Adolescent Gynecology Research Articles

The Use of Telemedicine in Pediatric and Adolescent Gynecology.

To study the feasibility of virtual visits for ambulatory encounters in pediatric and adolescent gynecology DESIGN: A retrospective review SETTING: Boston Children's Hospital PARTICIPANTS: Patients who were seen virtually through the Division of Gynecology between January 1, 2020 and June 1, 2020 MAIN OUTCOME MEASURE(S): Patient demographics, visit diagnoses, and operational characteristics of the completed visits RESULTS: There were a total of 654 virtual visits for 614 patients. Ninety-one percent (n=558) of patients were in-state, and the median age of patients was 17 years (range 0 - 37 years). The majority were return visits (n=502, 76.8%), 115 (17.6%) were new patient visits, and 32 (4.89%) were post-operative visits. The median virtual visit duration was 12 minutes and 39 seconds (range 5 minutes to over 1 hour). The most common gynecologic diagnoses were dysmenorrhea/endometriosis (n=485, 74.2%), abnormal uterine bleeding (n=225, 34.4%), and pelvic pain (n=82, 12.5%). The percentage of virtual visits which required an in-person follow-up visit within 90 days was low (n=14, 2.1%). Five of these were within 30 days from the initial virtual visit, 6 were within 60 days, and 3 were within 90 days. Telemedicine is a feasible method for expanding access to, and healthcare delivery for, pediatric and adolescent gynecology, with low rates of short interval in-person follow-up required. Virtual visits can be conducted for a range of patients with a variety of gynecologic conditions, upon initial presentation and follow-up.

Use of Concurrent Hormonal Agents to Treat Abnormal Uterine Bleeding in the Pediatric Population: A Retrospective Analysis

Background: Abnormal uterine bleeding (AUB) is a common medical problem in adolescents with significant impact on wellbeing. For patients with bothersome bleeding despite single-agent medical therapy, use of concurrent hormonal agents is a recognized approach but is not well studied. The aim of this study is to describe the population treated with concurrent hormonal therapies in a pediatric and adolescent gynecology (PAG) clinic, the various combination of agents used, and their effect on bleeding patterns.

NASPAG Clinical Opinion: Diagnosis and Management of Lichen Sclerosis in Pediatric and Adolescent Patients

This Clinical Opinion replaces the NASPAG Clinical Recommendation: Pediatric Lichen Sclerosus published in 2014. The objective of this document is to provide guidance in the diagnosis and management of vulvar lichen sclerosus (LS) in the pediatric and adolescent patient in order to treat patient symptoms and reduce long-term sequelae. LS is a chronic inflammatory condition affecting the anogenital region that may present in the prepubertal or adolescent patient. Clinical presentations include significant pruritus, loss of pigmentation and vulvar adhesions with loss of normal vulvar architecture. Management includes topical agents for induction and maintenance therapy, as well as long-term follow-up for identification and treatment of recurrence and sequelae. This document is intended for use by both primary and specialty pediatric and adolescent gynecology (PAG) providers, including specialists in pediatrics, gynecology, adolescent medicine, and dermatology.

Nitrous Oxide Use for Intrauterine System Placement in Adolescents.

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. 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=-29.32mm, 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. 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.

Use of the Levonorgestrel Intrauterine System to Treat Heavy Menstrual Bleeding in Adolescents and Young Adults with Inherited Bleeding Disorders and Ehlers-Danlos Syndrome.

To report on the rate of amenorrhea among adolescents and young adults with a bleeding diathesis after insertion of the 52-mg levonorgestrel intrauterine system (LNG-IUS) DESIGN: Retrospective chart review SETTING: Tertiary care, multidisciplinary Gynecology-Hematology clinic or Adolescent Gynecology clinic PARTICIPANTS: The cohort included 35 females aged 12-25 years presenting from January 2010 to January 2020 with heavy menstrual bleeding, 23 with an inherited blood disorder, and 12 with Ehlers-Danlos syndrome INTERVENTIONS: The 52-mg LNG-IUS MAIN OUTCOME MEASURES: Primary outcome was bleeding profile after LNG-IUS insertion. Secondary outcomes included rates of amenorrhea, intrauterine device (IUD) expulsion, IUD discontinuation, and unplanned pregnancy. Mean age at menarche was 11.6 years, with mean age at insertion of 16.9 (range 11-23). Most participants were white (n=26, 74.3%). Von Willebrand disease was present in 16 patients (45.7%) and Ehlers-Danlos syndrome in 12 (34.3%). Most (91.4%) had tried at least 1 hormonal regimen prior to LNG-IUS. Most participants (81.8%) reported improvement in bleeding, with 60.6% reporting spotting or amenorrhea. LNG-IUS expulsion occurred in 3 participants (9.1%) within the first 21 days, despite hemostatic agents at time of insertion. Mean continuation was 5.08 years (95% CI, 4.24-5.92), with 79% likelihood that participants kept their IUD in place for at least 2.5 years, and some up to 6 years. The 52-mg LNG-IUS is an effective treatment option for adolescents and young adults with heavy menstrual bleeding and a bleeding diathesis, with high rates of amenorrhea. Rates of IUD expulsion appeared higher during the first 30 days, but long-term continuation remained high.

