for obstetrics, trauma, and neonatology. An American College of Obstetricians and Gynecologists Presidential Task Force was established to develop a care system for gynecologic surgery. A group of experts who represent diverse perspectives in gynecologic practice proposed definitions of levels of gynecologic care using the Delphi method. The goal is to improve the quality of gynecologic surgical care performed in the United States by providing a framework of minimal institutional requirements for each level. Subgroups developed draft criteria for each level of care. The entire Task Force then met to reach consensus regarding the levels of care final definitions and parameters. The levels of gynecologic care framework focuses on systems of care by considering institutional resources and expertise, providing guidance on the provision of care in appropriate level facilities. These levels were defined by the ability to care for patients of increasing risk, complexity, and comorbidities, organizing gynecologic care around hospital capability. This framework can also be used to inform the escalation of care to appropriate facilities by identifying patients at risk and guiding them to facilities with the skills, expertise, and capabilities to safely and effectively meet their needs. The levels of gynecologic care framework is intended for use by patients, hospitals, and clinicians in the United States to guide where elective surgery can be done most safely and effectively by specialists and subspecialists in obstetrics and gynecology. The key features of the levels of gynecologic care include ensuring provision of risk-appropriate care and regionalization of care by facility capabilities.

Surgical considerations and challenges in the pediatric and adolescent gynecologic patient.

It is important for practitioners to recognize that there are special considerations when performing gynecologic surgery in a pediatric or adolescent patient. A provider must be familiar with differences in anatomy, physiology, surgical technique, and psychosocial concerns. This can be challenging for a provider who does not routinely operate on patients in this population. A minimally invasive surgical approach is preferred in the pediatric and adolescent patient whenever possible. While a good command of laparoscopy in the adult patient is certainly a useful skill when operating on pediatric and adolescent patients, there are technical adaptations and challenges to consider. This chapter reviews the pre-operative preparation, operative technique and challenges, and post-operative care of the surgical pediatric and adolescent gynecologic patient.

Gynecologic and Obstetric Consequences of Obesity in Adolescent Girls.

In the past few decades, there has been an overwhelming increase in childhood and adolescent obesity worldwide. Besides the well recognized cardiometabolic complications and other physical conditions associated with obesity, during adolescence, it causes psychological and social distress in a period of life that is already sensitive for a girl. This in turn increases their risk of low self-esteem and depression. Furthermore, obesity diminishes health-related quality of life and years of life. Overweight and obese teenagers are more likely to have gynecologic and obstetric complications, during adolescence and also later in life. Consequences of obese and overweight childhood and adolescence include sexual maturation and reproductive dysfunction, alterations in menstruation, dysmenorrhea, risky sexual behavior, and inefficient use of contraception, polycystic ovary syndrome, bone density abnormalities, macromastia, and an increased risk of breast and endometrial cancer. Obese adolescents are at greater risk of pregnancy and perinatal complications, such as preeclampsia, gestational hypertension and preeclampsia, gestational diabetes mellitus, primary cesarean delivery, and induction of labor, to mention a few. Evidence shows that infants born to obese teenagers are also more likely to have complications including preterm or post-term delivery, small-for-gestational age newborns, macrosomia, meconium aspiration, respiratory distress, and even stillbirth, among others. This comprehensive review focuses on the gynecological and obstetric consequences of obesity in adolescent girls.

Management of Large Ovarian Neoplasms in Pediatric and Adolescent Females.

The overwhelming majority of ovarian cysts in pediatric and adolescent girls are physiologic; however, large simple and complex ovarian lesions often require surgical intervention due to the increased risk of neoplasia. In this review article, we discuss the preoperative evaluation and intraoperative management of large ovarian neoplasms. We review the current literature regarding long term ovarian function and fertility, rates of recurrence and residual disease, and novel surgical approaches. Managing large ovarian neoplasms in the pediatric and adolescent population requires careful preoperative and intraoperative care to optimally resect neoplasia while maximizing fertility and minimizing pain.

Self-attempted labioplasty with elastic bands resulting in severe necrosis.

