Minimal access surgery in adolescent gynaecology

The benefits of a minimally invasive approach are now well documented in adult women, and thus surgeons have embraced the notion of expanding such expertise in adolescence with measured enthusiasm and a great sense of responsibility. Faster recovery is likely to have a positive impact on schooling, while less adhesion formation may reduce future fertility issues. Gynaecologists performing minimally invasive procedures in adolescents ought to be aware of the steep learning curve required for achieving proficiency with complex laparoscopic surgery. In the group of rare congenital anomalies and advanced endometriosis, the best surgical results can only be achieved after careful preoperative planning by a multidisciplinary team     

Dysmenorrhea in a multiethnic population of adolescent Asian girls

Objective

To determine the prevalence of dysmenorrhea, its impact, and the treatment-seeking behavior of adolescent Asian girls.

Method

A cross-sectional study with 1092 girls from 15 public secondary schools and 3 ethnic groups in the Federal Territory of Kuala Lumpur, Malaysia.

Results

Overall, 74.5% of the girls who had reached menarche had dysmenorrhea; 51.7% of these girls reported that it affected their concentration in class; 50.2% that it restricted their social activities; 21.5% that it caused them to miss school; and 12.0% that it caused poor school performance. Ethnicity and form at school were significantly associated with the poor concentration, absenteeism, and restriction of social and recreational activities attributed to dysmenorrhea. Only 12.0% had consulted a physician, and 53.3% did nothing about their conditions. There were ethnic differences in the prevalence, impact, and management of dysmenorrhea.

Conclusion

There is a need for culture-specific education regarding menstruation-related conditions in the school curriculum.     

Endometriosis in pediatric and adolescent gynecology

Endometriosis is the most common cause of chronic pelvic pain in adolescent girls (50-70%), unresponsive to treatment of oral contraceptives and non-steroidal anti-inflammatory drugs. The most common symptoms of the disease are: acquired or progressive dysmenorrhea, acyclic and cyclic pain, dyspareunia (in sexually active girls), urological symptoms and gastrointestinal complaints. When evaluating an adolescent with suspected endometriosis, a gynecological examination (rectal or vaginal examination) and imaging studies (ultrasonography, magnetic resonance) should be performed. Moreover, in diagnostic process laparoscopy should be carried out in all girls and teenagers with chronic pelvic pain unresponsive to medical treatment. Initial therapy of endometriosis in adolescent girls involves: surgical methods (laparoscopy/laparotomy), hormonal pharmacotherapy (combined contraceptives, progestin-only protocols), GnRH agonists (adolescents over 16 years of age), non-steroidal anti-inflammatory drugs, alternative pain therapies and psychotherapy. Early diagnosis and treatment during adolescence may decrease disease progression and prevent subsequent infertility.     

Dysmenorrhea in the female adolescent. Clinical, biological and therapeutic data

The physiology and pathology of dysmenorrhea in adolescent girls has become clear in the past 5 years. Although the prime cause of the disorder has not been identified, the obvious rise in PGF2 alpha prostaglandins is an objective biologic sign. As a result, more specific treatment has become possible with more definite and established care of this "condition" which is often distressing to the teenage girl affected.     

A review of paediatric and adolescent gynaecology services in a tertiary outpatient clinic

Adolescence is a distinctive stage in human development during which many simple and complex medical conditions can present for the first time. Paediatric and adolescent gynaecological conditions need careful multidisciplinary clinical management with a sensitive approach understanding the patients’ psychological and physiological circumstances. The objective of this study is to review the tertiary paediatric and adolescent gynaecology service in Leeds, United Kingdom and to present an overview of the various conditions that present to such a clinic. A total of 985 patients were seen over a 16-year period and the increasing number of patients seen over this time establishes the need for such a service to exist. Complex developmental anomalies of the genital tract and disorders of sexual differentiation formed a major portion of the referrals. Presence of a significant number of referrals for simple gynaecological conditions including menstrual irregularities, gynaecological pain, vulvovaginitis, polycystic ovary syndrome and concerns about labial appearance indicates the reluctance of general gynaecologists and general practitioners to manage such conditions in young patients. This emphasizes the need for continued education of primary health care professionals and establishment of clear guidelines and care pathways for the management of this special patient group.     

Adnexal torsion in pediatric and adolescent girls

PURPOSE OF REVIEW: This review provides timely information to assist in solving the diagnostic dilemma of adnexal or ovarian torsion. Knowledge and awareness of current literature is essential to help clinicians improve diagnostic accuracy and avoid potentially catastrophic consequences, including loss of ovarian tissue and function. RECENT FINDINGS: This article reviews recent evidence regarding radiologic tools used for efficient, timely diagnosis and management strategies for adnexal torsion, including detorsion. The role of oophoropexy in the pediatric and adolescent population is also reviewed. SUMMARY: The discussion reinforces the role of detorsion in lieu of oophorectomy or adnextomy in an effort to preserve reproductive capacity in a young population. Long-term follow-up, including reproductive outcomes, is needed to determine the role of oophoropexy.     

