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Background: Norethindrone acetate (NETA) is commonly used in adolescent patients for management of heavy menstrual bleeding, menstrual suppression, and endometriosis. Clinical guidelines do not address specific dosing strategies, clinical indications, contraindications, or monitoring. We sought to survey current prescribers of NETA to assess practice patterns of use among adolescent patients., Methods: An anonymous cross-sectional survey was sent via email list-serv to members of the North American Society for Pediatric and Adolescent Gynecology Providers (NASPAG). Participants were asked about their own demographics, patterns of use and monitoring of NETA., Results: Seventy-one providers participated in the survey including 46 gynecologists and 22 adolescent medicine trained clinicians. The most common indications for use were menstrual suppression and treatment of endometriosis. Most providers (n=51) used NETA in patients with estrogen contraindications, with over half limiting the maximum dose used (n=24). While 14%(n=9) of providers surveyed had concerns about effects on bone mineral density with prolonged NETA use, only 1 participant routinely obtained dual-energy X-ray absorptiometry (DEXA) scans. 43% of participants using NETA felt there were no absolute contraindications (n=27); others cited liver disease (n=15), active or prior venous thromboembolism (n=7), and inherited thrombophilia or increased clotting risk (n=3) as strict contraindications., Conclusions: NETA is commonly prescribed for adolescents by study participants. Despite widespread use, practice patterns vary regarding eligibility, monitoring, and perceived risks. This likely reflects limited data and highlights the need for further investigations of NETA use. Our study was limited by low response rate that may not be reflective of general clinical practice., Competing Interests: Declaration of competing interest No authors have conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Study Objective: To explore reasons for menstrual suppression method choice among transgender and gender-diverse (TGD) youth at the time of method initiation DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional analysis of baseline data from a prospective cohort study of menstruating TGD youth (N = 55), aged 12-17 years, initiating a hormonal method for menstrual suppression in a gender health specialty clinic at a single site, quaternary hospital in the Midwest INTERVENTIONS AND MAIN OUTCOME MEASURES: Participants completed a baseline survey that included identifying the most important reason, as well as other important reasons, for menstrual suppression method selection., Results: The mean age was 14.9 (SD 1.5) years, and most participants identified as White (81.8%) and male or transgender male (90.9%). For menstrual suppression, participants chose progestin-only pills (43.6%), followed by depot medroxyprogesterone acetate injections (29.1%), levonorgestrel intrauterine devices (21.8%), and continuous combined oral contraceptive pills (5.5%). The 3 most reported reasons important to method choice were "seemed like the best choice for me," "ease of use," and "I don't want anything with estrogen in it." "Uncomfortable with a device in my body" and "not wanting a pelvic exam" were also frequently indicated as important factors influencing method choice., Conclusion: Consistent with a patient-centered approach, comfort level with estrogen, implantable devices, and pelvic exam should be assessed early when discussing menstrual suppression options with TGD youth., Competing Interests: Conflicts of Interest The authors have no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Study Objective: Mullerian duct anomalies are common in females with anorectal malformations (ARMs), although there are no universally recommended screening protocols for identification. Historically, at our institution, we have recommended a screening pelvic ultrasound (PUS) 6 months after thelarche and menarche. We aimed to evaluate outcomes associated with our post-thelarche screening PUS in females with ARMs., Methods: An institutional review board-approved retrospective chart review was performed for all female patients 8 years old or older with ARMs and documented thelarche. Data were collected on demographic characteristics and clinical course. The primary outcome was adherence to the recommended PUS. Secondary outcomes included imaging correlation with suspected Mullerian anatomy and need for intervention on the basis of imaging findings., Results: A total of 112 patients met the inclusion criteria. Of them, 87 (77.7%) completed a recommended post-thelarche screening PUS. There were no differences in completion on the basis of age, race, establishment with a primary care provider, insurance status, or type of ARM. Nine patients (10.3%) had findings on their PUS that did not correlate with their suspected Mullerian anatomy; five (5.7%) required intervention, with two requiring menstrual suppression, two requiring surgical intervention, and one requiring further imaging., Conclusion: Most patients completed the recommended post-thelarche screening PUS. In a small subset of patients, PUS did not correlate with suspected Mullerian anatomy and generated a need for intervention. Post-thelarche PUS can be a useful adjunct in patients with ARMs to identify gynecologic abnormalities., Competing Interests: Conflicts of Interest The