NASPAG Annual Meeting 2013

SAN DIEGO – Long-acting reversible contraceptives reduced teen pregnancy by 56%, compared with national statistics for teens overall, preliminary results from an ongoing analysis demonstrated.

At the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Tessa Madden shared updated findings from the Contraceptive CHOICE Project, an effort to promote LARC use in the St. Louis region and to measure acceptability, satisfaction, side effects, and the rates of continuation across a variety of contraceptive methods, including LARCs. The goals were to increase IUD use in the St. Louis region from 1%-2% to 6% or greater, to improve the rates of postabortion IUD use from less than 1% to 10% or greater, and to increase the use of contraceptive implants to 3% or greater.

The investigators also hypothesized that teen pregnancy rates would decline by 10%. "It turns out that we were overly conservative in our estimates for what we could do," said Dr. Madden of Washington University in St. Louis. "We also hypothesized that women who got a LARC method would have higher rates of continuation and higher rates of satisfaction, compared with women who were using shorter-acting reversible methods."

Study participants included 9,256 women who lived in either the city of St. Louis or St. Louis County. The women were 14-45 years of age, were either currently sexually active or planning on becoming sexually active, did not want to become pregnant in the next 12 months, and were willing to start a new contraceptive method. Two-thirds of the participants enrolled at the Washington University School of Medicine, while the remainder enrolled at one of 13 partner community clinics.

Participants who enrolled in the clinical university site underwent formal standardized counseling. "Trained contraceptive counselors read a script to participants before they enrolled in the project, and they had models to demonstrate the different kinds of contraceptive methods," Dr. Madden explained. Study participants "heard about contraceptive methods in a tier-based approach, so they heard about the most effective methods first." Those who enrolled at the community clinic underwent "usual" counseling.

In a study from the first 5,087 enrolled in the Contraceptive CHOICE Project, Dr. Madden and her associates reported that at 12 months, 86% of patients who chose a LARC were still using it, compared with only 55% of those who chose a non-LARC method (Obstet. Gynecol. 2011;117:1105-13). This closely mirrored the percentage of patients who reported overall satisfaction with their chosen birth control method (84% in the LARC group vs. 53% in the non-LARC group). Comparing LARC and non-LARC methods, we see that 84% of participants were satisfied with their LARC method at 12-months, compared with 53% of participants using non-LARC methods.

At the meeting, Dr. Madden discussed preliminary findings from the overall study population, as well as from a cohort of 1,404 adolescents in CHOICE, who were aged 14-19 at the time of enrollment. Of the adolescents, 63% were black, 30% were white, and the rest were from other racial groups. Half of the teens had a prior pregnancy.

A full 75% of women in the overall population chose an IUD or an implant, compared with 72% of the adolescents, "which is still pretty high," Dr. Madden said. Implant use in the overall population was 17%, compared with 34% among adolescents. "Implants were more acceptable to the younger teens, and IUDs become more acceptable to the older teens," she noted.

Only 7% of those under age 20 years discontinued any LARC by 6 months, compared with 8% of those aged 20 years and older, a difference that was not statistically significant (P = .17). "I’m hoping this can help put to bed the notion that teens get these [LARC] methods and then decide 6 weeks later that they want the [device] out," Dr. Madden said. "This does not happen in most cases."

The annual pregnancy rate among adolescents in CHOICE who chose a LARC was 29.9/1,000, compared with the 2008 U.S. teen pregnancy rate of 67.8/1,000, a reduction of 56%.

The findings matter, she added, "because LARCs really are better at preventing unintended pregnancy compared with non-LARC methods. Our follow-up rates at 1 year are greater than 90%. We found that women who were using contraceptive pills, patches, or rings had a 20-fold increased risk of unintended pregnancy, compared with women using a LARC method. We also found that LARCs were just as effective in young women compared with older women."

Dr. Madden predicted that consumer interest in LARCs will continue to grow because "more women and adolescents are asking for these methods. They’re reading about them online and people are blogging about them, so they’re more empowered to ask for them."

Dr. Madden disclosed that she receives honoraria for serving on an advisory board for Bayer Healthcare Pharmaceuticals and that she receives research funding from Merck.

[email protected]

SAN DIEGO – Long-acting reversible contraceptives reduced teen pregnancy by 56%, compared with national statistics for teens overall, preliminary results from an ongoing analysis demonstrated.

At the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Tessa Madden shared updated findings from the Contraceptive CHOICE Project, an effort to promote LARC use in the St. Louis region and to measure acceptability, satisfaction, side effects, and the rates of continuation across a variety of contraceptive methods, including LARCs. The goals were to increase IUD use in the St. Louis region from 1%-2% to 6% or greater, to improve the rates of postabortion IUD use from less than 1% to 10% or greater, and to increase the use of contraceptive implants to 3% or greater.

The investigators also hypothesized that teen pregnancy rates would decline by 10%. "It turns out that we were overly conservative in our estimates for what we could do," said Dr. Madden of Washington University in St. Louis. "We also hypothesized that women who got a LARC method would have higher rates of continuation and higher rates of satisfaction, compared with women who were using shorter-acting reversible methods."

Study participants included 9,256 women who lived in either the city of St. Louis or St. Louis County. The women were 14-45 years of age, were either currently sexually active or planning on becoming sexually active, did not want to become pregnant in the next 12 months, and were willing to start a new contraceptive method. Two-thirds of the participants enrolled at the Washington University School of Medicine, while the remainder enrolled at one of 13 partner community clinics.

Participants who enrolled in the clinical university site underwent formal standardized counseling. "Trained contraceptive counselors read a script to participants before they enrolled in the project, and they had models to demonstrate the different kinds of contraceptive methods," Dr. Madden explained. Study participants "heard about contraceptive methods in a tier-based approach, so they heard about the most effective methods first." Those who enrolled at the community clinic underwent "usual" counseling.

In a study from the first 5,087 enrolled in the Contraceptive CHOICE Project, Dr. Madden and her associates reported that at 12 months, 86% of patients who chose a LARC were still using it, compared with only 55% of those who chose a non-LARC method (Obstet. Gynecol. 2011;117:1105-13). This closely mirrored the percentage of patients who reported overall satisfaction with their chosen birth control method (84% in the LARC group vs. 53% in the non-LARC group). Comparing LARC and non-LARC methods, we see that 84% of participants were satisfied with their LARC method at 12-months, compared with 53% of participants using non-LARC methods.

At the meeting, Dr. Madden discussed preliminary findings from the overall study population, as well as from a cohort of 1,404 adolescents in CHOICE, who were aged 14-19 at the time of enrollment. Of the adolescents, 63% were black, 30% were white, and the rest were from other racial groups. Half of the teens had a prior pregnancy.

A full 75% of women in the overall population chose an IUD or an implant, compared with 72% of the adolescents, "which is still pretty high," Dr. Madden said. Implant use in the overall population was 17%, compared with 34% among adolescents. "Implants were more acceptable to the younger teens, and IUDs become more acceptable to the older teens," she noted.

Only 7% of those under age 20 years discontinued any LARC by 6 months, compared with 8% of those aged 20 years and older, a difference that was not statistically significant (P = .17). "I’m hoping this can help put to bed the notion that teens get these [LARC] methods and then decide 6 weeks later that they want the [device] out," Dr. Madden said. "This does not happen in most cases."

The annual pregnancy rate among adolescents in CHOICE who chose a LARC was 29.9/1,000, compared with the 2008 U.S. teen pregnancy rate of 67.8/1,000, a reduction of 56%.

The findings matter, she added, "because LARCs really are better at preventing unintended pregnancy compared with non-LARC methods. Our follow-up rates at 1 year are greater than 90%. We found that women who were using contraceptive pills, patches, or rings had a 20-fold increased risk of unintended pregnancy, compared with women using a LARC method. We also found that LARCs were just as effective in young women compared with older women."

Dr. Madden predicted that consumer interest in LARCs will continue to grow because "more women and adolescents are asking for these methods. They’re reading about them online and people are blogging about them, so they’re more empowered to ask for them."

Dr. Madden disclosed that she receives honoraria for serving on an advisory board for Bayer Healthcare Pharmaceuticals and that she receives research funding from Merck.

[email protected]

SAN DIEGO – Long-acting reversible contraceptives reduced teen pregnancy by 56%, compared with national statistics for teens overall, preliminary results from an ongoing analysis demonstrated.

At the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Tessa Madden shared updated findings from the Contraceptive CHOICE Project, an effort to promote LARC use in the St. Louis region and to measure acceptability, satisfaction, side effects, and the rates of continuation across a variety of contraceptive methods, including LARCs. The goals were to increase IUD use in the St. Louis region from 1%-2% to 6% or greater, to improve the rates of postabortion IUD use from less than 1% to 10% or greater, and to increase the use of contraceptive implants to 3% or greater.

