Meredith Loveless

Retrospective Review of Intrauterine Device in Adolescent and Young Women

STUDY OBJECTIVEnTo examine our experience with intrauterine device (IUD) use in adolescents and young women.nnnDESIGNnRetrospective descriptive study evaluating outcomes after IUD insertion for patients 21 years or less over an 8-year period.nnnSETTINGnThree sites including a Pediatric and Adolescent gynecology private practice, a Title X clinic, and community based, grant funded clinic serving a high risk teen population.nnnPARTICIPANTSnFemales from menarche to age 21.nnnMAIN OUTCOMES MEASUREDnThe probability of IUD retention, differences in IUD retention probabilities between two age groups, and risk factors for IUD removal, expulsion, and infection were evaluated.nnnRESULTSn233 records showed 50% of the <18-year-old age group and 71.5% of the 18-21-year-old group had their IUD in place at 5 years. Age was found to be a significant factor for removal (P < 0.001), with under 18-year-olds at greater risk of removal/expulsion (hazard ratio (HR) = 2.85). Parity (RR = 5.6 for nulliparous vs multiparous patients, P < 0.001) and prior STI (RR = 5.5, P < 0.001) were significant risk factors for infection. Nulliparous patients were at higher risk of expulsion (P = 0.045), though age was not a statistically significant risk factor.nnnCONCLUSIONSnThe rate of continuation was lower in adolescents under 18 compared to 18-21-year-olds, but was still higher than for other hormonal contraceptives. Despite this groups high risk for STI the IUD did not increase the risk of infection and may offer some degree of protection. IUDs appear to be a safe option in young adolescents (<18 years old) and nulliparous women.

A Simulation Program for Teaching Obstetrics and Gynecology Residents the Pediatric Gynecology Examination and Procedures

STUDY OBJECTIVEnTo assess the use of a pelvic simulation curriculum to teach obstetrics and gynecologic residents the pediatric gynecology examination and procedures.nnnDESIGNnResidents in obstetrics and gynecology participated in a simulation curriculum using a modified pelvic hemimodel to simulate a pediatric pelvis.nnnPARTICIPANTSn19 obstetrics and gynecology residents completed the study protocol.nnnINTERVENTIONSnDigitally recorded encounters with a standardized patient scenario using the simulator were utilized. After the initial encounter the trainees participated in a formal lecture and demonstration using the model. The trainees were then reassessed at least four weeks after the initial encounter; results were reviewed by a blinded evaluator. Scores were analyzed using the two-sided t-test and Wilcoxon signed-rank test.nnnMAIN OUTCOME MEASURESnScores from before to after the simulation training.nnnRESULTSnA total of 19 residents completed the study protocol and demonstrated significant improvement in scores from before to after the simulation training. Scores improved from a pre-training mean of 6.1 to post-training mean of 16.7 (P = 0.0001). Improvement was seen at all levels of residency training. Specific skill sets included in the Council for Resident Education in Obstetrics and Gynecology (CREOG) Educational objectives (1) were improved including: pediatric gynecologic examination, collection of microbial cultures, vaginal lavage and vaginoscopy.nnnCONCLUSIONSnThis teaching program using a simulation model was found to be an effective tool to improve resident knowledge and performance of the skills needed to accomplish the pediatric gynecology examination.

Van wyk and grumbach syndrome: an unusual case and review of the literature.

BACKGROUNDnThe syndrome consisting of primary hypothyroidism, precocious puberty, and massive ovarian cysts was termed Van Wyk and Grumbach syndrome in 1960. Little is known about the effect of the cysts on ovarian tumor markers.nnnCASEnA 12-year-old Caucasian female presented with headaches and fatigue. Imaging to evaluate her headaches revealed a pituitary macroadenoma. Soon after her macroadenoma was discovered, she presented to the emergency room with abdominal pain. Imaging at that time revealed massive bilateral ovarian masses with the left measuring 17 × 13 × 8.5 cm and the right measuring 18 × 11 × 10 cm. Ovarian tumor markers were drawn at this time, most of which were highly elevated. Subsequent evaluation revealed extreme hypothyroidism. Given these findings of a pituitary macroadenoma, bilateral ovarian masses, and severe hypothyroidism, the patient was diagnosed with Van Wyk and Grumbach syndrome. We followed the cyst conservatively and the ovaries and tumor markers returned to normal after adequate thyroid replacement.nnnCOMMENTSnThis case supports conservative treatment as the first-line approach to massive ovarian cysts caused by hypothyroidism. In addition this case shows that tumor markers can be abnormal in the absence of a malignancy in this setting. Before proceeding with surgical evaluation, exclusion of hypothyroidism to exclude this rare but treatable syndrome should be undertaken. The most important diagnostic clue that the cyst may be caused by an endocrine source is the finding of bilateral ovarian cysts rather than one ovary affected as seen in most ovarian malignancies in this age group.

Diagnosis and Treatment of Interstitial Cystitis in Adolescents

Interstitial cystitis (IC), or painful bladder syndrome, is characterized by irritative voiding symptoms and can be a challenging problem that affects children and adolescents. Diagnosis and management in children and adolescents is challenging because of strict diagnostic criteria and the paucity of investigations focusing on this age group, which often can lead to delayed or missed diagnosis. Clinical features suggestive of IC include bladder pain, urgency, frequency, nocturia, and pressure. Symptoms may wax and wane and often are exacerbated by menstruation, intercourse, dietary triggers, and stress. Diagnosis can be made by history, physical exam findings such as suprapubic tenderness, voiding diaries, and exclusion of other etiologies. Some diagnostic tests such as the potassium sensitivity test and cystoscopy are invasive and often impractical in younger patients. Treatment of IC consists of a multimodal approach that should be tailored to the individual needs of the patient. Therapies for younger patients include oral medication, intravesical therapy, cystoscopy with hydrodistention, and conservative measures such as dietary modification. This review of the literature focuses on diagnosing IC in younger patients and on what treatment modalities are appropriate and effective for this age group.

Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology

Vulvovaginitis is one of the most common gynecological complaints presenting in the pediatric and adolescent female. The common causes of vulvovaginitis in the pediatric patient differ than that considered in adolescent females. When a child present with vulvar itching, burning and irritation the most common etiology is non-specific and hygiene measures are recommended. However these symptoms can mimic more serious etiologies including infection, labial adhesion, lichen sclerosis, pinworms and foreign body must be considered. Yeast infection is rare in the pediatric population but common in the adolescent. In the adolescent patient infections are more common. Yeast and bacterial vaginosis are commonly seen but due to the higher rate of sexual activity in this population sexually transmitted infections must also be considered.