authors have no conflicts of interest to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Objective: To describe time to cessation of menses in adolescent and young adult transgender males with testosterone and/or other hormonal therapies DESIGN: Retrospective chart review SETTING: Tertiary children's hospital PARTICIPANTS: Patients, aged 10-24, who began gender-affirming hormonal therapy between January 2013 and January 2019 (n = 220) INTERVENTION(S): None MAIN OUTCOME MEASURE(S): Time to cessation of menses RESULTS: Most patients identified as transgender male or transmasculine (211/220, 95.9%), with an average age of 15.8 (±1.9) years. Approximately 53.6% (118/220) of patients reported regular menstrual cycles; 18.2% (40/220) reported irregular cycles. Median time to cessation of menses for all patients was 182 days. Patients treated with testosterone alone (n = 105) reported a median time to cessation of menses of 151 days. Patients who concurrently began testosterone and norethindrone acetate (NETA) (n = 5) had a median time to cessation of menses of 188 days, compared with 168 days for those on testosterone and depot medroxyprogesterone acetate (DMPA, n = 15). In 15 patients who began testosterone, a progestin therapy was later added to induce menstrual suppression, and the median time to cessation of menses was 168 days (+DMPA, n = 4) or 56 days (+NETA, n = 11). Patients treated with NETA (n = 14) or depot leuprolide (n = 11) reported a median time to cessation of menses of 78 days or 77 days, respectively. Considerable variability in prescribing patterns was noted in the remaining 36.4% of patients (n = 80)., Conclusion: Patients used a variety of different hormonal regimens for menstrual suppression. Less than half achieved cessation of menses within 6 months. NETA and depot leuprolide users reported the most rapid cessation of menses., (Copyright © 2022. Published by Elsevier Inc.)

Study Objective: To describe menstrual history, associated dysphoria, and desire for menstrual management in transgender male and gender diverse adolescents who were assigned female at birth DESIGN: Retrospective chart review SETTING: Tertiary care children's hospital PARTICIPANTS: All patients seen in a multidisciplinary pediatric gender program from March 2015 through December 2020 who were assigned female at birth, identified as transgender male or gender nonbinary, and had achieved menarche INTERVENTION: None MAIN OUTCOME MEASURES: Patient demographics, menstrual history, interest in and prior experiences with menstrual management, parental support, and concerns about menstrual management RESULTS: Of the 129 included patients, 116 (90%) identified as transgender male and 13 (10%) as gender nonbinary, with an average age of 15 (SD 1.6) years. Almost all (93%) patients reported menstrual-related dysphoria. Most (88%) were interested in menstrual suppression. The most common reasons for desiring suppression were achievement of amenorrhea (97%) and improvement of menstrual-related dysphoria (63%)., Conclusions: Most gender diverse patients assigned female at birth reported dysphoria associated with menses and desired menstrual suppression. This information can encourage physicians to raise this topic and offer menstrual management for gender diverse patients who experience distress related to menses, especially for those who are not ready for or do not desire gender-affirming hormonal treatment. Future research is needed to better understand patients' experiences with menses and to determine the optimal menstrual management methods. This could be an important intervention to improve outcomes for this vulnerable population., (Copyright © 2022. Published by Elsevier Inc.)

Study Objective: To evaluate the impact of nitrous oxide on patient-reported pain for placement of intrauterine systems (IUSs) in adolescents STUDY DESIGN: : Prospective observational study SETTING: : IUS placement in an ambulatory clinic compared with placement with nitrous oxide in a hospital-based sedation unit PARTICIPANTS: : English-speaking adolescents aged 12 to 20 presenting to a pediatric and adolescent gynecologist with a medical indication for IUS placement MAIN OUTCOME MEASURES: : Patient-reported procedural pain measured on a visual analog scale 2 minutes post IUS insertion procedure. Secondary outcome measurement of likelihood of recommending an IUS to a peer., Results: Seventy-four patients agreed to participate. Forty-five patients underwent IUS placement in the clinic. Controlling for age, history of dysmenorrhea, and body mass index, a significant time (change in reported pain scores pre- vs post IUS insertion) by treatment (nitrous oxide vs standard of care) interaction was observed for patient-reported pain (b = -29.32 mm, P < 0.01). Patients receiving nitrous oxide were more likely to recommend an intrauterine placement than patients who received the current standard of care for pain management (b = 0.47, P = 0.02) after controlling for age, baseline pain score, and dysmenorrhea history., Conclusion: Patient-reported pain was attenuated for patients who received nitrous oxide relative to those who received standard IUS placement. Patient-reported satisfaction was higher for patients who received nitrous oxide relative to those who received standard IUS placement., Competing Interests: Disclosures The authors report no conflicts of interest. This study received no funding support., (Copyright © 2021. Published by Elsevier Inc.)

