Anjali Aggarwal

Ovarian epithelial tumors of low malignant potential: a case series of 5 adolescent patients

Epithelial ovarian neoplasms are uncommon in pediatric and adolescent patients, accounting for approximately 20% to 30% of ovarian tumors in adolescent females and women younger than 25. Tumors of low malignant potential (LMP) account for a significant proportion of epithelial neoplasms in this patient population. This case series describes 5 adolescent patients, with a mean age of 14.4 +/- 2.4 years, diagnosed with ovarian tumors of LMP at one institution. Between November 2001 and January 2006, 5 patients were diagnosed with ovarian tumors of LMP of 126 patients who had surgery for adnexal masses. All patients underwent initial surgery via laparotomy. Two patients underwent ovarian cystectomy, and 3 had at least a unilateral salpingo-oophorectomy. One patient had stage IIIc disease, whereas the other 4 patients, not all completely staged, had presumed stage I disease. Three patients developed recurrent ovarian masses on follow-up. Two had recurrent LMP tumors (one bilateral) and one was a benign mucinous cystadenoma. This case series of 5 adolescent patients with ovarian tumors of LMP highlights the importance of considering epithelial neoplasms in any pediatric or adolescent patient with a pelvic mass and supports conservative management, with staging and fertility-sparing surgery; however, appropriate follow-up is essential, as evidenced by 3 of 5 patients exhibiting recurrent ovarian masses.

Recalcitrant Trichomonas Vaginalis Infections Successfully Treated With Vaginal Acidification

BACKGROUND Recalcitrant vaginal trichomoniasis is extremely distressing for patients and frustrating for physicians because there are no current guidelines for treatment. Numerous studies have shown that an increase in vaginal pH creates a better environment for the growth of Trichomonas vaginalis. We describe two patients with recalcitrant trichomoniasis who were successfully treated using vaginal acidification. CASES The first patient with trichomoniasis had a severe reaction to metronidazole, but the infection subsequently resolved after treatment with a combination of boric acid and clotrimazole. The second patient with resistant trichomoniasis had been treated unsuccessfully with multiple courses of metronidazole but was treated successfully with vaginal acidification using boric acid. CONCLUSION A process of vaginal acidification resulted in resolution of recalcitrant Trichomonas vaginalis in two patients.

Missed Hormonal Contraceptives: New Recommendations

OBJECTIVE To provide evidence-based guidance for women and their health care providers on the management of missed or delayed hormonal contraceptive doses in order to prevent unintended pregnancy. EVIDENCE Medline, PubMed, and the Cochrane Database were searched for articles published in English, from 1974 to 2007, about hormonal contraceptive methods that are available in Canada and that may be missed or delayed. Relevant publications and position papers from appropriate reproductive health and family planning organizations were also reviewed. The quality of evidence is rated using the criteria developed by the Canadian Task Force on Preventive Health Care. BENEFITS, HARMS, AND COSTS This committee opinion will help health care providers offer clear information to women who have not been adherent in using hormonal contraception with the purpose of preventing unintended pregnancy. SPONSORS The Society of Obstetricians and Gynaecologists of Canada. SUMMARY STATEMENTS: 1. Instructions for what women should do when they miss hormonal contraception have been complex and women do not understand them correctly. (I) 2. The highest risk of ovulation occurs when the hormone-free interval is prolonged for more than seven days, either by delaying the start of combined hormonal contraceptives or by missing active hormone doses during the first or third weeks of combined oral contraceptives. (II) Ovulation rarely occurs after seven consecutive days of combined oral contraceptive use. (II) RECOMMENDATIONS: 1. Health care providers should give clear, simple instructions, both written and oral, on missed hormonal contraceptive pills as part of contraceptive counselling. (III-A) 2. Health care providers should provide women with telephone/electronic resources for reference in the event of missed or delayed hormonal contraceptives. (III-A) 3. In order to avoid an increased risk of unintended pregnancy, the hormone-free interval should not exceed seven days in combined hormonal contraceptive users. (II-A) 4. Back-up contraception should be used after one missed dose in the first week of hormones until seven consecutive days of correct hormone use are established. In the case of missed combined hormonal contraceptives in the second or third week of hormones, the hormone-free interval should be eliminated for that cycle. (III-A) 5. Emergency contraception and back-up contraception may be required in some instances of missed hormonal contraceptives, in particular when the hormone-free interval has been extended for more than seven days. (III-A) 6. Back-up contraception should be used when three or more consecutive doses/days of combined hormonal contraceptives are missed in the second and third week until seven consecutive days of correct hormone use are established. For practical reasons, the scheduled hormone-free interval should be eliminated in these cases. (II-A) 7. Emergency contraception is rarely indicated for missed combined hormonal contraceptives in the second or third week of the cycle unless there are repeated omissions or failure to institute back-up contraception after the missed doses. In cases of repeated omissions of combined hormonal contraceptives, emergency contraception may be required, and back-up contraception should be used. Health care professionals should counsel women in these situations on alternative methods of contraception that do not demand such stringent compliance. (III-A).

