Female athlete triad.

PURPOSE OF REVIEW: The obstetrician/gynecologist (ob/gyn) may be the first provider to have the opportunity to recognize and diagnose female athlete triad. This review will help the ob/gyn to understand the female athlete triad and what is new on this topic, how to screen and diagnose the condition and the ob/gyn's role in treatment. RECENT FINDINGS: Female athlete triad, also known as relative energy deficiency in sports, involves an interrelationship among energy availability, menstrual function and low bone density. When these components are not balanced, the health of the athlete is at risk. By using menstrual cycle as a vital sign, a careful medical history may alert you to this condition. The mainstay of treatment is achieving optimal energy balance and resumption of menses. This may involve dietary invention by increasing caloric intake or activity modification by limiting or restricting participation in sports. A multidisciplinary team, including the ob/gyn, athlete, coach, parents, sport nutritionist and sometimes psychiatrist/psychologist, is optimal for management. Medication may supplement but not replace treating the underlying condition. SUMMARY: The female athlete triad is an important disorder to identify, as early diagnosis and intervention may prevent long-term consequences, some of which may not be reversible if not diagnosed and treated.

Retrospective review of intrauterine device in adolescent and young women.

STUDY OBJECTIVE: To examine our experience with intrauterine device (IUD) use in adolescents and young women. DESIGN: Retrospective descriptive study evaluating outcomes after IUD insertion for patients 21 years or less over an 8-year period. SETTING: Three sites including a Pediatric and Adolescent gynecology private practice, a Title X clinic, and community based, grant funded clinic serving a high risk teen population. PARTICIPANTS: Females from menarche to age 21. MAIN OUTCOMES MEASURED: The probability of IUD retention, differences in IUD retention probabilities between two age groups, and risk factors for IUD removal, expulsion, and infection were evaluated. RESULTS: 233 records showed 50% of the <18-year-old age group and 71.5% of the 18-21-year-old group had their IUD in place at 5 years. Age was found to be a significant factor for removal (P < 0.001), with under 18-year-olds at greater risk of removal/expulsion (hazard ratio (HR) = 2.85). Parity (RR = 5.6 for nulliparous vs multiparous patients, P < 0.001) and prior STI (RR = 5.5, P < 0.001) were significant risk factors for infection. Nulliparous patients were at higher risk of expulsion (P = 0.045), though age was not a statistically significant risk factor. CONCLUSIONS: The rate of continuation was lower in adolescents under 18 compared to 18-21-year-olds, but was still higher than for other hormonal contraceptives. Despite this groups' high risk for STI the IUD did not increase the risk of infection and may offer some degree of protection. IUDs appear to be a safe option in young adolescents (<18 years old) and nulliparous women.

Van wyk and grumbach syndrome: an unusual case and review of the literature.

BACKGROUND: The syndrome consisting of primary hypothyroidism, precocious puberty, and massive ovarian cysts was termed Van Wyk and Grumbach syndrome in 1960. Little is known about the effect of the cysts on ovarian tumor markers. CASE: A 12-year-old Caucasian female presented with headaches and fatigue. Imaging to evaluate her headaches revealed a pituitary macroadenoma. Soon after her macroadenoma was discovered, she presented to the emergency room with abdominal pain. Imaging at that time revealed massive bilateral ovarian masses with the left measuring 17 × 13 × 8.5 cm and the right measuring 18 × 11 × 10 cm. Ovarian tumor markers were drawn at this time, most of which were highly elevated. Subsequent evaluation revealed extreme hypothyroidism. Given these findings of a pituitary macroadenoma, bilateral ovarian masses, and severe hypothyroidism, the patient was diagnosed with Van Wyk and Grumbach syndrome. We followed the cyst conservatively and the ovaries and tumor markers returned to normal after adequate thyroid replacement. COMMENTS: This case supports conservative treatment as the first-line approach to massive ovarian cysts caused by hypothyroidism. In addition this case shows that tumor markers can be abnormal in the absence of a malignancy in this setting. Before proceeding with surgical evaluation, exclusion of hypothyroidism to exclude this rare but treatable syndrome should be undertaken. The most important diagnostic clue that the cyst may be caused by an endocrine source is the finding of bilateral ovarian cysts rather than one ovary affected as seen in most ovarian malignancies in this age group.

