Impact of employer-covered planned oocyte cryopreservation on decision-making for medical training.

PURPOSE: To characterize how employer coverage of planned oocyte cryopreservation (POC) might impact medical career decision-making. METHODS: A cross-sectional survey was distributed to all medical students at two large academic programs in December 2022 to better understand attitudes towards childbearing, POC, and how employer coverage of POC might influence future career decisions. RESULTS: Of the 630/1933 (32.6%) medical students who participated, 71.8% identified as women and 28.1% as men. More women (89.2%) than men (75.1%, P < 0.001) felt pressure to delay childbearing. Regarding childbearing, women more than men were concerned about the physical demand of residency (76.5% vs. 50.8%, P < 0.001), stigma in residency hiring practices (41.2% vs. 9.0%, P < 0.001), and parental leave interfering with team dynamics (49.6% vs. 20.9%, P < 0.001). Respondents were more likely to pursue POC if it were covered by residency employer health insurance (60.0% vs. 11.6%, P < 0.001). Women were more likely than men to state that employer-sponsored POC would influence their residency ranking (46.0% vs. 23.7%, P < 0.001), pursuit of additional degrees (50.9% vs. 30.5%, P < 0.001), and pursuit of fellowship training (50.9% vs. 30.5%, P < 0.001). Additionally, 25.4% of women and 19.8% of men felt their choice in medical specialty would be impacted by employer-sponsored POC. CONCLUSIONS: Medical students, particularly women, feel pressure to delay childbearing during medical training and are concerned about future fertility. Both male and female students were interested in employer-sponsored POC and more likely to pursue it with financial coverage. Further research is needed to determine the full impact of employer-sponsored POC on medical career decision-making.

"They had the lunch lady coming up to assist": The experiences of menarche and menstrual management for adolescents with physical disabilities.

BACKGROUND: Menarche is a pivotal time in an adolescent's life but can be experienced differently by those with physical disabilities. Parents typically serve as the primary educators and support for their daughters during this time. Little is known about the parent's perspective of their daughter's experience preparing for menarche and learning to manage menses. OBJECTIVE: We sought to understand the parent's perspective of the experience of their daughter with a physical disability around menarche and their preferences for health care provider support. METHODS: Individual semi-structured interviews were conducted with 21 parents of a daughter with a physical disability ages 7-26. Interviews were coded by 2 reviewers using Grounded Theory, with disagreements resolved by consensus. RESULTS: Six themes emerged regarding the parent's perception of the experiences, including 1) variation in emotional responses to menarche, 2) parent's perception of their daughter's experience with menses and menstrual symptoms, 3) cross-section of disability and menstrual management, 4) menstrual management at school, 5) parental knowledge correlating to daughter's preparation for menarche, and 6) desires for health care provider support. CONCLUSIONS: All parents reported that their daughters faced challenges during menarche, ranging from emotional distress to dealing with the inaccessibility of hygiene products. Managing periods at schools was particularly burdensome. Parents who were better educated about what to expect were better able to prepare their daughters, but had difficulties finding informed, supportive providers. Health care providers should provide both anticipatory guidance and holistic, respectful, and equitable options for the management of menstrual symptoms.

Pregnancy Outcomes in Patients with Obstructed Hemivagina Ipsilateral Renal Agenesis.

STUDY OBJECTIVE: Obstructed hemivagina with ipsilateral renal agenesis (OHVIRA) is a rare congenital Müllerian anomaly. We sought to explore the impact of OHVIRA on pregnancy outcomes. METHODS: A retrospective chart review identified 8 patients with an OHVIRA diagnosis and at least 1 documented pregnancy. Data collected included demographic characteristics, age at diagnosis and repair, gynecologic history, and pregnancy outcomes. Descriptive analysis was performed. RESULTS: Twenty-three pregnancies were identified among the 8 patients (range 1-5 pregnancies per patient), resulting in 9 term births, 6 preterm births, and 8 first-trimester spontaneous abortions. The most common pregnancy complications were fetal growth restriction (2/15) and preeclampsia with severe features (2/15). The average gestational age at delivery was 37 2/7 weeks; however, 60% (9/15) of live births were at term. Two patients delivered after going into preterm labor, one of whom also had preterm premature rupture of membranes. Of the 15 live births, there were 10 cesarean deliveries, 4 vaginal deliveries, and 1 forceps-assisted vaginal delivery. Three patients (30%) underwent primary cesarean deliveries due to fetal malpresentation. Five live births were repeat cesarean deliveries, and 2 were unscheduled cesareans, at 34 and 36 weeks, due to preeclampsia with severe features. CONCLUSION: This study is among the first to examine pregnancy outcomes in patients with OHVIRA. Among these patients, there were 23 total pregnancies, with higher incidences of spontaneous abortion, preterm birth, breech presentation, and cesarean delivery compared with the general population. This descriptive data set addresses a knowledge gap to help clinicians more effectively advise patients with OHVIRA about pregnancy outcomes.

