NASPAG Annual Meeting 2012

MIAMI BEACH – Acute menorrhagia or abnormally heavy and prolonged menstrual bleeding can be a serious condition for any adolescent girl, but it becomes even more so if she has an underlying bleeding disorder, according to an expert.

Hormonal therapy, antifibrinolytic therapy, balloon tamponade, and correction of any specific hemostatic defect are the primary management strategies for acute menorrhagia, Dr. Andra H. James said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "It is not clear which therapy should come first and in what order."

This lack of clarity stems in part from a paucity of evidence-based medicine in the literature, said Dr. James, professor of ob.gyn. and assistant professor of medicine at Duke University Medical Center in Durham, N.C.

She recognized the need for more guidance on acute menorrhagia and was the primary author of consensus guidelines on evaluation and management of acute menorrhagia (Eur. J. Obstet. Gynecol. Reprod. Biol. 2011;158:124-34). Dr. James and some international experts systemically reviewed what was in the literature – primarily case reports and expert opinion – to devise recommendations for acute menorrhagia for girls and women with and without underlying bleeding disorders.

Important elements of patient history, physical exam, medication review, and laboratory testing are outlined in the guidelines, as well as advice on when an ultrasound examination is warranted.

Adolescents with acute menorrhagia differ from adults in some important ways. Anticoagulation therapy is rarely a cause of abnormal bleeding in a young woman, but "anovulatory bleeding is often a precipitating factor in adolescence," she said.

In addition, acute signs of an underlying bleeding disorder can first appear during the teenage years, Dr. James said.

Thrombocytopenia, von Willebrand disease, platelet function disorders, and clotting factor deficiencies are among the most relevant bleeding disorders in this setting. "These bleeding disorders are important to gynecologists [because] the leading symptom in the women and girls with a bleeding disorder is heavy menstrual bleeding," she said.

There also are girls and women who present with rare factor deficiency disorders, and the relatively fewer treatment options for these patients are outlined in the guidelines.

"Acute menorrhagia is not a benign condition for an adolescent, whether or not they have a bleeding disorder. They are often seen in an acute setting," Dr. James said. "Heavy menstrual bleeding is pretty morbid for adolescents."

She recommended an eight-question screening tool to identify bleeding disorders in patients with menorrhagia (Am. J. Obstet. Gynecol. 2011;204:209.e1-7). Dr. Claire Philipp of Robert Wood Johnson Medical School, New Brunswick, N.J., and her colleagues developed this screen to help gynecologists and primary care physicians determine which patients to refer for hemostatic work-up. The screening questions fall into four categories: menorrhagia severity, family history of a diagnosed bleeding disorder, personal history of excessive bleeding after specific challenges, and history of treatment for anemia.

"I feel pretty good if they have one of those four, I am going to go ahead and test them," Dr. James said.

The screen is more than 90% sensitive for identification of von Willebrand disease, for example, "and you can avoid testing everyone who says they have heavy menstrual bleeding," said Dr. James, who is also founder of the Duke University Medical Center Women’s Hemostasis and Thrombosis Clinic.

"Dr. Erik von Willebrand, who described von Willebrand disease, lost his first patient to her fourth menstrual period," Dr. James said. "But [now] acute menorrhagia in adolescence can be evaluated and can be managed."

The guideline authors also proposed a consensus definition of acute menorrhagia: life-threatening bleeding of uterine origin with sufficient volume, in the absence of pregnancy or malignancy that occurs during childbearing years (teen to perimenopause). The condition occurs in patients with or without a previously diagnosed bleeding disorder. Patients present to the emergency department and require immediate evaluation and intervention.

The guidelines highlight considerations for hormonal treatment, antifibrinolytic therapy, balloon tamponade, and correction of hemostatic deficiencies. Even though treatment relies to a great deal on clinician judgment, "many of us feel comfortable starting with hormone therapy," she said.

Regarding balloon tamponade therapy, "there are no randomized trials, but there are multiple case reports of its effectiveness in the very acute situation in the emergency department," Dr. James said. "We all have conversations about how long we leave the balloon in." Jokingly, she added: "None of us want to take it out before the woman goes to college."

With a nod to a lack of rigorous studies in the literature, Dr. James proposed that groups such as NASPAG establish registries to collect data on acute menorrhagia evaluation and management. She also recommended www.fwgbd.org, the site for the Foundation for Women & Girls with Blood Disorders, for additional information on bleeding disorders. Dr. James is a board member of the foundation.

Dr. James said that she receives research funding from CSL Behring and Grifols. She is also a member of the von Willebrand disease medical advisory board sponsored by CSL Behring, Octapharma, and Baxter.

MIAMI BEACH – Acute menorrhagia or abnormally heavy and prolonged menstrual bleeding can be a serious condition for any adolescent girl, but it becomes even more so if she has an underlying bleeding disorder, according to an expert.

Hormonal therapy, antifibrinolytic therapy, balloon tamponade, and correction of any specific hemostatic defect are the primary management strategies for acute menorrhagia, Dr. Andra H. James said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "It is not clear which therapy should come first and in what order."

This lack of clarity stems in part from a paucity of evidence-based medicine in the literature, said Dr. James, professor of ob.gyn. and assistant professor of medicine at Duke University Medical Center in Durham, N.C.

She recognized the need for more guidance on acute menorrhagia and was the primary author of consensus guidelines on evaluation and management of acute menorrhagia (Eur. J. Obstet. Gynecol. Reprod. Biol. 2011;158:124-34). Dr. James and some international experts systemically reviewed what was in the literature – primarily case reports and expert opinion – to devise recommendations for acute menorrhagia for girls and women with and without underlying bleeding disorders.

Important elements of patient history, physical exam, medication review, and laboratory testing are outlined in the guidelines, as well as advice on when an ultrasound examination is warranted.

Adolescents with acute menorrhagia differ from adults in some important ways. Anticoagulation therapy is rarely a cause of abnormal bleeding in a young woman, but "anovulatory bleeding is often a precipitating factor in adolescence," she said.

In addition, acute signs of an underlying bleeding disorder can first appear during the teenage years, Dr. James said.

Thrombocytopenia, von Willebrand disease, platelet function disorders, and clotting factor deficiencies are among the most relevant bleeding disorders in this setting. "These bleeding disorders are important to gynecologists [because] the leading symptom in the women and girls with a bleeding disorder is heavy menstrual bleeding," she said.

There also are girls and women who present with rare factor deficiency disorders, and the relatively fewer treatment options for these patients are outlined in the guidelines.

"Acute menorrhagia is not a benign condition for an adolescent, whether or not they have a bleeding disorder. They are often seen in an acute setting," Dr. James said. "Heavy menstrual bleeding is pretty morbid for adolescents."

She recommended an eight-question screening tool to identify bleeding disorders in patients with menorrhagia (Am. J. Obstet. Gynecol. 2011;204:209.e1-7). Dr. Claire Philipp of Robert Wood Johnson Medical School, New Brunswick, N.J., and her colleagues developed this screen to help gynecologists and primary care physicians determine which patients to refer for hemostatic work-up. The screening questions fall into four categories: menorrhagia severity, family history of a diagnosed bleeding disorder, personal history of excessive bleeding after specific challenges, and history of treatment for anemia.

"I feel pretty good if they have one of those four, I am going to go ahead and test them," Dr. James said.

The screen is more than 90% sensitive for identification of von Willebrand disease, for example, "and you can avoid testing everyone who says they have heavy menstrual bleeding," said Dr. James, who is also founder of the Duke University Medical Center Women’s Hemostasis and Thrombosis Clinic.

"Dr. Erik von Willebrand, who described von Willebrand disease, lost his first patient to her fourth menstrual period," Dr. James said. "But [now] acute menorrhagia in adolescence can be evaluated and can be managed."

The guideline authors also proposed a consensus definition of acute menorrhagia: life-threatening bleeding of uterine origin with sufficient volume, in the absence of pregnancy or malignancy that occurs during childbearing years (teen to perimenopause). The condition occurs in patients with or without a previously diagnosed bleeding disorder. Patients present to the emergency department and require immediate evaluation and intervention.

The guidelines highlight considerations for hormonal treatment, antifibrinolytic therapy, balloon tamponade, and correction of hemostatic deficiencies. Even though treatment relies to a great deal on clinician judgment, "many of us feel comfortable starting with hormone therapy," she said.

Regarding balloon tamponade therapy, "there are no randomized trials, but there are multiple case reports of its effectiveness in the very acute situation in the emergency department," Dr. James said. "We all have conversations about how long we leave the balloon in." Jokingly, she added: "None of us want to take it out before the woman goes to college."

With a nod to a lack of rigorous studies in the literature, Dr. James proposed that groups such as NASPAG establish registries to collect data on acute menorrhagia evaluation and management. She also recommended www.fwgbd.org, the site for the Foundation for Women & Girls with Blood Disorders, for additional information on bleeding disorders. Dr. James is a board member of the foundation.

Dr. James said that she receives research funding from CSL Behring and Grifols. She is also a member of the von Willebrand disease medical advisory board sponsored by CSL Behring, Octapharma, and Baxter.

MIAMI BEACH – Acute menorrhagia or abnormally heavy and prolonged menstrual bleeding can be a serious condition for any adolescent girl, but it becomes even more so if she has an underlying bleeding disorder, according to an expert.

Hormonal therapy, antifibrinolytic therapy, balloon tamponade, and correction of any specific hemostatic defect are the primary management strategies for acute menorrhagia, Dr. Andra H. James said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "It is not clear which therapy should come first and in what order."

This lack of clarity stems in part from a paucity of evidence-based medicine in the literature, said Dr. James, professor of ob.gyn. and assistant professor of medicine at Duke University Medical Center in Durham, N.C.

She recognized the need for more guidance on acute menorrhagia and was the primary author of consensus guidelines on evaluation and management of acute menorrhagia (Eur. J. Obstet. Gynecol. Reprod. Biol. 2011;158:124-34). Dr. James and some international experts systemically reviewed what was in the literature – primarily case reports and expert opinion – to devise recommendations for acute menorrhagia for girls and women with and without underlying bleeding disorders.

Important elements of patient history, physical exam, medication review, and laboratory testing are outlined in the guidelines, as well as advice on when an ultrasound examination is warranted.

Adolescents with acute menorrhagia differ from adults in some important ways. Anticoagulation therapy is rarely a cause of abnormal bleeding in a young woman, but "anovulatory bleeding is often a precipitating factor in adolescence," she said.

In addition, acute signs of an underlying bleeding disorder can first appear during the teenage years, Dr. James said.

Thrombocytopenia, von Willebrand disease, platelet function disorders, and clotting factor deficiencies are among the most relevant bleeding disorders in this setting. "These bleeding disorders are important to gynecologists [because] the leading symptom in the women and girls with a bleeding disorder is heavy menstrual bleeding," she said.

There also are girls and women who present with rare factor deficiency disorders, and the relatively fewer treatment options for these patients are outlined in the guidelines.

"Acute menorrhagia is not a benign condition for an adolescent, whether or not they have a bleeding disorder. They are often seen in an acute setting," Dr. James said. "Heavy menstrual bleeding is pretty morbid for adolescents."

