Sally Perlman

A Prospective Study Evaluating the Effects of Depo Proveba® on Bone Mineral Density in Adolescent Females: A Preliminary Report

Background Depot medroxyprogesterone acetate (Depo Provera ® ) is a popular contraceptive method among adolescents. Little is known, however, about the long term effects of Depo Provera ® on bone mineral density in adolescent females. This ongoing study prospectively evaluates the effects of Depo Provera ® and oral contraceptive pills on bone mineral density, compared to normally menstruating adolescents receiving no hormonal contraception. Methods From March 1, 1995 to December 31, 1997, 55 patients aged 12 to 17 presenting for new start hormonal contraception (Depo Provera ® : nxa0=xa030, oral contraceptive pills: nxa0=xa025) received baseline lumbar vertebral bone mineral density evaluation by dual energy x-ray absorptiometry (DEXA). Patients continuing with their original contraceptive method received bone mineral density evaluation every six months. Patients who subsequently discontinued hormonal contraception, became, pregnant or switched to an alternative contraceptive method were removed from the study. Exclusion criteria included prior use of hormonal contraception, previous pregnancy, and pre-existing risk factors for osteoporosis. Results Baseline DEXA scans revealed no significant difference in bone mineral density between the three groups. After 1 year, bone mineral density decreased from baseline by 0.017xa0gm/cm 2 or 1.8% in the Depo Provera ® group (nxa0=xa015), and increased by 0.030xa0gm/cm 2 or 3.0% in the oral contraceptive group (nxa0=xa08), pxa0=xa00.013. Bone mineral density increased by 0.0093xa0gm/cm 2 or 1.2% in the normally menstruating group over 1 year. After 18 months, bone mineral density decreased from baseline by 0.036xa0gm/cm 2 or 3.8% in the Depo Provera ® group (nxa0=xa010), and increased by 0.062xa0gm/cm 2 or 6.1% in the oral contraceptive group (nxa0=xa04), pxa0 2 (2.0%) in the same time period. A subset of patients receiving Depo Provera ® over 24 months (nxa0=xa05) experienced a decrease of 0.222xa0gm/cm 2 or 4.8% in bone mineral density from baseline. There were no significant differences between the Depo Provera ® and oral contraceptive groups with respect to body mass index, race, smoking, alcohol consumption, or osteoporosis risk factors. Conclusions Depo Provera ® administration in adolescent females appears to be associated with a decrease in bone mineral density which becomes more pronounced with long term use. This is particularly significant as peak bone mineral density is accrued during the adolescent years. Further research is needed to determine whether decreased skeletal bone mineralization induced by Depo Provera ® is reversible on discontinuation of Depo Provera ® , or may be prevented by the concurrent administration of anti resorptive/bone forming agents.

Unrecognized coital laceration in a series of nonvirginal adolescent girls

Abstract BACKGROUND: Nonvirginal adolescent patients with vaginal injuries as a result of apparently normal sexual intercourse constitute a small but important group of Emergency Room presentations. METHODS: A series of three nonvirginal adolescents who sustained vaginal injuries during normal coitus is presented. RESULTS: The ages were fourteen, fifteen, and sixteen. All presented to the Pediatric Emergency Department with profuse or prolonged vaginal bleeding. Two had previous hypotensive episodes. None had a hemoglobin less than 10%. One had admitted to sexual activity 24 hours prior to presentation. The other two had initially denied it but upon confidential questioning by the Gynecology consult admitted to the act many hours prior to presentation. For all of the young women, it was their second act of sexual intercourse. All denied the use of excess force or inanimate objects. All felt that the act was no different than the previous act although it was a different partner. Only one patient presented with abdominal pain. The diagnosis was not suspected in any of the patients prior to the gynecologic consult. Two of the patients were taken directly to the operating room because of profuse bleeding and the diagnosis was quickly made. One was admitted for observation for presumed dysfunctional bleeding but continued to be hypotensive with a decreasing H&H and was diagnosed by reexam. All had significant lacerations to the right vaginal fornix, one involving entry into the peritoneal cavity yet had no laceration or injury to the perineum. All had immediate repair and have done well since. None have resumed sexual activity. CONCLUSIONS: The pelvic organs are well suited for intercourse thus coital injuries, especially from consensual sex, are highly unusual. Minor injuries of the female external genitalia and introitus often occur with initial intercourse but rarely present with anything more than minor pain and bleeding. Laceration and rupture of the vaginal vault are more serious but the etiology of most is unclear. It has been postulated that the right vaginal fornix is larger than the left and because of the pouching of the glans is probably stretched most during coitus. The almost universal presentation is vaginal bleeding. Deaths from exsanguination have been reported with infection as a late complication. Management consists of control of hemorrhage and management of shock if present, prophylaxis, treatment of infection and repair of injuries. Prompt recognition and treatment of coital injuries is vital as there is significant morbidity and mortality. This series reemphasizes the importance of a detailed confidential sexual history in all our adolescent patients who present to the ER as this information may not be voluntarily given to the physician. Any patient with postintercourse pain or vaginal bleeding deserves full evaluation by the physician.

