Body Mass Index and Levonorgestrel Device Expulsion in Adolescents and Young Adults.

STUDY OBJECTIVE: To evaluate the relationship between body mass and levonorgestrel intrauterine device (LNG-IUD) expulsion in adolescents and young adults (AYA). DESIGN, SETTING, PARTICIPANTS & INTERVENTIONS: A retrospective chart review was conducted of nulliparous females aged 10-24 years who had a 52-milligram LNG-IUD placed between November 2017 and May 2021 by pediatric and adolescent gynecology providers at a tertiary children's hospital, including those who underwent metabolic and bariatric surgery (MBS). Primary analysis focused on 10-19 year olds as they had comparable anthropometrics (namely BMI percentile [BMIP] as defined by the Centers for Disease Control). Descriptive statistics included means, standard deviations (SD), and ranges for continuous variables counts and percentages for categorical variables. Chi-square or Fisher's exact tests were used to assess associations. Logistic regressions were fit to test the associations between BMIP, MBS, and the odds of expulsion. MAIN OUTCOME MEASURES & RESULTS: A total of 588 patients were included in the primary analysis (10-19 years). Mean age was 15.8 years (±2.0). Using BMIP, 15.5% (n = 91) of the sample was overweight and 22.3% (n = 131) were obese. Within 12 months, 33 patients (5.6%) experienced expulsion. Every one-unit increase in BMIP was associated with a 3% increase in the odds of expulsion (P = .008), and each increase in BMIP category (eg, overweight vs average/underweight) was significantly associated with increased odds of expulsion (OR = 2.77-4.28). Patients who had LNG-IUD placement during MBS (n = 43) had higher odds of expulsion (OR = 3.23; P = .024) than other patients. CONCLUSION: AYA with higher BMIP and/or who undergo MBS are at increased risk of LNG-IUD expulsion within one year of placement.

Caregiver goals and satisfaction for menstrual suppression in adolescent females with developmental disabilities: A prospective cohort study.

BACKGROUND: Adolescents with developmental disabilities and their caregivers often seek menstrual management. Caregivers frequently serve as medical decision-makers, and little is known about caregiver goals for menstrual management and satisfaction over time. OBJECTIVE: Assess caregiver reasons for initiating menstrual management in adolescents with disabilities and satisfaction over 12 months. METHODS: Prospective cohort study of caregivers of adolescents with developmental disabilities seeking menstrual management at a pediatric and adolescent gynecology clinic. Data derive from caregiver surveys and adolescents' electronic medical records. RESULTS: Ninety-two caregiver-adolescent pairs enrolled. The mean age of adolescents was 14.4 (±2.6). The most common method started was levonorgestrel intrauterine device (LNG-IUD; 52, 56.5%), followed by oral norethindrone acetate (21, 22.8%). Caregivers cited hygiene concerns (84.8%), behavioral problems (52.2%), and heavy/excessive bleeding (48.9%) as reasons for initiating menstrual suppression. Caregivers who identified hygiene or heavy/excessive bleeding as the most important reason for management were more likely to select LNG-IUD (p = 0.009). Caregivers who cited behavioral/mood or seizure concerns as the most important reason were more likely to choose other methods (p < 0.05). At 12 months, caregiver satisfaction with all methods was high (66.2-86.9 on a 100-point scale). For every additional day of bleeding, satisfaction decreased by 3.7 points (95% CI: 2.3-5.0). CONCLUSIONS: Caregiver satisfaction with all methods is high; however, it negatively correlates with days of bleeding. Caregiver reasons for menstrual suppression influence the method chosen. Management may reflect both patient and caregiver priorities; research is needed to better understand shared decision-making models that promote reproductive autonomy in adolescents with a developmental disability.

Vulvar Aphthous Ulcers in an Adolescent After Coronavirus Disease 2019 (COVID-19) Vaccination.