Postoperative Bleeding Two Weeks After Longitudinal Vaginal Septum Resection with the LigaSure Device: A Case Report.

BACKGROUND: A longitudinal vaginal septum (LVS) is a rare congenital anomaly often identified during adolescence. Surgical removal is a mainstay in treatment of symptomatic cases; however, there is variation in the techniques used. Little is known about the risk for postoperative complications associated with novel methods. CASES: We present the cases of 2 adolescent females, ages 15 and 22, diagnosed with an LVS who elected to undergo surgical removal. A LigaSure device was used for resection, and both individuals experienced significant postoperative bleeding almost 2 weeks following resection. SUMMARY AND CONCLUSIONS: This report outlines two occurrences of postoperative bleeding after LVS resection, which may suggest inadequate surgical site hemostasis with use of the LigaSure apparatus. Further research on outcomes related to this technique is needed.

Norethindrone dosing for adequate menstrual suppression in adolescents.

OBJECTIVES: We sought to study factors predictive of achieving menstrual suppression with norethindrone vs. norethindrone acetate in adolescents, as optimal dosing is unknown. Secondary outcomes included analyzing prescriber practices and patient satisfaction. METHODS: We performed a retrospective chart review of adolescents ages <18 years presenting to an academic medical center from 2010 to 2022. Data collected included demographics, menstrual history, and norethindrone and norethindrone acetate use. Follow-up was measured at one, three, and 12 months. Main outcome measures were starting norethindrone 0.35 mg, continuing norethindrone 0.35 mg, achieving menstrual suppression, and patient satisfaction. Analysis included Chi-square and multivariate logistic regression. RESULTS: Of 262 adolescents initiating norethindrone or norethindrone acetate, 219 completed ≥1 follow-up. Providers less often started norethindrone 0.35 mg for patients with body mass index ≥25 kg/m2, prolonged bleeding, or younger age at menarche, but more often for patients who were younger, had migraines with aura, or were at risk of venous thromboembolism. Those with prolonged bleeding or older age at menarche were less likely to continue norethindrone 0.35 mg. Obesity, heavy menstrual bleeding, and younger age were negatively associated with achieving menstrual suppression. Patients with disabilities reported greater satisfaction. CONCLUSIONS: While younger patients more often received norethindrone 0.35 mg vs. norethindrone acetate, they were less likely to achieve menstrual suppression. Patients with obesity or heavy menstrual bleeding may achieve suppression with higher doses of norethindrone acetate. These results reveal opportunities to improve norethindrone and norethindrone acetate prescribing practices for adolescent menstrual suppression.

The Utility of Pelvic Ultrasounds in Adolescents Presenting to the Emergency Department with Abnormal Uterine Bleeding.

STUDY OBJECTIVE: To analyze what factors influence a provider's decision to order a pelvic ultrasound (PUS) in the emergency department (ED) for adolescents with abnormal uterine bleeding (AUB), to determine if endometrial stripe (EMS) measurements are used in treatment decisions, and to evaluate if treatment outcomes differ based on EMS thicknesses. METHODS: Retrospective chart review of patients aged 11-19 presenting to the ED with AUB from 2006 to 2018. Those receiving a PUS were divided into three EMS groups: ≤5 mm, 6-9 mm, and ≥10 mm. Outcomes were evaluated in admitted patients by progress notes indicating resolution of bleeding. Cross-tab, χ2, and logistic and linear regression analysis were performed. RESULTS: Of 258 adolescents meeting study criteria, 113 (43.8%) had a PUS. None had an abnormality. A PUS was more likely to be performed in patients with lower hemoglobin values (P < .003). Provider decision to order a PUS did not differ by age or bleeding duration (P > .1). Among those with a PUS, 67 (59%) received hormonal therapy (pill, progestin-only, IV estrogen). There were no significant differences in treatment choices based on EMS (P < .061) or, among the 44 admitted patients (17%), in the time it took bleeding to stop after initiating treatment (pill: P = .227, progestin-only: P = .211, IV estrogen: P = .229). CONCLUSION: In adolescents with AUB in the ED, performing a PUS was more common in those with low hemoglobin. EMS thickness did not appear to affect treatment decisions or inpatient outcomes. Larger studies are needed to confirm the current findings and determine if PUS is needed in the evaluation of AUB.

