Julie L. Strickland

Female circumcision/female genital mutilation.

Female circumcision/female genital mutilation (FC/FGM) refers to any alteration of the genitalia by excision or covering of the introitus done for nonmedical reasons. This procedure is widely prevalent in sub-Saharan Africa and is traditionally performed on children and young adolescents. FC/FGM is associated with acute and long-term genitourinary and reproductive disorders that may require medical intervention. Due to turbulent economic and political immigration patterns, Western physicians may be called upon to care for children or adolescents from this part of the world. This review explains the procedure and the resultant physical alterations as well as the cultural and historic basis of this ancient tradition. Emphasis is also placed on the elements of culturally competent and compassionate care for young women who have undergone FC/FGM.

A randomized controlled trial to evaluate the use of the endocervical brush after endocervical curettage

Objective To determine if using the endocervical brush after curetting the endocervix will increase the yield of endocervical tissue retrieved for an endocervical curettage (FCC) specimen. Methods Between March 1, 1995, and June 30, 1996, we recruited for participation patients with abnormal Papanicolaou smears referred for colposcopy. Exclusion criteria were pregnancy, previous hysterectomy, and a history of diethylstilbestrol exposure. Colposcopy and biopsies were performed by residents under direct supervision of the attending staff. Endocervical curettages were performed using the Kevorkian endocervical curette. The subjects were then assigned randomly to one of two ways of collecting the FCC tissue: with either a curette or an endocervical brush. Specimens were reviewed by pathologists, who were blinded to the method of ECC collection. Results During the study period, 124 patients agreed to participate; 62 were assigned to the control group, and 62 to the study group. Six subjects had missing data, leaving 118 patients available for analysis. In the control group, six of the 58 FCC samples obtained contained insufficient endocervical tissue for pathologic diagnosis. None of the 60 samples from the endocervical brush group was insufficient. The difference between the two groups was statistically significant (P = .01). Conclusion The addition of the endocervical brush to endocervical tissue sampling at colposcopy in the study decreased the number of insufficient samples. The endocervical brush method of collection of an ECC specimen from the canal after the Kevorkian curette is used is a valuable addition to this diagnostic tool. We recommend its use in obtaining an ECC specimen.

Satisfaction with and intention to continue Depo-Provera versus the Mirena IUD among post-partum adolescents through 12 months of follow-up.

STUDY OBJECTIVE No prior study has directly compared satisfaction with Depo-Provera to the Mirena intra-uterine device (IUD) among post-partum parous adolescents. Our aim was to make this comparison among post-partum adolescents at 3, 6, and 12 months of follow-up. PARTICIPANTS Post-partum/parous adolescents (aged 20 and younger) choosing either Depo-Provera or the Mirena IUD as their method of contraception. DESIGN Prospective longitudinal survey. SETTING The adolescent clinic at the Truman Medical Center, Kansas City Missouri. MAIN OUTCOME MEASURE Satisfaction with and intention to continue the chosen method at 3, 6, and 12 months of follow-up. INTERVENTIONS None. RESULTS Sixty-six post-partum/parous adolescents were recruited, 37 choosing the Mirena IUD and 29 choosing Depo-Provera for contraception. The 2 groups had similar baseline characteristics. There was no statistically significant difference in overall satisfaction with Depo-Provera versus the Mirena IUD at 3, 6, or 12 months of follow-up. For both contraceptive methods, unpredictable bleeding was most unacceptable at 6 months of follow-up but the trend was only statistically significant for Depo-Provera. For Depo-Provera, there was a significantly lower proportion of participants actually continuing the method at 12 months (42.9%) relative to the proportion who at 6 months had expressed an intention to continue (80.0%; P = .01). This trend was not seen for the Mirena IUD. CONCLUSION Among post-partum/parous adolescents, overall subjective satisfaction with Depo-Provera and the Mirena IUD is similarly high over 12 months of follow-up. With Depo-Provera, however, there appears to be a disconnect between intention to continue at 6 months and actual continuation at 12 months.

Virilizing Ovarian Dermoid Cyst with Leydig Cells

BACKGROUND The clinical observation of virilization is a rare finding that has a number of possible explanations. Overall, ovarian tumors causing virilization are exceedingly rare and mostly occur in post-menopausal women. In fact, there are no reported cases of virilization from a testosterone-producing ovarian dermoid in the adolescent female age group. The most frequent germ cell tumor derived from the ovaries is the benign cystic teratoma (dermoid) which accounts for 25% of all ovarian neoplasms. Teratomas consist of tissues that recapitulate the ectoderm, endoderm, and mesoderm. Usually the tumors are asymptomatic, but they occasionally can cause severe pain if there is torsion or if sebaceous material perforates the cyst wall, leading to reactive peritonitis. CASE A 12-year-old female was found to have a large 3 5 x 19 x 12 cm ovarian mature cystic teratoma arising from her right ovary. The patient also displayed evidence of masculinization demonstrated by a deepening voice and clitoromegaly. The dermoid was producing large amounts of testosterone from a nest of Leydig cells found pathologically in the mass. CONCLUSION Benign cystic teratomas can produce active hormones, albeit rarely. This is a finding important to consider when ovarian cystectomy is performed for removal of a benign cystic teratoma.