Aldara™ as treatment for condylomata acuminata in the prepubertal child

Abstract BACKGROUND: Treatment of condylomata acuminata in the prepubertal child has previously presented difficulties. Initial treatment has often involved the expense and morbidity of general anesthesia and CO 2 laser. Adult modalities have been tried such as tricarboxylic acid (TCA) or intralesional interferon but often are discontinued because of significant pain and/or morbidity. Aldara TM is the brand name for an Imiquimod containing cream. Imiquimod is an immune response modifier. It has been approved by the FDA for the treatment of genital and perianal warts in the population 18 years of age and older. METHODS: JH is a 7-YO WF seen for evaluation for sexual abuse. The perpetrator is known. She had a normal hymeneal circumference and STD cultures and serologies. However, her exam was complicated by multiple condylomata of the clitoral, periclitoral, labia majora and minora, and perihymeneal area. She was significantly symptomatic with burning and itching that was mildly helped by the constant use of Desitin cream. One condyloma was selected for a test dose of the Aldara TM cream (enough to cover a Calgiswab). The mother was asked to give her daughter a sitz bath in six hours and to continue them BID until return. RESULTS: Upon return in one week, patient described no untoward complaints. All of the condylomata were gone except one perihymeneal area at 7 oclock. The previous areas were still slightly red but this resolved over time. Sitz baths were continued. Two weeks later the remaining perihymeneal lesion was excised and sent for documentation at the request of the prosecuting attorney and the mother. To date, at three months, there has been no recurrence. CONCLUSION: The exact mechanism of Aldara TM upon the eradication of genital warts is unknown. Side effects are usually mild to moderate. Most common side effects are redness, peeling, and swelling in the area where the Aldara TM is applied. This patient had mild redness with only a very small test dose. Other reported side effects not experienced by this patient are burning, itching, swelling and difficulty with urination. There may be a significant role for Aldara TM in the treatment of symptomatic genital condyloma in the prepubertal child. More research and experience is needed especially in establishing correct dosing and safety for this population.

Endoscopic Surgery in the Pediatric-Adolescent Patient

The first report of endoscopic surgery was in the Babylonian Talmud (Niddah Treatise, Section 65b). A lead funnel with a bent mouthpiece equipped with a wooden drainpipe was introduced into the vagina, enabling direct visualization of the uterine cervix. Light reflected from a mirror placed in front of the exposed vulva enabled illumination of internal body structures as recorded by the Arabian physician Albukassim (912-1013 A.D.). The first endoscopic light source was attributed to the pioneering work of Guilio Cesare Aranzi (1587). Subsequent to this event, the camera obscura was invented by the Benedictine monk Don Panuce. Next in sequence was Bozzani in 1805, who used a tube and candlelight to examine the urethra. Further innovation efforts were ascribed to Ott in 1901, who was the first to inspect abdominal viscera by focusing a head mirror into a speculum introduced through a small incision, perhaps indeed the first laparoscopic procedure. The introduction of the pneumoperitoneum is attributed to Kelling and Jacobaeus, followed by the introduction of the cystoscope. The use of carbon dioxide insufflation is attributed to Zollikofer, and the insufflation needle in use daily as ascribed to the work of Veress.l Hope and subsequently Riddock were the first to diagnose an ectopic pregnancy through the laparoscope, as reported by Semm.2 Of all of the advances within the area of laparoscopic surgery, the true “neophyte” is that of application to the pediatric patient. Operative laparoscopy has been performed successfully in preterm infants as well as in neonates and children.