Sonographic Predictors of Ovarian Torsion in Premenarchal Girls.

STUDY OBJECTIVE: To identify preoperative transabdominal sonographic predictors of surgically confirmed ovarian torsion (OT) in premenarchal girls METHODS: We conducted a retrospective case-control study of 32 premenarchal girls aged 0-12 undergoing surgery for OT (cases) or a non-torsed ovarian mass (controls) from 2006 to 2017 at a single academic center. Cases had ICD-9/10 codes for torsion of the ovary, adnexa, ovarian pedicle, or fallopian tube and surgically confirmed OT; controls had codes for ovarian mass or cyst and surgically confirmed absence of OT. Preoperative transabdominal ultrasounds were analyzed by 3 radiologists blinded to final diagnosis. We used χ2, Fisher[s exact, and Student's t tests for statistical comparisons. RESULTS: From 2016 to 2017, 32 patients presented with acute abdominal pain or symptoms concerning for ovarian mass requiring ultrasound imaging and subsequent diagnostic laparoscopy; 24 (75.0%) had confirmed OT by laparoscopy, and 8 (25.0%) did not. The mean age in both groups was similar (7.3 ± 2.9 years). Preoperative sonographic variables significantly associated with OT included presence of a simple cyst (20.8% vs 12.5%), ovarian heterogeneity (100% vs 12.5%), presence of peripheralized follicles (70.8% vs 0%), and asymmetry of color Doppler (75.0% vs 37.5%; all P < .05). Presence of free fluid, arterial color Doppler, and a whirlpool sign were not predictive of OT. CONCLUSION: In premenarchal patients, although certain variables on transabdominal sonography predicted surgically confirmed OT, only the presence of peripheralized follicles was unique to girls with OT. The decision to proceed with diagnostic laparoscopy for suspected OT can be aided by these specific sonographic findings but should ultimately be based on high clinical suspicion.

The relationship between estrogen and subsequent growth restriction among adolescents with heavy menstrual bleeding at menarche.

OBJECTIVES: We sought to evaluate the impact of estrogen-containing treatment for heavy menstrual bleeding (HMB) on subsequent height compared to progesterone-only or non-hormonal treatment when initiated at menarche. METHODS: We performed a retrospective chart review of adolescent females aged 10-15 years who presented to an institution-affiliated outpatient, inpatient, or emergency setting for management of HMB within three months of menarche. Growth records over a 2 year period starting at menarche were recorded, and comparisons made among patients treated with 1) estrogen, 2) progesterone, and 3) non-hormonal methods (controls). Groups were compared using bivariate analysis with Chi-square or Fisher's exact test and linear regression. RESULTS: In an analysis of 80 patients at 24 months, the mean increase in height from menarche was 6.4 cm among controls (n=54), 7.2 cm among the progesterone-only group (n=10), and 3.8 cm among the estrogen group (n=16). The estrogen group's increase in height was significantly lower than the control group's, by a mean of 1.8 cm (p=0.04). Change in height did not differ significantly between the progesterone and control groups (p=0.87). Additionally, for every year younger at menarche, there was 1 fewer cm of growth (change in height) at 24 months after menarche (p<0.002). CONCLUSIONS: Estrogen-containing treatment for HMB initiated within three months of menarche was associated with reduced growth at 24 months compared to progesterone-only or non-hormonal methods. The clinical applicability of the estrogen group's 1.8 cm absolute reduction in height may have considerable significance for those who are shorter at baseline.

Lichen Sclerosus throughout Childhood and Adolescence: Not Only a Premenarchal Disease.

