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The overwhelming majority of ovarian cysts in pediatric and adolescent girls are physiologic; however, large simple and complex ovarian lesions often require surgical intervention due to the increased risk of neoplasia. In this review article, we discuss the preoperative evaluation and intraoperative management of large ovarian neoplasms. We review the current literature regarding long term ovarian function and fertility, rates of recurrence and residual disease, and novel surgical approaches. Managing large ovarian neoplasms in the pediatric and adolescent population requires careful preoperative and intraoperative care to optimally resect neoplasia while maximizing fertility and minimizing pain.

Introduction Permanent female sterilization remains one of the most popular methods of birth control. It is the fifth most commonly performed procedure in the United States, following cesarean section, abortion, cholecystectomy, and coronary angioplasty. [1] It provides a safe and effective method of birth control for women who have completed childbearing. It remains a viable option for women who have contraindications to medical contraceptives. It can be performed at any time and there are multiple ways to achieve blockage of the tubes. Different approaches are available which have their own risks and benefits, and provides women with options to choose from. Scope of the Problem It is estimated that as much as half of all pregnancies in the United States are unintended at the time of conception.[2] Unintended pregnancies are associated with a number of adverse maternal behaviors including lack of or limited prenatal care, smoking, and drinking during the pregnancy, failure to breastfeed, and poor maternal-child bonding. The costs of caring for these unintended pregnancies are estimated to be anywhere from $11.1 billion to $11.3 billion per year. These costs include only prenatal care, labor and delivery, and infant care for a year; they do not include nonmedical care and long-term costs because they are more difficult to estimate. [3] Nor do they consider the emotional burden or the costs to the woman in terms of her personal or professional goals. This highlights the importance of safe and effective contraception. According to data from the National Survey of Family Growth, which provides data from 2011 to 2013, the most commonly used methods for contraception include the pills (25.9 percent), female sterilization (25.1 percent), the male condom (15.3 percent), and intrauterine devices/subdermal implants (11.6 percent). [4] In choosing a contraceptive option, one has to consider efficacy, safety profile, ease of use and adverse effects. For women who have completed childbearing, the option of female permanent sterilization is certainly practical and cost-effective. Timing Female sterilization can be performed at any time during the menstrual cycle, following a pregnancy or an abortion, or during cesarean delivery. If the procedure is not performed immediately postabortion or postpartum, the patient should be using an effective contraceptive, or the sterilization procedure should be performed during the follicular phase, to avoid the chances of a concurrent, undiagnosed pregnancy.

It is important for practitioners to recognize that there are special considerations when performing gynecologic surgery in a pediatric or adolescent patient. A provider must be familiar with differences in anatomy, physiology, surgical technique, and psychosocial concerns. This can be challenging for a provider who does not routinely operate on patients in this population. A minimally invasive surgical approach is preferred in the pediatric and adolescent patient whenever possible. While a good command of laparoscopy in the adult patient is certainly a useful skill when operating on pediatric and adolescent patients, there are technical adaptations and challenges to consider. This chapter reviews the pre-operative preparation, operative technique and challenges, and post-operative care of the surgical pediatric and adolescent gynecologic patient.

Background Labial hypertrophy is protuberant labial tissue extending beyond the labia majora. Self-perception of poor cosmetic appearance is common in young patients and not necessarily pathologic. Labioplasty is indicated for patients with persistent symptoms including entrapment and painful intercourse. Case A 26-year-old woman presented with genital pain and foul odor after self-applying elastic bands to her labia minora. The bands were applied for a self-perceived abnormal appearance and lack of insurance for medical consultation. Surgical debridement and revision of the labia were performed using a straight vertical approach. Conclusions Self-attempted labioplasty can result in necrosis and infection. Education and counseling of patients on the normal variants of labial anatomy and the recommended therapeutic methods will lead to better cosmetic results and prevent self-mutilation.

