Management of heavy menstrual bleeding in women with bleeding disorders in a tertiary care center.

Background: Heavy menstrual bleeding (HMB) affects a significant number of women with bleeding disorders and has a negative impact on their quality of life. Objective: This retrospective study examined the management of patients with inherited bleeding disorders who used medical treatments, alone or in combination, for HMB. Methods: Chart review was performed on women attending the Women with Bleeding Disorders Clinic in Kingston, Ontario, between 2005 and 2017. Data collected included patient demographics, the reason for presentation and diagnosis, medical history, treatments, and patient satisfaction. Results: One hundred nine women were included in this cohort. Of these, only 74 (68%) were satisfied with medical management, and only 18 (17%) with first-line therapy. Treatments included combined contraceptives (oral pill, transdermal patch, and vaginal ring), progesterone-only pills, tranexamic acid, 52-mg levonorgestrel intrauterine system (LIUS), depomedroxyprogesterone acetate, and desmopressin, either alone or in combination. Satisfactory control of HMB occurred most often with the LIUS. Conclusion: In this cohort, managed in a tertiary care Women with Bleeding Disorders Clinic, only 68% of patients had successful control of HMB with medical treatment, and a minority were satisfied with first-line therapy. These data clearly highlight the need for additional research, including treatment approaches and novel therapies for this population.

Prevalence of Chlamydia and Gonorrhea Among Pregnant Adolescents Screened in the Third Trimester Using a Urine PCR Test: A Retrospective Review.

OBJECTIVE: Our study assessed the rate of new and recurrent Chlamydia trachomatis and Neisseria gonorrhoeae infections in the third trimester at an adolescent obstetrics clinic. METHOD: Between October 2016 and June 2020, routine third-trimester screening for C. trachomatis and N. gonorrhoeae was implemented according to new Canadian recommendations. Urine nucleic acid amplification was performed. Patient records were reviewed retrospectively, and demographic data; pregnancy and delivery characteristics; and information on screening at presentation to care, third-trimester screening (33-38 weeks), and other STI testing was recorded. RESULTS: A total of 115 adolescents (mean age 17.90 ± 1.43 y) with 125 pregnancies presented for care. Twenty-three pregnancies were excluded (12 transferred out and 11 experienced a pregnancy loss). At presentation, screening was performed in 100 of 102 pregnancies: 64 of 100 at <13 weeks, 32 of 100 at 13-27 weeks, and 4 of 100 at 28-30 weeks. Nine tested positive for C. trachomatis and none tested positive for N. gonorrhoeae. In the third trimester, there were 3 positive C. trachomatis tests, but all were indicated: test of cure was due for 1 patient, 1 patient had a new sexual partner, and 1 patient presented with symptoms. The remaining 89 of 102 pregnancies were screened (with no other indication) and none were positive for C. trachomatis or N. gonorrhoeae. Ten patients could not be sampled (5 missed, 4 pre-term deliveries, and 1 non-compliant with testing). CONCLUSION: No cases of C. trachomatis or N. gonorrhoeae infection were identified on third-trimester screening in our study. Adolescent obstetrics providers implementing Canadian screening guidelines may want to monitor their screening results to determine whether their yield warrants universal implementation.

Cause or Coincidence? Spontaneous Hematometra in Young Women Receiving Depomedroxyprogesterone Acetate: A Small Case Series.

BACKGROUND: Abdominal pain, secondary amenorrhea, and abnormal uterine bleeding are common gynecologic presentations in adolescence. Rarely this can be associated with an acquired hematometra. Hematometra is a condition of retained blood or clot within the uterus. High-dose progestogenic agents in this age group have been implicated in the accumulation of a hematometra without other explanation. CASES: We present 4 cases of hematometra after depomedroxyprogesterone acetate (DMPA) therapy in previously menstruating adolescents. All 4 presented with abdominal pelvic pain and/or persistent abnormal uterine bleeding, with the diagnosis confirmed via ultrasound. Suction dilation and curettage was required in each case. SUMMARY AND CONCLUSION: DMPA is a possible cause of hematometra and should be considered in anatomically normal young women experiencing pain or abnormal bleeding out of character for typical long-term DMPA use.