She recommended an eight-question screening tool to identify bleeding disorders in patients with menorrhagia (Am. J. Obstet. Gynecol. 2011;204:209.e1-7). Dr. Claire Philipp of Robert Wood Johnson Medical School, New Brunswick, N.J., and her colleagues developed this screen to help gynecologists and primary care physicians determine which patients to refer for hemostatic work-up. The screening questions fall into four categories: menorrhagia severity, family history of a diagnosed bleeding disorder, personal history of excessive bleeding after specific challenges, and history of treatment for anemia.

"I feel pretty good if they have one of those four, I am going to go ahead and test them," Dr. James said.

The screen is more than 90% sensitive for identification of von Willebrand disease, for example, "and you can avoid testing everyone who says they have heavy menstrual bleeding," said Dr. James, who is also founder of the Duke University Medical Center Women’s Hemostasis and Thrombosis Clinic.

"Dr. Erik von Willebrand, who described von Willebrand disease, lost his first patient to her fourth menstrual period," Dr. James said. "But [now] acute menorrhagia in adolescence can be evaluated and can be managed."

The guideline authors also proposed a consensus definition of acute menorrhagia: life-threatening bleeding of uterine origin with sufficient volume, in the absence of pregnancy or malignancy that occurs during childbearing years (teen to perimenopause). The condition occurs in patients with or without a previously diagnosed bleeding disorder. Patients present to the emergency department and require immediate evaluation and intervention.

The guidelines highlight considerations for hormonal treatment, antifibrinolytic therapy, balloon tamponade, and correction of hemostatic deficiencies. Even though treatment relies to a great deal on clinician judgment, "many of us feel comfortable starting with hormone therapy," she said.

Regarding balloon tamponade therapy, "there are no randomized trials, but there are multiple case reports of its effectiveness in the very acute situation in the emergency department," Dr. James said. "We all have conversations about how long we leave the balloon in." Jokingly, she added: "None of us want to take it out before the woman goes to college."

With a nod to a lack of rigorous studies in the literature, Dr. James proposed that groups such as NASPAG establish registries to collect data on acute menorrhagia evaluation and management. She also recommended www.fwgbd.org, the site for the Foundation for Women & Girls with Blood Disorders, for additional information on bleeding disorders. Dr. James is a board member of the foundation.

Dr. James said that she receives research funding from CSL Behring and Grifols. She is also a member of the von Willebrand disease medical advisory board sponsored by CSL Behring, Octapharma, and Baxter.

MIAMI BEACH – "Primary ovarian insufficiency: it’s not menopause!"

So began a primer on the important ways in which affected girls and adolescents can be diagnosed and managed, and importantly, counseled about their future with primary ovarian insufficiency.

"The sequelae of primary ovarian insufficiency are almost shocking," Dr. Beth W. Rackow said. Ovarian function is potentially lost decades before menopause. Diagnosis and long-term monitoring are important because primary ovarian insufficiency (POI) can cause adverse effects on skeletal metabolism, lipid profiles, insulin sensitivity, and endothelial dysfunction, which in turn can potentiate atherosclerosis and cardiovascular disease.

The timing of POI presentation varies – some girls will present before puberty, some with stalled puberty, and others after puberty, Dr. Rackow said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. Unlike in menopause, ovarian dysfunction may not be permanent, which is why the term "ovarian insufficiency" is preferred to "ovarian failure," she added.

"It’s very likely you will see women with POI in your practice," Dr. Rackow said. Incidence increases with age, affecting about 1 in 10,000 girls and adolescents by age 20 years; 1 in 1,000 women by age 30; and 1 in 250 by age 35. Overall, about 1% of women will develop POI, she added.

Consider initially sharing a POI diagnosis face to face with parents before you talk to the child "so there is not global shock in the room," Dr. Rackow said. "They can support the child because they already know the diagnosis. They may also have insight into how their child will react." Explain why POI occurs, its impact on future fertility, and management options.

Although there is a genetic component to POI, the etiology for 90% of cases can be unclear, making this a challenging diagnosis. "We often don’t have a reason why a girl is presenting with this condition," said Dr. Rackow, a reproductive endocrinologist who is board certified in pediatric and adolescent gynecology within the department of clinical obstetrics & gynecology at New York Presbyterian Hospital/Columbia University Medical Center.

Follicle depletion and follicle dysfunction are the two main mechanisms. Depletion can stem from a lower baseline number of primordial follicles – "they start with less" – and/or from an increased rate of atresia. Follicle dysfunction, on the other hand, can result from impaired folliculogenesis or inappropriate luteinization that leads, over time, to a decreased complement or complete absence of oocytes.

Future fertility will be a leading concern. The spontaneous pregnancy rate for women with POI is 5%-10%. Some may consider in vitro fertilization or fertility assistance, but a poor to no response to gonadotropins "makes going through fertility treatment very challenging," Dr. Rackow said. There are many options for these patients to have a family, she added, including use of donor oocytes, donated embryos, and adoption. She sometimes tells patients: "You will be a mom someday. It just may be through a different way than you thought."

Psychological support can help patients and families after a diagnosis of POI. Dr. Rackow recommended two websites with more information: IPOFA & Rachel’s Well.

Menstrual anomalies could be your first clue. "Girls who have some abnormal menses for 3 months or more probably deserve further work-up," Dr. Rackow said. Also ask about pubertal history; any prior ovarian surgery, chemotherapy, or radiation; and their medical history because 20% of affected women have autoimmune disease. In addition, about 25% of girls with POI will have a thyroid disorder, but the 3% with adrenal disorders are particularly important to identify quickly. Consider checking the patient for adrenocortical antibodies, which in a girl with POI can point to significantly elevated risk for adrenal insufficiency. "They can get very sick with autoimmune adrenal failure."

In addition to an autoimmune work-up, "clearly we are going to get a karyotype on these patients," Dr. Rackow said. An estimated 6%-14% of women with POI carry a FMR-1 mutation, for example. X chromosome abnormalities, including trisomy X, are also possible.

Useful laboratory assays include measures of human chorionic gonadotropin and follicle stimulating hormone plus estradiol levels. "We tend to see low estradiol ... a sign of no estrogen production from the ovaries," Dr. Rackow said. "Normally, estrogen suppresses FSH more than luteinizing hormone, but in POI you tend to see elevated FSH."

Pelvic ultrasound to check for any antral follicles or any endometrium build-up also can be helpful. Bone densitometry also is helpful as a baseline measure after the POI diagnosis. "The bones can take a significant hit from POI in terms of bone density," Dr. Rackow said.

Following diagnosis of POI, consider annual, routine surveillance for endocrine disorders. Test for complete blood count, complete metabolic panel, calcium, phosphorus, fasting glucose, insulin, thyroid stimulating hormone, and thyroid peroxidase antibodies.

Estrogen replacement is part of management of these patients. "They require higher doses than [do] menopausal women. Also, if you give estrogen, [they] will need progestins for endometrial protection," Dr. Rackow said. Hormone replacement therapy can improve endothelial function within 6 months, potentially improve their long-term cardiovascular health, and mitigate bone loss.

"The lowest dose oral contraceptives have the higher end dose of estrogen you would give for POI. These girls do not need more," Dr. Rackow said. For more information, including hormone replacement therapy dosing guidance, see the September 2011 American College of Obstetrics and Gynecology Committee Opinion No. 502 on primary ovarian insufficiency in the adolescent (Obstet. Gynecol. 2011;118:741-5).

Dr. Rackow said she had no relevant financial disclosures.

MIAMI BEACH – "Primary ovarian insufficiency: it’s not menopause!"

So began a primer on the important ways in which affected girls and adolescents can be diagnosed and managed, and importantly, counseled about their future with primary ovarian insufficiency.

"The sequelae of primary ovarian insufficiency are almost shocking," Dr. Beth W. Rackow said. Ovarian function is potentially lost decades before menopause. Diagnosis and long-term monitoring are important because primary ovarian insufficiency (POI) can cause adverse effects on skeletal metabolism, lipid profiles, insulin sensitivity, and endothelial dysfunction, which in turn can potentiate atherosclerosis and cardiovascular disease.

The timing of POI presentation varies – some girls will present before puberty, some with stalled puberty, and others after puberty, Dr. Rackow said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. Unlike in menopause, ovarian dysfunction may not be permanent, which is why the term "ovarian insufficiency" is preferred to "ovarian failure," she added.

"It’s very likely you will see women with POI in your practice," Dr. Rackow said. Incidence increases with age, affecting about 1 in 10,000 girls and adolescents by age 20 years; 1 in 1,000 women by age 30; and 1 in 250 by age 35. Overall, about 1% of women will develop POI, she added.

Consider initially sharing a POI diagnosis face to face with parents before you talk to the child "so there is not global shock in the room," Dr. Rackow said. "They can support the child because they already know the diagnosis. They may also have insight into how their child will react." Explain why POI occurs, its impact on future fertility, and management options.

Although there is a genetic component to POI, the etiology for 90% of cases can be unclear, making this a challenging diagnosis. "We often don’t have a reason why a girl is presenting with this condition," said Dr. Rackow, a reproductive endocrinologist who is board certified in pediatric and adolescent gynecology within the department of clinical obstetrics & gynecology at New York Presbyterian Hospital/Columbia University Medical Center.

Follicle depletion and follicle dysfunction are the two main mechanisms. Depletion can stem from a lower baseline number of primordial follicles – "they start with less" – and/or from an increased rate of atresia. Follicle dysfunction, on the other hand, can result from impaired folliculogenesis or inappropriate luteinization that leads, over time, to a decreased complement or complete absence of oocytes.

Future fertility will be a leading concern. The spontaneous pregnancy rate for women with POI is 5%-10%. Some may consider in vitro fertilization or fertility assistance, but a poor to no response to gonadotropins "makes going through fertility treatment very challenging," Dr. Rackow said. There are many options for these patients to have a family, she added, including use of donor oocytes, donated embryos, and adoption. She sometimes tells patients: "You will be a mom someday. It just may be through a different way than you thought."

Psychological support can help patients and families after a diagnosis of POI. Dr. Rackow recommended two websites with more information: IPOFA & Rachel’s Well.

Menstrual anomalies could be your first clue. "Girls who have some abnormal menses for 3 months or more probably deserve further work-up," Dr. Rackow said. Also ask about pubertal history; any prior ovarian surgery, chemotherapy, or radiation; and their medical history because 20% of affected women have autoimmune disease. In addition, about 25% of girls with POI will have a thyroid disorder, but the 3% with adrenal disorders are particularly important to identify quickly. Consider checking the patient for adrenocortical antibodies, which in a girl with POI can point to significantly elevated risk for adrenal insufficiency. "They can get very sick with autoimmune adrenal failure."

In addition to an autoimmune work-up, "clearly we are going to get a karyotype on these patients," Dr. Rackow said. An estimated 6%-14% of women with POI carry a FMR-1 mutation, for example. X chromosome abnormalities, including trisomy X, are also possible.

Useful laboratory assays include measures of human chorionic gonadotropin and follicle stimulating hormone plus estradiol levels. "We tend to see low estradiol ... a sign of no estrogen production from the ovaries," Dr. Rackow said. "Normally, estrogen suppresses FSH more than luteinizing hormone, but in POI you tend to see elevated FSH."

Pelvic ultrasound to check for any antral follicles or any endometrium build-up also can be helpful. Bone densitometry also is helpful as a baseline measure after the POI diagnosis. "The bones can take a significant hit from POI in terms of bone density," Dr. Rackow said.