AM:STARs, the Adolescent Medicine State of the Art Reviews series published by the American Academy of Pediatrics, devoted its April 2012 issue to the topic of Adolescent Gynecology. Developed in conjunction with the North American Society for Pediatric and Adolescent Gynecology (NASPAG), the issue consists of twelve articles, written mostly by members of NASPAG. As editors of the issue, we present in this review for the Journal of Pediatric and Adolescent Gynecology (JPAG) a synopsis of the most salient concepts presented in those 12 articles. This review of reviews is intended to be an update on the “state of the art” in adolescent gynecology.

In the past few decades, there has been an overwhelming increase in childhood and adolescent obesity worldwide. Besides the well recognized cardiometabolic complications and other physical conditions associated with obesity, during adolescence, it causes psychological and social distress in a period of life that is already sensitive for a girl. This in turn increases their risk of low self-esteem and depression. Furthermore, obesity diminishes health-related quality of life and years of life. Overweight and obese teenagers are more likely to have gynecologic and obstetric complications, during adolescence and also later in life. Consequences of obese and overweight childhood and adolescence include sexual maturation and reproductive dysfunction, alterations in menstruation, dysmenorrhea, risky sexual behavior, and inefficient use of contraception, polycystic ovary syndrome, bone density abnormalities, macromastia, and an increased risk of breast and endometrial cancer. Obese adolescents are at greater risk of pregnancy and perinatal complications, such as preeclampsia, gestational hypertension and preeclampsia, gestational diabetes mellitus, primary cesarean delivery, and induction of labor, to mention a few. Evidence shows that infants born to obese teenagers are also more likely to have complications including preterm or post-term delivery, small-for-gestational age newborns, macrosomia, meconium aspiration, respiratory distress, and even stillbirth, among others. This comprehensive review focuses on the gynecological and obstetric consequences of obesity in adolescent girls.

Objective: The purpose of this study was to compare the costs and net revenue associated with robotic versus traditional laparoscopic hysterectomies. Design: The study was designed as a retrospective chart review. Methods: The study group consisted of patients who underwent laparoscopic hysterectomies using the robotic versus standard laparoscopy from January 2005 to March 2009. Data were collected as the mean for the cohort and included total charges, total collected, total direct costs, and operative margin (OM). Total costs were divided into operating room costs (labor, supplies, and equipment), hospital costs (anesthesia, pharmacy, room, and board) and additional costs. Statistical analysis was performed comparing the two groups by the Wilcoxon rank sum test, two sided t test, and Fisher exact test. Results: Twenty-eight robotic cases were matched to 48 laparoscopic cases. Demographics were similar between groups. Total charges where higher with the robot, ($30,725 vs. $22,526, p

In the past few years, key changes in reproductive health for adolescents has created both renewed interest and concern for healthcare providers. This article will focus on the current provision of reproductive health and new challenges to come, in order to familiarize the practitioner with new guidelines and practice patterns in the evaluation and management of adolescent gynecological problems.

Background Massive edema of the ovary is a rare entity affecting mainly young women. It is often misdiagnosed for a malignancy, posing the young patient at risk for over-treatment with resultant loss of hormonal function and fertility. Case A 13-year-old premenarchal girl presented with a large solid pelvic mass after recurrent episodes of self-limited abdominal pain. With a working diagnosis of malignant ovarian tumor, an exploratory laparotomy was done in which a twisted ovarian mass was found and excised completely. Pathological examination of the mass revealed massive edema of the ovary with hemorrhagic necrosis. Conclusion After extensive review of the literature, it seems most cases were over-treated, as was ours. This entity should be suspected in women at the fertile age range with solid enlargement of the ovary and definite treatment should be undertaken only after confirmed pathological diagnosis. Conservative treatment is feasible and should be the rule in these cases, where fertility preservation is mandatory.