Outcomes of a Decade of Routine Cervical Screening in a Canadian Adolescent Obstetrics Clinic.

OBJECTIVE: New recommendations from the Ontario Cervical Cancer Screening Program indicate that initiation of screening should be delayed to age 21. However, there is sparse evidence pertaining to pregnant adolescents. Our objective was to determine whether early cervical cancer screening in pregnant adolescents confers an advantage over delayed screening in the prevention of cervical carcinoma. METHODS: We conducted a retrospective cohort study of cervical cancer screening in all pregnant adolescents receiving antenatal care through an obstetrics clinic for adolescents between 2000 and 2010. Clinic attendees had an antenatal and/or postpartum Pap smear, with follow-up according to standard recommendations. Results were recorded together with information on regression, persistence, or progression of abnormal cytology, colposcopy referrals, and cervical biopsies. There is a single regional colposcopy clinic. RESULTS: At least one Pap smear result was documented in 365 of the 388 patients. Of these 365 smears, 88 had abnormal cytology, 76 (86.4%) of which were reported as atypical cells of undetermined significance/low-grade squamous intraepithelial lesion, 11 (12.5%) high-grade squamous intraepithelial lesion (HSIL), and one atypical glandular cells (1.1%). Follow-up cytology was available for 78 patients. No patient lost to follow-up had subsequent referrals for colposcopic assessment in the region. Overall, cytologic abnormalities regressed in 75 (96.1%), persisted in two (2.6%), and progressed in one patient (1.3%). Twenty-three patients (of 365) required a total of 68 colposcopy visits and 17 biopsies, but ultimately only three loop electrosurgical excision procedures (LEEPs) and one laser vaporization were performed. Only one LEEP in a 20-year-old demonstrated HSIL. CONCLUSION: This population of pregnant adolescents had a high incidence of low-grade cervical abnormalities with a high rate of regression. Routinely screening these pregnant adolescents resulted in numerous repeat visits, repeat Pap smears, and colposcopy referrals, and led to patient anxiety and systemic costs. Not a single case of cervical cancer was prevented that would not otherwise have been identified by adherence to the new guidelines.

Transmural migration and perforation of a levonorgestrel intrauterine system: a case report and review of the literature.

INTRODUCTION: Uterine perforation is an uncommon yet well-known complication of copper intrauterine devices and the levonorgestrel intrauterine system (IUS). While initial extrauterine placement at the time of insertion is felt to be the cause of perforation in most cases, some hypothesize that delayed transmural migration and subsequent perforation can occur with slightly malpositioned or even properly placed devices. CASE: A 46-year-old female had a 52-mg levonorgestrel IUS inserted for menstrual management and contraception. We arranged a follow-up ultrasound as the uterus was enlarged on bimanual examination and the cavity sounded to 11cm. This ultrasound was completed 6days after insertion and reported the IUS to be in the "upper uterine cavity". Over time, transmural displacement and perforation of the horizontal arms of the device occurred. Computed tomography scans performed over 2years for nongynecologic indications document this gradual migration. A retrospective review of initial ultrasound images showed no evidence of uterine defect, embedment or perforation but the cavity length did appear to be less than 11cm. CONCLUSIONS: While initial extrauterine placement at the time of insertion is the most common mechanism of perforation, delayed transmural migration is another mechanism that can occur.

The North American Society for Pediatric and Adolescent Gynecology Fellowship Family Tree.

