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Sexual assault and intimate partner violence (IPV) of children, adolescents, and adult women are prevalent in the United States and have long-term physical and mental health, financial, and social effects. Pregnant women and women of color are particularly high-risk populations. Obstetrics and gynecology providers are uniquely situated to assess and treat survivors of IPV and sexual assault. A timely, thorough forensic medical examination, appropriate evaluation, and prophylactic therapy are all vital components in the care of these patients.

Documentation of sexual orientation (SO) and gender identity (GI) is crucial to identify lesbian, gay, bisexual, and transgender youth and perform meaningful research to improve health disparities in this community. As a result, some electronic medical records (EMRs) have incorporated SO and GI into part of the provider's workflow for documentation. We aimed to evaluate the effect this modification has had on the frequency of SO and GI documentation. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This was a retrospective chart review of patient encounters from an outpatient pediatric and adolescent gynecology clinical practice. The rate of documentation of SO and GI were compared between encounters that took place before the implementation of the EMR modification and those that took place after. Additionally, we examined rates of GI and SO documentation according to visit type and patient race.A statistically significant increase in the frequency of SO and GI documentation after the EMR modification was detected. The documentation rate of SO increased from 10/73 (13.7%) to 32/73 (45.1%) (P .01) and GI documentation rate went from 1.4% to 46.5% (P .01) after the EMR changes were implemented. SO or GI was most commonly documented in social history (90%). There were no differences in documentation on the basis of race or type of encounter.Including a specific tab for SO and GI in the EMR significantly increased the frequency of SO and GI documentation. Despite this increase, frequency of documentation remained at less than 50%, emphasizing the need for further improvement.

Purpose of review This review aims to emphasize the importance of including adolescents in research, outline current standards and evaluate barriers that prevent adolescent research. We also hope to provide some guidance and call for much needed additional direction in the field. Recent findings The absolute necessity for including adolescents in research has been an area of focus within the community of adolescent providers and care takers. Recent policy and support from major organizations has emphasized the importance of including this population in research but also pointed out many of the complexities. Summary Adolescent research is imperative to guiding policy and promoting evidence-based care. Current standards provide both guidance and barriers, yet more research is needed to further guide conduct of ethical research in this population.

Study Objective To evaluate clinical outcomes of labial adhesions (LA) and to examine the association between LA, lichen sclerosus (LS), eczema (ECZ), or asthma. Design Retrospective study. Setting Single pediatric and adolescent gynecology clinic, Houston, Texas. Participants 50 girls diagnosed with LA from 2006-2011. Interventions and Main Outcome Measures Resolution, recurrence, single vs multiple treatments, need for surgery, and conditions such as LS, ECZ, and asthma were reviewed. Results Mean age was 19.6 months (range 0-84 months), and 48% were Caucasian. Most patients were symptomatic (62%) and all 50 patients chose estrogen treatment. The majority (74%) required multiple treatments, as opposed to a single treatment (26%). Patients with multiple treatments were more likely to be severely agglutinated ( P = .05) and to need manual separation after failed topical treatment ( P = .08). The prevalence of asthma, LS, and ECZ was 9.8%, 7.8%, and 3.9% respectively. There was no association between LS, ECZ, or asthma, and number of treatments. Both asthma (N = 3; 8%), and LS (N = 2; 5%) were present among the severe agglutinated group; however, this difference was not statistically significant ( P values .59 and .99). No association with ECZ was seen in either group. Conclusion Severe agglutination tends to be associated with need of multiple treatments and manual separation. A concurrent diagnosis of LS, ECZ, or asthma was not associated with number of treatments but there appears to be a trend towards severity of LA in patients with asthma and LS.

The anatomy, embryology, and physiology of the ovary are reviewed in detail in this chapter. Familiarity with the anatomy and development of the ovary is essential to appreciate many of the pathological findings and malformations of the ovary discussed in other chapters. Knowledge of ovarian anatomy and development is also critical to understand the conduct of operations involving the ovary. A brief review of ovarian and menstrual physiology provides the foundation to understand normal and abnormal ovarian function.

Background Ovarian mature cystic teratomas (MCTs) rarely transform to primary primitive neuroectodermal tumors. This case report offers evidence that MCTs might have undetected microfoci of malignant neural tumors. Case We describe the case of a 12-year-old girl who presented with right-sided abdominal pain and distention. Intraoperative findings revealed a right ovarian MCT. However, pathology showed a 0.5-cm focus of malignant neural tumor within the 11-cm MCT. Summary and Conclusion This patient will need close follow-up with a multidisciplinary team because the clinical implications of this transformation has yet to be defined.

This article provides an overview of the prevalence and pathophysiology of platelet function disorders (PFDs) in adolescents with menorrhagia. In addition, this article reviews the various testing modalities employed for diagnosing PFDs including platelet aggregometry, platelet function analyzer (PFA-100), platelet electron microscopy (EM), flow cytometry, and thromboelastography (TEG), discuss their utility and drawbacks, and allude to the recent recommendations and consensus statements about some of these modalities. Finally, the authors have sketched out a diagnostic algorithm for platelet function testing, which will guide treating physicians to a step-wise approach while evaluating adolescents with menorrhagia for PFDs.