BACKGROUND: Nonsexually acquired genital ulcers have been described among girls who are prepubertal after various viral illnesses due to mucosal inflammation from an immunologic response. Until recently, nonsexually acquired genital ulcers have only been associated with viral infections. CASE: We present a case of an adolescent girl developing nonsexually acquired genital ulcers after both her first and second coronavirus disease 2019 (COVID-19) vaccine doses. Her course followed an expected timeline for severity and resolution of ulcers. CONCLUSIONS: Aphthous ulcers may arise from inflammatory effects of COVID-19 vaccination. Clinical monitoring after COVID-19 vaccination from all formulations should include assessment for nonsexually acquired genital ulcers if vaginal pain is reported.

Tamoxifen for the Treatment of Etonogestrel Implant-Associated Bleeding in an Adolescent Gynecology Practice.

OBJECTIVE: To describe clinical outcomes in a cohort of adolescent female patients using tamoxifen for the treatment of bothersome etonogestrel (ENG) implant-associated bleeding. DESIGN: Retrospective chart review SETTING: A tertiary children's hospital PARTICIPANTS: Adolescent female patients ages 12-21 seen between August 2016 and August 2019 with an ENG implant in place who received a tamoxifen prescription for the indication of implant-associated bleeding. INTERVENTIONS: None MAIN OUTCOME MEASURES: Main outcome measures were implant continuation rates, average time to implant discontinuation after tamoxifen prescription, reasons for implant removal, number of doses and timing of tamoxifen use, bleeding patterns, and adverse effects. RESULTS: A total of 67 patients met the inclusion criteria. The mean age of patients was 16.7 years old. Of the patients with available follow-up data, 49 out of 60 (81.7%) were still using the implant at 12 months, 29 out of 53 (54.7%) at 24 months, and 9 out of 40 (22.5%) at 36 months. The average time from tamoxifen prescription to implant removal was 12.1 months. Bothersome bleeding was the primary reason for ENG implant discontinuation (68.6%). No side effects from tamoxifen use were reported. CONCLUSION: Tamoxifen was well-tolerated among this cohort of patients and can be considered a treatment option to manage bothersome implant bleeding in adolescents.

Twelve-month Continuation of the Etonogestrel Implant in Adolescents With Polycystic Ovary Syndrome.

STUDY OBJECTIVE: To identify why adolescents with polycystic ovary syndrome (PCOS) chose the etonogestrel (ENG) contraceptive implant, to determine the 12-month continuation rate, and to characterize factors related to discontinuation. DESIGN, SETTING, AND PARTICIPANTS: Retrospective chart review of adolescents seen at a tertiary care children's hospital between July 1, 2008, and August 30, 2019, with PCOS diagnosis confirmed per National Institutes of Health criteria and ≥12-month ENG follow-up. INTERVENTIONS AND MAIN OUTCOME MEASURES: Demographic characteristics, reasons for ENG insertion and removal, and information on other hormonal/contraceptive therapies were collected. Patients were categorized as ENG continuers (use ≥12 months) or discontinuers (removal at <12 months), and groups were compared. RESULTS: A total of 96 patients met inclusion criteria (age 17.7 ± 2.2 years, body mass index 34.8 ± 8 kg/m2). Reasons for ENG were documented in 74% (51% contraception, 32% ease of use, 15% other, 13% estrogen avoidance). In all, 27% had never been sexually active, and 67% had had prior sexual activity. Treatments prior to ENG placement included 74% combined hormonal contraception, 20% medroxyprogesterone acetate withdrawal, and 17% depot medroxyprogesterone. A total of 77% continued ENG at 12 months. The main reasons for discontinuation were bleeding (41%), concern about weight gain (23%), and mood changes (18%). No preimplantation characteristics were independently predictive of continuation, although 100% of patients with type 2 diabetes (n = 11) continued. Patients who sought additional care, including telephone calls (41% vs 12%, P = .006) and clinic visits (64% vs 20%, P < .001) were more likely to discontinue. CONCLUSIONS: The ENG implant was well tolerated in adolescents with PCOS and similar to published 12-month continuation rates.

Diminished Ovarian Reserve in Girls and Adolescents with Trisomy X Syndrome.