The investigators also hypothesized that teen pregnancy rates would decline by 10%. "It turns out that we were overly conservative in our estimates for what we could do," said Dr. Madden of Washington University in St. Louis. "We also hypothesized that women who got a LARC method would have higher rates of continuation and higher rates of satisfaction, compared with women who were using shorter-acting reversible methods."

Study participants included 9,256 women who lived in either the city of St. Louis or St. Louis County. The women were 14-45 years of age, were either currently sexually active or planning on becoming sexually active, did not want to become pregnant in the next 12 months, and were willing to start a new contraceptive method. Two-thirds of the participants enrolled at the Washington University School of Medicine, while the remainder enrolled at one of 13 partner community clinics.

Participants who enrolled in the clinical university site underwent formal standardized counseling. "Trained contraceptive counselors read a script to participants before they enrolled in the project, and they had models to demonstrate the different kinds of contraceptive methods," Dr. Madden explained. Study participants "heard about contraceptive methods in a tier-based approach, so they heard about the most effective methods first." Those who enrolled at the community clinic underwent "usual" counseling.

In a study from the first 5,087 enrolled in the Contraceptive CHOICE Project, Dr. Madden and her associates reported that at 12 months, 86% of patients who chose a LARC were still using it, compared with only 55% of those who chose a non-LARC method (Obstet. Gynecol. 2011;117:1105-13). This closely mirrored the percentage of patients who reported overall satisfaction with their chosen birth control method (84% in the LARC group vs. 53% in the non-LARC group). Comparing LARC and non-LARC methods, we see that 84% of participants were satisfied with their LARC method at 12-months, compared with 53% of participants using non-LARC methods.

At the meeting, Dr. Madden discussed preliminary findings from the overall study population, as well as from a cohort of 1,404 adolescents in CHOICE, who were aged 14-19 at the time of enrollment. Of the adolescents, 63% were black, 30% were white, and the rest were from other racial groups. Half of the teens had a prior pregnancy.

A full 75% of women in the overall population chose an IUD or an implant, compared with 72% of the adolescents, "which is still pretty high," Dr. Madden said. Implant use in the overall population was 17%, compared with 34% among adolescents. "Implants were more acceptable to the younger teens, and IUDs become more acceptable to the older teens," she noted.

Only 7% of those under age 20 years discontinued any LARC by 6 months, compared with 8% of those aged 20 years and older, a difference that was not statistically significant (P = .17). "I’m hoping this can help put to bed the notion that teens get these [LARC] methods and then decide 6 weeks later that they want the [device] out," Dr. Madden said. "This does not happen in most cases."

The annual pregnancy rate among adolescents in CHOICE who chose a LARC was 29.9/1,000, compared with the 2008 U.S. teen pregnancy rate of 67.8/1,000, a reduction of 56%.

The findings matter, she added, "because LARCs really are better at preventing unintended pregnancy compared with non-LARC methods. Our follow-up rates at 1 year are greater than 90%. We found that women who were using contraceptive pills, patches, or rings had a 20-fold increased risk of unintended pregnancy, compared with women using a LARC method. We also found that LARCs were just as effective in young women compared with older women."

Dr. Madden predicted that consumer interest in LARCs will continue to grow because "more women and adolescents are asking for these methods. They’re reading about them online and people are blogging about them, so they’re more empowered to ask for them."

Dr. Madden disclosed that she receives honoraria for serving on an advisory board for Bayer Healthcare Pharmaceuticals and that she receives research funding from Merck.

[email protected]

SAN DIEGO – Most ovarian cysts in adolescents will resolve, but those greater than 100 mL in size are the most predictive of ovarian pathology and need for surgical intervention.

The findings, presented during a poster session at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, come from a study of 78 adolescent females at Children’s Mercy Hospital, Kansas City, who were given a diagnostic ICD-9 code consistent with ovarian cyst or mass between 2004 and 2012.

"There is insufficient documentation that most cysts will either decrease in size or resolve, but clear criteria for conservative management in this group has not been described," researchers led by Dr. Crystal Meacham wrote in the poster. "When indicated, laparoscopic intervention of ovarian cysts in adolescents has been well studied and is the preferred surgical approach."

In an effort to determine predictive characteristics that would aid in safe observation and expectant management versus the need for surgical intervention, Dr. Meacham and her associates limited their analysis to adolescents with ovarian cysts greater than or equal to 3 cm in largest diameter on imaging. They recorded cyst volume at initial presentation and follow-up imaging was recorded. Cysts were categorized into three groups based on size: small (0-49 mL), medium (50-100 mL), and large (greater than 100 mL).

The average cyst volume at initial imaging was 62.17 mL, while the average volume at follow-up imaging was 25.81 mL, a reduction that reached statistical significance (P is less than .0001). Of the 78 cysts, 61 (90%) resolved and 17 did not. The researchers found that cysts in the large-volume category were most likely to persist and require surgical intervention.

"Level of cyst complexity is not a predictive characteristic for ovarian cyst resolution nor an indication for surgical management," they wrote. "The pathology most consistent with cysts of the large-volume category, and thus requiring surgery, is serous cystadenoma. Large cyst volume is most predictive of ovarian pathology and need for surgical intervention."

The researchers had no relevant financial disclosures.

[email protected]

SAN DIEGO – Most ovarian cysts in adolescents will resolve, but those greater than 100 mL in size are the most predictive of ovarian pathology and need for surgical intervention.

The findings, presented during a poster session at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, come from a study of 78 adolescent females at Children’s Mercy Hospital, Kansas City, who were given a diagnostic ICD-9 code consistent with ovarian cyst or mass between 2004 and 2012.

"There is insufficient documentation that most cysts will either decrease in size or resolve, but clear criteria for conservative management in this group has not been described," researchers led by Dr. Crystal Meacham wrote in the poster. "When indicated, laparoscopic intervention of ovarian cysts in adolescents has been well studied and is the preferred surgical approach."

In an effort to determine predictive characteristics that would aid in safe observation and expectant management versus the need for surgical intervention, Dr. Meacham and her associates limited their analysis to adolescents with ovarian cysts greater than or equal to 3 cm in largest diameter on imaging. They recorded cyst volume at initial presentation and follow-up imaging was recorded. Cysts were categorized into three groups based on size: small (0-49 mL), medium (50-100 mL), and large (greater than 100 mL).

The average cyst volume at initial imaging was 62.17 mL, while the average volume at follow-up imaging was 25.81 mL, a reduction that reached statistical significance (P is less than .0001). Of the 78 cysts, 61 (90%) resolved and 17 did not. The researchers found that cysts in the large-volume category were most likely to persist and require surgical intervention.

"Level of cyst complexity is not a predictive characteristic for ovarian cyst resolution nor an indication for surgical management," they wrote. "The pathology most consistent with cysts of the large-volume category, and thus requiring surgery, is serous cystadenoma. Large cyst volume is most predictive of ovarian pathology and need for surgical intervention."

The researchers had no relevant financial disclosures.

[email protected]

SAN DIEGO – Most ovarian cysts in adolescents will resolve, but those greater than 100 mL in size are the most predictive of ovarian pathology and need for surgical intervention.

The findings, presented during a poster session at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, come from a study of 78 adolescent females at Children’s Mercy Hospital, Kansas City, who were given a diagnostic ICD-9 code consistent with ovarian cyst or mass between 2004 and 2012.

"There is insufficient documentation that most cysts will either decrease in size or resolve, but clear criteria for conservative management in this group has not been described," researchers led by Dr. Crystal Meacham wrote in the poster. "When indicated, laparoscopic intervention of ovarian cysts in adolescents has been well studied and is the preferred surgical approach."

In an effort to determine predictive characteristics that would aid in safe observation and expectant management versus the need for surgical intervention, Dr. Meacham and her associates limited their analysis to adolescents with ovarian cysts greater than or equal to 3 cm in largest diameter on imaging. They recorded cyst volume at initial presentation and follow-up imaging was recorded. Cysts were categorized into three groups based on size: small (0-49 mL), medium (50-100 mL), and large (greater than 100 mL).

The average cyst volume at initial imaging was 62.17 mL, while the average volume at follow-up imaging was 25.81 mL, a reduction that reached statistical significance (P is less than .0001). Of the 78 cysts, 61 (90%) resolved and 17 did not. The researchers found that cysts in the large-volume category were most likely to persist and require surgical intervention.