Background Epidermal cysts of the clitoris are uncommon and usually associated with previous trauma. Surgical removal is the preferred treatment with close attention to preserve sensation and vascular supply. The use of an alternative coil during Magnetic Resonance (MR) imaging to visualize the anatomy may improve surgical management and outcomes. Case A 15-year-old adolescent had a 2-year history of clitoral enlargement. Physical exam revealed a 4 × 5 cm clitoral cyst and normal hormonal evaluation. Initial MR with a pelvic coil showed poor resolution of neurovascular supply. MR was repeated using a small flex coil (commonly used on the wrist) placed as a sanitary napkin providing a higher resolution image of the neurovascular structures, which guided surgical intervention. Conclusion The use of the MR small flex coil to better visualize the external genital structures and clitoral anatomy improved preoperative evaluation and guided surgical management of the clitorial cyst.

There are several issues that arise regarding the evaluation of teens with urethritis and cervicitis. What are the appropriate treatments for adolescents? What are the issues regarding rescreening and do we need to consider tests of cure? Chlamydia is the most common bacterial sexually transmitted disease in adolescents in the United States. The prevalence appears to be leveling off or decreasing which may reflect several reasons. More frequent screening utilizing more sensitive diagnostic techniques such as nucleic acid amplification techniques and screening populations that are traditionally more difficult to reach may have led to the lower rates. However there still are many young men and women with high-risk behaviors who are not receiving appropriate screening. (excerpt)

Jennifer E. Dietrich, MD, Alan Kaplan, MD, Henry Lopez, MD, and Ian Jaffee, MD Kaza Medical Group, Milford, Delaware, USA; Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas, USA; Division of Gynecologic Oncology, Baylor College of Medicine, Houston, Texas; Division of Medical Oncology, Wharton Clinic, Wharton, Texas; Department of Pathology, Baylor College of Medicine, Houston, Texas

Objective The objective of this study was to determine the prevalence of vulvar intraepithelial neoplasia (VIN) in adolescents presenting for cervical colposcopy in an adolescent gynecology office. Materials and methods We conducted a retrospective chart review from 1999 to 2002 of the concomitant diagnosis of cervical intraepithelial neoplasia and VIN in our private general pediatric and adolescent practice in patients younger than 22 years of age who underwent cervical colposcopy as well as evaluation of the vulva secondary to gross and microscopic visualized lesions. Results Sixty-one patients underwent colposcopy for abnormal Pap smears; we found a 10% overall prevalence of vulvar intraepithelial neoplasia. Forty-four percent (n = 27) underwent concomitant evaluation of the vulva; from these, 22% (n = 6) fulfilled the characteristics of vulvar and cervical intraepithelial neoplasia. Conclusion In the presence of cervical cytology abnormalities, VIN may be more common than recognized and careful screening is definitely warranted.

Background Klippel-Trenaunay syndrome is a rare disease characterized by capillary malformationsand soft tissue and bony hypertrophy and atypical varicosities. Management of this syndrome is focused primarily on treatment of the complications that arise from these malformations. Ascites and lymphedema are two of the more common complications in these patients. Case A 15-year-old female with Klippel-Trenaunay syndrome presented with chylous ascites, vaginal drainage, and unilateral lower extremity lymphedema. Treatment included dilation, hysteroscopy and curettage, and laparoscopic evacuation of abdomino-pelvic ascites with resolution of symptoms for 32 months. Repeat laparoscopic drainage was successful and remains symptom free after 12 months. Conclusion Vaginal drainage of chylous ascites is a rare complication from Klippel-Trenaunay syndrome and can be successfully managed by techniques to remove abdomino-pelvic ascites.