Following diagnosis of POI, consider annual, routine surveillance for endocrine disorders. Test for complete blood count, complete metabolic panel, calcium, phosphorus, fasting glucose, insulin, thyroid stimulating hormone, and thyroid peroxidase antibodies.

Estrogen replacement is part of management of these patients. "They require higher doses than [do] menopausal women. Also, if you give estrogen, [they] will need progestins for endometrial protection," Dr. Rackow said. Hormone replacement therapy can improve endothelial function within 6 months, potentially improve their long-term cardiovascular health, and mitigate bone loss.

"The lowest dose oral contraceptives have the higher end dose of estrogen you would give for POI. These girls do not need more," Dr. Rackow said. For more information, including hormone replacement therapy dosing guidance, see the September 2011 American College of Obstetrics and Gynecology Committee Opinion No. 502 on primary ovarian insufficiency in the adolescent (Obstet. Gynecol. 2011;118:741-5).

Dr. Rackow said she had no relevant financial disclosures.

MIAMI BEACH – "Primary ovarian insufficiency: it’s not menopause!"

So began a primer on the important ways in which affected girls and adolescents can be diagnosed and managed, and importantly, counseled about their future with primary ovarian insufficiency.

"The sequelae of primary ovarian insufficiency are almost shocking," Dr. Beth W. Rackow said. Ovarian function is potentially lost decades before menopause. Diagnosis and long-term monitoring are important because primary ovarian insufficiency (POI) can cause adverse effects on skeletal metabolism, lipid profiles, insulin sensitivity, and endothelial dysfunction, which in turn can potentiate atherosclerosis and cardiovascular disease.

The timing of POI presentation varies – some girls will present before puberty, some with stalled puberty, and others after puberty, Dr. Rackow said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. Unlike in menopause, ovarian dysfunction may not be permanent, which is why the term "ovarian insufficiency" is preferred to "ovarian failure," she added.

"It’s very likely you will see women with POI in your practice," Dr. Rackow said. Incidence increases with age, affecting about 1 in 10,000 girls and adolescents by age 20 years; 1 in 1,000 women by age 30; and 1 in 250 by age 35. Overall, about 1% of women will develop POI, she added.

Consider initially sharing a POI diagnosis face to face with parents before you talk to the child "so there is not global shock in the room," Dr. Rackow said. "They can support the child because they already know the diagnosis. They may also have insight into how their child will react." Explain why POI occurs, its impact on future fertility, and management options.

Although there is a genetic component to POI, the etiology for 90% of cases can be unclear, making this a challenging diagnosis. "We often don’t have a reason why a girl is presenting with this condition," said Dr. Rackow, a reproductive endocrinologist who is board certified in pediatric and adolescent gynecology within the department of clinical obstetrics & gynecology at New York Presbyterian Hospital/Columbia University Medical Center.

Follicle depletion and follicle dysfunction are the two main mechanisms. Depletion can stem from a lower baseline number of primordial follicles – "they start with less" – and/or from an increased rate of atresia. Follicle dysfunction, on the other hand, can result from impaired folliculogenesis or inappropriate luteinization that leads, over time, to a decreased complement or complete absence of oocytes.

Future fertility will be a leading concern. The spontaneous pregnancy rate for women with POI is 5%-10%. Some may consider in vitro fertilization or fertility assistance, but a poor to no response to gonadotropins "makes going through fertility treatment very challenging," Dr. Rackow said. There are many options for these patients to have a family, she added, including use of donor oocytes, donated embryos, and adoption. She sometimes tells patients: "You will be a mom someday. It just may be through a different way than you thought."

Psychological support can help patients and families after a diagnosis of POI. Dr. Rackow recommended two websites with more information: IPOFA & Rachel’s Well.

Menstrual anomalies could be your first clue. "Girls who have some abnormal menses for 3 months or more probably deserve further work-up," Dr. Rackow said. Also ask about pubertal history; any prior ovarian surgery, chemotherapy, or radiation; and their medical history because 20% of affected women have autoimmune disease. In addition, about 25% of girls with POI will have a thyroid disorder, but the 3% with adrenal disorders are particularly important to identify quickly. Consider checking the patient for adrenocortical antibodies, which in a girl with POI can point to significantly elevated risk for adrenal insufficiency. "They can get very sick with autoimmune adrenal failure."

In addition to an autoimmune work-up, "clearly we are going to get a karyotype on these patients," Dr. Rackow said. An estimated 6%-14% of women with POI carry a FMR-1 mutation, for example. X chromosome abnormalities, including trisomy X, are also possible.

Useful laboratory assays include measures of human chorionic gonadotropin and follicle stimulating hormone plus estradiol levels. "We tend to see low estradiol ... a sign of no estrogen production from the ovaries," Dr. Rackow said. "Normally, estrogen suppresses FSH more than luteinizing hormone, but in POI you tend to see elevated FSH."

Pelvic ultrasound to check for any antral follicles or any endometrium build-up also can be helpful. Bone densitometry also is helpful as a baseline measure after the POI diagnosis. "The bones can take a significant hit from POI in terms of bone density," Dr. Rackow said.

Following diagnosis of POI, consider annual, routine surveillance for endocrine disorders. Test for complete blood count, complete metabolic panel, calcium, phosphorus, fasting glucose, insulin, thyroid stimulating hormone, and thyroid peroxidase antibodies.

Estrogen replacement is part of management of these patients. "They require higher doses than [do] menopausal women. Also, if you give estrogen, [they] will need progestins for endometrial protection," Dr. Rackow said. Hormone replacement therapy can improve endothelial function within 6 months, potentially improve their long-term cardiovascular health, and mitigate bone loss.

"The lowest dose oral contraceptives have the higher end dose of estrogen you would give for POI. These girls do not need more," Dr. Rackow said. For more information, including hormone replacement therapy dosing guidance, see the September 2011 American College of Obstetrics and Gynecology Committee Opinion No. 502 on primary ovarian insufficiency in the adolescent (Obstet. Gynecol. 2011;118:741-5).

Dr. Rackow said she had no relevant financial disclosures.

MIAMI BEACH – High-dose topical steroids provide significant symptomatic relief for young girls with lichen sclerosus, a retrospective study has shown.

Less clear and more controversial, however, is whether this painful and itchy dermatologic condition spontaneously resolves after prepubertal girls reach menarche, Dr. Kathryn Squires** said. "We hypothesize that ... lichen sclerosus is a relapsing and remitting disease."

One important implication is a need for long-term follow-up, particularly because lichen sclerosus carries an increased risk of vulvar squamous cell carcinoma in adult women, Dr. Squires said.

With only a handful of published studies that assess the natural progression of lichen sclerosus in pediatric patients, Dr. Squires and her colleagues decided to find out more. They identified 97 premenarchal girls with lichen sclerosus treated at a gynecology or dermatology clinic at the Washington University in St. Louis* between 1995 and 2010. The mean patient age was 7 years at the time of diagnosis.

A total of 36 patients (or their parent) participated in a 10- to 15-minute, scripted telephone interview with at a mean follow-up of 5.3 years and were studied further. The main outcome was resolution of symptoms of pain and/or pruritus.

Thirty patients (83%) reported a period of remission after initial treatment. A total of 26 patients (72%) were in remission at the time of the telephone interview. Seven (78%) of the nine patients who continued to report symptoms at follow-up were still premenarchal.

"Most young women will experience symptomatic relief with high-dose topical steroid treatment, which in our study was clobetasol ointment," Dr. Squires said. Specifically, this therapeutic approach yielded significant improvement of symptoms within an average of 14 weeks in 33 girls.

Part of the treatment challenge stems from a lack of standardized protocol with regard to dose, frequency and duration of treatment, or need to taper, Dr. Squires said. In the current study, the duration of treatment varied, "but it appears that 3-4 months will be adequate for most patients," she added.

A total of 16 patients reported a relapse that required maintenance therapy. The average length of remission was 3.6 years (range, 1-10 years).

Because of these findings, the prognosis and long-term course of lichen sclerosus diagnosed prior to menarche remains unclear, Dr. Squires said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Lichen sclerosus is a common dermatologic condition. It is often found on the vulva, most commonly in postmenopausal women, [but] prepubertal girls account for about 5%-15% of cases," said Dr. Squires of the department of obstetrics and gynecology at Washington University in St. Louis. The condition is likely underrecognized and underreported in this pediatric population, she added.

Lichen sclerosus often presents as characteristic white, sharply demarcated plaques on the vulva and perianal skin. Some girls will have smooth and waxy skin; others present with crinkling or cellophane paper–type skin. Lichenification also can occur, in which case the skin becomes thick and leathery. The labia minora can adhere to adjacent structures in some cases. The precise etiology is unknown.

An unanswered question is whether lichen sclerosus in postmenopausal women is somehow distinct or on a continuum that includes the prepubertal presentations, Dr. Squires said.

A limitation of the telephone follow-up design of the study was the inability to verify physical findings.

Future research could compare the effectiveness and safety of treatment with calcineurin inhibitors versus topical steroids. In addition, it would be helpful to identify any factors that predict relapse versus achievement of complete remission.

Information for patients and families on pediatric vulvar lichen sclerosus is available online from the North American Society for Pediatric and Adolescent Gynecology.

Dr. Squires reported that she had no relevant financial disclosures.

* Correction: The university name was intially misstated as the University of Washington. 5/24/2012

**Correction: The investigator's name was initially misstated as Dr. Lauren C. Squires. 5/30/2012

MIAMI BEACH – High-dose topical steroids provide significant symptomatic relief for young girls with lichen sclerosus, a retrospective study has shown.

Less clear and more controversial, however, is whether this painful and itchy dermatologic condition spontaneously resolves after prepubertal girls reach menarche, Dr. Kathryn Squires** said. "We hypothesize that ... lichen sclerosus is a relapsing and remitting disease."

One important implication is a need for long-term follow-up, particularly because lichen sclerosus carries an increased risk of vulvar squamous cell carcinoma in adult women, Dr. Squires said.

With only a handful of published studies that assess the natural progression of lichen sclerosus in pediatric patients, Dr. Squires and her colleagues decided to find out more. They identified 97 premenarchal girls with lichen sclerosus treated at a gynecology or dermatology clinic at the Washington University in St. Louis* between 1995 and 2010. The mean patient age was 7 years at the time of diagnosis.

A total of 36 patients (or their parent) participated in a 10- to 15-minute, scripted telephone interview with at a mean follow-up of 5.3 years and were studied further. The main outcome was resolution of symptoms of pain and/or pruritus.

Thirty patients (83%) reported a period of remission after initial treatment. A total of 26 patients (72%) were in remission at the time of the telephone interview. Seven (78%) of the nine patients who continued to report symptoms at follow-up were still premenarchal.

"Most young women will experience symptomatic relief with high-dose topical steroid treatment, which in our study was clobetasol ointment," Dr. Squires said. Specifically, this therapeutic approach yielded significant improvement of symptoms within an average of 14 weeks in 33 girls.

Part of the treatment challenge stems from a lack of standardized protocol with regard to dose, frequency and duration of treatment, or need to taper, Dr. Squires said. In the current study, the duration of treatment varied, "but it appears that 3-4 months will be adequate for most patients," she added.

A total of 16 patients reported a relapse that required maintenance therapy. The average length of remission was 3.6 years (range, 1-10 years).