STUDY OBJECTIVE: To determine the frequency of persistence of vulvar lichen sclerosus (LS) through the pubertal transition and assess if the symptomatology and exam findings differ by menarchal status at onset of symptoms DESIGN: A retrospective cohort study SETTING: Academic tertiary care hospital PARTICIPANTS: Females aged 21 years or younger with a diagnosis of vulvar LS INTERVENTION: None MAIN OUTCOME MEASURES: Menarchal status at symptom onset, presenting symptoms, exam findings, persistence after menarche RESULTS AND CONCLUSIONS: Of the 196 patients who met criteria, 141 were premenarchal and 55 postmenarchal. Of these 55, 36 had postmenarchal symptom onset, and the others had premenarchal symptom onset or LS diagnosis. Over the data review period, 26 patients were followed through the pubertal transition, and 10 (38.5%) had continued symptoms of LS. The premenarchal group (n = 141) was significantly more likely than the symptom-onset postmenarchal group (n = 36) to present with vulvar itching (70.2% vs 52.8%; P = .048), vulvar bleeding (26.2% vs 5.6%; P = .008), and bowel symptoms (16.3% vs 0%; P = .009). The premenarchal group was significantly more likely on exam to have subepithelial hemorrhages (24.8% vs 5.6%; P = .01). The postmenarchal group had more clitoral adhesions (25.0% vs 4.3%; P < .0001) and loss of labia minora (47.2% vs 2.1%; P < .0001). Thirteen postmenarchal patients presented with dyspareunia. This study suggests that premenarchal LS can persist after menarche in about 40% of adolescents and can initially develop in postmenarchal adolescents. Initial symptoms and exam findings differ on the basis of menarchal status. Continued surveillance is recommended.

Use of Two Levonorgestrel Intrauterine Devices in a Patient with a Uterus Didelphys: A Case Report.

BACKGROUND: Intrauterine devices (IUDs) are contraindicated in patients with known uterine anomalies, eliminating an extremely effective contraceptive option. However, data regarding contraceptive desires in these patients are limited to a few case reports. CASE: A 20-year-old nulligravida with a uterus didelphys desired contraception after oral contraceptive pills and an etonogestrel implant failed. Despite extensive counseling, including Centers for Disease Control and Prevention guidelines regarding contraindications for IUD placement in the setting of a uterine anomaly, she desired to proceed with placement of 2 IUDs. Two 13.5-mg levonorgestrel IUDs were successfully placed into each uterine horn. SUMMARY AND CONCLUSION: In select patients with uterine anomalies, IUD placement can be a safe and effective option. This is especially important in adolescents who might be at increased risk for unintended pregnancy and poor obstetric outcomes.

Assessment of Iron Status in Adolescents Presenting to the Emergency Department With Heavy Menstrual Bleeding.

OBJECTIVE: Iron deficiency is extremely common in adolescents with heavy menstrual bleeding (HMB) presenting to the emergency department; however, patients are rarely screened for this. The objective of this study was to evaluate screening for iron deficiency in adolescents presenting to the emergency department for HMB. METHODS: This is a secondary analysis of a single-center, cross-sectional observational study using retrospective chart review. The study subjects are adolescents ages 11 to 19 years with International Classification of Diseases, Ninth Revision, Clinical Modification/International Classification of Diseases, Tenth Revision, Clinical Modification, codes for HMB who presented to the emergency department at a national tertiary care hospital from 2006 to 2018. Pregnant adolescents with HMB were excluded. Chart abstraction for demographic data, symptoms, laboratory tests, treatments, and outcomes was performed. The main outcome measure was the number of adolescents who had an iron evaluation in the emergency department and were discharged on oral iron. RESULTS: Of the 258 nonpregnant adolescents who sought care for HMB in the emergency department, 225 (87.2%) were evaluated with serum hemoglobin testing. Ninety-four (41.7%) of those tested were anemic. Only 23 of the 258 patients (8.9%) had iron studies (serum ferritin) performed; 18 of 23 (78.3%) had iron deficiency and 21 of 23 (92.3%) were anemic. Subjects presenting with fatigue, headache, or palpitations were more likely to have iron studies performed than those without these symptoms (all P < 0.01). Thirty-two of the 258 subjects (12.4%) were discharged on oral iron therapy, which included only 15 of the 18 subjects (83.3%) with iron deficiency determined by ferritin testing. CONCLUSIONS: Adolescents presenting to the emergency department with HMB are at significant risk of iron deficiency but are not being screened or treated, which may have significant consequences.