Objective Studies indicate a deficiency in knowledge of sexually transmitted infections (STIs) among adolescents, yet adolescents comprise 25% of the sexually active (SA) population and account for 48% of STIs acquired annually. This survey assesses knowledge of STIs among adolescent females. The goal of this study was to assess knowledge of STIs and how it relates to safe sex behaviors and educational access. Design A confidential 10-question STI survey was administered to a convenience sample of female adolescents. Data analysis included descriptive statistics, chi-square analysis, and linear regression analysis. Setting Texas Children’s Hospital Pediatric and Adolescent Gynecology Clinic. Interventions None. Participants Seventy-five female participants between the ages of 10–21 years. Main Outcome Measures Age, sexual activity, educational access, preferred methods of risk reduction and questions answered correctly on the STI survey. Results The mean age of participants was 14.9 ± 2.4 years; mean age of menarche was 10.9 ± 2.9 years. Based on survey responses, all adolescents demonstrated similar knowledge of specific STIs regardless of demographic factors. However, middle and late adolescent groups had increased awareness of STIs. SA participants (36%) were more likely to choose 2 or more methods of risk reduction compared to non-SA participants (P = 0.014). There was no correlation between educational access and preferred methods of risk reduction even though 92% of respondents reported receiving STI education from school, parents, or peers. Conclusions Current efforts at STI education are not effective. Different approaches to STI education are necessary to increase knowledge and motivate adolescents to reduce high risk behaviors.

To assess knowledge about contraceptive efficacy and side effects in an adolescent population seen in Pediatric and Adolescent Gynecology referral centers.This is a multisite cross-sectional survey study. A 23-question survey assessing knowledge of contraception and demographic information was administered. Data analysis was performed using descriptive statistics, simple paired t tests, and chi-square analyses using SAS 9.3.Pediatric and Adolescent Gynecology clinics in 4 tertiary care centers. The study was conducted in 3 institutions in the United States and 1 institution in Canada.A convenience sample of 354 female patients aged 10-24 y seeking reproductive healthcare at participating institutions.NoneThe percentage of correct answers to questions assessing general knowledge about contraception, familiarity with different contraceptive methods, and comparison of results between study sites.The mean percentage of correct answers among all participants was 55.8% ± 17%. Younger participants (age 10-13 years) scored significantly lower than their older counterparts (49%, 55%, and 60% respectively, P.05). There was no correlation between score and ethnicity or location of the participating site. Subjects reporting the internet as a source of information, those who were sexually active, and those familiar with long acting reversible contraceptives scored significantly higher. Of all contraceptive methods, participants were least likely to have heard of etonogestrel implants (18%), rhythm method/natural family planning (28%), and IUDs (32%).Adolescents and young adults performed poorly overall demonstrating both the lack of overall knowledge regarding methods of contraception and misinformation about side effects.

Background Laparoscopy is the most common procedure for minimally invasive intraabdominal surveys. Patients with pulmonary hypertension (PHTN) may need an alternate approach because the systemic absorption of carbon dioxide may lead to hypercapnia, acidemia, and increases in systemic and pulmonary pressures. We report a case of intraabdominal survey using a microcatheter trocar (Check-Flo Introducer) in a patient with a large adnexal mass and PHTN. Case An adolescent girl with severe PHTN and multiple cardiac anomalies presented with oligomenorrhea. During the course of workup, an ultrasound revealed an 8-cm simple cyst in the right adnexa, which required removal. The decision was made to proceed with cystectomy. The patient was not a candidate for laparoscopy, and an alternative method was used. The Check-Flo Introducer, a microcatheter trocar; crystalloid fluid infusion; and a 3-mm laparoscopic camera were used to survey the abdominal cavity, revealing a 10-cm simple paratubal cyst that could be safely drained and removed via a minilaparotomy incision. Conclusion The microcatheter trocar is a useful and novel alternative in patients who cannot tolerate increases in intraabdominal pressure.

Background Von Willebrand disease (VWD) maybe inherited or acquired; both etiologies can be associated with heavy menstrual bleeding. Pulmonary arterial hypertension may result in acquired VWD due to the destruction of high molecular weight von Willebrand multimers. We report a case of menorrhagia due to acquired VWD in a patient with idiopathic pulmonary hypertension. Case An adolescent female with known idiopathic pulmonary hypertension developed acquired VWD. Her primary disease necessitates the use of platelet inhibitors and intermittent anticoagulation. At menarche she also developed menorrhagia due to acquired VWD. She is currently controlled with stimate and progesterone-only therapy. VWD in a patient with idiopathic pulmonary hypertension causing menorrhagia. Although VWD and menorrhagia are commonly linked, the treatment and disease process in a patient with idiopathic pulmonary arterial hypertension is incredibly complex.