Caregiver Knowledge of and Attitudes Toward the Levonorgestrel-Containing Intrauterine Device for the Treatment of Heavy Menstrual Bleeding in Adolescents and Young Adults.

We evaluated caretaker knowledge of and attitudes toward the levonorgestrel-containing intrauterine device (L-IUD) as a treatment option for adolescents and young adults with heavy menstrual bleeding. A survey assessed demographic characteristics, menstrual history, perception of the L-IUD, and knowledge of the indications, risks, and benefits of the L-IUD. Participant recruitment occurred in the offices of a pediatric gynecologist, pediatric hematologist, and adolescent medicine physician in a hospital-based practice in New York. English-speaking caretakers of patients with a chief concern of heavy menstrual bleeding (<21 years old) were invited to participate. Electronic and paper surveys were administered prior to seeing the physician. The primary outcome was participant willingness to allow their daughter to use the L-IUD for heavy menstrual bleeding. Additional outcomes were explored by calculating a mean knowledge score and conducting a descriptive analysis of the perception questions. Forty surveys were included. Seventy percent of participants said they would allow their daughter to use birth control pills for heavy menstrual bleeding, whereas only 10% said the same of the L-IUD. The mean knowledge score was 73.3% (±15.7). Sixty-five percent of participants expressed the need for additional information on the L-IUD. Caretaker acceptance of the L-IUD as treatment for their daughter with heavy menstrual bleeding is limited. Although baseline knowledge was high, many indicated needing additional information. Because heavy menstrual bleeding can negatively impact quality of life, potential caretaker bias must be addressed to ensure full access to this highly effective treatment option.

Equity in visual representation of vulvar conditions in major gynecology textbooks

ObjectivesTo evaluate images of vulvar conditions (VCs) in major gynecologic textbooks and describe the skin tone representation. MethodsImages of VCs in gynecological textbooks for medical students, obstetrics and gynecology (OBG) residents, and fellows were compiled. Texts were categorized into education levels (medical student, resident, or fellow) and selected based on the recommendations of OBG attendings and fellows at LSUHSCNew Orleans. Skin tones were scored according to the Fitzpatrick Scale (FS) and categorized as benign, infectious, inflammatory, and dysplasia/cancerous. Publishing and primary author demographics were collected. Proportional odds regression (POR) predicted FS based on image pathologies and book titles. ResultsOf 512 images selected from 21 textbooks, 77.0% [N = 395] were lighter skin tones (FS I-III). VCs were represented by the darkest skin tone (FS of VI) in 19.6% of images in texts targeting residents, compared to 8.5% and 4.5% in fellow and student textbooks, respectively (p <0.001). Compared to a cornerstone surgical atlas, the pediatric and adolescent gynecology text consisted of lighter skin tones. A prominent general gynecology text used darker skin tones. Images of infectious conditions were more likely to be darker skin tones than other VCs (p = 0.010). ConclusionsMost textbook images of VCs represent lighter skin tones, and women with darker skin are more underrepresented in texts geared at fellows and students. Inadequate exposure to the appearance of VCs on darker skin promotes and propagates racial inequities in healthcare. Medical textbooks should present visually diverse images of vulvar pathologies to train physicians to be well versed in caring for patients of all skin tones.

Exposure of 3rd and 4th Medical Students to Pediatric and Adolescent Gynecology - A pilot study

Background: Most United States (US) medical schools allocate 6 weeks of the academic year for clerkships in Obstetrics and Gynecology. This time limitation may prevent students from gaining exposure to many subspecialties in OB/GYN, including Pediatric and Adolescent Gynecology (PAG), which may account for fewer physicians being formally trained in this area. The purpose of this study was to quantify and characterize the level of medical student exposure to PAG.

Telehealth Care in a Pediatric and Adolescent Gynecology Clinic During the COVID Pandemic

Background: Telehealth (TH) has been implemented successfully in a variety of medical specialties, including pediatric and adolescent care. While there has been an increased reliance on TH due to the COVID-19 pandemic, there remain barriers to implementing Pediatric and Adolescent Gynecology (PAG) TH. The goal of this study was to assess TH use, ease of access, and patient satisfaction in the PAG ambulatory care setting to improve TH delivery in the future.

