Hypomenorrhea in Adolescents and Youths: Normal Variant or Menstrual Disorder? Revision of Literature and Personal Experience.

Menstrual health affects a large number of women throughout reproductive life since adolescence. Knowledge of the duration and variation of the menstrual cycle is necessary for patient education and to identify deviations from normal  to guide clinical evaluation. The average duration of menstrual flow is between 4 to 6 days, with anormal range from 2 up to 8 days ; the mean blood loss per menstrual cycle is 25- 30 mL. In general, descriptive data falling outside the normal range are considered to be indicative of menstrual disorders. Although the American Academy of Pediatrics and American College of Obstetricians and Gynecologists advocate for clinicians to consider the menstrual cycle as a vital sign in adolescents, the identification of subjects with hypomenorrhea is neither well defined nor routinely practiced. In this paper we have summarized the published prevalence of hypomenorrhea (lighter and/or shorter menstrual bleeding) in adolescents and youths in different countries and report the personal experience in four adolescents.

Immigration and screening programs for hemoglobinopathies in Italy, Spain and Turkey.

Sickle cell disease (SCD) and thalassemias are the most common monogenic diseases in the world. The number of migrants and refugees in Europe and Turkey, in the past decade, has increased dramatically due to war, violence or prosecutions in their homeland. Prevention and management of haemoglobin disorders is well established and managed in countries where these conditions were traditionally endemic or in countries that have a longstanding tradition of receiving migrants. Therefore, preventive and diagnostic programmes regarding hemoglobinopathies in immigrant populations have been implemented. The purpose of this paper it to report a summary of the experience gained in Italy, Spain and Turkey in migrants, asylum seekers and refugees.

For Debate: Testicular Volume Development along Ages: Evaluation by Different Methods.

In the last five decades an increasing number of studies and clinical reports demonstrated the importance of testicular volume assessment in pediatric and adolescent population. Reliable and accurate determination of testicular volume (TV) through infancy and adolescence is of great importance for assessing normal pubertal development to diagnose disturbances in development and to suspect certain genetic and endocrine diseases. Various approaches are available for the assessment of TV, including orchidometry, rulers, callipers, and ultrasonography (USG). Our report focuses on the importance of the evolution of TV from birth to adulthood and debates the main factors influencing the accuracy of different TV measurements. We endorse that any method for the evaluation of TV must satisfy certain criteria: a. be applicable to persons of all ages from pre-adolescence, through the pubertal spurt to full maturity, b. be simple to use, c. be free from observer error as possible, and d. have a high degree of correlation with other observable developmental characteristics.

Testicular damage in children and adolescents treated for malignancy: a short review.

Significant advances have been made over recent decades in the treatment of childhood malignancies. These advances had an incredible cost, as an increasing number of young survivors suffer subfertility or infertility, because of the high sensitivity of testicular cells, especially the rapidly dividing germ cells, to cytotoxic drugs and irradiation. Therefore, the impact of treatment on future fertility is of significant concern, both to parents and patients. Assessment of fertility damage in childhood remains problematic. For post-pubertal males, semen analysis represents a good indicator of spermatogenesis and testicular function, and allows for sperm cryopreservation. The available method for prepubertal children is only gonadal tissue cryopreservation. This method is still experimental and raises ethical concerns. Ideally, a multidisciplinary team approach needs to be used in addressing the needs of fertility preservation for this population. Precise knowledge of these issues would help pediatric oncologists and endocrinologists to counsel their patients and inform them for factors and resources that may protect or preserve parenthood options in the future.

An adolescent with an asymptomatic adnexal cyst: To worry or not to worry? Medical versus surgical management options.

Paraovarian cysts or paratubal cysts (PTCs) arise from either the mesothelium or from paramesonephric remnants. These present as either adnexal mass or as an incidental finding. Diagnosis is usually established on ultrasound and it is important to differentiate these from ovarian cysts. Typically PCTs appear as simple cysts by ultrasound and are indistinguishable from ovarian cysts if one does not recognize the extraovarian location. Occasionally, PTCs have internal echoes due to hemorrhage. PTCs are usually asymptomatic and benign. The differential diagnosis includes a simple ovarian cyst, peritoneal inclusion cyst and hydrosalpinx. Malignant changes have been reported in about 2% to 3%, and it should be suspected if papillary projections are present. PTCs management depend upon the presence and severity of the symptoms, the cyst size and US characteristics, CA 125 results, age of the patient and the risk of malignancy. Simple PTCs can be expected to regress and may be managed expectantly. When surgery is indicated, a joint multidisciplinary management by the paediatric surgeons and trained paediatric gynaecologists should be the gold standard.