Laparoscopy in the pediatric and adolescent population

The use of laparoscopy by gynecologists in treating pediatric and adolescent patients is a relatively new phenomenon. This article discusses the specialized instrumentation necessary for operating on these patients and preoperative considerations and generalized techniques unique to this population. Although laparoscopy has a myriad of uses, the main focus is on the diagnosis and treatment of pelvic pain, adnexal masses, and pelvic inflammatory disease. Incidental appendectomy in these patients is also discussed.     

Breast disorders in the pediatric and adolescent patient

Despite the wide range of breast abnormalities that affect patients in the pediatric and adolescent populations, some conclusions can be drawn. Breast self-examination in the adolescent population is controversial but is recommended for girls who carry the BRCA1 or BRCA2 gene beginning at age 18 to 21 years. All girls with a disorder of breast size or symmetry should be given the opportunity of consultation with a plastic surgeon to discuss reconstructive options. Ultrasound is the most appropriate initial investigation in any adolescent patient with a breast mass owing to the dense nature of breast tissue in this age group. Although it is extremely rare in this population, breast cancer must always be included in the differential diagnosis of a breast mass, particularly in the patient with a prior history of childhood malignancy or chest irradiation.     

Expressive therapy in pediatric and adolescent gynecology.

Children and adolescents seen by gynecologists may have a broad spectrum of emotional needs that can affect the gynecologic examination as well as the young person's overall well-being. The field of expressive therapy is a relatively new one. The therapist uses a variety of techniques to allow the patient to explore feelings, attitudes, or events in ways that may help the patient to develop new strategies to cope with distress. The application of expressive therapy in pediatric and adolescent gynecology appears to be ever more encompassing.     

Ovarian cortex cryopreservation in pediatric and adolescent medicine

Background: Increased pediatric/adolescent cancer survivor rates have enhanced awareness of long-term effects of therapy, specifically gonadal failure. Ovarian cortex cryopreservation may hold the promise of fertility for those at risk for ovarian failure due to medical therapy. The object of this study was to determine if an ovarian cryopreservation program is feasible and to define suitable candidates.Method: A MEDLINE search supplemented by bibliographies. The review was limited to English articles on ovarian failure rates following radiation and/or chemotherapy and on ovarian cryopreservation. Investigators in the field were consulted to identify other sources.Results: Approximately one third of postpubertal females exposed to chemotherapy or radiotherapy develop ovarian failure. The risk is mostly significant for patients exposed to pelvic radiotherapy (up to 32% decrease in fertility) and alkylating agent based chemotherapy (infertility in 22%). A ninefold increase in premature ovarian failure results from exposure to combined pelvic radiotherapy and alkylator based chemotherapy. Practically all patients exposed to multiple agent chemotherapy combined with pelvic radiotherapy at doses used in preparation for bone marrow transplant will undergo irreversible loss of ovarian function. Currently human ovarian cortex can be cryopreserved, thawed and stimulated with gonadotrophins to produce follicles when transplanted into immunosuppressed mice, however there has yet to be any human pregnancies. The immunosupressed mouse model could also serve as a test to determine whether the tissue carries metastatic risk prior to reimplantation into the donor.Conclusion: Based on the literature we propose ovarian cortex cryopreservation and banking for postpubertal females prior to chemotherapy and/or radiation therapy that holds a high risk of ovarian failure. In the future this may provide oocytes for reproductive purposes. A protocol is currently under approval by the Hospital for Sick Children's ethics committee.     

Common problems in pediatric and adolescent gynecologic surgery

Clinical studies on the myriad of problems that are encompassed by pediatric and adolescent gynecologic surgery are extremely difficult to carry out due to the low numbers of patients with these diagnoses in any one location or institution. Our current understanding of diagnosis, treatment, and outcome is drawn from case reports and the sharing of information. Frequently, clinical practice embraces technology long before the reports of such technology appear in the literature. As clinicians join together to study the various pathologies seen in this group of patients, we may see some impressive studies in the future. This review will focus on the current information available, which may contribute to the treatment and understanding of pediatric and adolescent gynecologic surgery.     

The physical examination in pediatric and adolescent patients

The initial evaluation and examination of both the pediatric and adolescent patients provides the opportunity for the clinician to establish a relationship that will ensure the successful outcome of the visit. In the younger age group, cooperation of the child before performing an examination should be the focus at the first encounter. This cooperation will enable proper positioning and a systematic approach to examination and documentation of findings. Although the adolescent patients may be older and better able to understand the specifics of the examination, these patients present additional challenges for the examining practitioner.