BACKGROUND: Labial hypertrophy is protuberant labial tissue extending beyond the labia majora. Self-perception of poor cosmetic appearance is common in young patients and not necessarily pathologic. Labioplasty is indicated for patients with persistent symptoms including entrapment and painful intercourse. CASE: A 26-year-old woman presented with genital pain and foul odor after self-applying elastic bands to her labia minora. The bands were applied for a self-perceived abnormal appearance and lack of insurance for medical consultation. Surgical debridement and revision of the labia were performed using a straight vertical approach. CONCLUSIONS: Self-attempted labioplasty can result in necrosis and infection. Education and counseling of patients on the normal variants of labial anatomy and the recommended therapeutic methods will lead to better cosmetic results and prevent self-mutilation.

Development of a web-based laparoscopic technical skills assessment and testing instrument: a pilot study.

OBJECTIVE: Current surgical training programs rely heavily on subjective assessments to measure operative proficiency, despite heavy emphasis on standardized testing as a means to rank scholastic ability. A compact laparoscopic simulator was developed with the intention to create a technical skill evaluation system that resembles standardized testing to provide the user with real-time percentile scores in a variety of skill metrics. The calculation of percentiles is only accurate if the pool of scores resembles a specific distribution (e.g., normal or log-normal distribution). We hypothesize that the grading measures provided by the simulator will follow normal or log-normal distributions. MATERIALS AND METHODS: A total of 29 surgical trainees with varying levels of laparoscopic experience were surveyed regarding their current training, proficiencies, and experience with the Fundamentals of Laparoscopic Surgery curriculum and then asked to perform a standard peg-transfer task 5 times. A proprietary device placed along the trocars of a laparoscopic box trainer was used to gather data that, when subjected to unique algorithms, gave real-time, web-based feedback to trainees on the following metrics: volume of instrument use, economy of movement, angular instrument path, instrument rotation, bimanual coordination, smoothness, time to task completion, and depth perception. Numerical data were plotted on a frequency histogram. Minitab software was used to identify if individual metrics fit a standard distribution curve. Analysis of variance was used to differentiate among 3 established physician skill levels, as a means of assessing construct validity. RESULTS: In the goodness-of-fit tests performed, angular path, depth perception, rotation, and smoothness were found to best fit a log-normal distribution (p > 0.1). Bimanual coordination was found to fit a normal distribution (p ≥ 0.067). However, both normal and log-normal distributions were rejected (p ≤ 0.01) for the metrics of time, volume, and economy of movement. After separating participants into 3 groups based on level of experience with the Fundamentals of Laparoscopic Surgery curriculum, analysis of variance showed significant differences among all group means across the 5 metrics (i.e., angular path, depth perception, rotation, smoothness, and bimanual coordination; p ≤ 0.023). CONCLUSION: A proprietary device provided quantitative assessment of laparoscopic skills, which can be used to differentiate among skill levels. Of the 8 tested metrics, 5 fit a normal or log-normal distribution, meaning the scores can statistically be ranked by percentile. Time, volume, and economy of movement did not fit desired distributions. The grading system proved to have construct validity, indicating it may be useful in the longitudinal assessment of laparoscopic skills of surgical trainees.

Single-site laparoscopic management of a large adnexal mass.

INTRODUCTION: Single-site laparoscopy is gaining acceptance in many surgical fields including gynecology. The purpose of this report is to demonstrate the technique and outcome for removing a large adnexal mass through a single site. CASE DESCRIPTION: A 41-y-old female was referred to gynecology oncology for increased abdominal girth for 3 mo. An ultrasound confirmed a benign-appearing, 37-cm left adnexal mass. The mass was removed through a single-site laparoscopic incision with the aid of drainage and a morcellator. The operating time was 84 min. The patient was discharged 2 h and 35 min later with full return to normal activity in 5 d. CONCLUSION: Large, benign-appearing adnexal masses can be managed safely with superior cosmetic results using single-site laparoscopy.

