Diane F. Merritt

Cervical dysplasia in adolescents.

Background: Although the incidence of cervical dysplasia in adolescents is increasing, a paucity of data exists regarding the outcomes of adolescents with Pap test abnormalities. We determined the natural history and outcome of adolescents with low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL). Methods: A review of all women aged 18 years or younger with a cytologic diagnosis of LSIL or HSIL between 1997 and 2003 was performed. Follow-up cytologic and histologic samples were evaluated. The most significant abnormality was recorded for each patient. Rates of regression, persistence, and progression were calculated. Results: A total of 646 adolescents were identified. Follow-up was available for 477 teenagers with LSIL and for 55 with HSIL. Among adolescents with LSIL, 146 (35%) had negative follow-up. Low-grade abnormalities (atypical squamous cells of undetermined significance, LSIL, and cervical intraepithelial neoplasia grade 1) were seen in 199 (47%), whereas high-grade abnormalities were documented in 77 (18%). After 36 months, 62% had regressed, whereas 31% had progressive dysplasia. For the HSIL cohort, negative follow-up was documented in 12 (21.8%) adolescents, and 15 (27.3%) had low-grade abnormalities, whereas more than one half (50.9%) were found to have a high-grade abnormality. At 36 months, 31% of HSIL subjects had progressed to cervical intraepithelial neoplasia 3. Conclusion: Adolescents with LSIL and HSIL cytology are at significant risk for progression to high-grade cervical abnormalities. The rate of development of high-grade cervical abnormalities in adolescents is similar to adults. Adolescents with cytologic abnormalities mandate close follow-up. Level of Evidence: II-3

Effect of raloxifene on the response to conjugated estrogen vaginal cream or nonhormonal moisturizers in postmenopausal vaginal atrophy

OBJECTIVE To study the effect of raloxifene on the response to conjugated estrogen cream or nonhormonal moisturizer in postmenopausal women with preexisting signs of vaginal atrophy. METHODS Postmenopausal women with preexisting and untreated vaginal atrophy were enrolled in this parallel, placebo-controlled, randomized study. A total of 187 women were randomized to four treatment groups: daily oral raloxifene (60 mg per day) or a placebo in a double-blind manner plus one application of conjugated estrogen cream (0.5 g) or one applicator full of nonhormonal moisturizer, open label. The conjugated estrogen cream or non-hormonal moisturizer was applied daily for the first 2 weeks, and then twice weekly thereafter for 3 months. Efficacy of treatment regimens on signs and symptoms of vaginal atrophy was evaluated by monitoring objective and subjective parameters. RESULTS Signs and symptoms of vaginal atrophy improved in all four treatment groups. Raloxifene did not diminish the magnitude of improvement when administered with either vaginal preparation. Conjugated estrogen cream produced a statistically greater improvement in signs (P < .05) but not in individual symptoms or overall satisfaction relative to nonhormonal moisturizer. CONCLUSION Postmenopausal women with evidence of preexisting vaginal atrophy may use either low-dose conjugated estrogen cream or nonhormonal moisturizer to treat the atrophy concurrently with raloxifene (60 mg per day).

Adenomyotic Cyst in an Adolescent Girl

BACKGROUND Cystic adenomyosis is an extremely rare form of adenomyosis, particularly in the pediatric population. We report a unique case of an adenomyotic cyst in an adolescent girl. CASE A 16-year-old G0P0 presented with cyclic pelvic pain. Ultrasonography demonstrated a large cystic lesion, which was localized to the myometrium on computed tomography and magnetic resonance imaging. The lesion was surgically excised and confirmed to be cystic adenomyosis by pathology. SUMMARY AND CONCLUSION Cystic adenomyosis is a rare cause of abdominopelvic pain and dysmenorrhea in adolescents. Imaging is key in distinguishing this disease from other congenital and acquired gynecological disorders. Awareness of this condition is important for timely, accurate diagnosis and intervention.

Anti-NMDA-receptor encephalitis: an adolescent with an ovarian teratoma.

BACKGROUND Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis has been reported to be associated with ovarian teratomas. In many patients, surgical excision has resulted in improvement. CASE A previously healthy 14-year-old girl presented with confusion which later evolved into a comatose state. Imaging revealed an adnexal mass which was surgically removed and confirmed to be a mature teratoma. Her cerebral spinal fluid was positive for antibodies to NR1/NR2 heteromers of NMDA receptors. COMMENTS Cystic teratomas are one of the most common benign ovarian lesions in children and young women. While an association of ovarian teratomas and paraneoplastic encephalitis is published in the neurologic literature, this association needs to be clarified for the practicing gynecologist who may be asked to consult on these patients.