Because of these findings, the prognosis and long-term course of lichen sclerosus diagnosed prior to menarche remains unclear, Dr. Squires said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Lichen sclerosus is a common dermatologic condition. It is often found on the vulva, most commonly in postmenopausal women, [but] prepubertal girls account for about 5%-15% of cases," said Dr. Squires of the department of obstetrics and gynecology at Washington University in St. Louis. The condition is likely underrecognized and underreported in this pediatric population, she added.

Lichen sclerosus often presents as characteristic white, sharply demarcated plaques on the vulva and perianal skin. Some girls will have smooth and waxy skin; others present with crinkling or cellophane paper–type skin. Lichenification also can occur, in which case the skin becomes thick and leathery. The labia minora can adhere to adjacent structures in some cases. The precise etiology is unknown.

An unanswered question is whether lichen sclerosus in postmenopausal women is somehow distinct or on a continuum that includes the prepubertal presentations, Dr. Squires said.

A limitation of the telephone follow-up design of the study was the inability to verify physical findings.

Future research could compare the effectiveness and safety of treatment with calcineurin inhibitors versus topical steroids. In addition, it would be helpful to identify any factors that predict relapse versus achievement of complete remission.

Information for patients and families on pediatric vulvar lichen sclerosus is available online from the North American Society for Pediatric and Adolescent Gynecology.

Dr. Squires reported that she had no relevant financial disclosures.

* Correction: The university name was intially misstated as the University of Washington. 5/24/2012

**Correction: The investigator's name was initially misstated as Dr. Lauren C. Squires. 5/30/2012

MIAMI BEACH – High-dose topical steroids provide significant symptomatic relief for young girls with lichen sclerosus, a retrospective study has shown.

Less clear and more controversial, however, is whether this painful and itchy dermatologic condition spontaneously resolves after prepubertal girls reach menarche, Dr. Kathryn Squires** said. "We hypothesize that ... lichen sclerosus is a relapsing and remitting disease."

One important implication is a need for long-term follow-up, particularly because lichen sclerosus carries an increased risk of vulvar squamous cell carcinoma in adult women, Dr. Squires said.

With only a handful of published studies that assess the natural progression of lichen sclerosus in pediatric patients, Dr. Squires and her colleagues decided to find out more. They identified 97 premenarchal girls with lichen sclerosus treated at a gynecology or dermatology clinic at the Washington University in St. Louis* between 1995 and 2010. The mean patient age was 7 years at the time of diagnosis.

A total of 36 patients (or their parent) participated in a 10- to 15-minute, scripted telephone interview with at a mean follow-up of 5.3 years and were studied further. The main outcome was resolution of symptoms of pain and/or pruritus.

Thirty patients (83%) reported a period of remission after initial treatment. A total of 26 patients (72%) were in remission at the time of the telephone interview. Seven (78%) of the nine patients who continued to report symptoms at follow-up were still premenarchal.

"Most young women will experience symptomatic relief with high-dose topical steroid treatment, which in our study was clobetasol ointment," Dr. Squires said. Specifically, this therapeutic approach yielded significant improvement of symptoms within an average of 14 weeks in 33 girls.

Part of the treatment challenge stems from a lack of standardized protocol with regard to dose, frequency and duration of treatment, or need to taper, Dr. Squires said. In the current study, the duration of treatment varied, "but it appears that 3-4 months will be adequate for most patients," she added.

A total of 16 patients reported a relapse that required maintenance therapy. The average length of remission was 3.6 years (range, 1-10 years).

Because of these findings, the prognosis and long-term course of lichen sclerosus diagnosed prior to menarche remains unclear, Dr. Squires said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Lichen sclerosus is a common dermatologic condition. It is often found on the vulva, most commonly in postmenopausal women, [but] prepubertal girls account for about 5%-15% of cases," said Dr. Squires of the department of obstetrics and gynecology at Washington University in St. Louis. The condition is likely underrecognized and underreported in this pediatric population, she added.

Lichen sclerosus often presents as characteristic white, sharply demarcated plaques on the vulva and perianal skin. Some girls will have smooth and waxy skin; others present with crinkling or cellophane paper–type skin. Lichenification also can occur, in which case the skin becomes thick and leathery. The labia minora can adhere to adjacent structures in some cases. The precise etiology is unknown.

An unanswered question is whether lichen sclerosus in postmenopausal women is somehow distinct or on a continuum that includes the prepubertal presentations, Dr. Squires said.

A limitation of the telephone follow-up design of the study was the inability to verify physical findings.

Future research could compare the effectiveness and safety of treatment with calcineurin inhibitors versus topical steroids. In addition, it would be helpful to identify any factors that predict relapse versus achievement of complete remission.

Information for patients and families on pediatric vulvar lichen sclerosus is available online from the North American Society for Pediatric and Adolescent Gynecology.

Dr. Squires reported that she had no relevant financial disclosures.

* Correction: The university name was intially misstated as the University of Washington. 5/24/2012

**Correction: The investigator's name was initially misstated as Dr. Lauren C. Squires. 5/30/2012

MIAMI BEACH – A study of more than 150,000 pregnancies indicates adolescents and their newborns run an increased risk for complications.

Dr. Kathy Wilson and her colleagues at Washington Hospital Center and Georgetown University Hospital, in Washington, compared peripartum outcomes among 1,312 teens aged 15 years and younger; 19,403 teens aged 16 to 19 years; and 130,453 adults aged 20-34 years. Each had a singleton pregnancy of at least 24 weeks’ gestation between 2002 and 2008.

Adolescent mothers had higher rates of complications, including anemia, preterm premature rupture of membranes (PPROM), chorioamnionitis, and eclampsia, compared with adults.

Anemia affected 9.4% of the teens under age 16 years and 10.2% of the older teenagers. These rates were significantly higher than was the 8.2% rate in adults.

PPROM was noted in the records of 2.1% of younger teens, 2.5% of older teens, and 1.9% of adults. Chorioamnionitis occurred in 8.8% of young adolescents, 8.0% of older adolescents, and 4.8% of adults. Rates of both complications were significantly different between adolescents and adults.

Other researchers have researched risks in adolescent pregnancy, but most of these studies have been small, Dr. Wilson said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. Clinical and demographic data for the 151,476 women in this study come from the Consortium on Safe Labor, which includes electronic medical records from 19 hospitals in the United States. The consortium is sponsored by the National Institute of Child Health and Human Development.

The researchers found a nonsignificant trend for higher prevalence of eclampsia in the adolescent mothers as well – 0.25% of the younger teenagers and 0.12% of the older teenagers vs. 0.008% among adult mothers.

Neonates born to adolescent mothers were more likely to be delivered preterm, to be low birth weight or very low birth weight, to have lower APGAR scores, and to have higher rates of admission to a neonatal intensive care unit.

Preterm births occurred in 21.1% of the teens under age 16 years, 18.3% of teens aged 16-19 years, and 16% of adults.

Low birth weight infants were born to 13.1% of the younger teen mothers, 12% of the older teen mothers, and 7.8% of adult mothers. Very low birth weight infants were born to 2.7% of the young teens, 2.5% of the older teens, and 1.7% of the adults. All differences between infants born to adolescents and adults were statistically significant.

Other findings include a higher percentage of 5-minute APGAR scores below 7 for neonates of younger teen mothers, 2.8%, compared with 2.3% for older teens and 2% for adult mothers. Neonatal ICU admission rates were 14.8% for the newborns of young teens, 14% for those born to older teens, and 11.8% for those born to adults.

Cesarean section rate was one factor that was significantly lower among the younger adolescent mothers. Their c-section rate was 15.9%, compared with 21.1% for the older teenagers and 24.8% for the adults.

Young adolescents were more likely to have public health insurance, 70.3%, compared with 66.6% of older adolescents and 39.1% of adult mothers.

Dr. Wilson had no relevant financial disclosures.

MIAMI BEACH – A study of more than 150,000 pregnancies indicates adolescents and their newborns run an increased risk for complications.

Dr. Kathy Wilson and her colleagues at Washington Hospital Center and Georgetown University Hospital, in Washington, compared peripartum outcomes among 1,312 teens aged 15 years and younger; 19,403 teens aged 16 to 19 years; and 130,453 adults aged 20-34 years. Each had a singleton pregnancy of at least 24 weeks’ gestation between 2002 and 2008.

Adolescent mothers had higher rates of complications, including anemia, preterm premature rupture of membranes (PPROM), chorioamnionitis, and eclampsia, compared with adults.

Anemia affected 9.4% of the teens under age 16 years and 10.2% of the older teenagers. These rates were significantly higher than was the 8.2% rate in adults.

PPROM was noted in the records of 2.1% of younger teens, 2.5% of older teens, and 1.9% of adults. Chorioamnionitis occurred in 8.8% of young adolescents, 8.0% of older adolescents, and 4.8% of adults. Rates of both complications were significantly different between adolescents and adults.

Other researchers have researched risks in adolescent pregnancy, but most of these studies have been small, Dr. Wilson said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. Clinical and demographic data for the 151,476 women in this study come from the Consortium on Safe Labor, which includes electronic medical records from 19 hospitals in the United States. The consortium is sponsored by the National Institute of Child Health and Human Development.

The researchers found a nonsignificant trend for higher prevalence of eclampsia in the adolescent mothers as well – 0.25% of the younger teenagers and 0.12% of the older teenagers vs. 0.008% among adult mothers.

Neonates born to adolescent mothers were more likely to be delivered preterm, to be low birth weight or very low birth weight, to have lower APGAR scores, and to have higher rates of admission to a neonatal intensive care unit.

Preterm births occurred in 21.1% of the teens under age 16 years, 18.3% of teens aged 16-19 years, and 16% of adults.

Low birth weight infants were born to 13.1% of the younger teen mothers, 12% of the older teen mothers, and 7.8% of adult mothers. Very low birth weight infants were born to 2.7% of the young teens, 2.5% of the older teens, and 1.7% of the adults. All differences between infants born to adolescents and adults were statistically significant.

Other findings include a higher percentage of 5-minute APGAR scores below 7 for neonates of younger teen mothers, 2.8%, compared with 2.3% for older teens and 2% for adult mothers. Neonatal ICU admission rates were 14.8% for the newborns of young teens, 14% for those born to older teens, and 11.8% for those born to adults.

Cesarean section rate was one factor that was significantly lower among the younger adolescent mothers. Their c-section rate was 15.9%, compared with 21.1% for the older teenagers and 24.8% for the adults.

Young adolescents were more likely to have public health insurance, 70.3%, compared with 66.6% of older adolescents and 39.1% of adult mothers.

Dr. Wilson had no relevant financial disclosures.

MIAMI BEACH – A study of more than 150,000 pregnancies indicates adolescents and their newborns run an increased risk for complications.

Dr. Kathy Wilson and her colleagues at Washington Hospital Center and Georgetown University Hospital, in Washington, compared peripartum outcomes among 1,312 teens aged 15 years and younger; 19,403 teens aged 16 to 19 years; and 130,453 adults aged 20-34 years. Each had a singleton pregnancy of at least 24 weeks’ gestation between 2002 and 2008.

Adolescent mothers had higher rates of complications, including anemia, preterm premature rupture of membranes (PPROM), chorioamnionitis, and eclampsia, compared with adults.