STUDY OBJECTIVE: To create a family tree to chronicle the proliferation of our specialty through fellowships (formal and informal) within the pediatric and adolescent gynecology practice and among the membership of the North American Society for Pediatric and Adolescent Gynecology (NASPAG). This historical project was undertaken as a way to demonstrate NASPAG's rich sense of heritage and community. The tree is meant to be a dynamic project, a living document, changing and expanding as this field of medicine grows, and offers a form of institutional memory for NASPAG. DESIGN, SETTING, PARTICIPANTS, AND INTERVENTIONS: Questionnaires were sent out to all current NASPAG members via e-mail (and the list-serve) and were available at the 2014 NASPAG Annual Clinical and Research Meeting. Data from the questionnaires were recorded within GRAMPS 3.4.8, software used to create a family tree. MAIN OUTCOME MEASURES AND RESULTS: The result of the project was an elegant and intricate tree, containing 379 "family members" including physicians who specialize in pediatric and adolescent gynecology, adolescent medicine, reproductive endocrinology and infertility, and pediatric endocrinology. CONCLUSION: The family tree, which shows how one mentor might train multiple trainees and how past trainees later become mentors, highlights the value of physicians who take on supervisory and educational roles and the existence of comprehensive and inspirational training programs.

The Collection and Analysis of Carbon Monoxide Levels as an Indirect Measure of Smoke Exposure in Pregnant Adolescents at a Multidisciplinary Teen Obstetrics Clinic.

STUDY OBJECTIVE: In this study we aimed to collect and analyze CO levels as an indirect measure of smoke exposure in pregnant adolescents. DESIGN, SETTING, AND PARTICIPANTS: Participants included pregnant adolescents who received antenatal care over 18 months (2012-2013) at the Multidisciplinary Teen Obstetrics Clinic at a tertiary-care hospital in Southeastern Ontario. INTERVENTIONS: The CO breath test is a noninvasive method that is used to assess smoke exposure, in which nonsmokers have levels of 0-6 ppm, and levels of 7-10, 11-20 and more than 20 ppm are consistent with light, typical, and heavy smokers, respectively. Expired CO, smoking status, cigarette number, and home secondhand smoke exposure were documented at 3 clinic visits. MAIN OUTCOME MEASURES: To determine mean CO levels as a measure of smoke exposure and prevalence of secondhand smoke exposure. RESULTS: The mean age of participants was 17.6 years. CO means (ppm) across 3 visits were 6.0, 5.9, and 4.8. Sixty-two percent of patients were self-reported nonsmokers, 38% were self-reported smokers (n = 93). CO means (standard error of the mean) were consistently different for nonsmokers vs smokers at visits 1 to 3, respectively: 2.9 (0.79) vs 9.7 (1.8); 3.0 (0.71) vs 12.9 (2.2), and 2.4 (0.71) vs 8.8 (1.5; P < .01, t test; n = 91). Of patient's highest CO (COmax), 62%, 9%, 15%, and 12% had levels of 6 or less, 7-10, 11-20, and greater than 20, respectively. Eighty-four percent of pregnant adolescents had home secondhand smoke exposure, which included 40% of nonsmokers and 100% of smokers (n = 57). Although most nonsmokers had a COmax of 6 or fewer ppm, 56% of smokers had COmax greater than 10 ppm (P < .05, χ(2)). CONCLUSION: Emphasis on smoking cessation is imperative in pregnant adolescents and should particularly target partners and families, because secondhand smoke exposure was very prevalent.

Disorders of Menstruation in Adolescent Girls.

Abnormal menstruation in adolescent girls can cause psychological and physical strain from excess, unpredictable, painful, or even absent bleeding. Care providers who understand what is normal and what is concerning can educate and often reassure the young woman and her family. When there is an abnormal or concerning scenario, they can initiate investigations and/or treatment in an expedient fashion to limit psychosocial and/or physical morbidity. This article provides pediatricians, family doctors, nurse practitioners, and adult gynecologists with the knowledge and understanding of the common complaints, differential diagnoses, and treatment strategies.

Spontaneous Recovery of Ovarian Function in an Adolescent with Galactosemia and Apparent Premature Ovarian Insufficiency.