Objective: To determine if a preoperative conference impacts the resident recommended surgery on gynecology patients seen in continuity clinics. Study Design: A twice monthly preoperative conference was initiated in January of 2009 where residents presented their proposed surgical intervention. A retrospective review of the first 100 preoperative conference submission forms was performed and analysis made on how often the type or route of surgery was changed based on conference discussion and if further workup or tests were requested prior to scheduling surgery. Results: Discussion of patients through a preoperative conference venue resulted in a change in surgical management of 36% of patients, and further medical management prior to surgery was recommended in 29%. Conclusions: A preoperative gynecology conference does impact the chosen surgery for resident patients. This venue may be a valuable tool for teaching residents optimization of the preoperative evaluation and selection of the appropriate surgical intervention.

OBJECTIVE: Describe characteristics compliance efficacy and side effect profile of adolescents and young women who use intrauterine contraception (IC). STUDY DESIGN: Retrospective chart review of adolescent and young women who had IC devices placed over a 3-year period. Comparative statistics between devices and population characteristics were performed using the Fisher exact and the t test. RESULTS: Eighty-nine patients were included in the study. The mean age at insertion was 19.5 years (range 16-22 years). Copper was used in 13% of patients; levonorgestrel (LNG) was used in 87%. The mean duration of use was 331.3 days (copper vs LNG; P = .2254). Side effects included infection (9% but no pelvic inflammatory disease) pain (28%) partner felt strings (9%) and bleeding (32%). Reasons for removal included side effects (25%) desired fertility (5%) expulsion (3%) and pregnancy (2%). There were no pregnancies associated with the LNG IC and there were fewer removals because of side effects than with the copper IUD (P = .0180). CONCLUSION: IC is a reliable method of contraception in teens and young adults. There were fewer removals because of side effects in the LNG group although overall other variables are similar between methods. Copyright A(c) 2011 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.

Objective Current surgical training programs rely heavily on subjective assessments to measure operative proficiency, despite heavy emphasis on standardized testing as a means to rank scholastic ability. A compact laparoscopic simulator was developed with the intention to create a technical skill evaluation system that resembles standardized testing to provide the user with real-time percentile scores in a variety of skill metrics. The calculation of percentiles is only accurate if the pool of scores resembles a specific distribution (e.g., normal or log-normal distribution). We hypothesize that the grading measures provided by the simulator will follow normal or log-normal distributions. Materials and Methods A total of 29 surgical trainees with varying levels of laparoscopic experience were surveyed regarding their current training, proficiencies, and experience with the Fundamentals of Laparoscopic Surgery curriculum and then asked to perform a standard peg-transfer task 5 times. A proprietary device placed along the trocars of a laparoscopic box trainer was used to gather data that, when subjected to unique algorithms, gave real-time, web-based feedback to trainees on the following metrics: volume of instrument use, economy of movement, angular instrument path, instrument rotation, bimanual coordination, smoothness, time to task completion, and depth perception. Numerical data were plotted on a frequency histogram. Minitab software was used to identify if individual metrics fit a standard distribution curve. Analysis of variance was used to differentiate among 3 established physician skill levels, as a means of assessing construct validity. Results In the goodness-of-fit tests performed, angular path, depth perception, rotation, and smoothness were found to best fit a log-normal distribution (p > 0.1). Bimanual coordination was found to fit a normal distribution (p ≥ 0.067). However, both normal and log-normal distributions were rejected (p ≤ 0.01) for the metrics of time, volume, and economy of movement. After separating participants into 3 groups based on level of experience with the Fundamentals of Laparoscopic Surgery curriculum, analysis of variance showed significant differences among all group means across the 5 metrics (i.e., angular path, depth perception, rotation, smoothness, and bimanual coordination; p ≤ 0.023). Conclusion A proprietary device provided quantitative assessment of laparoscopic skills, which can be used to differentiate among skill levels. Of the 8 tested metrics, 5 fit a normal or log-normal distribution, meaning the scores can statistically be ranked by percentile. Time, volume, and economy of movement did not fit desired distributions. The grading system proved to have construct validity, indicating it may be useful in the longitudinal assessment of laparoscopic skills of surgical trainees.