"Level of cyst complexity is not a predictive characteristic for ovarian cyst resolution nor an indication for surgical management," they wrote. "The pathology most consistent with cysts of the large-volume category, and thus requiring surgery, is serous cystadenoma. Large cyst volume is most predictive of ovarian pathology and need for surgical intervention."

The researchers had no relevant financial disclosures.

[email protected]

SAN DIEGO – Counseling adolescent females about the use of long-acting reversible contraceptives can be tricky business because not all of them will be forthright with clinicians about their reproductive life needs during office visits.

At the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Aparna Sridhar emphasized the four key components of LARC use in teens: counseling, confidentiality, consent, and cost.

She highlighted the importance of establishing confidentiality before counseling teens on the use of LARCs. Start the dialogue by informing the patient that "all services are provided to you in confidence. Our discussion about birth control methods will remain private unless you give me written permission to share it with someone else," she recommended.

Before discussing LARCs specifically, Dr. Sridhar asks the patient about her readiness for pregnancy, as birth control methods work best when integrated with a reproductive life plan. Sample questions may include: How old do you want to be when you have your first/next child? Why then and not now? How would it be for you if you got pregnant by accident right now? How would your partner feel?

Next, ask specific questions to assess the patient’s fears, worries, and negative information they may have about LARC options. "Do not wait for the adolescent patient to raise concerns," said Dr. Sridhar, a clinical fellow in family planning in the department of obstetrics and gynecology at the University of California, Los Angeles. "Explain in nontechnical terms how each long-acting method works to prevent pregnancy, and assure patients that they can always share concerns and worries."

She also recommends that clinicians elicit what the patient knows about contraceptive methods, ask permission before providing information, and elicit the patient’s reaction to information or advice by asking a question such as, "How would you feel about using this method?" Dr. Sridhar also makes it a point to offer condoms to teen women seeking advice about LARCs and counsels them about the correct way to use them for protection against sexually transmitted infections.

Currently, no state or federal laws require minors to obtain parental consent to get contraception. "Two federal programs – Title X and Medicaid – protect teens’ privacy and prohibit parental consent requirements for teens seeking contraception," she said. "Teens and minors have a right to privacy that includes their ability to use contraception."

Dr. Sridhar said that she had no relevant financial disclosures.

[email protected]

SAN DIEGO – Counseling adolescent females about the use of long-acting reversible contraceptives can be tricky business because not all of them will be forthright with clinicians about their reproductive life needs during office visits.

At the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Aparna Sridhar emphasized the four key components of LARC use in teens: counseling, confidentiality, consent, and cost.

She highlighted the importance of establishing confidentiality before counseling teens on the use of LARCs. Start the dialogue by informing the patient that "all services are provided to you in confidence. Our discussion about birth control methods will remain private unless you give me written permission to share it with someone else," she recommended.

Before discussing LARCs specifically, Dr. Sridhar asks the patient about her readiness for pregnancy, as birth control methods work best when integrated with a reproductive life plan. Sample questions may include: How old do you want to be when you have your first/next child? Why then and not now? How would it be for you if you got pregnant by accident right now? How would your partner feel?

Next, ask specific questions to assess the patient’s fears, worries, and negative information they may have about LARC options. "Do not wait for the adolescent patient to raise concerns," said Dr. Sridhar, a clinical fellow in family planning in the department of obstetrics and gynecology at the University of California, Los Angeles. "Explain in nontechnical terms how each long-acting method works to prevent pregnancy, and assure patients that they can always share concerns and worries."

She also recommends that clinicians elicit what the patient knows about contraceptive methods, ask permission before providing information, and elicit the patient’s reaction to information or advice by asking a question such as, "How would you feel about using this method?" Dr. Sridhar also makes it a point to offer condoms to teen women seeking advice about LARCs and counsels them about the correct way to use them for protection against sexually transmitted infections.

Currently, no state or federal laws require minors to obtain parental consent to get contraception. "Two federal programs – Title X and Medicaid – protect teens’ privacy and prohibit parental consent requirements for teens seeking contraception," she said. "Teens and minors have a right to privacy that includes their ability to use contraception."

Dr. Sridhar said that she had no relevant financial disclosures.

[email protected]

SAN DIEGO – Counseling adolescent females about the use of long-acting reversible contraceptives can be tricky business because not all of them will be forthright with clinicians about their reproductive life needs during office visits.

At the annual meeting of the North American Society for Pediatric and Adolescent Gynecology, Dr. Aparna Sridhar emphasized the four key components of LARC use in teens: counseling, confidentiality, consent, and cost.

She highlighted the importance of establishing confidentiality before counseling teens on the use of LARCs. Start the dialogue by informing the patient that "all services are provided to you in confidence. Our discussion about birth control methods will remain private unless you give me written permission to share it with someone else," she recommended.

Before discussing LARCs specifically, Dr. Sridhar asks the patient about her readiness for pregnancy, as birth control methods work best when integrated with a reproductive life plan. Sample questions may include: How old do you want to be when you have your first/next child? Why then and not now? How would it be for you if you got pregnant by accident right now? How would your partner feel?

Next, ask specific questions to assess the patient’s fears, worries, and negative information they may have about LARC options. "Do not wait for the adolescent patient to raise concerns," said Dr. Sridhar, a clinical fellow in family planning in the department of obstetrics and gynecology at the University of California, Los Angeles. "Explain in nontechnical terms how each long-acting method works to prevent pregnancy, and assure patients that they can always share concerns and worries."

She also recommends that clinicians elicit what the patient knows about contraceptive methods, ask permission before providing information, and elicit the patient’s reaction to information or advice by asking a question such as, "How would you feel about using this method?" Dr. Sridhar also makes it a point to offer condoms to teen women seeking advice about LARCs and counsels them about the correct way to use them for protection against sexually transmitted infections.

Currently, no state or federal laws require minors to obtain parental consent to get contraception. "Two federal programs – Title X and Medicaid – protect teens’ privacy and prohibit parental consent requirements for teens seeking contraception," she said. "Teens and minors have a right to privacy that includes their ability to use contraception."

Dr. Sridhar said that she had no relevant financial disclosures.

[email protected]

SAN DIEGO – Adolescents who participated in a centering pregnancy program were more likely to obtain long-acting reversible contraception and were less likely to have postpartum depression, compared with their peers in two control groups, results from a single-center study demonstrated.

"Although the number of adolescent pregnancies each year has declined, it’s still a major issue facing our teens," Dr. Gayatri Chhatre said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"The United States has the highest teen pregnancy rate in the Western industrialized world, with 418,870 teen pregnancies in 2012 alone [Curr. Opin. Pediatr. 2012;24:446-52]. This is a huge problem because adolescents in pregnancy are at increased risk for adverse outcomes, including gestational morbidity and mortality, low-birth-weight infants, excessive weight gain in pregnancy, and most importantly, repeat unintended pregnancy," said Dr. Chhatre, a fourth-year resident at Washington (D.C.) Hospital Medical Center.

One way to address this issue, she said, is with centering pregnancy (CP), a program developed by nurse practitioner Sharon Schindler Rising in the 1990s. Dr. Chhatre described CP as "a model of care that aims to provide all components of prenatal care in one accessible process. Visits are divided into one-on-one time with providers, as well as group discussions with 8-12 women at similar gestational ages on various topics ranging from what to expect in pregnancy to what to expect postpartum and contraception options."

For the current study, Dr. Chhatre and her associates reviewed 150 adolescent females aged 21 years and younger who received prenatal care through the ob.gyn. clinics at the medical center between 2008 and 2012. Fifty of the patients participated in a CP program while patients in two other groups served as time- and age-matched controls: 50 who received single-provider prenatal care (SPPC) and 50 who received multiple-provider prenatal care (MPPC).

Outcome measures evaluated included weight gain during pregnancy, missed prenatal care appointments, feeding method, postpartum follow-up, and postpartum contraception. The researchers used chi-square analysis to compare outcomes between the three groups at a two-tailed alpha of 0.05.

Dr Chhatre reported that the only statistically significant difference in demographics was a slightly higher proportion of African American patients in the CP group than in the MPPC group (96 vs. 88%, respectively). No difference in preexisting medical conditions, nulliparous status, or substance abuse was observed among the three groups.

More than half of patients in the CP group (62%) met Institute of Medicine guidelines for weight gain during pregnancy, compared with 37% of those in the MPPC group and 40% of those in the SPPC group, a difference that was statistically significant compared with both control groups. However, there were no differences between the three groups in the rates of preterm delivery, cesarean section, or admission to the neonatal intensive care unit.