BACKGROUND: Galactosemia is an inborn error of metabolism resulting in premature ovarian insufficiency in 80-90% of females. There have been no reported cases of biochemical ovarian failure followed by normal menses. CASE: A 12-year-old girl with galactosemia presented for gynecologic consultation. Her follicle-stimulating hormone (FSH) and estradiol levels were 52.9 U/L and less than 100 pmol/L, respectively. She started exogenous estrogen to stimulate puberty. At 16, she had spontaneous regular menstrual cycles. FSH and luteinizing hormone (LH) levels reflected normal ovarian function. Hormonal contraception was provided. One year later, she was found to be in ovarian failure (FSH 86.6 U/L, LH 33.3 U/L), and both estradiol and anti-Müllerian hormone were undetectable. SUMMARY AND CONCLUSIONS: This case documents spontaneous resumption of ovarian function after galactosemia-related ovarian failure. The use of FSH and LH is potentially limited in predicting ovarian function in this population.

Pelvic inflammatory disease in virginal adolescent females without tubo-ovarian abscess.

Pelvic inflammatory disease (PID) is an infection of the upper genital tract that is often caused by an ascending sexually transmitted infection. The complications of PID include pyosalpinx and tubo-ovarian abscess, infertility or ectopic pregnancy, and chronic pelvic pain of varying degrees. These sequelae underscore the importance of prompt diagnosis. We present 2 cases of PID in young women who denied any history of sexual activity or sexual abuse. Both cases were brought to the operating room with suspected appendicitis; however, laparoscopic evaluation revealed purulent fluid surrounding the pelvic organs. The literature is scant with respect to PID in the virginal patient. It is important to keep pelvic infection in the differential diagnosis of virginal patients who present with clinical symptoms of an acute abdomen.

Use of intranasal midazolam for manual separation of labial adhesions in the office.

Use of orally administered flavored midazolam elixir in the office setting has been previously described as an alternative to general anesthetic for manual separation of severe or persistent labial adhesions. We share the technique of using atomized intranasal midazolam for sedation (and amnesia) that has quicker onset, shorter duration, and well described safety and patient tolerance. This technique eliminates the problems associated with a child who refuses to swallow the elixir.

Ambiguous genitalia in the newborn: an overview and teaching tool.

Ambiguous genitalia is a significant example of a disorder of sexual development, in which the external genitalia do not have the typical appearance of either sex. Although the birth of a child with ambiguous genitalia is rare, the emergent nature of the issue demands that healthcare providers have at least a familiarity with the underlying etiologies, the issues, and the initial approach to diagnosis and management. With numerous etiologies, potential difficulties with reaching a diagnosis, and many challenges with immediate and long-term care, the topic of ambiguous genitalia can be daunting. We provide a review of basic embryology, as well as a classification system for understanding the various etiological causes of ambiguous genitalia. The important clinical aspects of diagnosis and management are also highlighted, and a teaching tool has been included to help the reader (or their learners) to solidify information presented. Our overall goal is to provide practical information on ambiguous genitalia and allow the clinician to apply this information to clinically relevant scenarios.

Adolescent users of an online contraception selection tool: how user preferences and characteristics differ from those of adults.

STUDY OBJECTIVE: The objective of this study was to report user statistics of an online contraception selection tool over a 6-month period, comparing preferences and characteristics of adolescents to those of adults. SETTING: Choosing Wisely, available on the website www.SexualityandU.ca, is an interactive program that helps women select an ideal birth control method. DESIGN: Answers to the online questionnaire were logged for a 6-month period. Answers of adolescent users were retrospectively reviewed for responses to questions regarding personal preferences and compared with those of adults. PARTICIPANTS: Participants of the study included users who self-identified as first-time users of Choosing Wisely. RESULTS: 3178 adolescents (age ≤19) and 4206 adults self-identified as new users and completed the software module. Adolescents less commonly reported weighing over 198 pounds or to be smokers. 61% of adolescents would prefer to avoid menses (vs 52% of adults) and 83% of adolescent would find a pregnancy devastating (vs 64% of adults). 1720 (54%) of the adolescents had menstrual complaints; of these 500 (29%) did not believe they could reliably take a pill daily. The majority of both adolescents (73%) and adults (71%) claimed to be willing to use a contraceptive method that required interruption of intercourse. CONCLUSIONS: Choosing Wisely is attracting large numbers of teens and adults, whose responses provide insight into the characteristics of those seeking contraception. Our data corroborate the need for contraceptive options such as combined contraceptives that do not require daily pill-taking and contraceptives that offer menstrual management. However, the magnitude of these statistically significant differences was not always as impressive clinically.