Multidisciplinary Clinical Considerations in the Treatment of Pediatric Epithelial Ovarian Cancer.

BACKGROUND: Epithelial ovarian cancers are a rare subset of the less than 1% of ovarian cancers diagnosed in children. This case highlights considerations when caring for these patients. CASE: Evaluation of a 12-year-old postmenarchal girl who presented with suprapubic pain revealed a solid/cystic pelvic mass involving bilateral adnexa and elevated Cancer Antigen 125 (CA-125) level. Diagnostic laparoscopy pathology confirmed low-grade papillary serous ovarian carcinoma. Treatment involved surgical tumor debulking, hysterectomy, bilateral salpingo-oophorectomy, and omentectomy; adjuvant chemotherapy with no residual disease, and normalization of Cancer Antigen 125 (CA-125) level; and an aromatase inhibitor for maintenance. SUMMARY AND CONCLUSION: In children with adult-type gynecologic cancers necessitating treatments including surgical sterilization and hormone-modulating therapy, psychological support and developmentally informed collaboration between adult and pediatric services is essential. Clinical decisions for long-term bone and sexual health present opportunities for future research.

Considerations in Adolescent Use of the Etonogestrel Subdermal Implant: A Cohort Study.

Objectives: To describe bleeding patterns and other side effects in adolescent implant users and characterize their impact on early discontinuation of the implant. Study Design: This is a retrospective cohort study of female patients under 18 years who had an implant placed from 2013 to 2018. Data were collected on demographics, medical history, and side effects. Results: Of 212 adolescents, the average age at insertion was 16 years and 84% desired placement for contraception. Common side effects included AUB (80%), mood changes (10%), and perceived weight gain (9%). Most (76%) used the implant for at least 12 months. Average time to removal was 22.1 months (SD 13.0 months) and this did not depend on presence of side effects. Twenty-seven percent of teens were able to achieve amenorrhea. Adolescents with frequent or prolonged bleeding were more likely to have implant removal prior to 12 months than those with other bleeding patterns (p = 0.003). Early removal was also more common in girls reporting weight or mood issues than those who did not (p < 0.001 and p = 0.045, respectively). BMI increased in 64% of adolescents. Average percentage change in BMI was 3.2% (0.87 kg/m2). There was no difference in baseline use of any mood-modulating medications in patients who did and did not complain of mood side effects following implant placement (p = 0.801). Conclusion: Characterization of bleeding patterns following implant placement in adolescents have not previously been reported. Prolonged or heavy bleeding, mood issues, and perceived weight gain were associated with earlier removal of the implant. A relatively small number had early removal of the implant due to weight or mood complaints. Therefore, a history of obesity, depression, or other mood disorders should not be a deterrent to implant placement.

Interdisciplinary Care and a Focus on Fertility Preservation When Multi-cystic Ovaries Cause Ovarian Torsion: A Case of a 9-year-old Girl with Severe, Undiagnosed Hypothyroidism.

BACKGROUND: Ovarian torsion can occur in Van Wyk Grumbach syndrome, a disorder characterized by severe primary hypothyroidism and ovarian enlargement. To date, all documented cases of torsion in this setting describe oophorectomy, which has significant hormonal and fertility implications. CASE: A 9-year-old pubertal girl presented to the emergency room with abdominal pain. Magnetic resonance imaging demonstrated bilateral, multi-cystic ovaries. Operative laparoscopy confirmed unilateral adnexal torsion, and detorsion without oophorectomy was accomplished. Postoperative laboratory tests revealed severe primary hypothyroidism. Ovarian size was reduced with hormone replacement therapy. SUMMARY AND CONCLUSION: This case demonstrates that prompt interdisciplinary intervention and awareness of severe hypothyroidism as a cause of ovarian torsion related to enlarged, multi-cystic ovaries may reduce the rate of oophorectomy, allowing preservation of pediatric patients' future fertility, and reducing morbidity postoperatively through prompt, long-term thyroid supplementation.

Outpatient Management of Heavy Menstrual Bleeding in Adolescent and Young Women with Inherited Platelet Function Disorders.