Adolescents in the SPPC group were more likely to solely breast-feed compared with those in the CP or MPPC groups (50% vs. 40% and 20%, respectively), while patients in the CP group were significantly more likely to include breast-feeding with their bottle-feeding compared with those in the MPPC or SPPC groups (32% vs. 14% and 10%, respectively). In addition, a significantly higher proportion of patients in the CP group were compliant with the 6-week postpartum visit compared with those in the SPPC group (68% vs. 42%; the rate for the MPPC group was 49%).

The researchers also found that patients in the CP group were significantly more likely to obtain postpartum long-acting reversible contraception than patients in the MPPC or SPPC groups (76% vs. 53% and 54%, respectively). Patients in the CP group also were significantly less likely to have a repeat pregnancy within 12 months than were patients in the MPPC group (2% vs. 17%).

Finally, no patients in the CP group received a diagnosis of postpartum depression, compared with 4% of those in the MPPC group and 2% of those in the SPPC group, a difference that reached statistical significance.

Dr. Chhatre said that she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Adolescents who participated in a centering pregnancy program were more likely to obtain long-acting reversible contraception and were less likely to have postpartum depression, compared with their peers in two control groups, results from a single-center study demonstrated.

"Although the number of adolescent pregnancies each year has declined, it’s still a major issue facing our teens," Dr. Gayatri Chhatre said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"The United States has the highest teen pregnancy rate in the Western industrialized world, with 418,870 teen pregnancies in 2012 alone [Curr. Opin. Pediatr. 2012;24:446-52]. This is a huge problem because adolescents in pregnancy are at increased risk for adverse outcomes, including gestational morbidity and mortality, low-birth-weight infants, excessive weight gain in pregnancy, and most importantly, repeat unintended pregnancy," said Dr. Chhatre, a fourth-year resident at Washington (D.C.) Hospital Medical Center.

One way to address this issue, she said, is with centering pregnancy (CP), a program developed by nurse practitioner Sharon Schindler Rising in the 1990s. Dr. Chhatre described CP as "a model of care that aims to provide all components of prenatal care in one accessible process. Visits are divided into one-on-one time with providers, as well as group discussions with 8-12 women at similar gestational ages on various topics ranging from what to expect in pregnancy to what to expect postpartum and contraception options."

For the current study, Dr. Chhatre and her associates reviewed 150 adolescent females aged 21 years and younger who received prenatal care through the ob.gyn. clinics at the medical center between 2008 and 2012. Fifty of the patients participated in a CP program while patients in two other groups served as time- and age-matched controls: 50 who received single-provider prenatal care (SPPC) and 50 who received multiple-provider prenatal care (MPPC).

Outcome measures evaluated included weight gain during pregnancy, missed prenatal care appointments, feeding method, postpartum follow-up, and postpartum contraception. The researchers used chi-square analysis to compare outcomes between the three groups at a two-tailed alpha of 0.05.

Dr Chhatre reported that the only statistically significant difference in demographics was a slightly higher proportion of African American patients in the CP group than in the MPPC group (96 vs. 88%, respectively). No difference in preexisting medical conditions, nulliparous status, or substance abuse was observed among the three groups.

More than half of patients in the CP group (62%) met Institute of Medicine guidelines for weight gain during pregnancy, compared with 37% of those in the MPPC group and 40% of those in the SPPC group, a difference that was statistically significant compared with both control groups. However, there were no differences between the three groups in the rates of preterm delivery, cesarean section, or admission to the neonatal intensive care unit.

Adolescents in the SPPC group were more likely to solely breast-feed compared with those in the CP or MPPC groups (50% vs. 40% and 20%, respectively), while patients in the CP group were significantly more likely to include breast-feeding with their bottle-feeding compared with those in the MPPC or SPPC groups (32% vs. 14% and 10%, respectively). In addition, a significantly higher proportion of patients in the CP group were compliant with the 6-week postpartum visit compared with those in the SPPC group (68% vs. 42%; the rate for the MPPC group was 49%).

The researchers also found that patients in the CP group were significantly more likely to obtain postpartum long-acting reversible contraception than patients in the MPPC or SPPC groups (76% vs. 53% and 54%, respectively). Patients in the CP group also were significantly less likely to have a repeat pregnancy within 12 months than were patients in the MPPC group (2% vs. 17%).

Finally, no patients in the CP group received a diagnosis of postpartum depression, compared with 4% of those in the MPPC group and 2% of those in the SPPC group, a difference that reached statistical significance.

Dr. Chhatre said that she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Adolescents who participated in a centering pregnancy program were more likely to obtain long-acting reversible contraception and were less likely to have postpartum depression, compared with their peers in two control groups, results from a single-center study demonstrated.

"Although the number of adolescent pregnancies each year has declined, it’s still a major issue facing our teens," Dr. Gayatri Chhatre said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"The United States has the highest teen pregnancy rate in the Western industrialized world, with 418,870 teen pregnancies in 2012 alone [Curr. Opin. Pediatr. 2012;24:446-52]. This is a huge problem because adolescents in pregnancy are at increased risk for adverse outcomes, including gestational morbidity and mortality, low-birth-weight infants, excessive weight gain in pregnancy, and most importantly, repeat unintended pregnancy," said Dr. Chhatre, a fourth-year resident at Washington (D.C.) Hospital Medical Center.

One way to address this issue, she said, is with centering pregnancy (CP), a program developed by nurse practitioner Sharon Schindler Rising in the 1990s. Dr. Chhatre described CP as "a model of care that aims to provide all components of prenatal care in one accessible process. Visits are divided into one-on-one time with providers, as well as group discussions with 8-12 women at similar gestational ages on various topics ranging from what to expect in pregnancy to what to expect postpartum and contraception options."

For the current study, Dr. Chhatre and her associates reviewed 150 adolescent females aged 21 years and younger who received prenatal care through the ob.gyn. clinics at the medical center between 2008 and 2012. Fifty of the patients participated in a CP program while patients in two other groups served as time- and age-matched controls: 50 who received single-provider prenatal care (SPPC) and 50 who received multiple-provider prenatal care (MPPC).

Outcome measures evaluated included weight gain during pregnancy, missed prenatal care appointments, feeding method, postpartum follow-up, and postpartum contraception. The researchers used chi-square analysis to compare outcomes between the three groups at a two-tailed alpha of 0.05.

Dr Chhatre reported that the only statistically significant difference in demographics was a slightly higher proportion of African American patients in the CP group than in the MPPC group (96 vs. 88%, respectively). No difference in preexisting medical conditions, nulliparous status, or substance abuse was observed among the three groups.

More than half of patients in the CP group (62%) met Institute of Medicine guidelines for weight gain during pregnancy, compared with 37% of those in the MPPC group and 40% of those in the SPPC group, a difference that was statistically significant compared with both control groups. However, there were no differences between the three groups in the rates of preterm delivery, cesarean section, or admission to the neonatal intensive care unit.

Adolescents in the SPPC group were more likely to solely breast-feed compared with those in the CP or MPPC groups (50% vs. 40% and 20%, respectively), while patients in the CP group were significantly more likely to include breast-feeding with their bottle-feeding compared with those in the MPPC or SPPC groups (32% vs. 14% and 10%, respectively). In addition, a significantly higher proportion of patients in the CP group were compliant with the 6-week postpartum visit compared with those in the SPPC group (68% vs. 42%; the rate for the MPPC group was 49%).

The researchers also found that patients in the CP group were significantly more likely to obtain postpartum long-acting reversible contraception than patients in the MPPC or SPPC groups (76% vs. 53% and 54%, respectively). Patients in the CP group also were significantly less likely to have a repeat pregnancy within 12 months than were patients in the MPPC group (2% vs. 17%).

Finally, no patients in the CP group received a diagnosis of postpartum depression, compared with 4% of those in the MPPC group and 2% of those in the SPPC group, a difference that reached statistical significance.

Dr. Chhatre said that she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Long-acting reversible contraceptive devices appear safe and effective for adolescents with congenital heart defects and cardiovascular disease, results from a retrospective case series demonstrated.

"Pregnancies can be complicated for patients with congenital cardiac defects," Dr. Anne-Marie Amies Oelschlager said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "Physiologic changes of pregnancy pose an increased risk of complications in women with congenital cardiac anomalies. We know that the levonorgestrel-releasing intrauterine system [LNG-IUS] is effective for heavy menstrual bleeding, endometriosis, and dysmenorrhea. Long-acting reversible contraceptive [LARC] methods also have minimal interaction with other medications, they’re not known to exacerbate hypertension, and they are not known to be thrombogenic."