Seasonal trends in adolescent pregnancy conception rates.

STUDY OBJECTIVE: The objectives of this study were to determine if a seasonal trend exists in adolescent pregnancies and to compare the teen conception rate per month to an adult population. SETTING: The study was conducted in a tertiary care Canadian hospital that has a one-site model of care. DESIGN: A retrospective chart review of all adolescent pregnancies over a 5-year period (N = 838) was undertaken. From the 13,554 adult pregnancies over the same time period, a random sample of 838 pregnancies was chosen for similar chart review. A chi-square test was used to compare the proportion of pregnancies conceived in each calendar month between the two groups. PARTICIPANTS: Pregnancies ending in spontaneous abortions, elective terminations, ectopic pregnancies, as well as obstetrical deliveries, were included. RESULTS: There was a significantly different monthly trend seen in adolescent pregnancy conceptions when compared with the adult group (χ² = 24.38, df = 11, P = 0.0112). The adolescent group was observed to have a unique peak in the number of pregnancies conceived in March (10.5% of pregnancies conceived compared to 7.3% in adults). In addition, 8.5% of conceptions in adolescents occurred in December compared to 10.4% in adults. CONCLUSIONS: There are several plausible explanations for the modest but real differences identified in this study including trends in fecundity/fertility or social/school events that lead to increased sexual activity. Peaks in conception indicate times when a greater need for health care services exists, and when preventive education can be most effective.

Characteristics and concerns of women choosing an online contraception selection tool ("choosing wisely").

BACKGROUND: Choosing Wisely, a user-friendly and interactive application developed and tested at Queen's University, is a self-administered computer-based questionnaire that aims to assist women, their partners, and their health care providers in deciding among contraceptive options. The application asks specific, direct questions regarding a patient's preferences, health, and lifestyle, and it then generates three lists: (1) indicated contraceptive methods, (2) options that may be suitable, and (3) contraindicated methods. OBJECTIVE: To report statistics on the users of Choosing Wisely in the first 13 months since the launch of the program on the award-winning SOGC website Sexualityandu.ca in June, 2007. METHODS: At the end of the program module, each user's answers were logged anonymously in a Microsoft Excel spreadsheet along with the time and date of completion. Descriptive statistics were generated in SPSS version 16.0. RESULTS: Between June 21, 2007, and July 25, 2008, 9775 users completed the Choosing Wisely program. Of these users, 8942 (91.5%) were female, and 8745 (89.5%) were under 35. At least one concern regarding contraceptive options was reported by 7359 users (75.3%), and the most common of these was weight gain, selected by 4806 (65.3%). CONCLUSION: Choosing Wisely has attracted an average of 24 users per day seeking more information on birth control methods. The responses gathered from the program will likely allow for both a better understanding of the characteristics of women who desire birth control and refinement of the program, with the aim of better serving those who are seeking contraceptive advice.

Pediatric vulvovaginal disorders: a diagnostic approach and review of the literature.

Vulvovaginal complaints in the prepubertal child are a common reason for referral to the health care provider. The Cochrane Library and Medline databases were searched for articles published in English from 1980 to December 2004 relating to vulvovaginal conditions in girls. The following search terms were used: vulvovaginitis, prepubertal, pediatric, lichen sclerosis, labial fusion, labial adhesion, genital ulcers, urethral prolapse, psoriasis, and straddle injuries. The objectives of this article are to review the normal vulvovaginal anatomy, describe how to perform an age-appropriate examination, and discuss common vulvovaginal disorders and their management in young girls.

A photo album of pediatric and adolescent gynecology.