Anemia affected 9.4% of the teens under age 16 years and 10.2% of the older teenagers. These rates were significantly higher than was the 8.2% rate in adults.

PPROM was noted in the records of 2.1% of younger teens, 2.5% of older teens, and 1.9% of adults. Chorioamnionitis occurred in 8.8% of young adolescents, 8.0% of older adolescents, and 4.8% of adults. Rates of both complications were significantly different between adolescents and adults.

Other researchers have researched risks in adolescent pregnancy, but most of these studies have been small, Dr. Wilson said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. Clinical and demographic data for the 151,476 women in this study come from the Consortium on Safe Labor, which includes electronic medical records from 19 hospitals in the United States. The consortium is sponsored by the National Institute of Child Health and Human Development.

The researchers found a nonsignificant trend for higher prevalence of eclampsia in the adolescent mothers as well – 0.25% of the younger teenagers and 0.12% of the older teenagers vs. 0.008% among adult mothers.

Neonates born to adolescent mothers were more likely to be delivered preterm, to be low birth weight or very low birth weight, to have lower APGAR scores, and to have higher rates of admission to a neonatal intensive care unit.

Preterm births occurred in 21.1% of the teens under age 16 years, 18.3% of teens aged 16-19 years, and 16% of adults.

Low birth weight infants were born to 13.1% of the younger teen mothers, 12% of the older teen mothers, and 7.8% of adult mothers. Very low birth weight infants were born to 2.7% of the young teens, 2.5% of the older teens, and 1.7% of the adults. All differences between infants born to adolescents and adults were statistically significant.

Other findings include a higher percentage of 5-minute APGAR scores below 7 for neonates of younger teen mothers, 2.8%, compared with 2.3% for older teens and 2% for adult mothers. Neonatal ICU admission rates were 14.8% for the newborns of young teens, 14% for those born to older teens, and 11.8% for those born to adults.

Cesarean section rate was one factor that was significantly lower among the younger adolescent mothers. Their c-section rate was 15.9%, compared with 21.1% for the older teenagers and 24.8% for the adults.

Young adolescents were more likely to have public health insurance, 70.3%, compared with 66.6% of older adolescents and 39.1% of adult mothers.

Dr. Wilson had no relevant financial disclosures.

MIAMI BEACH – Certain clinical factors – and a scoring system that incorporates them – could help physicians in the differential diagnosis of adnexal torsion when girls present with acute abdominal pain, according to a small retrospective study.

Researchers compared 45 pediatric patients who had adnexal torsion confirmed at the time of surgery vs. another 49 without this problem to determine factors associated with higher risk. Abdominal tenderness, type of pain, pain radiation, ovary size (as well presence of a mass, and its size and palpability) were found to be potential predictors. Ultimately, however, the following three combined factors emerged as significantly associated with adnexal torsion:

• Presence of intermittent pain.

• Absence of radiating pain.

• An adnexal mass larger than 4 cm.

"There was a high level of distinction as to who had ovarian torsion and who did not," Dr. Cynthia Abraham said. "If they have these three factors, they should go straight to the OR."

In statistical terms, an area under the curve of 0.8601 on a receiver operating curve for these three factors "suggests an excellent discrimination between adnexal torsion and other causes of abdominal pain."

"This study thus demonstrates that key clinical and imaging parameters can be combined into a model that can aid in the early diagnosis of adnexal torsion," Dr. Abraham said at a poster during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. Girls included in the study were aged 2-18 years.

Even though the condition occurs in only 3% of patients with abdominal pain, adnexal torsion can be life threatening, and the differential diagnosis from other etiologies (for example, appendicitis or gastritis) is important. "The diagnosis is extremely critical and may lead to ovarian salvage," she added. If the diagnosis is missed or delayed, tissue necrosis and a diminished future fertility could ensue.

A weighted scoring system based on these factors would be helpful because "very often gynecologists are called to evaluate many patients who do not have ovarian torsion," said Dr. Abraham, a fourth year resident at the Steven and Alexandra Cohen Children’s Medical Center of New York, New Hyde Park

"Other studies have looked at physical examination and history," Dr. Abraham said. "We looked at a score for ovarian torsion." The scoring system is still in development. "We have not used it yet [in practice]. That is the next step."

Dr. Abraham said she had no relevant financial disclosures.

MIAMI BEACH – Certain clinical factors – and a scoring system that incorporates them – could help physicians in the differential diagnosis of adnexal torsion when girls present with acute abdominal pain, according to a small retrospective study.

Researchers compared 45 pediatric patients who had adnexal torsion confirmed at the time of surgery vs. another 49 without this problem to determine factors associated with higher risk. Abdominal tenderness, type of pain, pain radiation, ovary size (as well presence of a mass, and its size and palpability) were found to be potential predictors. Ultimately, however, the following three combined factors emerged as significantly associated with adnexal torsion:

• Presence of intermittent pain.

• Absence of radiating pain.

• An adnexal mass larger than 4 cm.

"There was a high level of distinction as to who had ovarian torsion and who did not," Dr. Cynthia Abraham said. "If they have these three factors, they should go straight to the OR."

In statistical terms, an area under the curve of 0.8601 on a receiver operating curve for these three factors "suggests an excellent discrimination between adnexal torsion and other causes of abdominal pain."

"This study thus demonstrates that key clinical and imaging parameters can be combined into a model that can aid in the early diagnosis of adnexal torsion," Dr. Abraham said at a poster during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. Girls included in the study were aged 2-18 years.

Even though the condition occurs in only 3% of patients with abdominal pain, adnexal torsion can be life threatening, and the differential diagnosis from other etiologies (for example, appendicitis or gastritis) is important. "The diagnosis is extremely critical and may lead to ovarian salvage," she added. If the diagnosis is missed or delayed, tissue necrosis and a diminished future fertility could ensue.

A weighted scoring system based on these factors would be helpful because "very often gynecologists are called to evaluate many patients who do not have ovarian torsion," said Dr. Abraham, a fourth year resident at the Steven and Alexandra Cohen Children’s Medical Center of New York, New Hyde Park

"Other studies have looked at physical examination and history," Dr. Abraham said. "We looked at a score for ovarian torsion." The scoring system is still in development. "We have not used it yet [in practice]. That is the next step."

Dr. Abraham said she had no relevant financial disclosures.

MIAMI BEACH – Certain clinical factors – and a scoring system that incorporates them – could help physicians in the differential diagnosis of adnexal torsion when girls present with acute abdominal pain, according to a small retrospective study.

Researchers compared 45 pediatric patients who had adnexal torsion confirmed at the time of surgery vs. another 49 without this problem to determine factors associated with higher risk. Abdominal tenderness, type of pain, pain radiation, ovary size (as well presence of a mass, and its size and palpability) were found to be potential predictors. Ultimately, however, the following three combined factors emerged as significantly associated with adnexal torsion:

• Presence of intermittent pain.

• Absence of radiating pain.

• An adnexal mass larger than 4 cm.

"There was a high level of distinction as to who had ovarian torsion and who did not," Dr. Cynthia Abraham said. "If they have these three factors, they should go straight to the OR."

In statistical terms, an area under the curve of 0.8601 on a receiver operating curve for these three factors "suggests an excellent discrimination between adnexal torsion and other causes of abdominal pain."

"This study thus demonstrates that key clinical and imaging parameters can be combined into a model that can aid in the early diagnosis of adnexal torsion," Dr. Abraham said at a poster during the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. Girls included in the study were aged 2-18 years.

Even though the condition occurs in only 3% of patients with abdominal pain, adnexal torsion can be life threatening, and the differential diagnosis from other etiologies (for example, appendicitis or gastritis) is important. "The diagnosis is extremely critical and may lead to ovarian salvage," she added. If the diagnosis is missed or delayed, tissue necrosis and a diminished future fertility could ensue.

A weighted scoring system based on these factors would be helpful because "very often gynecologists are called to evaluate many patients who do not have ovarian torsion," said Dr. Abraham, a fourth year resident at the Steven and Alexandra Cohen Children’s Medical Center of New York, New Hyde Park

"Other studies have looked at physical examination and history," Dr. Abraham said. "We looked at a score for ovarian torsion." The scoring system is still in development. "We have not used it yet [in practice]. That is the next step."

Dr. Abraham said she had no relevant financial disclosures.

MIAMI BEACH – A scoring system based on three factors identified in a study could aid your decision whether to proceed with surgery for girls with suspected adnexal torsion, results of a small study suggest.

Adnexal torsion is often part of the differential diagnosis of girls who present to an emergency department with abdominal or pelvic pain. An accurate diagnosis of torsion and swift surgical intervention can be important to preclude serious reproductive consequences including loss of an ovary or adnexa.

Dr. Samantha E. Montgomery and her colleagues prospectively studied 32 girls who underwent surgery for suspected adnexal torsion. They compared 16 cases with confirmed torsion (13 ovarian, 2 tubal, and 1 paratubal) with 16 controls with other adnexal findings.

They looked for significant predictors based on patient presentation. "No single factor was significant alone, so we developed a composite score," Dr. Montgomery said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

A score of 0 to 6 is possible based on premenarchal status (yes = 2, no = 0); presence of nausea and/or vomiting (nausea = 1, vomiting = 2, none = 0); and adnexal volume (20 mL or less = 0, 21 mL to 70 mL = 1, greater than 70 mL = 2).

There were six girls who scored a 0 or 1 and none were diagnosed with torsion, for 100% specificity. A score of 4 or more correctly identified 12 out of 14 girls with torsion, for 75% sensitivity and 86% specificity. A score of 2 or 3 was less definitive; this group included four girls with torsion and eight girls without this condition. Patients who score 2 or 3 should be considered for surgery, said Dr. Montgomery, a pediatric and adolescent gynecology fellow at the University of Cincinnati and Cincinnati Children’s Hospital.

Doppler flow, duration of pain, affected volume in mL, and adnexal ratio were not significantly associated with torsion in the study.

The cross-sectional study included patients 6-21 years of age with abdominal or pelvic pain. They each presented to the emergency department at Cincinnati Children’s Hospital Medical Center between August 2007 and August 2009.

Strengths of the study include its prospective design and inclusion of prepubertal patients, Dr. Montgomery said. Limitations include a small sample size and an inability to distinguish ovarian from isolated tubal torsion so all cases were termed "adnexal torsion."

The composite score has not yet been validated, Dr. Montgomery said in response to a meeting attendee question.

Radiologic assessment was standardized in a sequential protocol that started with right lower quadrant ultrasound followed by pelvic ultrasound. If the appendix could not be visualized at this point, an abdominal/pelvic CT scan could be ordered as well.

A future aim is to assess a larger sample of premenarchal girls, Dr. Montgomery said.

Dr. Montgomery said she had no relevant financial disclosures.

MIAMI BEACH – A scoring system based on three factors identified in a study could aid your decision whether to proceed with surgery for girls with suspected adnexal torsion, results of a small study suggest.

Adnexal torsion is often part of the differential diagnosis of girls who present to an emergency department with abdominal or pelvic pain. An accurate diagnosis of torsion and swift surgical intervention can be important to preclude serious reproductive consequences including loss of an ovary or adnexa.

Dr. Samantha E. Montgomery and her colleagues prospectively studied 32 girls who underwent surgery for suspected adnexal torsion. They compared 16 cases with confirmed torsion (13 ovarian, 2 tubal, and 1 paratubal) with 16 controls with other adnexal findings.