Repeat screening for sexually transmitted infection in adolescent obstetric patients.

OBJECTIVE To determine if repeat screening for sexually transmitted infection is appropriate for adolescent obstetric patients and to identify any risk factors associated with increased risk of contracting a sexually transmitted infection (STI) during pregnancy. METHODS We conducted a retrospective review of the medical records of adolescent obstetric patients seen over a five-year period in the Young Prenatal Program at the Hospital for Sick Children (Toronto, Ontario). RESULTS Between January 2003 and December 2007, 201 patients with 211 pregnancies attended the Young Prenatal Program. Of the 211 pregnancies reviewed, all patients had screening at baseline for HIV, syphilis, hepatitis B, chlamydia, gonorrhea, and trichomonas; 173 patients were screened in the third trimester, two were tested at another point in the pregnancy because of symptoms, and 161 were screened at their postpartum visit. In 53 pregnancies, STI was diagnosed either during pregnancy or postpartum. Fourteen patients had multiple sexually transmitted infections for a total of 71 infections. Thirty-four infections were diagnosed at baseline, 15 in the third trimester, two because of symptoms, and seven were diagnosed postpartum. In patients who did not develop an STI during pregnancy, the previous use of contraception (excluding condoms), being in a relationship with the babys father, and living with their partner were identified as significant protective factors against STI. There was a trend towards significance for contracting an STI in patients with a history of abuse, in those with a higher than average number of sexual partners, and in those with a younger than average age of coitarche. CONCLUSION Sexually transmitted infections were diagnosed in 25.1% of adolescent pregnancies (53/211) in our cohort. Of the 71 sexually transmitted infections diagnosed, 22.5% (16/71) were diagnosed on routine third trimester screening. Because of the high rates of STI and the small number of identified risk factors, routine repeat screening in the third trimester for chlamydia, gonorrhea, and trichomonas is warranted in pregnant adolescents.

Menstrual Suppression in Special Circumstances

OBJECTIVE To provide a Canadian consensus document for health care providers with recommendations for menstrual suppression in patients with physical and/or cognitive challenges or those who are undergoing cancer treatment in whom menstruation may have a deleterious effect on their health. OPTIONS This document reviews the options available for menstrual suppression, its specific indications, contraindications, and side effects, both immediate and long-term, and the investigations and monitoring necessary throughout suppression. OUTCOMES Clinicians will be better informed about the options and indications for menstrual suppression in patients with cognitive and/or physical disabilities and patients undergoing chemotherapy, radiation, or other treatments for cancer. EVIDENCE Published literature was retrieved through searches of Medline, EMBASE, OVID, and the Cochrane Library using appropriate controlled vocabulary and key words (heavy menstrual bleeding, menstrual suppression, chemotherapy/radiation, cognitive disability, physical disability, learning disability). Results were restricted to systematic reviews, randomized controlled trials, observation studies, and pilot studies. There were no language or date restrictions. Searches were updated on a regular basis and new material was incorporated into the guideline until September 2013. Grey (unpublished) literature was identified through searching websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALUES The quality of evidence was rated using the criteria described in the Report of the Canadian Task Force on Preventive Health Care (Table 1). BENEFITS, HARMS, AND COSTS There is a need for specific guidelines on menstrual suppression in at-risk populations for health care providers. Recommendations 1. Menstrual suppression and therapeutic amenorrhea should be considered safe and viable options for women who need or want to have fewer or no menses. (II-2A) 2. Menstrual suppression should not be initiated in young women with developmental disabilities until after the onset of menses. (II-2B) 3. Combined hormonal or progesterone-only products can be used in an extended or continuous manner to obtain menstrual suppression. (I-A) 4. Gynaecologic consultation should be considered prior to the initiation of treatment in all premenopausal women at risk for abnormal uterine bleeding from chemotherapy. (II-1A) 5. Leuprolide acetate or combined hormonal contraception should be considered highly effective in preventing abnormal uterine bleeding when initiated prior to cancer treatment in premenopausal women at risk for thrombocytopenia. (II-2A).