Although dysmenorrhea, pelvic mass or pain, genital irritation, and amenorrhea are relatively common complaints, the astute clinician needs a broad differential diagnosis to avoid missing uncommon underlying etiologies such as Müllerian anomalies and cryptomenorrhea, ovarian teratomas and torsion, labial hypertrophy, vaginal foreign bodies, dermopathies, genital ulcers, imperforate hymen, and the absent vagina. This article discusses and illustrates uncommon pediatric and adolescent gynecologic conditions that present with these common complaints.

Comparing pregnancy in adolescents and adults: obstetric outcomes and prevalence of anemia.

OBJECTIVE: To characterize the obstetric outcome and prevalence of anemia in primiparous adolescents and compare them with those in older primiparas. METHODS: We conducted a retrospective chart review of 207 adolescents (or20 years old) whose prenatal care was provided by a single obstetrician in Kingston, Ontario, and who had a live singleton birth at >or24 weeks gestation between 1996 and 2004. RESULTS: The mean age of the adolescents (T) was 17.5 years and of the adults (A) 27.3 years. More than 95% of the women were Caucasian. Mean gestational age at delivery was similar in the two groups (T 39.4 weeks, A 39.6 weeks, P = 0.25). Adolescents were more likely to have a preterm delivery (T 12.6%, A 7.5%, P = 0.038), although smoking rather than young maternal age was an independent risk factor for preterm delivery (odds ratio [OR] 3.2; 95% confidence intervals [CI] 1.47.5). A significantly lower proportion of adolescents delivered by Caesarean section (CS) (T 12.1%, A 27.7%, P < 0.001). Older maternal age, higher pre-pregnancy BMI, increased weight gain during pregnancy, and pre-delivery anemia were all independent risk factors for CS. Smoking was the most influential factor in predicting infant birth weight. Adolescents had significantly more low birth weight infants (< 2500 g) than adults (T 10.1% vs. A 4.3%, P = 0.008). Gestational age rather than young maternal age was the most significant risk factor for low birth weight (OR 3.3; 95% CI 1.95.7). After controlling for smoking status, adolescents were 2.5 times more likely than adults to be anemic at 26 to 35 weeks gestation and pre-delivery. CONCLUSION: Our results suggest that primiparous adolescents have significantly different obstetric outcomes from primiparous adults. Smoking and anemia are significant risk factors for poor obstetric outcomes and are potentially modifiable.

Revisiting the intrauterine contraceptive device in adolescents.

STUDY OBJECTIVE: The purpose of this study was to report on our experience with the intrauterine contraceptive device (IUCD) in a group of properly counseled adolescents and to determine whether traditional hesitation with use in this population should be reconsidered. DESIGN: Patients who had an IUCD inserted between April 1999 and March 2003 were identified using medical records and chart review. SETTING: A single Canadian University teaching hospital supervised by a single gynecologist. PARTICIPANTS: Twenty-eight patients, 21 years of age and under, were identified. Twenty agreed to participate in the study. INTERVENTIONS: Patients were contacted by mail to inform them of the study and subsequently interviewed using a 10-minute structured phone interview that contained seven primary questions with additional follow-up questions. MAIN OUTCOME MEASURES: Duration of use, reasons for removal, side effects experienced, satisfaction with use, prior contraception. RESULT: The average age at insertion was 18.7 years, the average time of use was 19.6 months and the average number of pregnancies prior to insertion was 1.4. Seven patients (35%) had discontinued use of their IUCD prior to the interview, with an average of 13.4 months between the time of insertion and removal. The most common reason for removal was increased bleeding. The most common side effect was increased cramping. Eighty-five percent (17/20) of users were either somewhat satisfied, satisfied or very satisfied with the IUCD. CONCLUSIONS: Following pre-insertion screening for STI-related cervicitis and with consistent follow-up following insertion, IUCDs are well-tolerated by properly selected and counseled adolescents who require an easy and effective long-term method of birth control.

Barrier and spermicidal contraceptives in adolescence.

This article describes both barrier and spermicide methods of contraception including the male and female condom, diaphragm, contraceptive sponge, Lea Shield, cervical cap and multiple spermicide options. Their efficacy, differences and proper use are discussed with an emphasis on the adolescent user.