They looked for significant predictors based on patient presentation. "No single factor was significant alone, so we developed a composite score," Dr. Montgomery said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

A score of 0 to 6 is possible based on premenarchal status (yes = 2, no = 0); presence of nausea and/or vomiting (nausea = 1, vomiting = 2, none = 0); and adnexal volume (20 mL or less = 0, 21 mL to 70 mL = 1, greater than 70 mL = 2).

There were six girls who scored a 0 or 1 and none were diagnosed with torsion, for 100% specificity. A score of 4 or more correctly identified 12 out of 14 girls with torsion, for 75% sensitivity and 86% specificity. A score of 2 or 3 was less definitive; this group included four girls with torsion and eight girls without this condition. Patients who score 2 or 3 should be considered for surgery, said Dr. Montgomery, a pediatric and adolescent gynecology fellow at the University of Cincinnati and Cincinnati Children’s Hospital.

Doppler flow, duration of pain, affected volume in mL, and adnexal ratio were not significantly associated with torsion in the study.

The cross-sectional study included patients 6-21 years of age with abdominal or pelvic pain. They each presented to the emergency department at Cincinnati Children’s Hospital Medical Center between August 2007 and August 2009.

Strengths of the study include its prospective design and inclusion of prepubertal patients, Dr. Montgomery said. Limitations include a small sample size and an inability to distinguish ovarian from isolated tubal torsion so all cases were termed "adnexal torsion."

The composite score has not yet been validated, Dr. Montgomery said in response to a meeting attendee question.

Radiologic assessment was standardized in a sequential protocol that started with right lower quadrant ultrasound followed by pelvic ultrasound. If the appendix could not be visualized at this point, an abdominal/pelvic CT scan could be ordered as well.

A future aim is to assess a larger sample of premenarchal girls, Dr. Montgomery said.

Dr. Montgomery said she had no relevant financial disclosures.

MIAMI BEACH – A scoring system based on three factors identified in a study could aid your decision whether to proceed with surgery for girls with suspected adnexal torsion, results of a small study suggest.

Adnexal torsion is often part of the differential diagnosis of girls who present to an emergency department with abdominal or pelvic pain. An accurate diagnosis of torsion and swift surgical intervention can be important to preclude serious reproductive consequences including loss of an ovary or adnexa.

Dr. Samantha E. Montgomery and her colleagues prospectively studied 32 girls who underwent surgery for suspected adnexal torsion. They compared 16 cases with confirmed torsion (13 ovarian, 2 tubal, and 1 paratubal) with 16 controls with other adnexal findings.

They looked for significant predictors based on patient presentation. "No single factor was significant alone, so we developed a composite score," Dr. Montgomery said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

A score of 0 to 6 is possible based on premenarchal status (yes = 2, no = 0); presence of nausea and/or vomiting (nausea = 1, vomiting = 2, none = 0); and adnexal volume (20 mL or less = 0, 21 mL to 70 mL = 1, greater than 70 mL = 2).

There were six girls who scored a 0 or 1 and none were diagnosed with torsion, for 100% specificity. A score of 4 or more correctly identified 12 out of 14 girls with torsion, for 75% sensitivity and 86% specificity. A score of 2 or 3 was less definitive; this group included four girls with torsion and eight girls without this condition. Patients who score 2 or 3 should be considered for surgery, said Dr. Montgomery, a pediatric and adolescent gynecology fellow at the University of Cincinnati and Cincinnati Children’s Hospital.

Doppler flow, duration of pain, affected volume in mL, and adnexal ratio were not significantly associated with torsion in the study.

The cross-sectional study included patients 6-21 years of age with abdominal or pelvic pain. They each presented to the emergency department at Cincinnati Children’s Hospital Medical Center between August 2007 and August 2009.

Strengths of the study include its prospective design and inclusion of prepubertal patients, Dr. Montgomery said. Limitations include a small sample size and an inability to distinguish ovarian from isolated tubal torsion so all cases were termed "adnexal torsion."

The composite score has not yet been validated, Dr. Montgomery said in response to a meeting attendee question.

Radiologic assessment was standardized in a sequential protocol that started with right lower quadrant ultrasound followed by pelvic ultrasound. If the appendix could not be visualized at this point, an abdominal/pelvic CT scan could be ordered as well.

A future aim is to assess a larger sample of premenarchal girls, Dr. Montgomery said.

Dr. Montgomery said she had no relevant financial disclosures.

MIAMI BEACH – Physician champions can spur the adoption of long-acting reversible contraception post partum among teenaged mothers, a study has shown.

Researchers at the Medical University of South Carolina in Charleston assessed the records of 720 adolescents aged 13-19 years who received prenatal care at their institution and were delivered of a viable baby between December 2005 and May 2010.

Dr. Ashlyn H. Savage and her associates found that if an adolescent mother had a documented postpartum contraception plan in her prenatal record, she was more likely to receive long-acting reversible contraception (LARC) at her 6-week postpartum visit (odds ratio, 3.7), compared with those without such a plan.

An estimated 15%-30% of adolescent mothers become pregnant again within 1 year of delivery, and LARC is one of the best strategies to reduce this risk, Dr. Savage said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Early on [in the study] almost no teenagers had a documented plan prenatally for postpartum pregnancy prevention," she said.

Dr. Savage suggested that physician champions are responsible, at least in part, for a significant increase in prenatal documentation for any form of postpartum contraception. Such written plans in the prenatal records increased 13.5-fold between 2006 and 2009.

"At our institution, in the last few years we’ve had an influx of new faculty members, including a family planning specialist. The three of us are physician champions of long-acting reversible contraception in adolescents," said Dr. Savage of the department of obstetrics and gynecology at the university.

LARC use increased 3 years after the physician champions joined the staff, with an odds ratio of 5.2 for 2009 vs. 2006.

She and her colleagues plan to continue emphasizing the importance of prenatal plans for postpartum contraception based on these findings, Dr. Savage said. In addition, because 293 (41%) of 720 adolescent mothers did not return for a postpartum visit, "we are now studying implantation [of LARC] in the hospital before they leave."

Of the 427 teenaged mothers who did return at 6 weeks post partum, 66 (15%) obtained LARC at this visit. LARC was either an intrauterine device or an etonogestrel hormonal implant (Implanon, Organon). Another 218 patients (51%) were using medroxyprogesterone (Depo-Provera) as contraception; 101 (24%) selected a combination hormonal contraceptive; and 21 (5%) chose a barrier method. A total of 21 adolescent mothers (5%) chose no form of contraception.

Race was associated with the likelihood of receiving LARC at 6 weeks. "African American and Hispanic girls had the highest risks of repeat teen pregnancy. Unfortunately, they were also the least likely to use LARC," Dr. Savage said. Compared with white adolescents, for example, the odds ratio for postpartum LARC use at 6 weeks was 0.48 for African American teenagers and 0.15 for Hispanic teens. She and her colleagues plan to focus more effort on encouraging LARC use among African American and Hispanic adolescent mothers.

Age, parity, marital status, and funding for contraception did not predict LARC use in the study.

Dr. Savage said she had no relevant financial disclosures.

MIAMI BEACH – Physician champions can spur the adoption of long-acting reversible contraception post partum among teenaged mothers, a study has shown.

Researchers at the Medical University of South Carolina in Charleston assessed the records of 720 adolescents aged 13-19 years who received prenatal care at their institution and were delivered of a viable baby between December 2005 and May 2010.

Dr. Ashlyn H. Savage and her associates found that if an adolescent mother had a documented postpartum contraception plan in her prenatal record, she was more likely to receive long-acting reversible contraception (LARC) at her 6-week postpartum visit (odds ratio, 3.7), compared with those without such a plan.

An estimated 15%-30% of adolescent mothers become pregnant again within 1 year of delivery, and LARC is one of the best strategies to reduce this risk, Dr. Savage said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Early on [in the study] almost no teenagers had a documented plan prenatally for postpartum pregnancy prevention," she said.

Dr. Savage suggested that physician champions are responsible, at least in part, for a significant increase in prenatal documentation for any form of postpartum contraception. Such written plans in the prenatal records increased 13.5-fold between 2006 and 2009.

"At our institution, in the last few years we’ve had an influx of new faculty members, including a family planning specialist. The three of us are physician champions of long-acting reversible contraception in adolescents," said Dr. Savage of the department of obstetrics and gynecology at the university.

LARC use increased 3 years after the physician champions joined the staff, with an odds ratio of 5.2 for 2009 vs. 2006.

She and her colleagues plan to continue emphasizing the importance of prenatal plans for postpartum contraception based on these findings, Dr. Savage said. In addition, because 293 (41%) of 720 adolescent mothers did not return for a postpartum visit, "we are now studying implantation [of LARC] in the hospital before they leave."

Of the 427 teenaged mothers who did return at 6 weeks post partum, 66 (15%) obtained LARC at this visit. LARC was either an intrauterine device or an etonogestrel hormonal implant (Implanon, Organon). Another 218 patients (51%) were using medroxyprogesterone (Depo-Provera) as contraception; 101 (24%) selected a combination hormonal contraceptive; and 21 (5%) chose a barrier method. A total of 21 adolescent mothers (5%) chose no form of contraception.

Race was associated with the likelihood of receiving LARC at 6 weeks. "African American and Hispanic girls had the highest risks of repeat teen pregnancy. Unfortunately, they were also the least likely to use LARC," Dr. Savage said. Compared with white adolescents, for example, the odds ratio for postpartum LARC use at 6 weeks was 0.48 for African American teenagers and 0.15 for Hispanic teens. She and her colleagues plan to focus more effort on encouraging LARC use among African American and Hispanic adolescent mothers.

Age, parity, marital status, and funding for contraception did not predict LARC use in the study.

Dr. Savage said she had no relevant financial disclosures.

MIAMI BEACH – Physician champions can spur the adoption of long-acting reversible contraception post partum among teenaged mothers, a study has shown.

Researchers at the Medical University of South Carolina in Charleston assessed the records of 720 adolescents aged 13-19 years who received prenatal care at their institution and were delivered of a viable baby between December 2005 and May 2010.

Dr. Ashlyn H. Savage and her associates found that if an adolescent mother had a documented postpartum contraception plan in her prenatal record, she was more likely to receive long-acting reversible contraception (LARC) at her 6-week postpartum visit (odds ratio, 3.7), compared with those without such a plan.

An estimated 15%-30% of adolescent mothers become pregnant again within 1 year of delivery, and LARC is one of the best strategies to reduce this risk, Dr. Savage said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Early on [in the study] almost no teenagers had a documented plan prenatally for postpartum pregnancy prevention," she said.

Dr. Savage suggested that physician champions are responsible, at least in part, for a significant increase in prenatal documentation for any form of postpartum contraception. Such written plans in the prenatal records increased 13.5-fold between 2006 and 2009.

"At our institution, in the last few years we’ve had an influx of new faculty members, including a family planning specialist. The three of us are physician champions of long-acting reversible contraception in adolescents," said Dr. Savage of the department of obstetrics and gynecology at the university.

LARC use increased 3 years after the physician champions joined the staff, with an odds ratio of 5.2 for 2009 vs. 2006.