Pediatric and Adolescent Gynecology Population's Satisfaction with Telemedicine Consultation on Contraception During the Covid-2019 Pandemic

Background: The use of telemedicine consultation is becoming a promising alternative to face-to-face practices for all healthcare providers especially since the Coronavirus 2019 pandemic. Overall high-level of patient satisfaction with telemedicine has been highlighted in literature, but to our knowledge no specific research has been conducted on a Pediatric and Adolescent Gynecology (PAG) population especially for contraception purposes.

Post COVID-19 Vaccination Vulvar Aphthous Ulcers: An Unpopular Case Series

Background: Vulvar aphthous ulcers have been described since the early 1900s. These non-sexually acquired genital ulcers typically appear in the perimenarchal population as 1-3 painful ulcers that spontaneously resolve within 21 days. Etiology is not completely understood but there is believed to be a large immunologic component given a high association with a recent viral infection. With the COVID-19 pandemic, our institution saw COVID associated aphthous ulcers. After increased use of the Pfizer vaccine in those 12 years old and over, our institution also saw a series of post vaccination aphthous ulcers. Case: At our tertiary care children's hospital the division of pediatric and adolescent gynecology saw three patients from 6/2021 through 9/2021 presenting with vulvar aphthous ulcers all of whom were recently given their second COVID-19 Pfizer vaccination. Patients ranged from age 12 to 15 years old and were both pre- and post-menarchal. None of the patients to their knowledge had a history of COVID or a recent COVID exposure. In addition, there were no recent symptomatic viral illnesses. Of those who agreed to cytomegalovirus (CMV) and Epstein-Barr Virus (EBV) testing, all were negative. These patients had all received their first dose of the Pfizer vaccine without complications and were all 2 days post second vaccine when they first noticed pain. On average, they presented to the emergency room within 24-48 hours of presentation of symptoms and had gynecologic follow-up within 48 hours. Physical exam was consistent with a diagnosis of vulvar aphthous ulcers with no exceptional characteristics. There were multiple ulcerations with fibrinous exudate and some with necrotic islands. All resolved spontaneously by 3 weeks and no further follow-up was needed. There were no diagnoses of COVID-19 infection after the diagnosis of the aphthous ulcer. Comments: The COVID vaccine is safe and efficacious for protection against COVID-19. National organizations such as American College of Obstetricians and Gynecologists (ACOG), Society for Maternal-Fetal Medicine (SMFM), American Academy of Pediatrics (AAP), and North American Society for Pediatric and Adolescent Gynecology (NASPAG) have endorsed vaccination in their respective audience. Specifically, AAP and NASPAG have encouraged eligible patients 12 through 16 to receive the Pfizer COVID-19 vaccination. Although this is a series of adverse outcomes post COVID-10 vaccination, it does shed light on the multifaceted immune response one gains from a COVID-19 mRNA based vaccine. In addition, this series further supports the long-held belief that vulvar aphthous ulcers are an immunologic response rather than a sign of a genital infection themselves. https://www.abstractscorecard.com/uploads/Tasks/upload/15942/ZDJDEDZO-1134853-1-ANY.docx https://www.abstractscorecard.com/uploads/Tasks/upload/15942/ZDJDEDZO-1134853-2-ANY.pdf

Incidence of Dermabond hypersensitivity post laparoscopy in a PAG population prior to and after onset of the SARS-CoV-2 Pandemic

Background: Since the onset of the SARS-CoV-2 pandemic, there have been many studies evaluating hypersensitivity reactions, however, these have been limited to individuals with active COVID-19 infection or in relation to COVID-19 vaccination. The prevalence of hypersensitivity reactions in the general population relative to the start of the pandemic are lacking. We sought to determine if there was a difference in the rate of contact dermatitis (CD) secondary to Dermabond® use before and after the onset of the SARS-CoV-2 pandemic in Pediatric and adolescent Gynecology (PAG) laparoscopic (LSC) cases.

Adnexal Torsion Salvage Rates During the COVID-19 Pandemic in a Pediatric and Adolescent Gynecology Population

Background: Early diagnosis and surgical intervention for adnexal torsion (AT) increases the likelihood of ovarian salvage. The COVID-19 pandemic has introduced barriers that may delay time from symptom onset to intervention due to delayed presentation and requirement for COVID-19 testing preoperatively. The objective of this study was to determine any differences in ovarian salvage rates during the COVID-19 pandemic in a pediatric & adolescent gynecology (PAG) population compared to prior to the pandemic.