A case report of a premenarcheal patient with an ovarian torsion and müllerian agenesis is presented. An 11-year-old prepubertal girl presented with severe left lower quadrant abdominal pain and mild rebound. A computed tomography showed a normal appendix; an ultrasound showed a left ovary measuring 3 x 2 cm with multiple 0.5-mm simple cysts. A diagnostic laparoscopy showed the left ovary tube to be twisted, but the uterus was absent, and the right ovary and tube were not visualized in the appropriate location; instead, a right adnexal structure was buried in the right sidewall. The ovary was untwisted and fixed to the pelvic sidewall. Chromosomes were 46,XX, and her hormonal evaluation was normal. Ovarian torsion and müllerian agenesis are rarely reported. An association between the lax attachment of the adnexa and torsion may be a contributing factor in this condition.

Large benign adnexal masses may be safely managed with single-site laparoscopy., Introduction: Single-site laparoscopy is gaining acceptance in many surgical fields including gynecology. The purpose of this report is to demonstrate the technique and outcome for removing a large adnexal mass through a single site. Case Description: A 41-y-old female was referred to gynecology oncology for increased abdominal girth for 3 mo. An ultrasound confirmed a benign-appearing, 37-cm left adnexal mass. The mass was removed through a single-site laparoscopic incision with the aid of drainage and a morcellator. The operating time was 84 min. The patient was discharged 2 h and 35 min later with full return to normal activity in 5 d. Conclusion: Large, benign-appearing adnexal masses can be managed safely with superior cosmetic results using single-site laparoscopy.

Developments in the field of adolescent gynecology highlight the specific expertise and care required by this population. Given the ability to shape their future health choices, adolescents are a critical target for preventative health care. The approach to the evaluation and management of this unique population rests not only on the practitioner's adept ability to recognize the unique clinical challenges that may occur, but also rests on his/her understanding of these problems. Here, we review recent guidelines and practice patterns in the evaluation and management of issues in adolescent gynecology.

The challenges inherent in medical education are multiple, including recognition of different learning styles among students, incorporation of the Accreditation Council for Graduate Medical Education competencies and outcomes measurement into the curriculum, and compliance with mandated duty hours along with a heightened awareness of patient safety required by our regulatory institutions. With the requirement that safety become an explicit part of the residency curriculum across all specialties, educators are charged with innovative ways of achieving this goal. The following commentary addresses this need and suggests an innovative approach to the traditional daily rounds' SOAP (subjective, objective, assessment, and plan) note to incorporate a second S for safety. The use of a SOAPS note elevates each encounter by integrating quality and error avoidance as a component of care. This method teaches the next generation of physicians the importance of patient safety as an integral part of every doctor-patient interaction.

Pregnancy rates in the United States seem to have stabilized in the past decade but continue to be higher than those in other industrialized nations. Although abstinence and barrier methods are available and efficient in preventing pregnancy, a comprehensive approach is a better choice when counseling patients on available options. The new approach to old contraceptive methods provides new alternatives to adolescents seeking safe and reliable methods. The availability and proved safety with longterm reversible contraceptive methods, such as the intrauterine system and subdermal implant, may allow adolescents to make better choices in preventing pregnancy. Future efforts in research should concentrate on finding the reasons why adolescents are at increased risk for unplanned pregnancy and solutions for this problem. Future contraceptive technology continues to focus on safety and convenience to facilitate the use of contraceptives in adolescents.