Progresos en la atención ginecológicaen las adolescentes / Improved gynecologic care for adolescents

Los nuevos avances en el campo de la salud reproductiva adolescente produjeron un interés creciente en el sistema de salud. En esta reseña se destacan los patrones de la práctica clínica y las normas recientes para la evaluación y el tratamiento de los temas ginecológicos de la adolescencia. En primer lugar, la comprensión de las técnicas apropiadas para la evaluación y el examen inicial, que son esenciales para hacer sentir a la paciente lo más cómoda posible y para el establecimiento de una relación a largo plazo. La medicina preventiva es clave en esta población y los médicos deberían hablar de modo sencillo con sus pacientes diversos temas tales como la sexualidad, los trastornos alimentarios, el abuso de sustancias y la violencia en la pareja. Además, debe procurarse que los médicos hablen en la consulta sobre la vacuna contra el papilomavirus humano (HPV) y la indiquen, así como que implementen las modificaciones recientes más conservadoras sobre la pesquisa con citología cervical y su tratamiento en la población adolescente. La frecuencia con la que las adolescentes se inician sexualmente hacen necesario el asesoramiento sobre los métodos anticonceptivos eficaces y la pesquisa apropiada sobre las infecciones de transmisión sexual cuando sea necesario. Durante la transición por la pubertad, los trastornos menstruales son comunes y requieren la interconsulta por un ginecólogo. La etiología más frecuente de los sangrados es la anovulación. El síndrome de ovarios poliquísticos puede aparecer a comienzos de la pubertad y tiene consecuencias en la vida adulta. Por último, las consecuencias de la endometriosis sobre la fertilidad futura de los adolescentes merecen su pronto reconocimiento y tratamiento para evitar las repercusiones futuras de la enfermedad. Dados los progresos en el campo de la salud reproductiva de los adolescentes...

Large epidermal cyst of the clitoris: a novel diagnostic approach to assist in surgical removal.

BACKGROUND: Epidermal cysts of the clitoris are uncommon and usually associated with previous trauma. Surgical removal is the preferred treatment with close attention to preserve sensation and vascular supply. The use of an alternative coil during Magnetic Resonance (MR) imaging to visualize the anatomy may improve surgical management and outcomes. CASE: A 15-year-old adolescent had a 2-year history of clitoral enlargement. Physical exam revealed a 4 × 5 cm clitoral cyst and normal hormonal evaluation. Initial MR with a pelvic coil showed poor resolution of neurovascular supply. MR was repeated using a small flex coil (commonly used on the wrist) placed as a sanitary napkin providing a higher resolution image of the neurovascular structures, which guided surgical intervention. CONCLUSION: The use of the MR small flex coil to better visualize the external genital structures and clitoral anatomy improved preoperative evaluation and guided surgical management of the clitorial cyst.

Update on key topics in adolescent gynecology.

AM:STARs, the Adolescent Medicine State of the Art Reviews series published by the American Academy of Pediatrics, devoted its April 2012 issue to the topic of Adolescent Gynecology. Developed in conjunction with the North American Society for Pediatric and Adolescent Gynecology (NASPAG), the issue consists of twelve articles, written mostly by members of NASPAG. As editors of the issue, we present in this review for the Journal of Pediatric and Adolescent Gynecology (JPAG) a synopsis of the most salient concepts presented in those 12 articles. This review of reviews is intended to be an update on the "state of the art" in adolescent gynecology.

Klippel-Trenaunay syndrome complicated by ascites and vaginal lymphatic drainage in adolescence: a case report.

BACKGROUND: Klippel-Trenaunay syndrome is a rare disease characterized by capillary malformationsand soft tissue and bony hypertrophy and atypical varicosities. Management of this syndrome is focused primarily on treatment of the complications that arise from these malformations. Ascites and lymphedema are two of the more common complications in these patients. CASE: A 15-year-old female with Klippel-Trenaunay syndrome presented with chylous ascites, vaginal drainage, and unilateral lower extremity lymphedema. Treatment included dilation, hysteroscopy and curettage, and laparoscopic evacuation of abdomino-pelvic ascites with resolution of symptoms for 32 months. Repeat laparoscopic drainage was successful and remains symptom free after 12 months. CONCLUSION: Vaginal drainage of chylous ascites is a rare complication from Klippel-Trenaunay syndrome and can be successfully managed by techniques to remove abdomino-pelvic ascites.

Adolescent gynecology: special considerations for special patients.

Developments in the field of adolescent gynecology highlight the specific expertise and care required by this population. Given the ability to shape their future health choices, adolescents are a critical target for preventative health care. The approach to the evaluation and management of this unique population rests not only on the practitioner's adept ability to recognize the unique clinical challenges that may occur, but also rests on his/her understanding of these problems. Here, we review recent guidelines and practice patterns in the evaluation and management of issues in adolescent gynecology.