Menstrual Patterns and Treatment of Heavy Menstrual Bleeding in Adolescents with Bleeding Disorders.

STUDY OBJECTIVE To characterize menstrual bleeding patterns and treatment of heavy menstrual bleeding in adolescents with bleeding disorders. DESIGN, SETTING, AND PARTICIPANTS We conducted a retrospective review of female patients aged nine to 21 years with known bleeding disorders who attended a pediatric gynecology, hematology, and comprehensive hematology/gynecology clinic at a childrens hospital in a metropolitan area. MAIN OUTCOME MEASURES Prevalence of heavy menstrual bleeding at menarche, prolonged menses, and irregular menses among girls with bleeding disorders and patterns of initial and subsequent treatment for heavy menstrual bleeding in girls with bleeding disorders. RESULTS Of 115 participants aged nine to 21 years with known bleeding disorders, 102 were included in the final analysis. Of the 69 postmenarcheal girls, almost half (32/69, 46.4%) noted heavy menstrual bleeding at menarche. Girls with von Willebrand disease were more likely to have menses lasting longer than seven days. Only 28% of girls had discussed a treatment plan for heavy menstrual bleeding before menarche. Hormonal therapy was most commonly used as initial treatment of heavy menstrual bleeding. Half (53%) of the girls failed initial treatment. Combination (hormonal and non-hormonal therapy) was more frequently used for subsequent treatment. CONCLUSIONS Adolescents with bleeding disorders are at risk of heavy bleeding at and after menarche. Consultation with a pediatric gynecologist and/or hematologist prior to menarche may be helpful to outline abnormal patterns of menstrual bleeding and to discuss options of treatment in the event of heavy menstrual bleeding.

Use of Intraoperative Fluoroscopy During Laparotomy to Identify Fragments of Retained Essure Microinserts: Case Report

In previous case-reports of Essure microinsert perforation, the microinsert was successfully removed at laparoscopy. Herein is discussed the scenario of persistent pelvic pain over several years after an apparently successful laparoscopic retrieval of a perforating right-sided microinsert. In the interim, the patient underwent 2 unsuccessful exploratory laparotomy procedures in an attempt to retrieve additional microinsert fragments that had perforated the uterus. Successful management of Essure microinsert perforation in this patient ultimately required use of intraoperative fluoroscopy. Surgeons performing laparoscopy or laparotomy to retrieve Essure microinserts that have perforated should be aware that these are not always visible to the naked eye, and there should be a low threshold to use intraoperative fluoroscopy to ensure that all perforating fragments have been removed.

Recurrent mature cystic ovarian teratoma in adolescence: atypical case of the growing teratoma syndrome.

BACKGROUND: A primary mature cystic ovarian teratoma was diagnosed in an adolescent female. She was followed up after initial exploration with computed tomography, pelvic ultrasonography, and serum tumor markers. Recurrent tumor, consisting solely of mature teratomatous elements, was confirmed with 2 subsequent laparotomies. CASE: This is a report of the growing teratoma syndrome in a young woman with a primary diagnosis of a mature cystic ovarian teratoma not treated with adjuvant chemotherapy. CONCLUSION: The growing teratoma syndrome is an uncommon condition. Surgical resection of recurrent lesions is necessary to reduce potential complications of abdominopelvic organ compression and obstruction and to evaluate for the presence of malignant degeneration.

Adolescent acute sexual assault: contrasting with adult experiences

Background: Acute sexual assault is a serious and underreported crime with the potential to cause grave physical and emotional harm to victims. Despite its relatively high prevalence in adolescents, there is limited information detailing the experience in younger adolescents. Methods: We analyzed the emergency department records of 137 adolescent assault victims grouped with a similar adult population. We extracted demographic characteristics and details of the sexual assault as well as information about treatment and aftercare. Results: The circumstances of an assault were significantly different for adolescents than for adults. Adolescents were more likely than adults to know their assailant (65% versus 35%, P<0.01), to be assaulted during daytime hours (18% versus 16%, P <0.05), and to be assaulted in a residence. During the time of the assault, the majority of adolescents were not in situations where there was adult supervision. Adolescents were significantly less likely to sustain physical injury (37% versus 12%, P <0.01), to have a weapon used against them, or to be forced into multiple sexual acts. Follow-up rates were poor for assault victims, with adolescents having a higher rate of medical follow-up. Adolescents were less likely to receive rape-centered counseling referrals than were adults, (48% versus 58%, P <0.01), even when controlling for the violence of assault, race, or insurance status. Conclusion: Adolescent sexual assault appears to be less violent, typically occurring in familiar settings. Adolescents are more compliant with medical follow-up, but are less likely to be offered rape-centered counseling.

Factor VII deficiency diagnosed after minor genital trauma

This case presents the first documented report of the diagnosis of factor VII (FVII) deficiency associated with massive haematoma following a minor straddle injury and underscores the need for haematologic evaluation of bleeding disorders in young women who present with pain out of proportion to injury, prolonged bleeding, expanding haematoma or suggestive family history, after otherwise minor traumatic injury (Fig. 1).