She and her colleagues plan to continue emphasizing the importance of prenatal plans for postpartum contraception based on these findings, Dr. Savage said. In addition, because 293 (41%) of 720 adolescent mothers did not return for a postpartum visit, "we are now studying implantation [of LARC] in the hospital before they leave."

Of the 427 teenaged mothers who did return at 6 weeks post partum, 66 (15%) obtained LARC at this visit. LARC was either an intrauterine device or an etonogestrel hormonal implant (Implanon, Organon). Another 218 patients (51%) were using medroxyprogesterone (Depo-Provera) as contraception; 101 (24%) selected a combination hormonal contraceptive; and 21 (5%) chose a barrier method. A total of 21 adolescent mothers (5%) chose no form of contraception.

Race was associated with the likelihood of receiving LARC at 6 weeks. "African American and Hispanic girls had the highest risks of repeat teen pregnancy. Unfortunately, they were also the least likely to use LARC," Dr. Savage said. Compared with white adolescents, for example, the odds ratio for postpartum LARC use at 6 weeks was 0.48 for African American teenagers and 0.15 for Hispanic teens. She and her colleagues plan to focus more effort on encouraging LARC use among African American and Hispanic adolescent mothers.

Age, parity, marital status, and funding for contraception did not predict LARC use in the study.

Dr. Savage said she had no relevant financial disclosures.

MIAMI BEACH – Compliance with postpartum visits and long-acting reversible contraception significantly reduced repeat pregnancies among 210 first-time adolescent mothers, according to a retrospective chart review.

These are "the most important tools for preventing subsequent adolescent pregnancy," Dr. Lauren F. Damle said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We are currently at an all-time low in teenage pregnancies. However, despite this, rates are still higher in our country than in most other industrialized countries," Dr. Damle said.

"Rapid repeat pregnancy is a major problem, with up to 50% of adolescent mothers becoming pregnant again within 2 years of their first delivery. Adolescent mothers in general are also more likely to be living in poverty, and those who have a second child during their adolescence are less likely to ever achieve economic self-sufficiency," said Dr. Damle, a gynecology fellow at MedStar Washington Hospital Center in Washington.

Dr. Damle and her associates conducted a study to answer two questions: Does early initiation of contraception post partum prevent rapid repeat pregnancy? Do adolescent mothers who use long-acting reversible contraception (LARC) have a lower chance of a repeat pregnancy?

Of the 4,721 deliveries at MedStar Washington Hospital Center in 2008, 757 involved adolescents 18 years and younger. This group included 210 first time mothers who had a live birth, and this group was studied further.

A minority of the 210 first-time mothers, 19%, received a medroxyprogesterone (Depo-Provera, Pharmacia & Upjohn Company) injection before going home. The remaining 81% received no contraception prior to discharge.

At their 6-week postpartum follow-up visit, 23% had received a medroxyprogesterone shot, 11% had an IUD placed, and 4% received an etonogestrel 68 mg implant (Implanon). "Interestingly, only 10% were using oral contraceptives, a very, very common form of birth control," Dr. Damle said.

In terms of LARC usage, 16% had an implant or IUD placed within the first 8 weeks. Another 5% had documented their intention to start LARC.

The rapid repeat pregnancy rate was high in this cohort, Dr. Damle said. A total of 74 adolescent mothers had another pregnancy within 2 years, comprising 35% of the entire cohort and 49% of those within the 2 year follow-up. "This is in line with what is reported in the literature, but it is still very concerning."

Mean time between delivery and conception was 424 days.

In all, 74 of 152 (49%) first time adolescent mothers had a repeat pregnancy within 2 years.

Follow-up within 8 weeks post partum was associated with lower chance of repeat pregnancy (odds ratio, 0.246). Initiation of LARC also was associated with decreased chance of rapid repeat pregnancy (OR, 0.135).

An interesting finding was no significant difference in the repeat pregnancy rate between adolescent mothers who received medroxyprogesterone and those who did not, Dr. Damle said. She added that this was the only form of contraception administered at the hospital in 2008.

All participated in prenatal care at the institution, including 103 teenagers who participated in Teen Alliance for Prepared Parenting (TAPP), a program specifically aimed at preventing repeat teenage pregnancies. The TAPP cohort, however, did not have a significantly lower rapid repeat pregnancy rate, compared with the non-TAPP group.

The mean age at first delivery was 17.5 years. The majority of first time adolescent mothers, 197 of the 210 (94%), were black. A total 91% had Medicaid or other form of public insurance.

A meeting attendee asked if the lower repeat pregnancy rate for the group who returned for postpartum care within 8 weeks could be due to patient self-selection. "I don’t think my study answers that question," Dr. Damle said. "Those who come in may be more responsible adolescents in starting contraception." The next study is to do an intervention before people leave the hospital, she said, although that is difficult to do without research funding because patients are typically not reimbursed by their insurance for LARC in the hospital setting. "Implementing immediate postpartum LARC may further prevent unwanted pregnancy."

The retrospective cohort design of the study is a potential limitation, Dr. Damle said. In addition, she and her colleagues assumed all the adolescent pregnancies were undesired and unplanned, but admitted that may not have been the case in all instances. Also, 58 first-time mothers were lost to follow-up and were not included in the 2-year follow-up analysis.

Dr. Damle said she had no relevant financial disclosures.

MIAMI BEACH – Compliance with postpartum visits and long-acting reversible contraception significantly reduced repeat pregnancies among 210 first-time adolescent mothers, according to a retrospective chart review.

These are "the most important tools for preventing subsequent adolescent pregnancy," Dr. Lauren F. Damle said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We are currently at an all-time low in teenage pregnancies. However, despite this, rates are still higher in our country than in most other industrialized countries," Dr. Damle said.

"Rapid repeat pregnancy is a major problem, with up to 50% of adolescent mothers becoming pregnant again within 2 years of their first delivery. Adolescent mothers in general are also more likely to be living in poverty, and those who have a second child during their adolescence are less likely to ever achieve economic self-sufficiency," said Dr. Damle, a gynecology fellow at MedStar Washington Hospital Center in Washington.

Dr. Damle and her associates conducted a study to answer two questions: Does early initiation of contraception post partum prevent rapid repeat pregnancy? Do adolescent mothers who use long-acting reversible contraception (LARC) have a lower chance of a repeat pregnancy?

Of the 4,721 deliveries at MedStar Washington Hospital Center in 2008, 757 involved adolescents 18 years and younger. This group included 210 first time mothers who had a live birth, and this group was studied further.

A minority of the 210 first-time mothers, 19%, received a medroxyprogesterone (Depo-Provera, Pharmacia & Upjohn Company) injection before going home. The remaining 81% received no contraception prior to discharge.

At their 6-week postpartum follow-up visit, 23% had received a medroxyprogesterone shot, 11% had an IUD placed, and 4% received an etonogestrel 68 mg implant (Implanon). "Interestingly, only 10% were using oral contraceptives, a very, very common form of birth control," Dr. Damle said.

In terms of LARC usage, 16% had an implant or IUD placed within the first 8 weeks. Another 5% had documented their intention to start LARC.

The rapid repeat pregnancy rate was high in this cohort, Dr. Damle said. A total of 74 adolescent mothers had another pregnancy within 2 years, comprising 35% of the entire cohort and 49% of those within the 2 year follow-up. "This is in line with what is reported in the literature, but it is still very concerning."

Mean time between delivery and conception was 424 days.

In all, 74 of 152 (49%) first time adolescent mothers had a repeat pregnancy within 2 years.

Follow-up within 8 weeks post partum was associated with lower chance of repeat pregnancy (odds ratio, 0.246). Initiation of LARC also was associated with decreased chance of rapid repeat pregnancy (OR, 0.135).

An interesting finding was no significant difference in the repeat pregnancy rate between adolescent mothers who received medroxyprogesterone and those who did not, Dr. Damle said. She added that this was the only form of contraception administered at the hospital in 2008.

All participated in prenatal care at the institution, including 103 teenagers who participated in Teen Alliance for Prepared Parenting (TAPP), a program specifically aimed at preventing repeat teenage pregnancies. The TAPP cohort, however, did not have a significantly lower rapid repeat pregnancy rate, compared with the non-TAPP group.

The mean age at first delivery was 17.5 years. The majority of first time adolescent mothers, 197 of the 210 (94%), were black. A total 91% had Medicaid or other form of public insurance.

A meeting attendee asked if the lower repeat pregnancy rate for the group who returned for postpartum care within 8 weeks could be due to patient self-selection. "I don’t think my study answers that question," Dr. Damle said. "Those who come in may be more responsible adolescents in starting contraception." The next study is to do an intervention before people leave the hospital, she said, although that is difficult to do without research funding because patients are typically not reimbursed by their insurance for LARC in the hospital setting. "Implementing immediate postpartum LARC may further prevent unwanted pregnancy."

The retrospective cohort design of the study is a potential limitation, Dr. Damle said. In addition, she and her colleagues assumed all the adolescent pregnancies were undesired and unplanned, but admitted that may not have been the case in all instances. Also, 58 first-time mothers were lost to follow-up and were not included in the 2-year follow-up analysis.

Dr. Damle said she had no relevant financial disclosures.

MIAMI BEACH – Compliance with postpartum visits and long-acting reversible contraception significantly reduced repeat pregnancies among 210 first-time adolescent mothers, according to a retrospective chart review.

These are "the most important tools for preventing subsequent adolescent pregnancy," Dr. Lauren F. Damle said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We are currently at an all-time low in teenage pregnancies. However, despite this, rates are still higher in our country than in most other industrialized countries," Dr. Damle said.

"Rapid repeat pregnancy is a major problem, with up to 50% of adolescent mothers becoming pregnant again within 2 years of their first delivery. Adolescent mothers in general are also more likely to be living in poverty, and those who have a second child during their adolescence are less likely to ever achieve economic self-sufficiency," said Dr. Damle, a gynecology fellow at MedStar Washington Hospital Center in Washington.

Dr. Damle and her associates conducted a study to answer two questions: Does early initiation of contraception post partum prevent rapid repeat pregnancy? Do adolescent mothers who use long-acting reversible contraception (LARC) have a lower chance of a repeat pregnancy?

Of the 4,721 deliveries at MedStar Washington Hospital Center in 2008, 757 involved adolescents 18 years and younger. This group included 210 first time mothers who had a live birth, and this group was studied further.

A minority of the 210 first-time mothers, 19%, received a medroxyprogesterone (Depo-Provera, Pharmacia & Upjohn Company) injection before going home. The remaining 81% received no contraception prior to discharge.

At their 6-week postpartum follow-up visit, 23% had received a medroxyprogesterone shot, 11% had an IUD placed, and 4% received an etonogestrel 68 mg implant (Implanon). "Interestingly, only 10% were using oral contraceptives, a very, very common form of birth control," Dr. Damle said.

In terms of LARC usage, 16% had an implant or IUD placed within the first 8 weeks. Another 5% had documented their intention to start LARC.

The rapid repeat pregnancy rate was high in this cohort, Dr. Damle said. A total of 74 adolescent mothers had another pregnancy within 2 years, comprising 35% of the entire cohort and 49% of those within the 2 year follow-up. "This is in line with what is reported in the literature, but it is still very concerning."

Mean time between delivery and conception was 424 days.

In all, 74 of 152 (49%) first time adolescent mothers had a repeat pregnancy within 2 years.