A simulation program for teaching obstetrics and gynecology residents the pediatric gynecology examination and procedures.

STUDY OBJECTIVE: To assess the use of a pelvic simulation curriculum to teach obstetrics and gynecologic residents the pediatric gynecology examination and procedures. DESIGN: Residents in obstetrics and gynecology participated in a simulation curriculum using a modified pelvic hemimodel to simulate a pediatric pelvis. PARTICIPANTS: 19 obstetrics and gynecology residents completed the study protocol. INTERVENTIONS: Digitally recorded encounters with a standardized patient scenario using the simulator were utilized. After the initial encounter the trainees participated in a formal lecture and demonstration using the model. The trainees were then reassessed at least four weeks after the initial encounter; results were reviewed by a blinded evaluator. Scores were analyzed using the two-sided t-test and Wilcoxon signed-rank test. MAIN OUTCOME MEASURES: Scores from before to after the simulation training. RESULTS: A total of 19 residents completed the study protocol and demonstrated significant improvement in scores from before to after the simulation training. Scores improved from a pre-training mean of 6.1 to post-training mean of 16.7 (P = 0.0001). Improvement was seen at all levels of residency training. Specific skill sets included in the Council for Resident Education in Obstetrics and Gynecology (CREOG) Educational objectives (1) were improved including: pediatric gynecologic examination, collection of microbial cultures, vaginal lavage and vaginoscopy. CONCLUSIONS: This teaching program using a simulation model was found to be an effective tool to improve resident knowledge and performance of the skills needed to accomplish the pediatric gynecology examination.

Supernumerary nipple presenting as a vulvar mass in an adolescent: case report and literature review.

BACKGROUND: Ectopic breast tissues can be found along the embryonic mammary ridges and can occur in the vulva. While ectopic breast tissue is not uncommon, functional breast with overlying nipple located within the vulva is exceedingly rare. CASE: A 17-year-old with undiagnosed hypothyroidism presents with vulvar mass draining milky white fluid. A small lesion with appearance similar to a skin tag is noted and milky fluid expressed. Biopsy and excision of this mass confirmed the presence of a functional supernumerary nipple. SUMMARY AND CONCLUSIONS: This appears to be the first reported case of a supernumerary nipple with symptomatic lactation in a non-pregnant adolescent. Supernumerary nipple should be considered in the differential diagnosis of a vulvar mass. Ectopic breast tissue in the vulva can undergo malignant transformation, therefore excision of this tissue is generally recommended.

Primary and preventive healthcare in obstetrics and gynecology: a study of practice patterns in the mid-atlantic region.

OBJECTIVES: To assess the current perspective of regional obstetrician/gynecologists on providing primary/preventive healthcare, including their desire to provide primary care in their practices and whether or not they are adequately trained as primary care providers. METHODS: A self-administered survey with a Likert scale that included demographic information and questions about the practice of primary healthcare was mailed to regional obstetrician/gynecologists both in practice and in residency training. RESULTS: One hundred thirty-nine physicians responded to the survey (33% response rate). Respondents were divided (48% agreed vs. 52% disagreed) when asked if obstetrician/gynecologists should be considered primary healthcare providers. When asked if they viewed themselves as specialists who also provide primary care for women, the majority of physicians (62%) agreed. The majority of physicians (64%) disagreed when asked if they wanted to include primary care in their practice. When asked if they thought that they were adequately trained to provide primary healthcare, respondents were divided (47% agreed vs. 53% disagreed). However, a significant gender difference was found between respondents, with male physicians being more likely than female physicians to agree (55% vs. 33%, p < 0.05) when asked if they were adequately trained to provide primary care. CONCLUSIONS: In this regional study of obstetrician/gynecologists, physician opinions were divided regarding their status as primary care providers, but the majority of respondents did not want to include primary healthcare in their practice. A significant gender difference exists between physicians with regard to the question of adequate training for primary care, with male obstetrician/gynecologists being more likely as to agree that they are adequately trained to provide primary care.