Journal of pediatric and adolescent gynecology最新文献

Objective: To improve counseling and outcomes for the adolescent population (ages 10-24-years-old), with polycystic ovary syndrome we conducted a systematic review of randomized controlled trials with the primary objective to generate evidence-based recommendations for which lifestyle interventions with or without medications lead to the best outcomes.

Methods: A literature search was conducted. Randomized controlled trials on lifestyle interventions with or without medications in the adolescent population were included. Non-randomized trials, case-control studies, observational studies, and animal studies were excluded. Of 3,699 articles, 13 studies including 789 participants were included. Each included study was assessed for bias using the Cochrane Risk of Bias 2 tool. Due to significant inter-study heterogeneity, meta-analysis was infeasible; we synthesized results across lifestyle intervention/control types and outcome.

Results: Thirteen studies met inclusion criteria. These studies offer mixed support for lifestyle interventions improving hyperandrogenism. There is some evidence that lifestyle interventions improve menstrual regularity, cardiometabolic health, and metabolic function. Almost all studies found reduced body mass index, adiposity among participants who completed combined exercise and diet, exercise only, and diet only interventions.

Conclusions: The studies in this systematic review demonstrated that lifestyle interventions incorporating increased physical activity and/or healthy dietary choices show beneficial effects in the adolescent population aged ≥18-years-old with polycystic ovary syndrome. Medications may also play a key role in treating the disorder. More quality research is needed to identify specific lifestyle interventions that optimize the management of polycystic ovary syndrome amongst those aged 10-17-years-old as well.

Study objective: To explore reasons for menstrual suppression method choice among transgender and gender diverse (TGD) youth at time of method initiation.

Design, setting, and participants: A cross-sectional analyses of baseline data from a prospective cohort study of menstruating TGD youth (N=55), age 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 which included identifying the most important reason, as well as other important reasons in menstrual suppression method selection.

Results: 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 three most reported reasons important in 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.

Study objective: To evaluate the prevalence of germ cell tumors and the clinical monitoring practices for those who deferred prophylactic gonadectomy in a large North American cohort of individuals with Turner syndrome with Y-chromosome mosaicism (TS+Y).

Method: A query of the medical records at multiple North American children's hospitals was done using ICD codes related to Turner Syndrome. A retrospective chart review was conducted on those patients between ages 0 to 30 years with Y-mosaicism.

Results: The data of 57 participants were analyzed. Eight (25.8%, n=31) ≥ 13 years underwent spontaneous thelarche. One (3.2 %) had spontaneous menarche. Forty-seven (82.5%) had gonadectomy at a median age of 8 years (IQR 11.0, range <1 to 19 years). Sixteen (34%) had growth hormone therapy exposure prior to gonadectomy. Fourteen (29.8%) had gonadoblastoma. Two (4.3%) had dysgerminoma. Differences in age at gonadectomy, presence of the entire Y-chromosome, and exposure to growth hormone when comparing those with vs. without gonadal tumor were not statistically significant. Gonadectomy had not been performed in 10 individuals, median age 6.5 (IQR 9.0, range <1 to 14 years). There was no consistency in the plan for ultrasound and/or tumor markers for follow-up.

Conclusions: Our data shows a prevalence of 24.6% of gonadal tumors in individuals with TS +Y and a relatively low risk of malignant transformation (3.5%). Prior exposure to growth hormone was not predictive of the presence of gonadal tumor. Future cytogenetic studies are needed to better understand the factors involved in the development of gonadal tumors.

Study objective: Evaluate practice patterns in ovarian tissue cryopreservation (OTC) provision.

Methods: United States providers practicing or developing OTC at pediatric programs were invited to participate in a survey disseminated via the Oncofertility Consortium.

Results: Twenty-seven programs representing a wide geographic area responded, largely representing academic institutions (85.2%). Of these, 21 (77.4%) performed OTC at their facility, the majority for oncology patients receiving gonadotoxic therapy, relapsed patients and non-oncologic patients receiving gonadotoxic therapy (95.7, 87.0, 82.6% respectively). OTC procedures were most commonly performed by pediatric gynecology surgeons (71.4%) via laparoscopic oophorectomy (90.5%) using a heat-based method (55.0%) for dissection. Most centers used an outside compensated service (50%) or a reproductive endocrinology group (45%) for processing tissue. Many (13, 61.9%) performed OTC as standard of care and 7 utilized an IRB for data collection. Of the 8 centers whose OTC programs are in the planning or early stages, frequently identified barriers were lack of priority within their medical team or institution (5/8), lack of protected time (3/8), and lack of funding (3/8).

Conclusions: OTC is commonly offered to oncology patients receiving highly gonadotoxic therapy with pediatric gynecologists frequently involved in counseling and performing OTC. Variability exists in offering OTC to other patient populations, as well as in research practices, surgical technique and processing. Institutions continue to face barriers in offering OTC when necessary resources are not prioritized by leadership.

Introduction: The co-occurrence of a unicornuate uterus with a non-communicating, functioning rudimentary horn (UUNCFRH) and VACTERL association represents an extremely rare condition, with only three similar cases reported in the literature.