In one published prospective study of 40 patients aged 20 and older with heart disease who used the copper intrauterine device, no cases of endocarditis occurred (Contraception 2008; 78:315-8). One patient had pelvic inflammatory disease, and there were no expulsions, pregnancies, or early removals other than those due to a desire for pregnancy.

"However, there is limited data regarding the safety and efficacy of LARCs in adolescents with congenital cardiac defects and cardiovascular disease," said Dr. Amies Oelschlager, director of pediatric and adolescent gynecology in the department of obstetrics and gynecology at the University of Washington, Seattle.

In an effort to evaluate the safety and efficacy of LARC methods in adolescents with cardiovascular conditions, she and her associates conducted a retrospective chart study of 30 patients with congenital cardiac anomalies or other cardiovascular disease who were aged 22 or younger and who had a LARC device placed at Seattle Children’s Hospital or at the University of Washington Medical Center between Jan. 1, 2007, and March 1, 2012. The average age on device insertion was 18 years, and 12 patients (40%) reported a previous pregnancy. Contraception was the most commonly cited reason for placement (73%), followed by heavy menstrual bleeding and menstrual suppression (20% each).

All but one of the patients had structural lesions. The most common was ventricular septal defect, which affected six patients (20%). There were also five patients with cardiomyopathy (17%). One patient had rheumatic heart disease, and one had familial tachyarrhythmia.

In the 30 patients studied, 31 devices were placed: 27 LNG IUS in 26 patients (1 patient experienced expulsion of the device and subsequently had another one placed), 1 copper IUD in 1 patient, and 3 etonogestrel implants in 3 patients.

Ten patients (33%) had their IUDs placed immediately after delivery or at their postpartum visit. For the remainder of the patients who did not have their IUDs placed post partum, nine of the IUDs were placed in the clinic (31%), and eight were placed in the operating room (28%).

There were no cases of endocarditis, but two patients experienced subsequent pregnancies. "One occurred 3 months post expulsion, in a patient who was not using a contraceptive," Dr. Amies Oelschlager noted. "The other [patient] had postpartum placement. However, the date of removal was not noted and was reported as a desired pregnancy. Our assumption from our review is that this was a case of a desired removal for a desired pregnancy."

The researchers observed no cases of pelvic inflammatory disease or pregnancies while the implants and IUDs were in place. Twenty-seven of the patients (90%) were continuing LARC use at last follow-up.

Dr. Amies Oelschlager acknowledged certain limitations of the study, including its retrospective design and the potential for selection bias. Also, the duration of IUD use was less than 5 years, and the duration of etonogestrel implant use was less than 3 years. "So we don’t know what the expulsion rates would be farther out, and we don’t know if there will be a higher rate of contraceptive failure in the later years using these devices," she said. For now, "we recommend close monitoring and follow-up with these patients to confirm that their rate of expulsion is low and that they’re receiving adequate contraception."

Dr. Amies Oelschlager said she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Long-acting reversible contraceptive devices appear safe and effective for adolescents with congenital heart defects and cardiovascular disease, results from a retrospective case series demonstrated.

"Pregnancies can be complicated for patients with congenital cardiac defects," Dr. Anne-Marie Amies Oelschlager said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "Physiologic changes of pregnancy pose an increased risk of complications in women with congenital cardiac anomalies. We know that the levonorgestrel-releasing intrauterine system [LNG-IUS] is effective for heavy menstrual bleeding, endometriosis, and dysmenorrhea. Long-acting reversible contraceptive [LARC] methods also have minimal interaction with other medications, they’re not known to exacerbate hypertension, and they are not known to be thrombogenic."

In one published prospective study of 40 patients aged 20 and older with heart disease who used the copper intrauterine device, no cases of endocarditis occurred (Contraception 2008; 78:315-8). One patient had pelvic inflammatory disease, and there were no expulsions, pregnancies, or early removals other than those due to a desire for pregnancy.

"However, there is limited data regarding the safety and efficacy of LARCs in adolescents with congenital cardiac defects and cardiovascular disease," said Dr. Amies Oelschlager, director of pediatric and adolescent gynecology in the department of obstetrics and gynecology at the University of Washington, Seattle.

In an effort to evaluate the safety and efficacy of LARC methods in adolescents with cardiovascular conditions, she and her associates conducted a retrospective chart study of 30 patients with congenital cardiac anomalies or other cardiovascular disease who were aged 22 or younger and who had a LARC device placed at Seattle Children’s Hospital or at the University of Washington Medical Center between Jan. 1, 2007, and March 1, 2012. The average age on device insertion was 18 years, and 12 patients (40%) reported a previous pregnancy. Contraception was the most commonly cited reason for placement (73%), followed by heavy menstrual bleeding and menstrual suppression (20% each).

All but one of the patients had structural lesions. The most common was ventricular septal defect, which affected six patients (20%). There were also five patients with cardiomyopathy (17%). One patient had rheumatic heart disease, and one had familial tachyarrhythmia.

In the 30 patients studied, 31 devices were placed: 27 LNG IUS in 26 patients (1 patient experienced expulsion of the device and subsequently had another one placed), 1 copper IUD in 1 patient, and 3 etonogestrel implants in 3 patients.

Ten patients (33%) had their IUDs placed immediately after delivery or at their postpartum visit. For the remainder of the patients who did not have their IUDs placed post partum, nine of the IUDs were placed in the clinic (31%), and eight were placed in the operating room (28%).

There were no cases of endocarditis, but two patients experienced subsequent pregnancies. "One occurred 3 months post expulsion, in a patient who was not using a contraceptive," Dr. Amies Oelschlager noted. "The other [patient] had postpartum placement. However, the date of removal was not noted and was reported as a desired pregnancy. Our assumption from our review is that this was a case of a desired removal for a desired pregnancy."

The researchers observed no cases of pelvic inflammatory disease or pregnancies while the implants and IUDs were in place. Twenty-seven of the patients (90%) were continuing LARC use at last follow-up.

Dr. Amies Oelschlager acknowledged certain limitations of the study, including its retrospective design and the potential for selection bias. Also, the duration of IUD use was less than 5 years, and the duration of etonogestrel implant use was less than 3 years. "So we don’t know what the expulsion rates would be farther out, and we don’t know if there will be a higher rate of contraceptive failure in the later years using these devices," she said. For now, "we recommend close monitoring and follow-up with these patients to confirm that their rate of expulsion is low and that they’re receiving adequate contraception."

Dr. Amies Oelschlager said she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Long-acting reversible contraceptive devices appear safe and effective for adolescents with congenital heart defects and cardiovascular disease, results from a retrospective case series demonstrated.

"Pregnancies can be complicated for patients with congenital cardiac defects," Dr. Anne-Marie Amies Oelschlager said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "Physiologic changes of pregnancy pose an increased risk of complications in women with congenital cardiac anomalies. We know that the levonorgestrel-releasing intrauterine system [LNG-IUS] is effective for heavy menstrual bleeding, endometriosis, and dysmenorrhea. Long-acting reversible contraceptive [LARC] methods also have minimal interaction with other medications, they’re not known to exacerbate hypertension, and they are not known to be thrombogenic."

In one published prospective study of 40 patients aged 20 and older with heart disease who used the copper intrauterine device, no cases of endocarditis occurred (Contraception 2008; 78:315-8). One patient had pelvic inflammatory disease, and there were no expulsions, pregnancies, or early removals other than those due to a desire for pregnancy.

"However, there is limited data regarding the safety and efficacy of LARCs in adolescents with congenital cardiac defects and cardiovascular disease," said Dr. Amies Oelschlager, director of pediatric and adolescent gynecology in the department of obstetrics and gynecology at the University of Washington, Seattle.

In an effort to evaluate the safety and efficacy of LARC methods in adolescents with cardiovascular conditions, she and her associates conducted a retrospective chart study of 30 patients with congenital cardiac anomalies or other cardiovascular disease who were aged 22 or younger and who had a LARC device placed at Seattle Children’s Hospital or at the University of Washington Medical Center between Jan. 1, 2007, and March 1, 2012. The average age on device insertion was 18 years, and 12 patients (40%) reported a previous pregnancy. Contraception was the most commonly cited reason for placement (73%), followed by heavy menstrual bleeding and menstrual suppression (20% each).

All but one of the patients had structural lesions. The most common was ventricular septal defect, which affected six patients (20%). There were also five patients with cardiomyopathy (17%). One patient had rheumatic heart disease, and one had familial tachyarrhythmia.

In the 30 patients studied, 31 devices were placed: 27 LNG IUS in 26 patients (1 patient experienced expulsion of the device and subsequently had another one placed), 1 copper IUD in 1 patient, and 3 etonogestrel implants in 3 patients.