Pros and cons for the medical age assessments in unaccompanied minors: a mini-review.

Unaccompanied minors refer to immigrants who are under the age of 18 and are not under the care of a parent or legal guardian. Age assessment is used in Europe mainly to establish whether or not an individual is under 18 years of age and therefore eligible for protection under the United Nations' Convention on the Rights of the Child (UN - CRC). EU Member States use a combination of techniques to determine the age of a minor and to certify minor status, including interviews and documentation, physical examinations (anthropometric assessment; sexual maturity assessment; dental observation); psychological and sociological assessment; radiological tests (carpal, dental or collarbone x-rays). All such techniques are criticized as they are often arbitrary, do not take into account ethnic variations, and are based on reference materials that are outdated, invasive and may procure harm to the individuals whose age is assessed. They also generate a margin of error that makes them inaccurate to use. There is a debate about the risks and ethics associated with the use of X-rays for non-medical purposes versus the benefits of more accurate age assessments in the interest of justice. It appears that in European countries many individuals carrying out age assessment do not have sufficient training or are not sufficiently independent enough to be carrying out such assessments. Moreover, there is a lack of standardized approach between countries or even within the same country. Only some countries clearly indicate a margin of error in the results of age assessment examinations but there is no consensus - within and among countries - about the width of such margins in relation to each exams applied. It has been advised that the expert report should give the degree of age probability to allow Magistrate to interpret the age assessment results on the 'balance of probabilities' and give the detainee the right to the rule of the 'benefit of the doubt'. It also addresses concerns rested in the convention of the Rights of the Child.

Methods for Rating Sexual Development in Girls.

Sexual maturity rating (SMR) is important in population studies and in clinical care. Pubertal staging allows doctors to assess the maturation of adolescents to correlate several pubertal phenomena such as age at menarche, growth spurt and final height, to advise and manage patients appropriately and to have sensitive "sensors" of the effects of environmental exposure on human populations. The commonly used markers of the timing of female puberty are thelarche and menarche. Appearance of the breast bud is the first indicator of puberty onset in 90% of girls. Assessment of thelarche may be performed by a physician with expertise in adolescents or by self-assessment, in which the adolescent identifies her stage of maturation based on Tanner's photographs/illustrations. The assessment of Tanner stages by professionals provides more reliable information than self-assessment but may involve variations between observers. Tanner self-assessment has been proposed as an alternative in various studies. Some studies have found reasonable agreement between self-assessment and examination by a physician whereas others found discrepancies. Measuring nipple and areola diameters is feasible for sexual maturation staging. Both sizes show a significant increase during pubertal development and after menarche. However, the ratings using nipple/areola method need to be analyzed to establish their degree of concordance with standard techniques and other markers of development in girls.

Hand X-ray in pediatric endocrinology: Skeletal age assessment and beyond.

Skeletal age assessment (SAA) is a clinical procedure which is used in determining the SA of children and adolescents. Bone development is influenced by a number of factors, including nutrition, hormonal secretions, and genetics. There are several factors to be borne in mind when using methods of assessing skeletal maturity. These include: Variability among methods, degree of variability in the estimation of skeletal maturation, sources of low accuracy, and dispersion of the values of skeletal maturation. Currently, the main clinical methods for SAA are the Greulich and Pyle (GP) and Tanner and Whitehouse (TW) methods. The GP method has the advantage of being quick and easy to use. A well-trained radiologist takes few minutes to determine the bone age (BA) from a single hand radiograph. The method of TW, however, seems to be more reliable than the GP method. In recent years, the increasing speed in computer sciences and reduction of their cost has given the opportunity to create and use computerized BA estimation system. Despite the fact that the number of automated systems for BAA have increased, most are still within the experimental phase. The use of automated BA determination system, cleared for clinical use in Europe (BoneXpert), has been validated for various ethnicities and children with endocrine disorders. Ultrasound imaging has some limitations that include operator dependence, lower intra-rater and inter-rater reliability of assessment and difficulties with standardization of documentation and imaging transfer. Magnetic resonance imaging (MRI) is noninvasive alternative tool for SA assessment in children. However, few studies have been reported on this topic, and further research is needed to evaluate the reliability and validity of MRI BAAs. In conclusion, at present radiographic methods for the assessment of BA remain the gold standards. Whatever method one adopts, it is essential to minimize the causes of imprecision by taking care to consider the quality of the X-ray. Moreover, it is imperative to assume a correct hand positioning because poor positioning can change the appearance of some bones. It is also preferable to employ scoring methods to these techniques and percentiles rather than BA in years and months. In addition, the possible differences in maturation among different population should be kept in mind.