Study Objective: Amenorrhea is a goal of many transgender and gender diverse adolescent and young adult (TGD AYA) patients on testosterone gender-affirming hormone therapy (T-GAHT). Breakthrough bleeding can contribute to worsening gender dysphoria. Our objective was to evaluate breakthrough bleeding in TGD AYA on T-GAHT., Design: Institutional review board-approved retrospective cohort., Setting: Tertiary-care children's hospital., Participants: TGD AYA on T-GAHT >1 year., Interventions: None; observational., Main Outcome Measures: Presence of, and risk factors for, breakthrough bleeding., Results: Of the 232 patients who met inclusion criteria, one-fourth (n = 58) had 1 or more episodes of breakthrough bleeding, defined as bleeding after more than 1 year on T-GAHT. In comparing patients with breakthrough bleeding to those without, there were no significant differences between age of initiation, body mass index (BMI), race/ethnicity, testosterone type used, use of additional menstrual suppression, serum testosterone, or estradiol levels. Patients with breakthrough bleeding patients were on T-GAHT longer (37.3 ± 17.0 vs 28.5 ± 14.6 months, P < .001) and were more likely to have endometriosis (P = .049). Breakthrough bleeding began at a mean of 24.3 ± 17.2 months after T-GAHT initiation. Of those with breakthrough bleeding, 46 (79.3%) had no known cause, 10 (17.2%) bled only with missed T-GAHT doses, and 2 (3.4%) bled only when withdrawing from concomitant menstrual suppression. No breakthrough bleeding management method was found to be superior., Conclusion: Breakthrough bleeding is relatively common (25%) on T-GAHT despite early amenorrhea. Most cases do not have an identifiable cause. Our data did not show superiority of any 1 method for managing breakthrough bleeding on T-GAHT., (Copyright © 2021 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Study Objective: To characterize the patient population with cognitive or physical impairments that presents for anticipatory guidance of puberty, evaluate caregiver concerns with respect to puberty, and describe chosen management strategies and outcomes following menarche., Design: Retrospective cohort study SETTING: Academic tertiary care women and children's hospital PARTICIPANTS: Eligible female patients with special needs up to age 26 years presenting for anticipatory guidance from 2009 to 2018 MAIN OUTCOME MEASURES: Primary outcomes included characterization of patients presenting for anticipatory guidance and their reasons for menstrual management. Secondary outcomes were satisfaction with menstrual management and bleeding patterns., Results: A total of 61 patients presented for anticipatory guidance of puberty, on average 13.5 months prior to menarche. Compared to the overall adolescent population with special needs who presented for gynecologic care, patients who had autism spectrum disorder (ASD), were nonverbal, or had attention-deficit/hyperactivity disorder (ADD/ADHD) were more likely to present for a pre-menarchal visit to discuss anticipated pubertal development (P < .001, P = .009, and P = .04, respectively). More than half of families described potential behavioral changes as their main concern. The majority of post-menarchal patients (80%) desired hormonal management of menses, including 30% of patients who had placement of a levonorgestrel intrauterine device. In all, 96% of patients were satisfied with their final menstrual bleeding pattern; 50% achieved amenorrhea or light spotting., Conclusions: This study describes the important role of pre-menarchal reproductive counseling for girls with disabilities. Anticipation of puberty causes great anxiety in families and patients, especially those with ASD, ADD/ADHD, and non-verbal status. Providers should consider initiating these conversations early in pubertal development., (Copyright © 2021 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Background: Pyometra is an uncommon but serious condition that is generally diagnosed in postmenopausal women. It rarely occurs in premenopausal patients, particularly adolescents., Case: A 16-year-old girl with multiple comorbidities including severe intellectual disability, neurogenic bladder, and recurrent urinary tract infection presented with fever, abdominal pain, and vaginal discharge after prolonged treatment with depot medroxyprogesterone acetate. Ultrasound imaging showed an intrauterine fluid collection consistent with hematometra; however, hysteroscopic evaluation confirmed pyometra, which was evacuated using a suction curette. Despite postoperative antibiotic therapy, she re-presented with similar findings requiring additional hysteroscopic evaluation and evacuation. After a third evacuation, an intrauterine catheter was placed to aid in drainage. This was not tolerated by the patient, and she ultimately required total laparoscopic hysterectomy for definitive management, which was performed without incident., Summary and Conclusion: Pyometra is a rare occurrence that typically presents after menopause; however, it should be considered in patients with poor genitourinary hygiene and medically induced endometrial atrophy. In severe cases, hysterectomy might be required for definitive management., (Copyright © 2020 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Study Objective: To describe the bleeding patterns associated with the use of the levonorgestrel intrauterine device (IUD) in adolescents., Design, Setting, and