Given new developments in the field of adolescent reproductive health, this review focuses on highlighting new guidelines and practice patterns in evaluation and management of adolescent gynecologic problems. First, understanding the proper techniques for the initial examination is key to establishing a long-term relationship with this age group. Reservations about the first gynecologic examination are common, and the practitioner's goal is foremost to make the patient as comfortable as possible. Preventive health in this patient population is key, and practitioners should become comfortable with providing education about topics as diverse as sexuality, eating disorders, and dating violence. Furthermore, the frequency with which teenagers report sexual activity and the high unintended pregnancy rate in this age group makes counseling regarding effective contraception essential. Additionally, practitioners are encouraged to take the opportunity to discuss the availability of the human papillomavirus (HPV) vaccine with adolescents. In 2007, adolescents were designated as a special population, given the frequency with which they acquire and clear mild HPV-related cervical dysplasia. More conservative treatment in this population is generally favored. During their transition through puberty, disorders of menstruation become the most common complaint requiring the attention of the gynecologist. Most commonly, anovulation serves as the cause behind such abnormal bleeding. Polycystic ovarian syndrome can develop in early puberty and carry its consequences into adulthood. Infertility, diabetes, and hirsutism mark the most important components of the syndrome and require age-appropriate management. Finally, the consequences of endometriosis on the future fertility of adolescents have brought early intervention to light. Recognition and prompt treatment are advocated to prevent the future implications of this disease.

Clinical pediatric and adolescent gynecology / , Clinical pediatric and adolescent gynecology / , کتابخانه دیجیتال جندی شاپور اهواز

The initial evaluation and examination of both the pediatric and adolescent patients provides the opportunity for the clinician to establish a relationship that will ensure the successful outcome of the visit. In the younger age group, cooperation of the child before performing an examination should be the focus at the first encounter. This cooperation will enable proper positioning and a systematic approach to examination and documentation of findings. Although the adolescent patients may be older and better able to understand the specifics of the examination, these patients present additional challenges for the examining practitioner.

Study Objective Adolescent compliance with cytologic and histologic cervical abnormalities is poor. Recent changes in abnormal cytology follow-up and colposcopy indications in young women may delay the diagnosis of cervical dysplasia. The objective of our study was to determine the compliance with follow up. We also wanted to summarize regression or progression of disease, and to determine if the new guidelines could affect severity and time of diagnosis. Design Retrospective review of medical records from adolescent patients (defined as women aged 12 to 21) who had a colposcopy between January 2004 and December 2006. Patients were excluded if they were 22 or older or if they had a previously abnormal cytologic evaluation. Main Outcome Measures Colposcopy records between January 2004 and December 2006 were identified by CPT code from a computerized database. Cytology and histology results, follow-up compliance rates, and demographic data were collected. Data were analyzed with a power > 85% and a P value ≤ .05 for significance. Results Of the 210 records reviewed, 61.9% had atypical squamous cells of undetermined significance high-risk HPV, 33.7% had low-grade squamous intraepithelial lesion, and 4.5% had high-grade squamous intraepithelial lesions. Colposcopy was performed in 55.9%, and 15.2% required surgical intervention. Loop electrosurgical excision procedure (LEEP) was used in 87.5% of patients, and 12.5% had a cold knife cone. Mean time to follow in patients with a surgical intervention was 12.72 months and 11.02 months for those without (P = .371). Conclusion There appears to be no difference in compliance with follow-up, regardless of severity of disease or surgical intervention. There was no significant progression of disease and a high regression rate of abnormalities. This information supports the current American College of Obstetricians and Gynecologists and American Society for Colposcopy and Cervical Pathology guidelines to delay aggressive intervention in adolescents.

Periclitoral abscesses in premenarchal girls is a serious condition and can have negative implications for future reproductive health. Recurrent periclitoral abscess in premenarchal girls is rare.An 11-year-old, premenarchal girl presented complaining of dysuria, vulvar swelling, pain and erythema of the clitoral hood and a similar episode 12 months previously. Intravenous antibiotics and local measures resulted in spontaneous drainage of the abscess. On day 3 the area was healing, and the patient was discharged on oral antibiotics and sitz baths. At her 6-month follow-up, she had a normal clitoral hood without tenderness or erythema.Broad-spectrum antibiotics and local measures may prevent surgical treatment and potential associated reproductive morbidity.