Case: The patient, aged 12 years and 9 months, presented with pelvic pain and severe dysmenorrhea, which started shortly after her menarche at 12 years and 4 months. At birth she exhibited three characteristic components of VACTERL association: bronchoesophageal fistula/esophageal atresia, anal atresia, and polydactyly. An MRI revealed UUNCFRH, and subsequently, VACTERL association was diagnosed. The rudimentary horn was laparoscopically excised eight months post-menarche, resulting in symptom resolution.

Conclusions: Healthcare providers should consider the possibility of genital anomalies when diagnosing VACTERL association, especially in cases presenting with severe early dysmenorrhea.

Study objective: To determine the natural history of menstrual pain without pelvic pathology, the role of progesterone in its pathophysiology, and associated risk factors in a longitudinal study of early post-menarchal girls in North Carolina.

Methods: Participants contributed daily urine samples for up to 3.5 years to measure pregnanediol-3-glucuronide [PdG] (mean 589 urines/participant), completed menstrual diaries, and reported menstrual pain using the Menstrual Symptom Questionnaire (MSQ) biannually. MSQ scores were log-transformed and generalized estimating equations assessed associations with gynecologic age, cycle peak PdG, presumed ovulation, physical activity, anxiety, and depression. Models were adjusted for age at menarche, baseline body mass index, race/ethnicity, parental education and employment, and gynecologic age.

Results: Forty-three girls, aged 12.6 ± 1.1 years (mean ± SD) at enrollment with a gynecologic age 0.3 ± 0.2 years, participated. Total MSQ scores were higher for every 1-year increase in gynecologic age (MSQ score ratio: 1.12; 95% CI: 1.08, 1.17; p<0.0001). Overall MSQ (ratio: 1.04; 95% CI: 1.02, 1.06; p=0.0002) and abdominal pain-specific (ratio: 1.04; 95% CI: 1.01, 10.7; p=0.004) scores were higher for every 1000 ng/mg creatinine increase in peak PdG in the preceding cycle. Overall MSQ scores were higher (ratio 1.26; 95% CI: 1.11, 1.44; p=0.0005) if the preceding cycle was presumed ovulatory. Menstrual pain was not associated with physical activity, anxiety, or depression.

Conclusions: In early post-menarchal girls, gynecologic age and PdG were associated with menstrual pain, suggesting a pathophysiologic role for progesterone and other unknown factors in the development of menstrual pain.

Study objective: Bisexual adolescents have higher rates of unintended pregnancy than their heterosexual peers and increased rates of high-risk sexual behaviors. They may be less likely to use effective contraception, though limited data is available. This study sought to compare contraceptive choice and sexual risk behaviors of both-sex attracted and opposite-sex attracted adolescents and young adults (AYA) presenting to a contraception clinic.

Methods: A retrospective chart review of AYA aged 14-24 years who presented for an initial visit to a contraception clinic from 2014 to 2020. The primary outcome was contraceptive choice (long-acting reversible contraception (LARC), non-LARC, or nothing). Secondary outcomes included sexual behaviors. Results were analyzed using Pearson's chi-square and Wilcoxon tests.

Results: 2369 AYA were included in this study. Both-sex attracted and opposite-sex attracted patients were similar in age, race, and ethnicity. There was no difference between groups in percent selecting LARC (71% vs 66.1%, p=0.11). Both-sex attracted patients reported a younger age at first sex (14.6 years vs 15.5 years, p < .001), more lifetime sexual partners (4.1 vs 2.8, p < .001), and a higher prevalence of forced intercourse (21.9% vs 8.8%, p < .001).

Conclusions: Both-sex attracted and opposite-sex attracted AYA patients chose LARCs at similar rates in a setting with standardized contraceptive counseling. Both-sex attracted patients had more sexual risk behaviors. Healthcare providers should be inclusive in their approach to obtaining sexual health histories and providing contraceptive counseling and be cognizant that adolescents with both-sex attraction may be at higher risk of forced intercourse.

Objective: The objective of this study is to understand whether clinicians who provide contraceptive counseling to adolescent patients perceive that the Dobbs decision has influenced their counseling.

Study design: We conducted in-depth interviews with a convenience sample of 16 clinicians who provide contraceptive counseling to adolescents at the American Academy of Pediatrics annual conference in October 2022. We used thematic content analysis and an iterative process of constant comparison to identify themes inductively. This analysis focused on participants' perception of if and how the Dobbs decision has or will influence their contraceptive counseling with adolescents.

Results: Most clinicians in our study reported that the Dobbs decision influenced their contraceptive counseling. This included promoting long-acting, reversible methods more so than pre-Dobbs, and explicitly considering changing state-level abortion laws and restrictions. Many clinicians openly noted that their personal preferences influence their counseling, such as prioritizing pregnancy prevention and encouraging patients to use particular methods.

Conclusion: We found that most clinicians in our sample acknowledged that the Dobbs decision has influenced their contraceptive counseling practices with adolescents. Clinicians' responses demonstrate that, in many instances, the Dobbs decision motivated them to focus on method effectiveness, leading to tiered and directive contraceptive counseling. We recommend practice changes to support comprehensive contraceptive care provision, provider trainings in unbiased counseling, and developmentally tailored decision aids are needed to ensure that adolescent patients' autonomy is prioritized over a singular focus on pregnancy prevention.