Participants: A retrospective chart review of postmenarchal adolescent patients ages 8-19 years who had the levonorgestrel IUD inserted at Phoenix Children's Hospital from 2012 to 2018., Interventions: Insertion of the 52-mg and 13.5-mg levonorgestrel IUD., Main Outcome Measures: The rate of amenorrhea and other bleeding patterns after insertion of the levonorgestrel IUD and the factors that might predict those bleeding patterns., Results: A total of 260 charts were identified with 221/260 (85.0%) patients choosing the 52-mg IUD and 39/260 (15.0%) patients choosing the 13.5-mg IUD to be inserted. Follow-up data were available for 166 patients. The overall rate of amenorrhea among IUD users was 39.8% (n = 66) with no difference between 52-mg and 13.5-mg IUD users (P = .656). Regularity and flow of menstrual cycle, history of bleeding disorder, history of developmental delay, and current treatment with testosterone for gender dysphoria before IUD insertion did not appear to have a significant effect on the rate of amenorrhea or bleeding patterns post-IUD insertion., Conclusion: The levonorgestrel IUD can be successfully used to control abnormal uterine bleeding and suppress menses in adolescents. Menstrual cycle characteristics pre-IUD insertion did not result in predictable post-IUD bleeding patterns., (Copyright © 2020 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Study Objective: The aim of this study was to review the efficacy of different medical modalities for menstrual suppression in the cohort of patients with disabilities who presented to the Queensland Paediatric and Adolescent Gynaecology (PAG) Service between January 2005 and December 2015. Menstrual suppression in adolescents with disabilities is an important aspect of care to support the patient and their carers in managing the complexities of menstrual hygiene, pain, and other discomfort associated with menses. It is important for general practitioners, pediatricians, and gynecologists to establish the right modality of suppression for each individual adolescent. DESIGN, SETTINGS, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: The study was a retrospective case notes review of 68 adolescents who presented to the Queensland PAG Service, Brisbane, Australia with a request for menstrual suppression. The medical interventions included treatment with either combined oral hormonal contraceptive, oral medroxyprogesterone, depot medroxyprogesterone, or the levonorgestrel intrauterine system (Mirena, Bayer). The primary outcome measure was success of menstrual suppression from commencement of medical intervention to achievement of complete amenorrhea or very light bleeding described as spotting, for each medical modality. Secondary outcomes were length of time from first treatment to first observed menstrual suppression, and the number of outpatient appointments taken to achieve menstrual suppression., Results: Of the 68 adolescents, 59/68 (86.8%) successfully achieved menstrual suppression, with 9/68 (13.2%) having ongoing treatment or loss to follow-up at the time of conclusion of the study; 39/68 (57.4%) were menstrually suppressed with their chosen medical modality after their initial appointment., Conclusion: Medical modalities are highly effective in achieving menstrual suppression and no young women at this institution required a hysterectomy. Depot medroxyprogesterone was the most successful modality used to achieve menstrual suppression followed by the levonorgestrel intrauterine system. The combined oral hormonal contraceptive was the least successful medical treatment in achieving menstrual suppression., (Crown Copyright © 2019. Published by Elsevier Inc. All rights reserved.)

Menstrual suppression (the use of hormonal contraceptive methods to eliminate or significantly decrease the frequency of menstrual cycles) is frequently used in the adolescent population for the management of menstrual symptoms such as heavy or painful periods, premenstrual syndrome, menstrual migraines, or even for patient preference. However, in cases of menstrual suppression in special populations additional risks and benefits need to be considered. The purpose of this article is to review the options and medical considerations for menstrual suppression in patients undergoing chemotherapy who might be at risk of abnormal uterine bleeding, those with intellectual or physical disability, and transgender and gender nonbinary individuals., (Copyright © 2019. Published by Elsevier Inc.)

Background: The Mirena levonorgestrel intrauterine system (IUS; Bayer HealthCare Pharmaceuticals) is frequently used for menstrual suppression in adolescents with special needs. However, the presence of a uterine anomaly is generally considered a contraindication to IUS insertion, thereby excluding a potentially highly effective option for this patient population., Case: A Mirena IUS was used in a medically and surgically complex special needs 14-year-old adolescent with a didelphys uterus and obstructed hemivagina. With the IUS inserted into the unobstructed uterus, she achieved amenorrhea and significant reduction in pain, with interval reduction in hematometra in the contralateral obstructed uterus., Summary and Conclusion: We report the successful use of the Mirena IUS in a patient with a Müllerian anomaly, supporting the use of this device in carefully selected patients., (Copyright © 2018 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)