Follow-up within 8 weeks post partum was associated with lower chance of repeat pregnancy (odds ratio, 0.246). Initiation of LARC also was associated with decreased chance of rapid repeat pregnancy (OR, 0.135).

An interesting finding was no significant difference in the repeat pregnancy rate between adolescent mothers who received medroxyprogesterone and those who did not, Dr. Damle said. She added that this was the only form of contraception administered at the hospital in 2008.

All participated in prenatal care at the institution, including 103 teenagers who participated in Teen Alliance for Prepared Parenting (TAPP), a program specifically aimed at preventing repeat teenage pregnancies. The TAPP cohort, however, did not have a significantly lower rapid repeat pregnancy rate, compared with the non-TAPP group.

The mean age at first delivery was 17.5 years. The majority of first time adolescent mothers, 197 of the 210 (94%), were black. A total 91% had Medicaid or other form of public insurance.

A meeting attendee asked if the lower repeat pregnancy rate for the group who returned for postpartum care within 8 weeks could be due to patient self-selection. "I don’t think my study answers that question," Dr. Damle said. "Those who come in may be more responsible adolescents in starting contraception." The next study is to do an intervention before people leave the hospital, she said, although that is difficult to do without research funding because patients are typically not reimbursed by their insurance for LARC in the hospital setting. "Implementing immediate postpartum LARC may further prevent unwanted pregnancy."

The retrospective cohort design of the study is a potential limitation, Dr. Damle said. In addition, she and her colleagues assumed all the adolescent pregnancies were undesired and unplanned, but admitted that may not have been the case in all instances. Also, 58 first-time mothers were lost to follow-up and were not included in the 2-year follow-up analysis.

Dr. Damle said she had no relevant financial disclosures.

MIAMI BEACH – Advances in optical imaging may be shining a light on a higher prevalence of endometriosis among adolescent girls with chronic pelvic pain resistant to conventional treatment, according to a retrospective study.

Previously, researchers who focused on teen girls who failed conventional management of their chronic pelvic pain with nonsteroidal anti-inflammatory drugs or oral contraceptives found two-thirds or more had endometriosis, Dr. Jessica Opoku-Anane said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

In one systematic review reported at the annual congress of the Endometriosis Foundation of America by Stacey A. Missmer, Sc.D., for example, 62% of such adolescents had endometriosis. The prevalence was 70% in a previous study by Dr. Opoku-Anane’s colleague on the current study, Dr. Marc R. Laufer (J. Pediatr. Adolesc. Gynecol. 1997;199-202).

Even these estimates may seem low in light of a retrospective case series that revealed laparoscopic evidence of endometriosis in 98% of 124 adolescents with treatment-resistant chronic pelvic pain.

"There were only 2 patients out of 124 who did not have endometriosis. One patient had torsion and the other patient had adhesions," Dr. Opoku-Anane said. "Adolescents with chronic pelvic pain not responsive to oral contraceptives and NSAIDs may have a higher rate of endometriosis than previously perceived."

Better optical imaging that picks up more atypical lesions of endometriosis in adolescents – including "close tip" and "underwater" techniques – is partly responsible for the higher prevalence, said Dr. Opoku-Anane, a clinical fellow in obstetrics, gynecology, and reproductive biology at Brigham & Women’s Hospital and Harvard Medical School in Boston.

Along with Dr. Laufer, Dr. Opoku-Anane studied patients 21 or younger referred to Children’s Hospital Boston during 2009 for evaluation of chronic pelvic pain. Most were between 15 and 17 years old (60%), and the mean time from menarche to laparoscopy was 3.4 years.

A meeting attendee suggested referral bias was behind their higher prevalence – in other words, more adolescent girls presented to their institution because of better awareness of endometriosis among providers. Dr. Opoku-Anane said, however, that they compared patients in 1997 vs. 2009 "and there was not much difference."

Laparoscopic findings revealed 43% of patients had clear lesions, 43% had red lesions, and the "classic blue black lesions were found with much less frequency," Dr. Opoku-Anane said. "These patients probably should be referred to a gynecologist with experience with laparoscopic findings of endometriosis in adolescents."

The lesions were often found in multiple locations: 98% were in the posterior cul de sac; 42% were in the anterior cul de sac; and 21% were on the pelvic side wall. Lesions on the ovaries, fallopian tubes, and uterine serosa also were observed.

All those with endometriosis had stage I or stage II disease. Approximately half of the patients with endometriosis experienced pain that was cyclic only, about 40% had pain that was both cyclic and acyclic, and the remaining 10% complained of acyclic pain only. Gastrointestinal pain, back pain, irregular menses, and menorrhagia were among the less common presentations.

Future research could evaluate the clinical impact of earlier endometriosis detection in adolescents. The clinical significance of these lesions "is unclear as of now," Dr. Opoku-Anane said, "in terms of determining if early diagnosis and treatment prevents progression of endometriosis and [prevents] infertility."

Dr. Opoku-Anane said that she had no relevant financial disclosures.

MIAMI BEACH – Advances in optical imaging may be shining a light on a higher prevalence of endometriosis among adolescent girls with chronic pelvic pain resistant to conventional treatment, according to a retrospective study.

Previously, researchers who focused on teen girls who failed conventional management of their chronic pelvic pain with nonsteroidal anti-inflammatory drugs or oral contraceptives found two-thirds or more had endometriosis, Dr. Jessica Opoku-Anane said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

In one systematic review reported at the annual congress of the Endometriosis Foundation of America by Stacey A. Missmer, Sc.D., for example, 62% of such adolescents had endometriosis. The prevalence was 70% in a previous study by Dr. Opoku-Anane’s colleague on the current study, Dr. Marc R. Laufer (J. Pediatr. Adolesc. Gynecol. 1997;199-202).

Even these estimates may seem low in light of a retrospective case series that revealed laparoscopic evidence of endometriosis in 98% of 124 adolescents with treatment-resistant chronic pelvic pain.

"There were only 2 patients out of 124 who did not have endometriosis. One patient had torsion and the other patient had adhesions," Dr. Opoku-Anane said. "Adolescents with chronic pelvic pain not responsive to oral contraceptives and NSAIDs may have a higher rate of endometriosis than previously perceived."

Better optical imaging that picks up more atypical lesions of endometriosis in adolescents – including "close tip" and "underwater" techniques – is partly responsible for the higher prevalence, said Dr. Opoku-Anane, a clinical fellow in obstetrics, gynecology, and reproductive biology at Brigham & Women’s Hospital and Harvard Medical School in Boston.

Along with Dr. Laufer, Dr. Opoku-Anane studied patients 21 or younger referred to Children’s Hospital Boston during 2009 for evaluation of chronic pelvic pain. Most were between 15 and 17 years old (60%), and the mean time from menarche to laparoscopy was 3.4 years.

A meeting attendee suggested referral bias was behind their higher prevalence – in other words, more adolescent girls presented to their institution because of better awareness of endometriosis among providers. Dr. Opoku-Anane said, however, that they compared patients in 1997 vs. 2009 "and there was not much difference."

Laparoscopic findings revealed 43% of patients had clear lesions, 43% had red lesions, and the "classic blue black lesions were found with much less frequency," Dr. Opoku-Anane said. "These patients probably should be referred to a gynecologist with experience with laparoscopic findings of endometriosis in adolescents."

The lesions were often found in multiple locations: 98% were in the posterior cul de sac; 42% were in the anterior cul de sac; and 21% were on the pelvic side wall. Lesions on the ovaries, fallopian tubes, and uterine serosa also were observed.

All those with endometriosis had stage I or stage II disease. Approximately half of the patients with endometriosis experienced pain that was cyclic only, about 40% had pain that was both cyclic and acyclic, and the remaining 10% complained of acyclic pain only. Gastrointestinal pain, back pain, irregular menses, and menorrhagia were among the less common presentations.

Future research could evaluate the clinical impact of earlier endometriosis detection in adolescents. The clinical significance of these lesions "is unclear as of now," Dr. Opoku-Anane said, "in terms of determining if early diagnosis and treatment prevents progression of endometriosis and [prevents] infertility."

Dr. Opoku-Anane said that she had no relevant financial disclosures.

MIAMI BEACH – Advances in optical imaging may be shining a light on a higher prevalence of endometriosis among adolescent girls with chronic pelvic pain resistant to conventional treatment, according to a retrospective study.

Previously, researchers who focused on teen girls who failed conventional management of their chronic pelvic pain with nonsteroidal anti-inflammatory drugs or oral contraceptives found two-thirds or more had endometriosis, Dr. Jessica Opoku-Anane said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

In one systematic review reported at the annual congress of the Endometriosis Foundation of America by Stacey A. Missmer, Sc.D., for example, 62% of such adolescents had endometriosis. The prevalence was 70% in a previous study by Dr. Opoku-Anane’s colleague on the current study, Dr. Marc R. Laufer (J. Pediatr. Adolesc. Gynecol. 1997;199-202).

Even these estimates may seem low in light of a retrospective case series that revealed laparoscopic evidence of endometriosis in 98% of 124 adolescents with treatment-resistant chronic pelvic pain.

"There were only 2 patients out of 124 who did not have endometriosis. One patient had torsion and the other patient had adhesions," Dr. Opoku-Anane said. "Adolescents with chronic pelvic pain not responsive to oral contraceptives and NSAIDs may have a higher rate of endometriosis than previously perceived."

Better optical imaging that picks up more atypical lesions of endometriosis in adolescents – including "close tip" and "underwater" techniques – is partly responsible for the higher prevalence, said Dr. Opoku-Anane, a clinical fellow in obstetrics, gynecology, and reproductive biology at Brigham & Women’s Hospital and Harvard Medical School in Boston.

Along with Dr. Laufer, Dr. Opoku-Anane studied patients 21 or younger referred to Children’s Hospital Boston during 2009 for evaluation of chronic pelvic pain. Most were between 15 and 17 years old (60%), and the mean time from menarche to laparoscopy was 3.4 years.

A meeting attendee suggested referral bias was behind their higher prevalence – in other words, more adolescent girls presented to their institution because of better awareness of endometriosis among providers. Dr. Opoku-Anane said, however, that they compared patients in 1997 vs. 2009 "and there was not much difference."

Laparoscopic findings revealed 43% of patients had clear lesions, 43% had red lesions, and the "classic blue black lesions were found with much less frequency," Dr. Opoku-Anane said. "These patients probably should be referred to a gynecologist with experience with laparoscopic findings of endometriosis in adolescents."

The lesions were often found in multiple locations: 98% were in the posterior cul de sac; 42% were in the anterior cul de sac; and 21% were on the pelvic side wall. Lesions on the ovaries, fallopian tubes, and uterine serosa also were observed.

All those with endometriosis had stage I or stage II disease. Approximately half of the patients with endometriosis experienced pain that was cyclic only, about 40% had pain that was both cyclic and acyclic, and the remaining 10% complained of acyclic pain only. Gastrointestinal pain, back pain, irregular menses, and menorrhagia were among the less common presentations.

Future research could evaluate the clinical impact of earlier endometriosis detection in adolescents. The clinical significance of these lesions "is unclear as of now," Dr. Opoku-Anane said, "in terms of determining if early diagnosis and treatment prevents progression of endometriosis and [prevents] infertility."

Dr. Opoku-Anane said that she had no relevant financial disclosures.