STUDY OBJECTIVE: To assess the treatment patterns and efficacy of hormonal (HM) and non-HM (NHM) management of heavy menstrual bleeding (HMB) in young women with inherited platelet function disorders (IPFDs). DESIGN, SETTING, AND PARTICIPANTS: A retrospective chart review was performed of outpatient treatment of HMB in female patients age 9-25 years who were diagnosed with IPFDs and referred to gynecology and/or hematology at a tertiary care hospital between 2006 and 2018. INTERVENTIONS: The study sample was identified using billing codes for IPFDs. Data on HM and NHM treatments and outcomes over a one- to two-year period were collected. Initial treatment was defined as the first treatment prescribed after referral. Descriptive statistics, Pearson χ2, and t tests were used for analysis. MAIN OUTCOME MEASURES: Treatment failure was defined as a change in treatment method because of continued bleeding. RESULTS: Thirty-four girls met inclusion criteria. After their initial visit, 19/34 (56%) were treated with HM, 12/34 (35%) with NHM, 2/34 (6%) with a combination of methods, and 1/34 (3%) were untreated. Initial treatment failed in 19/34 (56%) and those patients subsequently required a mean of 2 additional treatments during follow-up. Of the 34 included, 6/34 (18%) remained uncontrolled despite numerous treatment changes and 2/34 (6%) because of noncompliance. When control was achieved, 7/26 (27%) of patients were receiving combined oral contraceptives and 6/26 (23%) desmopressin acetate. CONCLUSION: HMB in girls with IPFDs can be difficult to control despite ongoing follow-up and treatment changes. Although the most effective treatment for HMB in young women with IPFDs was not identified, these findings will help providers and patients with setting expectations. Prospective studies are needed to develop recommendations on best practices.

Trends in Emergency Department Visits among Adolescents with Abnormal Uterine Bleeding.

STUDY OBJECTIVE: To explore trends over time in the utilization of the Emergency Department (ED) for adolescents with abnormal uterine bleeding (AUB). DESIGN: Retrospective cross-sectional study. SETTING: Nationwide Emergency Department Sample database (Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality, Rockville, MD). PARTICIPANTS: Subset of adolescents aged 10-19 years from overall cohort of women aged 10-49 years. INTERVENTIONS: All ED visits from 2010-2014 for which International Classification of Diseases, ninth revision codes for AUB were listed as the principal diagnosis were compared. Health insurance coverage, demographic factors, hospital characteristics, comorbid anemia, and comorbid bleeding disorders were explored. MAIN OUTCOME MEASURES: Number of visits, ED disposition, blood transfusions, and billing for pelvic ultrasound. RESULTS: There were an estimated 262,939 ED visits nationally for women aged 10-49 years for AUB in 2014. Of these, 12.7% (33,511/262,939) were from adolescents aged 10-19 years. The number of adolescent visits with an AUB diagnosis declined by 11% from 2010-2014 (37,642 vs 33,511; P = .026), while visits by patients aged 20-49 did not change significantly (215,309 vs 229,428; P = .19). The number of adolescent visits for which Medicaid was the primary payer increased slightly, from 17,283 to 18,785, from 2010 to 2014 (P = .152), while the number using self-pay decreased from 8769 (23.4%) in 2010 to 5146 (15.4%) in 2014 (P < .0001). CONCLUSION: ED visits among adolescents with AUB decreased from 2010 to 2014. There was a sharp reduction in the number of visits funded by self-pay and a slight increase in visits funded by Medicaid.

Adolescents Presenting to the Emergency Department with Heavy Menstrual Bleeding.

STUDY OBJECTIVE: To describe the adolescent population that seeks care in the emergency department (ED) for heavy menstrual bleeding (HMB), and to compare those who are discharged to those who are admitted to the hospital. DESIGN: Retrospective study. SETTING: Emergency department and inpatient unit at a national tertiary care hospital from 2006-2018. PARTICIPANTS: Adolescents 11-19 years old with ICD-9 and ICD-10 codes for HMB. INTERVENTIONS: Chart abstraction for demographic data, symptoms, laboratory tests, outcomes, and treatments. MAIN OUTCOME MEASURE: Adolescents who were admitted were compared to girls who were treated as outpatients. RESULTS: There were 258 adolescents who sought care for HMB in the ED during the study period. A total of 44 patients (17%) were admitted to the hospital, whereas 214 (83%) were discharged. The average age of those admitted was 15 years, compared to 17 years for those discharged (P < .001). In the admitted group, the mean initial hemoglobin (Hgb) was 6.3 g/dL compared to 12.0 g/dL in the discharged group (P < .0001). Only 23% of the discharged patients were released with medications; the remainder did not receive treatment. Anovulation was the etiology of HMB in the majority (56%) of both inpatients and outpatients. Of the 44 adolescents admitted to the hospital for HMB, 12 (27%) had a bleeding disorder (BD) and 32 (73%) did not. CONCLUSION: The majority of adolescents who presented to the emergency department for HMB were not anemic and did not receive any treatment. Of those admitted, almost one-third had an underlying BD, which is higher than previously reported.