The Course of Lichen Sclerosus Diagnosed Prior to Puberty

STUDY OBJECTIVE To help determine the long-term course of girls diagnosed with lichen sclerosus before puberty. DESIGN Retrospective chart review and follow-up interview. SETTING Washington University pediatric gynecology and dermatology clinics. PARTICIPANTS Premenarchal girls diagnosed with lichen sclerosus from 1989-2010. INTERVENTIONS Telephone interview. MAIN OUTCOME MEASURES Resolution of symptoms, specifically pain and/or pruritus. RESULTS Follow-up was available for 36 premenarchal girls. The mean age at lichen sclerosus (LS) diagnosis was 7 years (range: 3-14 years). The mean duration of follow-up was 5.3 years (range: 2 months-15 years). Treatment with topical steroids (primarily 0.05% clobetasol propionate ointment) resulted in improvement in symptoms within an average of 14 weeks (range: 2 weeks-2 years) in 33 girls. Eighty-three percent of patients (n = 30) experienced remission after initial treatment. Sixteen patients reported relapses requiring an average of 3.1 years of intermittent maintenance therapy. The mean length of remission to date was 3.6 years (range 1 months-10 years). 72% of patients reported remission at the time of the phone interview. Of note, 7 out of 9 patients in our study who continue to report symptoms are still premenarchal. One postmenarchal patient was asymptomatic but had signs of LS on physical exam. CONCLUSION The prognosis and long term course of LS diagnosed prior to puberty is unclear. Although remission may occur prior to menarche in some cases, once children reach menarche with active disease, complete remission may be less likely. Treatment duration of LS in our study had a wide range, but 3 months appears to be adequate for most patients to obtain remission.

Evaluation of Vaginal Bleeding in the Preadolescent Child

Vaginal bleeding in a prepubertal child is always a serious medical concern. Vaginal bleeding in this age group may result from estrogen stimulation, which is more likely to be pathological than physiological, infections, tumors of the lower genital tract, ovarian tumors, foreign bodies, or trauma. Evaluation and management of the prepubertal child requires an understanding of the techniques of the physical examination, comprehension of the normal prepubertal unestrogenized anatomy, and indications for a more comprehensive examination under anesthesia. Caution should be exercised by the clinician so that the physical examination and workup do not further traumatize the child.

Torsion of the Uterine Adnexa: A Review

Abstract Torsion of the fallopian tube and ovary has an interesting and extensive history in the gynecologic literature. Frequent occurrence of this malady in children gives the topic added importance. Early diagnosis is made difficult by the symptoms, history, and physical findings that may be confusing and result in delayed initiation of a definitive therapy. Rapid and precise diagnosis of torsion is expected and necessary for early intervention to prevent loss of reproductive organs and function.

Physical examination of the female cancer patient with sexual concerns: What oncologists and patients should expect from consultation with a specialist

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Outcome of surgical reconstructive procedures for the treatment of vaginal anomalies

Abstract Study Objective: To determine the outcome of corrective surgical procedures used to treat congenital vaginal anomalies. Design: A retrospective international collaborative chart study which accumulated standardized data on patients who presented to these six institutions for surgical correction of vaginal anomalies. Participants: One hundred twenty-four procedures were performed on 74 patients. Forty-seven patients had congenital adrenal hyperplasia (CAH), 22 had congenital absence of the vagina (CAV), and 5 had complex cloacal anomalies. Primary surgical procedures were as follows: 23 of the total 28 vaginoplasties, 44 of the 76 perineoplasty procedures, and all of the 7 pull-through procedures. Main Outcome Measures: Success was based on the presence of a functioning vagina, conditional success on the presence of an acceptable vagina for stage of development, and failure on the need for further operative procedure. Results: Patients with CAH were predominantly prepubertal, noncompliant with dilators and had an overall success rate of 8.5%, conditional success rate of 22.5%, and failure rate of 66.0%. The patients with CAV had an overall success rate of any primary surgical procedure of 68.2% and all but two were postpubertal at the time of initial surgery. All five patients with complex anomalies required more than one surgery. Second procedures were more successful in all patients if performed after the age of 15 years. Conclusions: This study indicated a favorable out-come for vaginoplasty for CAV and for repeat surgical procedures if done after age 15, and that patients with CAH who have prepubertal surgery have a relatively high rate of repeat corrective surgery.

Acute abdominal pain with a calcified pelvic mass

A case of a 15-year-old with a calcified pelvic mass is presented with a review of the differential diagnosis.