Paige Hertweck

Recovery of bone mineral density in adolescents following the use of depot medroxyprogesterone acetate contraceptive injections

BACKGROUND Depot medroxyprogesterone acetate (DMPA) is a highly effective progestin-only contraceptive that is widely used by adolescents. We investigated bone mineral density (BMD) changes in female adolescents during and following use of this method. STUDY DESIGN A multicenter, prospective, non-randomized observational study in 98 healthy female adolescents aged 12-18 years who initiated DMPA intramuscular injections for contraception and provided BMD data for up to 240 weeks while receiving DMPA and for up to 300 weeks after DMPA cessation. BMD at the lumbar spine (LS), total hip (TH) and femoral neck (FN) was assessed by dual-energy X-ray absorptiometry. A mixed model analysis of variance was used to examine BMD changes. RESULTS At the time of their final DMPA injection, participants had mean BMD declines from baseline of 2.7% (LS), 4.1% (TH) and 3.9% (FN) (p<.001 at all three sites). Within 60 weeks of discontinuation of DMPA, mean LS BMD had returned to baseline levels, and 240 weeks after DMPA discontinuation, the mean LS BMD was 4.7% above baseline. Mean TH and FN BMD values recovered to baseline values more slowly: 240 weeks and 180 weeks, respectively, after the last DMPA injection. CONCLUSIONS BMD loss in female adolescents receiving DMPA for contraception is substantially or fully reversible in most girls following discontinuation of DMPA, with faster recovery at the LS than at the hip.

Testing a Bioecological Model to Examine Social Support in Postpartum Adolescents

PURPOSE The purpose was twofold and included examining a bioecological model as a framework to describe social support in postpartum adolescents. The second purpose was to determine the relationship between a comprehensive view of the context of social support and symptoms of depression. DESIGN Cross-sectional design with convenience sampling (n=85) of adolescents at 4-6 weeks postpartum, recruited from two community hospitals. METHODS Approval was received from the universitys IRB (institutional review board), each recruitment site, the adolescent mothers, and their parents or guardians. Data were collected by a research assistant during home visits using a battery of self-report instruments to measure macro, meso, and microsystems of social support. Demographics, exposure to community violence (macrosystem), social support, social network (mesosystem), and perceived stress, mastery, and self-esteem (microsystem) were predictor variables. Depressive symptoms were measured by using the Center for Epidemiologic Studies of Depression (CES-D) Scale. FINDINGS Variables from each system were significant predictors of depressive symptoms but perceived stress was the strongest predictor. Many postpartum adolescents reported that they had been victims of violence. Significant symptoms of depression were identified in 37% of the postpartum adolescents. CONCLUSIONS Context is important to consider in comparing international studies of social support. Researchers and clinicians should investigate variables associated with the low incidence of treatment for depressive symptoms in postpartum adolescents. CLINICAL RELEVANCE Feelings of high self-esteem and mastery should be fostered in nursing interventions with postpartum adolescents and routine screening for symptoms of depression should be considered in relevant healthcare settings.

Biopsychosocial variables associated with substantial bone mineral density loss during the use of depot medroxyprogesterone acetate in adolescents: adolescents who lost 5% or more from baseline vs. those who lost less than 5%

BACKGROUND It is unclear why some adolescents experience substantial bone mineral density (BMD) loss, while others experience a minimal decrease during depot medroxyprogesterone acetate (DMPA) use. We examined biopsychosocial factors in adolescents who experienced ≥5% BMD loss from baseline compared with adolescents who experienced <5% BMD loss during DMPA use. STUDY DESIGN A multicenter, prospective, nonrandomized study of 181 female adolescents who initiated DMPA for contraception was conducted. BMD (by dual-energy X-ray absorptiometry) and serum estradiol were measured at initiation and every 6 months for 240 weeks of DMPA use. RESULTS Half of participants experienced BMD loss of ≥5% from baseline at the hip, and a quarter experienced BMD loss of ≥5% at the lumbar spine (BMD substantial losers, SL). Hip and lumbar spine BMD-SL received a significantly greater number of DMPA injections than non-SL (p<.001). Decreased estradiol levels did not statistically differ between BMD loss subgroups. Hip BMD-SL had significantly lower baseline body mass index (BMI) than non-SL (p=.002), and there was an inverse relationship between weight gain and degree of BMD loss. Mean calcium intake was significantly lower (p<.05) in hip BMD-SL, and reported alcohol use was significantly higher (p<.05) in lumbar spine BMD-SL compared with non-SL. CONCLUSIONS BMD loss of ≥5% was more common at the hip than at the lumbar spine among adolescents using DMPA. Decreased serum estradiol levels did not correlate with magnitude of BMD loss. Lower BMI and calcium intake and greater alcohol use were associated with greater BMD loss in adolescents using DMPA.

Surgical and ethical challenges in disorders of sexual development.

A resolution to the difficulties faced by parents, physicians, and pediatric patients in treating DSDs will only come with better communication and improved research methodologies. Advocacy groups and the Internet have allowed the intersex community to have a larger role in guiding the research and the ethical frameworks that are used in treating these disorders. These disorders are unusual and collaboration across medical centers should be the rule rather than the exception. When possible, treatments that are innovative or experimental should be subjected to rigorous research oversight [29,30]. Defined periods of family crisis in which counseling and education become important are at the time of diagnosis [30,31], at the time of any surgical procedure, and at the beginning of major developmental stages. Historically, children were often left uninformed until someone judged them old and mature enough to comprehend how they were different. These attempts to protect individual children from their condition may have left them vulnerable to a personal crisis at an age when sexual identity and identity with a peer group are important. Both the needs of the child and the adult the child will become should be considered in making treatment decisions for children and adolescents with DSDs. It is best to counsel parents and educate developing children in a way that parallels chronologic and conceptual growth. When possible, the child should be involved in an age-appropriate fashion in the decision-making process and accurate information about the childs history and body should be made available. In addition, parents and families need as much information as possible and support systems that will help them navigate these challenging situations.

A new technique for the creation of a neovagina

Background: There are many described reconstructive techniques for vaginal agenesis including vaginal dilators, skin covered molds, sigmoid grafts, vulval and large muscle flaps all of which aim to produce a vagina of normal axis, secretory capacity and length. We report the laparoscopic approach to Davydovs operation which utilizes peritoneum to line the newly dissected vesicorectal space. Methods: A case report detailing preoperative evaluation, surgical technique and outcome.Results: There were no intraoperative or immediate postoperative complications. The patient was discharged from hospital within 23 hours of surgery. Six month follow up revealed a vagina 7-8 cm in length, lined with squamous epithelium. The patient reports satisfactory sexual intercourse.Conclusion: This technique provides a satisfactory option for the surgical management of vaginal agenesis.