Risk Factors for Endometrial Cancer or Hyperplasia in Adolescents and Women 25 Years Old or Younger.

STUDY OBJECTIVE: To evaluate characteristics of young women with endometrial hyperplasia or cancer. DESIGN: Retrospective chart review. SETTING: Tertiary care referral center. PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We included 10- to 25-year-old young women seen at a single institution between 2006 and 2017 with International Classification of Diseases 9th and 10th revision codes for endometrial cancer or hyperplasia (cases), or who underwent an endometrial biopsy with other benign pathologic diagnoses (controls). Exclusions included a diagnosis of Lynch syndrome. Comparisons were made using χ2, Fisher exact, and nonparametric Wilcoxon rank tests. RESULTS: Sixty-nine patients were identified: 13 cases, 54 controls, and 2 exclusions. Of the 13 cases, 3 had endometrial cancer, 5 had complex atypical hyperplasia (now called endometrioid intraepithelial neoplasia), and 5 had hyperplasia without atypia. A higher proportion of cases had a body mass index (BMI) greater than 30, compared with controls (76.9% vs 40.4%; P < .03). The proportion of patients who had a BMI greater than 30 and were smokers was significantly higher among cases (38.5% vs 9.3%; P < .02). The proportion of patients with a history of polycystic ovary syndrome (PCOS) and smoking was also significantly different between groups (30.8% vs 3.7%; P < .01). CONCLUSION: In women aged 25 years and younger with endometrial sampling, a BMI greater than 30 was statistically more common in patients with endometrioid intraepithelial neoplasia or cancer. Although smoking or PCOS alone was not related to endometrial hyperplasia or cancer in this small cohort study, there might be a relationship between endometrial abnormalities and multiple exposures, including smoking and BMI greater than 30 or smoking and a history of PCOS.

Pediatric Resident Training in Prepubertal Vulvar Conditions.

STUDY OBJECTIVE: To assess pediatric resident training in diagnosing and managing prepubertal gynecologic conditions. DESIGN: Voluntary 32-question survey e-mailed to participants. SETTING: E-mail contact through the American Academy of Pediatrics listserv. PARTICIPANTS: Seven thousand seventy-five US pediatrics and combined internal medicine-pediatric residents. INTERVENTIONS: Descriptive analysis including χ2 tests was performed on survey results. MAIN OUTCOME MEASURES: Residents' training experiences and comfort, confidence, and knowledge in evaluating pediatric gynecologic concerns. RESULTS: In the 866 of 7075 (12%) completed surveys, a greater proportion of residents reported they were "very" or "extremely" comfortable talking to parents about general pediatric topics compared with gynecologic topics (88.5% vs 30.4%; P < .001). Similarly, they reported being "very" or "extremely" confident diagnosing general pediatric conditions compared with prepubertal gynecologic conditions (87.6% vs 32.8%; P < .001). These differences were also observed according to residency year (comfort: first year, 10.2% vs third/fourth year, 39.9%; P < .001; confidence: first year, 22.5% vs third/fourth year, 37.6%; P < .001). Residents learned about vulvovaginal concerns from attendings in clinic (79.8%), residency-specific didactics (34.7%), and conferences, meetings, and workshops (24.1%). Confidence examining, diagnosing, and treating vulvovaginitis was associated with participation in any learning activity and exposure to more than 5 patients with this concern. Additional education or training in prepubertal vulvovaginal conditions was requested by 97% of residents. CONCLUSION: Our findings suggest that pediatric residents are lacking in comfort, confidence, and knowledge of prepubertal vulvovaginal conditions, especially compared with general pediatric topics. Although this improves during training, it remains low, and more education is indicated and desired by residents.