Intrauterine contraception in adolescents and young women: a descriptive study of use, side effects, and compliance.

OBJECTIVE: Describe characteristics, compliance, efficacy, and side effect profile of adolescents and young women who use intrauterine contraception (IC). STUDY DESIGN: Retrospective chart review of adolescent and young women who had IC devices placed over a 3-year period. Comparative statistics between devices and population characteristics were performed using the Fisher exact and the t test. RESULTS: Eighty-nine patients were included in the study. The mean age at insertion was 19.5 years (range 16-22 years). Copper was used in 13% of patients; levonorgestrel (LNG) was used in 87%. The mean duration of use was 331.3 days (copper vs LNG; P = .2254). Side effects included infection (9%, but no pelvic inflammatory disease), pain (28%), partner felt strings (9%), and bleeding (32%). Reasons for removal included side effects (25%), desired fertility (5%), expulsion (3%), and pregnancy (2%). There were no pregnancies associated with the LNG IC, and there were fewer removals because of side effects than with the copper IUD (P = .0180). CONCLUSION: IC is a reliable method of contraception in teens and young adults. There were fewer removals because of side effects in the LNG group, although overall other variables are similar between methods.

Follow-up compliance of adolescents with cervical dysplasia in an inner-city population.

STUDY OBJECTIVE: Adolescent compliance with cytologic and histologic cervical abnormalities is poor. Recent changes in abnormal cytology follow-up and colposcopy indications in young women may delay the diagnosis of cervical dysplasia. The objective of our study was to determine the compliance with follow up. We also wanted to summarize regression or progression of disease, and to determine if the new guidelines could affect severity and time of diagnosis. DESIGN: Retrospective review of medical records from adolescent patients (defined as women aged 12 to 21) who had a colposcopy between January 2004 and December 2006. Patients were excluded if they were 22 or older or if they had a previously abnormal cytologic evaluation. MAIN OUTCOME MEASURES: Colposcopy records between January 2004 and December 2006 were identified by CPT code from a computerized database. Cytology and histology results, follow-up compliance rates, and demographic data were collected. Data were analyzed with a power>85% and a P value

Update in adolescent contraception.

Pregnancy rates in the United States seem to have stabilized in the past decade but continue to be higher than those in other industrialized nations. Although abstinence and barrier methods are available and efficient in preventing pregnancy, a comprehensive approach is a better choice when counseling patients on available options. The new approach to old contraceptive methods provides new alternatives to adolescents seeking safe and reliable methods. The availability and proved safety with longterm reversible contraceptive methods, such as the intrauterine system and subdermal implant, may allow adolescents to make better choices in preventing pregnancy. Future efforts in research should concentrate on finding the reasons why adolescents are at increased risk for unplanned pregnancy and solutions for this problem. Future contraceptive technology continues to focus on safety and convenience to facilitate the use of contraceptives in adolescents.

Adolescent gynecology.

Given new developments in the field of adolescent reproductive health, this review focuses on highlighting new guidelines and practice patterns in evaluation and management of adolescent gynecologic problems. First, understanding the proper techniques for the initial examination is key to establishing a long-term relationship with this age group. Reservations about the first gynecologic examination are common, and the practitioner's goal is foremost to make the patient as comfortable as possible. Preventive health in this patient population is key, and practitioners should become comfortable with providing education about topics as diverse as sexuality, eating disorders, and dating violence. Furthermore, the frequency with which teenagers report sexual activity and the high unintended pregnancy rate in this age group makes counseling regarding effective contraception essential. Additionally, practitioners are encouraged to take the opportunity to discuss the availability of the human papillomavirus (HPV) vaccine with adolescents. In 2007, adolescents were designated as a special population, given the frequency with which they acquire and clear mild HPV-related cervical dysplasia. More conservative treatment in this population is generally favored. During their transition through puberty, disorders of menstruation become the most common complaint requiring the attention of the gynecologist. Most commonly, anovulation serves as the cause behind such abnormal bleeding. Polycystic ovarian syndrome can develop in early puberty and carry its consequences into adulthood. Infertility, diabetes, and hirsutism mark the most important components of the syndrome and require age-appropriate management. Finally, the consequences of endometriosis on the future fertility of adolescents have brought early intervention to light. Recognition and prompt treatment are advocated to prevent the future implications of this disease.