Patient Satisfaction with Pediatric and Adolescent Gynecology Telemedicine Visits

Background: The novel coronavirus pandemic required quick adoption of telemedicine in all specialties. Institutions used telemedicine visits for non-urgent patient care to limit in-person interaction, maintain social distancing, and not overburden health systems. Little is known about patients’ attitudes towards telemedicine for pediatric and adolescent gynecology concerns. Telehealth privacy can be critical for gynecological issues. Validated surveys for patient satisfaction with telemedicine have never been used for this patient population.

Is Telehealth Equivalent to In-person Visits for Menstrual and Vulvovaginal Issues in Pediatric and Adolescent Gynecology?

Background: The COVID-19 state of emergency brought a rapid transition to virtual medicine, or “telehealth.” Medical organizations released support statements of telehealth for specific clinical encounters, such as contraceptive counseling for adolescents. However, there is no data on telehealth visits for the common diagnoses of heavy menstrual bleeding, menstrual irregularity, or vulvovaginitis. We propose that telehealth for irregular or heavy menstrual bleeding and vulvovaginal complaints is equally effective to in-person office visits and may be routinely offered.

Pediatric Adolescent Gynecologic and Obstetric Presentations in Hospital Emergency Departments

Background: Little is known about disparities in diagnoses and dispositions of pediatric patients that present to emergency departments (ED), especially in hospitals that likely do not have access to pediatric adolescent gynecology (PAG) specialists. We sought to assess how pediatric and adolescent gynecologic and obstetric diagnoses and dispositions differ by metropolitan and teaching hospital status.

The utility of Endosee as a vaginoscope in the prepubertal child

Summary: Pediatric surgical specialties often utilize instruments in novel ways to accommodate both patient anatomy and participation when in an in-office setting. Specifically in the field of pediatric and adolescent gynecology, speculums are rarely appropriate or tolerated, however a vaginal exam may be warranted. Vaginoscopy, often under anesthesia, has thus been employed for evaluation of the vaginal cavity, mucosa, and cervix. Here we present a video offering instruction and guidance of how the Endosee® device has been modified in our practice to use as a vaginoscope in a pediatric population, helping our patients avoid a speculum exam or even sedation.

To keep in scope: vulvar aphthous ulcers after COVID-19 vaccination

Background: Vulvar ulcers are a rare finding in females who are not sexually active. Aphthous ulcers may arise from an excessive immune response to an infectious agent or physiologic stress in a predisposed patient. They are associated with severe local pain, discomfort, and in some cases systemic symptoms. The diagnostic and treatment approach for this entity may inflict significant distress and anxiety on both the patient and her family. We aim to add to the existing literature by describing two cases of acute vulvar ulcers arising in non-sexually active adolescents after completing Pfizer-BioNTech COVID-19 vaccination schedule (2 doses). Case: Two 16-year old Hispanic high school students arrived for evaluation at a Pediatric and Adolescent Gynecology focused practice in Mexico. Both denied sexual activity and had unremarkable personal and family medical histories. At the time of the encounter, their vital signs were in normal ranges. Patients' clinical characteristics are depicted in table 1. Both patients received supportive treatment with a cream containing zinc oxide as barrier protection, xylocaine 2% ointment for pain management (PRN), and were educated in general vulvar hygiene recommendations. Patient A endorsed significant symptom improvement after 3 days and had no evidence of lesions after 10 days. Patient B endorsed significant symptom improvement 1 day after the visit and had no evidence of lesions after 10 days. Comments: These cases illustrate the plausible association between COVID-19 vaccination and vulvar aphthous ulcers. We must include this diagnosis among our differentials when facing such cases. https://www.abstractscorecard.com/uploads/Tasks/upload/15942/ZDJDEDZO-1123181-1-ANY(1).docx

Novel Approach to Improving Confidence in Providing Sexual and Reproductive Healthcare to Adolescents for Pediatric Residents: A Pilot Study

Background: A recent study showed that about only 1/5 of recent graduates feel well trained to care for adolescent patients. There is an insufficient amount of data assessing the confidence of pediatric residents in providing sexual and reproductive healthcare (SRH) services to adolescents. We aimed to assess pediatric residents’ confidence in providing SRH education and services to adolescent patients before and after participating in clinic sessions in a Pediatric Adolescent Gynecology (PAG) Clinic.

Experience at a Multidisciplinary Pediatric Vulvar Dermatology Clinic

Background: Vulvar dermatology is a field in which pediatricians, gynecologists, adolescent medicine specialists, and dermatologists may lack sufficient comfort and training. Delays in diagnosis can prolong patient discomfort and result in irreversible anogenital anatomic changes. Relatively few multidisciplinary vulvar dermatology clinics exist in the United States. We present our preliminary experience at a multidisciplinary pediatric gynecology and dermatology clinic for pediatric and adolescent vulvar disorders.