Ten patients (33%) had their IUDs placed immediately after delivery or at their postpartum visit. For the remainder of the patients who did not have their IUDs placed post partum, nine of the IUDs were placed in the clinic (31%), and eight were placed in the operating room (28%).

There were no cases of endocarditis, but two patients experienced subsequent pregnancies. "One occurred 3 months post expulsion, in a patient who was not using a contraceptive," Dr. Amies Oelschlager noted. "The other [patient] had postpartum placement. However, the date of removal was not noted and was reported as a desired pregnancy. Our assumption from our review is that this was a case of a desired removal for a desired pregnancy."

The researchers observed no cases of pelvic inflammatory disease or pregnancies while the implants and IUDs were in place. Twenty-seven of the patients (90%) were continuing LARC use at last follow-up.

Dr. Amies Oelschlager acknowledged certain limitations of the study, including its retrospective design and the potential for selection bias. Also, the duration of IUD use was less than 5 years, and the duration of etonogestrel implant use was less than 3 years. "So we don’t know what the expulsion rates would be farther out, and we don’t know if there will be a higher rate of contraceptive failure in the later years using these devices," she said. For now, "we recommend close monitoring and follow-up with these patients to confirm that their rate of expulsion is low and that they’re receiving adequate contraception."

Dr. Amies Oelschlager said she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – Inconsistent diagnostic and treatment practices for the diagnosis of adolescent polycystic ovary syndrome exist among clinicians in adolescent medicine, gynecology, and endocrinology, results from a single-center, retrospective study demonstrated.

The differences "could reflect provider comfort within their specialty and how their specialty approaches these symptoms," Sarah Powers said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Many criteria exist for the diagnosis of polycystic ovary syndrome (PCOS), said Ms. Powers of Georgetown University in Washington. The National Institutes of Health criteria from 1990 state that, to make the diagnosis, menstrual irregularity and androgen excess must be present, as well as no other possible etiologies for the diagnosis. According to the Rotterdam criteria from 2003, patients must have two of three factors to meet the diagnosis: menstrual irregularity, evidence of androgen excess based on clinical or laboratory data, and polycystic ovaries on ultrasound. Meanwhile, the Androgen Excess and PCOS Society guideline from 2006 requires evidence of androgen excess and either menstrual irregularity or polycystic ovaries.

"Adolescents are an interesting subset of PCOS patients," Ms. Powers said. "In the first place, they are difficult to diagnose. Many signs of PCOS are physiologically common within the adolescent population, including menstrual irregularity, acne, and polycystic ovaries. Secondly, does the diagnosis even need to be made in teenagers? How long should we wait after menarche to make the diagnosis? If PCOS is diagnosed and treated early, does this make a difference for the patient?"

In addition, she continued, adolescents with PCOS "can present to a number of specialties, including adolescent medicine, gynecology, and endocrinology." In an effort to assess how these pediatric subspecialties would work up, diagnose, and treat patients with PCOS, Ms. Powers and her associates conducted a retrospective chart study of 261 postmenarchal females aged 11-18 years from Children’s National Medical Center who had been worked up for or diagnosed with PCOS between June 2009 and October 2011. They excluded patients with a coexisting diagnosis of other primary etiology for amenorrhea.

Of the 261 patients, 144 (55%) were seen by endocrinologists, 9 (3.5%) by gynecologists, and 108 (41.5%) by adolescent medicine specialists. The mean age of patients at the time of their initial work-up was 15 years. There were no significant differences between the three patient populations in age, age at first menses, body mass index, obesity rates, or type of insurance. However, a higher percentage of African American patients were seen by adolescent medicine specialists, compared with clinicians in the other specialties.

Ms. Powers reported that 49% of adolescent medicine specialists ordered lipid tests, compared with 22% of gynecologists and 16% of endocrinologists, a difference that reached statistical significance (P less than .0001). Meanwhile, 44% of gynecologists ordered fasting glucose measures, compared with 38% of adolescent medicine specialists and 22% of endocrinologists, a difference that was also statistically significant (P less than.05). The proportion of HbA_1c and fasting insulin measures ordered were similar among all three groups.

A significantly greater proportion of adolescent medicine specialists (31%; P less than.05) ordered total T₄ labs compared with their counterparts, while rates of ordering androgen labs were about the same in all three specialties. "More than 80% of patients worked up for PCOS had a total testosterone test ordered for them," Ms. Powers said. "Ordering measurements of the other sex hormones was much less consistent. Endocrinologists were more likely to order estradiol while adolescent medicine specialists ordered more prolactin, and gynecologists ordered more 17-hydroxyprogesterone."

In addition, the majority of gynecologists (89%) ordered pelvic ultrasounds, compared with 9% of adolescent medicine specialists and 24% of endocrinologists.

Of all the 261 patients who were worked up for PCOS, 187 (72%) had at least two of the Rotterdam criteria. "Only hirsutism was used as evidence of clinical hyperandrogenism," Ms. Powers said. "Acne was not used as a marker." Of these patients, 33% were diagnosed with PCOS and 38% were diagnosed with likely PCOS. "Some caveat was given: either likely PCOS, possible PCOS, or probable PCOS – some variation on that," she said. Upon chart review, irregular menses and clinical and biochemical evidence of hyperandrogenism were used most often as justification for a PCOS diagnosis.

As for the treatment of patients who met diagnostic criteria for PCOS, metformin was prescribed most often by endocrinologists (58%), compared with 30% of adolescent medicine specialists and 14% of gynecologists. At the same time, oral contraceptives were prescribed most often by adolescent medicine specialists (58%), compared with 43% of gynecologists and 24% of endocrinologists.

Ms. Powers acknowledged certain limitations of the study, including the relatively small number of patients seen by gynecologists. "There were also difficulties capturing patients using the current billing system," she said. "In the long term, it would be useful to collect prospective data to identify the best diagnostic criteria and lab tests for a work-up."

Ms. Powers said she had no relevant financial conflicts.

[email protected]

SAN DIEGO – Inconsistent diagnostic and treatment practices for the diagnosis of adolescent polycystic ovary syndrome exist among clinicians in adolescent medicine, gynecology, and endocrinology, results from a single-center, retrospective study demonstrated.

The differences "could reflect provider comfort within their specialty and how their specialty approaches these symptoms," Sarah Powers said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Many criteria exist for the diagnosis of polycystic ovary syndrome (PCOS), said Ms. Powers of Georgetown University in Washington. The National Institutes of Health criteria from 1990 state that, to make the diagnosis, menstrual irregularity and androgen excess must be present, as well as no other possible etiologies for the diagnosis. According to the Rotterdam criteria from 2003, patients must have two of three factors to meet the diagnosis: menstrual irregularity, evidence of androgen excess based on clinical or laboratory data, and polycystic ovaries on ultrasound. Meanwhile, the Androgen Excess and PCOS Society guideline from 2006 requires evidence of androgen excess and either menstrual irregularity or polycystic ovaries.

"Adolescents are an interesting subset of PCOS patients," Ms. Powers said. "In the first place, they are difficult to diagnose. Many signs of PCOS are physiologically common within the adolescent population, including menstrual irregularity, acne, and polycystic ovaries. Secondly, does the diagnosis even need to be made in teenagers? How long should we wait after menarche to make the diagnosis? If PCOS is diagnosed and treated early, does this make a difference for the patient?"

In addition, she continued, adolescents with PCOS "can present to a number of specialties, including adolescent medicine, gynecology, and endocrinology." In an effort to assess how these pediatric subspecialties would work up, diagnose, and treat patients with PCOS, Ms. Powers and her associates conducted a retrospective chart study of 261 postmenarchal females aged 11-18 years from Children’s National Medical Center who had been worked up for or diagnosed with PCOS between June 2009 and October 2011. They excluded patients with a coexisting diagnosis of other primary etiology for amenorrhea.

Of the 261 patients, 144 (55%) were seen by endocrinologists, 9 (3.5%) by gynecologists, and 108 (41.5%) by adolescent medicine specialists. The mean age of patients at the time of their initial work-up was 15 years. There were no significant differences between the three patient populations in age, age at first menses, body mass index, obesity rates, or type of insurance. However, a higher percentage of African American patients were seen by adolescent medicine specialists, compared with clinicians in the other specialties.

Ms. Powers reported that 49% of adolescent medicine specialists ordered lipid tests, compared with 22% of gynecologists and 16% of endocrinologists, a difference that reached statistical significance (P less than .0001). Meanwhile, 44% of gynecologists ordered fasting glucose measures, compared with 38% of adolescent medicine specialists and 22% of endocrinologists, a difference that was also statistically significant (P less than.05). The proportion of HbA_1c and fasting insulin measures ordered were similar among all three groups.