Pubertal development begins in utero with the formation of the fetal ovary, foundation of the hypothalamic-pituitary-ovarian axis, and production of sex hormones. Development of the fetal ovary and hormone production is incredibly complex. It has been studied extensively but the exact embryologic origin of the ovary remains uncertain. The gonadotropin and subsequent ovarian hormone production has been well documented, but the exact mechanism of the cycle is unknown. There are several physical findings that occur as a result of early hormonal exposure. Most of these findings are benign and self-limited, but it is important to be familiar with situations that are outside the realm of normal. There are circumstances where the hormonal milieu at birth is associated with developing medical complications later and these situations should be recognized.

Background Pelvic osteomyelitis is a rare but serious condition that has the potential for systemic and muscular complications if left untreated. The diagnosis is difficult due to the relative rarity of the disease, the difficulty of localizing the site of the infection, and the tendency for the presentation to mimic other disease processes. Case A 13-year-old female who presented with complaint of severe right lower abdominal pain thought to be related to a hemorrhagic cyst but was found to have pubic osteomyelitis resulting in an abscess and vaginal fistula. Conclusion Although rare, pelvic osteomyelitis should be included in the differential diagnosis of pelvic pain.

Heavy menstrual bleeding (HMB) is an extremely common problem among adolescents. This article reviews the differential diagnosis and clinical presentation. Additionally, we aim to present the most up-to-date guidelines for evaluation and treatment.Bleeding disorders are now recognized as a common cause for menorrhagia. The recommended laboratory evaluation has evolved in the last few years. Most forms of hormonal contraception, including the levonorgestrel intra-uterine device, are effective and have been studied in adolescents.HMB is prevalent in the adolescent population and is associated with serious complications. Laboratory analysis to rule out bleeding disorders should be considered. Medical management, the cornerstone of treatment, has been proven to be safe and effective in this population.

To report our intrapartum experience with routine delivery at 38 weeks of gestation of A-2 diabetic pregnancies requiring primarily oral hypoglycemic therapy.This retrospective study consisted of 143 consecutive women with gestational diabetes not controlled with diet alone (A-2). Each underwent a routine trial of labor at 38 weeks of gestation. The preinduction condition of the cervix, need for oxytocin, and primary cesarean rates were primary endpoints. For comparison, a control group during that same period consisted of 137 consecutive diet-controlled diabetic (A-1) pregnancies with the same eligibility criteria who underwent expectant management at 38 weeks.The study group was more likely to have an unfavorable cervix (75% versus 45%; p0.001) and to require oxytocin (76% versus 56%; p0.001). Early onset meconium was less common in the study group (3.5% versus 13.1%; p0.01). Primary cesarean rates were low and not different between the study and control groups (12.7% versus 11.7%; p0.8). The only stillbirth was in the control group and was associated with a tight double nuchal cord encirclement. Mean birth weights and the frequency of birth weights4000 g were not different between groups. Shoulder dystocia, low Apgar scores, and admissions to the special care nursery were infrequent in either group. No respiratory difficulties requiring resuscitation or prolonged nursery care were encountered.Routine delivery at 38 weeks in an A-2 diabetic population is not associated with additional intrapartum morbidity or a greater need for cesarean delivery.

Nancy Sokkary MD , Roshi Mansouri MD, Jennie Yoost MD , Mariel Focseneanu MD, Tania Dumont MD , Meera Nathwani BHSc , Lisa Allen MD, FRCSC , S. Paige Hertweck MD , Jennifer E Dietrich MD, MSc 1,2 1 Baylor College of Medicine, Houston, TX 2 Texas Children's Hospital, Houston, TX 3 University of Louisville, Louisville, KY 4 Washington University School of Medicine, St. Louis, MO 5 The Hospital for Sick Children, Toronto, Ontario

day. To our knowledge, we report the first confirmed case of pediatric synchronous bilateral ovarian torsion in bilaterally normal ovaries and offer a review of the literature. Case: A previously healthy twelve year old female was seen in clinic with a two year history of recurrent right lower quadrant pain with no associated symptoms. Initial ultrasound showed normal ovaries. Repeat imaging ten months later revealed bilateral bulky ovaries: right ovary 43x32x38mm (20cc) and left ovary 56x35x55mm (52.3 cc). Peripheral follicles in keeping with polycystic ovaries were noted. The patient was not yet menarchal. Workup for celiac disease was negative. Shortly following this ultrasound, she presented to the emergency department with a thirty hour history of periumbilical pain associated with nausea and vomiting. On exam, the pain was localized to the left lower quadrant with rebound tenderness. There was absence of leukocytosis. Ultrasound showed a significantly enlarged left ovary (61x45x49mm; 70cc) with diminished flow on Doppler assessment. She underwent laparoscopy with a presumed diagnosis of left ovarian torsion. However, on entering the abdomen, bilateral ovarian torsion of 720o was detected (Figures 1 and 2). Both ovaries were enlarged, left greater than right, without obvious focal lesions. Uteroovarian ligaments were noted to be abnormally long. The ovaries were detorted and pexed to their respective uterosacral ligaments using an intracorporeal technique with nonabsorbable suture.