An extra X chromosome occurs in ~ 1 in 1000 females, resulting in a karyotype 47,XXX also known as trisomy X syndrome (TXS). Women with TXS appear to be at increased risk for premature ovarian insufficiency; however, very little research on this relationship has been conducted. The objective of this case-control study is to compare ovarian function, as measured by anti-mullerian hormone (AMH) levels, between girls with TXS and controls. Serum AMH concentrations were compared between 15 females with TXS (median age 13.4 years) and 26 controls (median age 15.1 years). Females with TXS had significantly lower serum AMH compared to controls (0.7 ng/mL (IQR 0.2-1.7) vs 2.7 (IQR 1.3-4.8), p < 0.001). Additionally, girls with TXS were much more likely to have an AMH below the 2.5th percentile for age with 67% of them meeting these criteria (OR 11, 95% CI 2.3-42). Lower AMH concentrations in females with TXS may represent an increased risk for primary ovarian insufficiency in these patients and potentially a narrow window of opportunity to pursue fertility preservation options. Additional research is needed to understand the natural history of low AMH concentrations and future risk of premature ovarian insufficiency in girls with TXS.

A Study of Adolescent Female Genitalia: What is Normal?

STUDY OBJECTIVE: Female adolescents often present to health care providers with concerns about the appearance of their external genitalia. These patients might experience significant distress about their genital appearance and might request surgery to correct a perceived abnormality. Accurate descriptions of normal adolescent female genital anatomy are lacking in the literature. The purpose of this study was to examine a small sample of normal female adolescents to obtain measurements and descriptors of the external genital structures, with a focus on the size and morphology of the labia minora. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Participants were female adolescent patients, ages 10-19 years, who underwent routine surgical procedures in the operating room. RESULTS: Forty-four patients were examined. The mean age was 14.4 years (range 10-19 years). Mean height was 159.6 cm and mean weight was 60.8 kg. Most were non-Hispanic ethnicity (n = 32/44; 72%) and were Caucasian race (n = 38/44; 86%). Right and left labia minora lengths were different in n = 19/44 patients (43%). Right and left labia minora widths also differed, in stretched (n = 20/33; 61%) and unstretched (n = 24/44; 55%) labia, with a difference ranging from 1 to 22 mm. There was no correlation between size and shape of labia minora and patient age, height, weight, or race. CONCLUSION: Wide variability exists in female adolescent genital anatomy with no established normal range. This study provides a resource for physicians who care for adolescent girls, who need normative data to describe female genital anatomy. We propose that the role of labiaplasty in adolescents should be considered with extreme caution because of the wide range in size and morphology and paucity of data in this population.

Treatment of Acute Abnormal Uterine Bleeding in Adolescents: What Are Providers Doing in Various Specialties?

STUDY OBJECTIVE: The purpose of this study was to assess whether variability exists in the management of acute abnormal uterine bleeding (AUB) in adolescents between pediatric Emergency Department (ED) physicians, pediatric gynecologists, and adolescent medicine specialists. DESIGN: Retrospective chart review. SETTING: Tertiary care medical center ED. PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We included girls aged 9-22 years who presented from July 2008 to June 2014 with the complaint of acute AUB. Patients were identified using the International Classification of Diseases, ninth revision codes for heavy menstrual bleeding, AUB, and irregular menses. Exclusion criteria included pregnancy and current use of hormonal therapy. One hundred fifty patients were included. RESULTS: Among those evaluated, 61% (n = 92) were prescribed hormonal medication to stop their bleeding by providers from the ED, Adolescent Medicine, or Pediatric Gynecology. ED physicians prescribed mostly single-dose and multidose taper combined oral contraceptive pills (85%; n = 24), compared with Adolescent Medicine (54%, n = 7), and Gynecology (28%, n = 13). Pediatric gynecologists were more likely than ED physicians to treat patients with norethindrone acetate, either alone or in combination with a single dose combined oral contraceptive pill (61%, n = 33 vs 7%, n = 2; P < .001). CONCLUSION: Variations in treatment strategies for adolescents who present with acute AUB exist among pediatric specialties, which reflects a lack of standardized care for adolescents. Prospective evaluation of the shortest interval to cessation of bleeding, side effects, and patient satisfaction are valuable next steps.