A significantly greater proportion of adolescent medicine specialists (31%; P less than.05) ordered total T₄ labs compared with their counterparts, while rates of ordering androgen labs were about the same in all three specialties. "More than 80% of patients worked up for PCOS had a total testosterone test ordered for them," Ms. Powers said. "Ordering measurements of the other sex hormones was much less consistent. Endocrinologists were more likely to order estradiol while adolescent medicine specialists ordered more prolactin, and gynecologists ordered more 17-hydroxyprogesterone."

In addition, the majority of gynecologists (89%) ordered pelvic ultrasounds, compared with 9% of adolescent medicine specialists and 24% of endocrinologists.

Of all the 261 patients who were worked up for PCOS, 187 (72%) had at least two of the Rotterdam criteria. "Only hirsutism was used as evidence of clinical hyperandrogenism," Ms. Powers said. "Acne was not used as a marker." Of these patients, 33% were diagnosed with PCOS and 38% were diagnosed with likely PCOS. "Some caveat was given: either likely PCOS, possible PCOS, or probable PCOS – some variation on that," she said. Upon chart review, irregular menses and clinical and biochemical evidence of hyperandrogenism were used most often as justification for a PCOS diagnosis.

As for the treatment of patients who met diagnostic criteria for PCOS, metformin was prescribed most often by endocrinologists (58%), compared with 30% of adolescent medicine specialists and 14% of gynecologists. At the same time, oral contraceptives were prescribed most often by adolescent medicine specialists (58%), compared with 43% of gynecologists and 24% of endocrinologists.

Ms. Powers acknowledged certain limitations of the study, including the relatively small number of patients seen by gynecologists. "There were also difficulties capturing patients using the current billing system," she said. "In the long term, it would be useful to collect prospective data to identify the best diagnostic criteria and lab tests for a work-up."

Ms. Powers said she had no relevant financial conflicts.

[email protected]

SAN DIEGO – Inconsistent diagnostic and treatment practices for the diagnosis of adolescent polycystic ovary syndrome exist among clinicians in adolescent medicine, gynecology, and endocrinology, results from a single-center, retrospective study demonstrated.

The differences "could reflect provider comfort within their specialty and how their specialty approaches these symptoms," Sarah Powers said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Many criteria exist for the diagnosis of polycystic ovary syndrome (PCOS), said Ms. Powers of Georgetown University in Washington. The National Institutes of Health criteria from 1990 state that, to make the diagnosis, menstrual irregularity and androgen excess must be present, as well as no other possible etiologies for the diagnosis. According to the Rotterdam criteria from 2003, patients must have two of three factors to meet the diagnosis: menstrual irregularity, evidence of androgen excess based on clinical or laboratory data, and polycystic ovaries on ultrasound. Meanwhile, the Androgen Excess and PCOS Society guideline from 2006 requires evidence of androgen excess and either menstrual irregularity or polycystic ovaries.

"Adolescents are an interesting subset of PCOS patients," Ms. Powers said. "In the first place, they are difficult to diagnose. Many signs of PCOS are physiologically common within the adolescent population, including menstrual irregularity, acne, and polycystic ovaries. Secondly, does the diagnosis even need to be made in teenagers? How long should we wait after menarche to make the diagnosis? If PCOS is diagnosed and treated early, does this make a difference for the patient?"

In addition, she continued, adolescents with PCOS "can present to a number of specialties, including adolescent medicine, gynecology, and endocrinology." In an effort to assess how these pediatric subspecialties would work up, diagnose, and treat patients with PCOS, Ms. Powers and her associates conducted a retrospective chart study of 261 postmenarchal females aged 11-18 years from Children’s National Medical Center who had been worked up for or diagnosed with PCOS between June 2009 and October 2011. They excluded patients with a coexisting diagnosis of other primary etiology for amenorrhea.

Of the 261 patients, 144 (55%) were seen by endocrinologists, 9 (3.5%) by gynecologists, and 108 (41.5%) by adolescent medicine specialists. The mean age of patients at the time of their initial work-up was 15 years. There were no significant differences between the three patient populations in age, age at first menses, body mass index, obesity rates, or type of insurance. However, a higher percentage of African American patients were seen by adolescent medicine specialists, compared with clinicians in the other specialties.

Ms. Powers reported that 49% of adolescent medicine specialists ordered lipid tests, compared with 22% of gynecologists and 16% of endocrinologists, a difference that reached statistical significance (P less than .0001). Meanwhile, 44% of gynecologists ordered fasting glucose measures, compared with 38% of adolescent medicine specialists and 22% of endocrinologists, a difference that was also statistically significant (P less than.05). The proportion of HbA_1c and fasting insulin measures ordered were similar among all three groups.

A significantly greater proportion of adolescent medicine specialists (31%; P less than.05) ordered total T₄ labs compared with their counterparts, while rates of ordering androgen labs were about the same in all three specialties. "More than 80% of patients worked up for PCOS had a total testosterone test ordered for them," Ms. Powers said. "Ordering measurements of the other sex hormones was much less consistent. Endocrinologists were more likely to order estradiol while adolescent medicine specialists ordered more prolactin, and gynecologists ordered more 17-hydroxyprogesterone."

In addition, the majority of gynecologists (89%) ordered pelvic ultrasounds, compared with 9% of adolescent medicine specialists and 24% of endocrinologists.

Of all the 261 patients who were worked up for PCOS, 187 (72%) had at least two of the Rotterdam criteria. "Only hirsutism was used as evidence of clinical hyperandrogenism," Ms. Powers said. "Acne was not used as a marker." Of these patients, 33% were diagnosed with PCOS and 38% were diagnosed with likely PCOS. "Some caveat was given: either likely PCOS, possible PCOS, or probable PCOS – some variation on that," she said. Upon chart review, irregular menses and clinical and biochemical evidence of hyperandrogenism were used most often as justification for a PCOS diagnosis.

As for the treatment of patients who met diagnostic criteria for PCOS, metformin was prescribed most often by endocrinologists (58%), compared with 30% of adolescent medicine specialists and 14% of gynecologists. At the same time, oral contraceptives were prescribed most often by adolescent medicine specialists (58%), compared with 43% of gynecologists and 24% of endocrinologists.

Ms. Powers acknowledged certain limitations of the study, including the relatively small number of patients seen by gynecologists. "There were also difficulties capturing patients using the current billing system," she said. "In the long term, it would be useful to collect prospective data to identify the best diagnostic criteria and lab tests for a work-up."

Ms. Powers said she had no relevant financial conflicts.

[email protected]

SAN DIEGO – The total recurrence rate of ovarian dermoid cysts in a pediatric and adolescent population following cystectomy is 11%, and evidence of recurrence that requires a second operative management is 3%.

Moreover, the method of surgical intervention – laparoscopy or laparotomy – does not appear to influence the rate of cyst recurrence, Erin Rogers reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Dermoid cysts can represent up to 70% of benign ovarian tumors in women under age 30, said Ms. Rogers, a medical student at Queens University, Kingston, Ontario, Canada. "They have a slow growth rate and on average have been seen to grow at 1.8 mm per year."

The general presentation is an asymptomatic woman who has dermoid cysts that are discovered incidentally through imaging for other reasons. However, some patients can present with abdominal pain or an abdominal mass, she said.

The preferred way to image dermoid cysts is by ultrasound. Clinicians "manage them expectantly if they’re small and not growing that quickly," Ms. Rogers said. "Expectant management involves routine imaging every 6-12 months. Surgery is generally indicated if the cysts reach 4-5 cm in size or if they grow at a rate greater than 2 cm per year. Surgical management includes cystectomy or laparoscopy."

In a study conducted at the Hospital for Sick Children in Toronto, Ms. Rogers and her associates set out to determine the rate of dermoid cyst recurrence after cystectomy in a pediatric/adolescent population; evaluate if the mode of surgery impacts the rate of recurrence; and develop a postsurgical follow-up protocol for dermoid cysts. They retrospectively evaluated 66 patients under age 18 treated with dermoid cystectomy at the hospital between January 2003 and June 2012. Data collected included follow-up information, imaging, and demographic information. Recurrence was defined as any evidence of dermoid cyst on postoperative imaging.

The average age of patients at the time of surgery was 13 years, and the initial cyst size was an average of 8 cm. More than half of patients (61%) underwent laparoscopy, and the rest underwent laparotomy. The follow-up for patients "was quite varied," she said. "This is because the management of these patients is at the discretion of the managing physician." More than one-third of patients (39%) were followed with a single postoperative visit and no ultrasound imaging; 9% were followed with a single follow-up visit and ultrasound; and 53% were followed annually with a follow-up visit and ultrasound.