Emergency contraception: no. 280 (replaces No. 131, August 2003).

To review current knowledge about emergency contraception (EC), including available options, their modes of action, efficacy, safety, and the effective provision of EC within a practice setting.

Sexual and Reproductive Health Counselling by Health Care Professionals

This document reflects emerging clinical and scientific advances on the date issued, and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed. Local institutions can dictate amendments to these opinions. They should be well documented if modified at the local level. None of these contents may be reproduced in any form without prior written permission of the SOGC. This policy statement was prepared by the Social and Sexual Issues Committee, reviewed by the Family Physicians Advisory Committee and the Clinical Practice Gynaecology Committee, and approved by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada. SOCIAL AND SEXuAL ISSuES COMMITTEE Margaret Burnett, MD (Chair), Winnipeg MB Anjali Aggarwal, MD, Toronto ON Victoria Davis, MD, Scarborough ON Jeffrey Dempster, MD, Halifax NS William Fisher, PhD, London ON Karen MacKinnon, RN, PhD, Victoria BC Rosana Pellizzari, MD, Peterborough ON Viola Polomeno, RN, PhD, Ottawa ON Maegan Rutherford, MD, Halifax NS Vyta Senikas, MD, Ottawa ON Marie-Soleil Wagner, MD, Montreal QC FAMILY PHYSICIANS ADVISORY COMMITTEE William Ehman, MD (Chair), Nanaimo BC Anne Biringer, MD, Toronto ON Andrée Gagnon, MD, Blainville QC Lisa Graves, MD, Sudbury ON Jonathan Hey, MD, Saskatoon SK Jill Konkin, MD, Edmonton AB Francine Léger, MD, Montreal QC Cindy Marshall, MD, Lower Sackville NS

Use of Audio Computer-Assisted Self-Interviews to Gather Information on Risk Behaviors in a Population of Pregnant Adolescents

&NA; In a prospective study comparing the use of the Audio Computer‐Assisted Self‐Interview (ACASI) with a traditional clinical interview in 40 pregnant adolescents, there was significantly greater disclosure of violence with the ACASI method. Better identification of high‐risk behaviors may help to optimize care and programing for pregnant adolescents.

Torsion tubaire isolée chez une adolescente pubère

Au moment de la laparoscopie, nous avons constate que la trompe de Fallope droite etait torsadee a quatre reprises et qu’un kyste paraovarien droit de 6 cm etait egalement torsade. Les ovaires etaient normaux. La trompe a ete detorsadee et le kyste paraovarien a ete excise. L’appendice normal a ete laisse en place a la suite de la liberation des adherences. La patiente a connu une recuperation sans incidents.

Contraception d’urgence

Résultats : Les études publiées en anglais entre janvier 1998 et mars 2010 ont été récupérées par l’intermédiaire de recherches menées dans Medline et la base de données Cochrane, au moyen de mots clés appropriés («emergency contraception», «post-coital contraception», «emergency contraceptive pills», «post-coital copper IUD»). Les directives cliniques et les déclarations de principe élaborées par des organisations de santé ou de planification familiale ont également été analysées.