Seven of the 66 patients had a recurrence (11%). Of the patients with a recurrence, 5 were treated expectantly with imaging alone and 2 were followed with a second operation.

Recurrence occurred in 15% of patients treated with laparoscopy and 4% of patients treated with laparotomy, a difference that did not reach significance (P = .23). However, about 5% of patients who were treated initially with a laparoscopic procedure showed evidence of recurrence that required a second surgery, while none who were treated with a laparotomy showed evidence of recurrence that required a second surgery.

Based on the study results, Ms. Rogers and her associates propose that dermoid cysts treated with cystectomy should involve a single follow-up visit with an ultrasound 12 months postoperatively. "At that time, if there is no dermoid cyst on ultrasound, these patients can be discharged to the care of their family physician or pediatrician and advised to seek medical attention if they have any symptoms that may suggest recurrence," she said. If a dermoid cyst or a cyst of unknown origin is seen on ultrasound, "we suggest that they be followed with a second ultrasound in 3-6 months. If there is no evidence of a dermoid cyst at that time, that cyst can be presumed to have been a functional cyst, and patients can seek medical attention as needed. However, if a dermoid cyst is seen on ultrasound, we suggest they be treated expectantly, with repeat ultrasounds every 6-12 months. We can consider surgery if they become symptomatic or seem to grow at a rapid rate."

Ms. Rogers said that she had no relevant financial conflicts to disclose.

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SAN DIEGO – The total recurrence rate of ovarian dermoid cysts in a pediatric and adolescent population following cystectomy is 11%, and evidence of recurrence that requires a second operative management is 3%.

Moreover, the method of surgical intervention – laparoscopy or laparotomy – does not appear to influence the rate of cyst recurrence, Erin Rogers reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Dermoid cysts can represent up to 70% of benign ovarian tumors in women under age 30, said Ms. Rogers, a medical student at Queens University, Kingston, Ontario, Canada. "They have a slow growth rate and on average have been seen to grow at 1.8 mm per year."

The general presentation is an asymptomatic woman who has dermoid cysts that are discovered incidentally through imaging for other reasons. However, some patients can present with abdominal pain or an abdominal mass, she said.

The preferred way to image dermoid cysts is by ultrasound. Clinicians "manage them expectantly if they’re small and not growing that quickly," Ms. Rogers said. "Expectant management involves routine imaging every 6-12 months. Surgery is generally indicated if the cysts reach 4-5 cm in size or if they grow at a rate greater than 2 cm per year. Surgical management includes cystectomy or laparoscopy."

In a study conducted at the Hospital for Sick Children in Toronto, Ms. Rogers and her associates set out to determine the rate of dermoid cyst recurrence after cystectomy in a pediatric/adolescent population; evaluate if the mode of surgery impacts the rate of recurrence; and develop a postsurgical follow-up protocol for dermoid cysts. They retrospectively evaluated 66 patients under age 18 treated with dermoid cystectomy at the hospital between January 2003 and June 2012. Data collected included follow-up information, imaging, and demographic information. Recurrence was defined as any evidence of dermoid cyst on postoperative imaging.

The average age of patients at the time of surgery was 13 years, and the initial cyst size was an average of 8 cm. More than half of patients (61%) underwent laparoscopy, and the rest underwent laparotomy. The follow-up for patients "was quite varied," she said. "This is because the management of these patients is at the discretion of the managing physician." More than one-third of patients (39%) were followed with a single postoperative visit and no ultrasound imaging; 9% were followed with a single follow-up visit and ultrasound; and 53% were followed annually with a follow-up visit and ultrasound.

Seven of the 66 patients had a recurrence (11%). Of the patients with a recurrence, 5 were treated expectantly with imaging alone and 2 were followed with a second operation.

Recurrence occurred in 15% of patients treated with laparoscopy and 4% of patients treated with laparotomy, a difference that did not reach significance (P = .23). However, about 5% of patients who were treated initially with a laparoscopic procedure showed evidence of recurrence that required a second surgery, while none who were treated with a laparotomy showed evidence of recurrence that required a second surgery.

Based on the study results, Ms. Rogers and her associates propose that dermoid cysts treated with cystectomy should involve a single follow-up visit with an ultrasound 12 months postoperatively. "At that time, if there is no dermoid cyst on ultrasound, these patients can be discharged to the care of their family physician or pediatrician and advised to seek medical attention if they have any symptoms that may suggest recurrence," she said. If a dermoid cyst or a cyst of unknown origin is seen on ultrasound, "we suggest that they be followed with a second ultrasound in 3-6 months. If there is no evidence of a dermoid cyst at that time, that cyst can be presumed to have been a functional cyst, and patients can seek medical attention as needed. However, if a dermoid cyst is seen on ultrasound, we suggest they be treated expectantly, with repeat ultrasounds every 6-12 months. We can consider surgery if they become symptomatic or seem to grow at a rapid rate."

Ms. Rogers said that she had no relevant financial conflicts to disclose.

[email protected]

SAN DIEGO – The total recurrence rate of ovarian dermoid cysts in a pediatric and adolescent population following cystectomy is 11%, and evidence of recurrence that requires a second operative management is 3%.

Moreover, the method of surgical intervention – laparoscopy or laparotomy – does not appear to influence the rate of cyst recurrence, Erin Rogers reported at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Dermoid cysts can represent up to 70% of benign ovarian tumors in women under age 30, said Ms. Rogers, a medical student at Queens University, Kingston, Ontario, Canada. "They have a slow growth rate and on average have been seen to grow at 1.8 mm per year."

The general presentation is an asymptomatic woman who has dermoid cysts that are discovered incidentally through imaging for other reasons. However, some patients can present with abdominal pain or an abdominal mass, she said.

The preferred way to image dermoid cysts is by ultrasound. Clinicians "manage them expectantly if they’re small and not growing that quickly," Ms. Rogers said. "Expectant management involves routine imaging every 6-12 months. Surgery is generally indicated if the cysts reach 4-5 cm in size or if they grow at a rate greater than 2 cm per year. Surgical management includes cystectomy or laparoscopy."

In a study conducted at the Hospital for Sick Children in Toronto, Ms. Rogers and her associates set out to determine the rate of dermoid cyst recurrence after cystectomy in a pediatric/adolescent population; evaluate if the mode of surgery impacts the rate of recurrence; and develop a postsurgical follow-up protocol for dermoid cysts. They retrospectively evaluated 66 patients under age 18 treated with dermoid cystectomy at the hospital between January 2003 and June 2012. Data collected included follow-up information, imaging, and demographic information. Recurrence was defined as any evidence of dermoid cyst on postoperative imaging.

The average age of patients at the time of surgery was 13 years, and the initial cyst size was an average of 8 cm. More than half of patients (61%) underwent laparoscopy, and the rest underwent laparotomy. The follow-up for patients "was quite varied," she said. "This is because the management of these patients is at the discretion of the managing physician." More than one-third of patients (39%) were followed with a single postoperative visit and no ultrasound imaging; 9% were followed with a single follow-up visit and ultrasound; and 53% were followed annually with a follow-up visit and ultrasound.

Seven of the 66 patients had a recurrence (11%). Of the patients with a recurrence, 5 were treated expectantly with imaging alone and 2 were followed with a second operation.

Recurrence occurred in 15% of patients treated with laparoscopy and 4% of patients treated with laparotomy, a difference that did not reach significance (P = .23). However, about 5% of patients who were treated initially with a laparoscopic procedure showed evidence of recurrence that required a second surgery, while none who were treated with a laparotomy showed evidence of recurrence that required a second surgery.

Based on the study results, Ms. Rogers and her associates propose that dermoid cysts treated with cystectomy should involve a single follow-up visit with an ultrasound 12 months postoperatively. "At that time, if there is no dermoid cyst on ultrasound, these patients can be discharged to the care of their family physician or pediatrician and advised to seek medical attention if they have any symptoms that may suggest recurrence," she said. If a dermoid cyst or a cyst of unknown origin is seen on ultrasound, "we suggest that they be followed with a second ultrasound in 3-6 months. If there is no evidence of a dermoid cyst at that time, that cyst can be presumed to have been a functional cyst, and patients can seek medical attention as needed. However, if a dermoid cyst is seen on ultrasound, we suggest they be treated expectantly, with repeat ultrasounds every 6-12 months. We can consider surgery if they become symptomatic or seem to grow at a rapid rate."

Ms. Rogers said that she had no relevant financial conflicts to disclose.

[email protected]