Breast Disease in Children and Adolescents in Eastern Nigeria—a Five-Year Study

Aims and Objectives(1) To define the spectrum of breast diseases in the children and adolescents in Eastern Nigeria. (2) To provide where possible, an international comparison of statistical variations of both benign and malignant lesions in these age groups.Materials and MethodsThe Morbid Anatomy Department of the University of Nigeria Teaching Hospital (UNTH) Enugu is a referral center for over 30 million people. The laboratory receives around 2,000 surgical pathology specimens per year. Virtually all children and adolescents (4–19) years who complained of a breast mass had a biopsy, and results of all excised breast specimens from children and adolescent age groups from 4 to 19 years were included in the study. The case files of these patients were retrieved and reviewed to ascertain the size and duration of the breast lesions. The number of phyllodes tumors seen in the child and adolescent population was compared to those seen in the adult population at the same period.Two independent pathologists reviewed the slides, and their results compared.ResultsA total of 1050 breast specimens were received in the department of morbid anatomy from all age groups, from January 1, 2000 to December 31, 2004, out of which 121 (11.5%) were breast specimens from the children and adolescent age groups. On the average most patients with benign breast lesions presented within 3–5 months of their symptoms, which usually was a palpable lump detected in all cases by either the child or the mother. Their sizes vary from 2–3 cm and only ten were multiple but they were all confined to one breast. Those with phyllodes presented typically within 3 months probably because of the faster rate of growth. Their sizes varied from 5–13 cm and they were all unilateral. Phyllodes tumor in this age group constitute 28.6% of all phyllodes seen in this period and were all benign. The mean age was approximately 11.5 years while the median age was 18 years. Three cases were malignant.ConclusionFibro adenoma, fibrocystic breast disease, and low grade phyllodes tumor were the most common breast lesions seen in our children and adolescent population. The three cases of malignancy observed included invasive intraductal carcinoma, a non-hodgkin lymphoma, and metastases involving the lymph nodes from an uncharacterized secondary malignancy. Phyllodes tumors were typically larger in size and tended to present earlier. Genetic characterization of such lesions is recommended for future studies as well as their relationship to lesions seen among other Africans in Diaspora.     

Residents’ Confidence in Performing Robotic Hysterectomy in Obstetrics and Gynecologic Training Programs

Study ObjectiveTo compare residents’ perceptions of readiness to perform robotic-assisted laparoscopic hysterectomy with the perceptions of residency program directors in obstetrics and gynecology programs throughout the United States.DesignA survey was administered to all residents taking the 2019 Council on Resident Education in Obstetrics and Gynecology Exam and concurrently to program directors in all Accreditation Council for Graduate Medical Education–accredited training programs.SettingThe survey was designed to assess resident confidence to perform robotic hysterectomies by the time of graduation.PatientsNo patients were included in the study.InterventionsThe only intervention was administration of the survey.Measurements and Main ResultsDe-identified survey data were analyzed using chi-squared and Fisher's exact tests. A total of 5473 resident respondents and 241 residency program directors were included in the study. Fifty-two percent of graduating residents reported that they felt they were given surgical autonomy to perform robotic hysterectomies, and 53.7% reported that they could perform one independently (if it was an “emergency” and they had to). By the time of graduation, only 59% of residents reported confidence performing a robotic hysterectomy, and only 56% reported they felt that it would be an important procedure for their future career. Program directors were significantly more likely to report that their residents were given autonomy to perform robotic hysterectomy by graduation (61.0% [95% confidence interval (CI), 54.3–67.3]), could perform a robotic hysterectomy independently (60.9% [95% CI, 53.9–67.6]), or could perform a robotic hysterectomy by graduation (70.2% [95% CI, 63.5–76.3]) than residents themselves (38.6% [95% CI, 37.2–40.0], 22.8% [95% CI, 21.6–24.0], 62.6% [95% CI, 61.2–64.0], respectively).ConclusionAt the time of graduation, residents’ confidence in performing robotic hysterectomy independently is lower than their confidence in performing all other approaches to hysterectomy.     

Evaluation of the Supportive Needs of Adolescents during Childbirth Intrapartum Nursing Intervention on Adolescents’ Childbirth Satisfaction and Breastfeeding Rates

ObjectiveTo evaluate the effect of the Supportive Needs of Adolescents during Childbirth (SNAC) intrapartum nursing intervention on adolescents’ childbirth satisfaction and breastfeeding rates.DesignSeparate sample posttest quasi‐experimental.SettingA tertiary hospital intrapartum unit.ParticipantsA convenience sample of 106 parturient adolescents.MethodsDuring Phase 1 the control group received current standard of intrapartum care.During Phase 2, the interventionist nurses provided the SNAC intervention and standard of care to the intervention group.ResultsThe t test indicated higher childbirth satisfaction in the intervention group.Chi‐square analysis indicated that the intervention group was more likely to breastfeed within the first hour after birth. There was no significant relationship between childbirth satisfaction and breastfeeding at three months and no differences between the groups in breastfeeding rates at hospital discharge and three months.ConclusionsThese results suggest that learning the SNAC intervention may help nurses positively influence adolescents’ childbirth experience and timing of breastfeeding initiation. Replication of the study is needed to further explore whether the intervention can significantly influence breastfeeding duration.     

Parents’ and Adolescents’ Attitudes about Parental Involvement in Clinical Research

Study ObjectiveTo understand parent and adolescent attitudes toward parental involvement during clinical trials and factors related to those attitudes.DesignAs part of a study on willingness to participate in a hypothetical microbicide study, adolescents and their parents were interviewed separately.SettingAdolescent medicine clinics in New York City.ParticipantsThere were 301 dyads of adolescents (ages 14-17 years; 62% female; 72% Hispanic) and their parents.InterventionsNone.Main Outcome MeasuresThe interview included questions on demographic characteristics, sexual history, and family environment (subscales of the Family Environment Scale) that were associated with attitudes about parental involvement.ResultsFactor analysis of the parental involvement scale yielded 2 factors: LEARN, reflecting gaining knowledge about study test results and behaviors (4 items) and PROCEDURE, reflecting enrollment and permissions (4 items). Adolescents endorsed significantly fewer items on the LEARN scale and the PROCEDURE scale indicating that adolescents believed in less parental involvement. There was no significant concordance between adolescents and their own parents on the LEARN scale and the PROCEDURE scale. In final multivariate models predicting attitudes, adolescents who were female and had sexual contact beyond kissing, and non-Hispanic parents had lower LEARN scores. Adolescents who were older, had previous research experience, and reported less moral or religious emphasis in their family had lower PROCEDURE scores; there were no significant predictors for parents in the multivariate analyses.ConclusionParents wanted greater involvement in the research process than adolescents. Recruitment and retention might be enhanced by managing these differing expectations.     

Genital HPV in Children and Adolescents: Does Sexual Activity Make a Difference?

Study ObjectiveTo compare the prevalence of human papillomavirus (HPV) genital infection among prepubertal children, sexually active and not sexually active adolescents, and assess potential risk factors for transmission.DesignProspective study.SettingOutpatient adolescent health clinic.ParticipantsNinety-five girls aged 2-21 years; 38 sexually active adolescents (group A), 28 not sexually active adolescents (group B), and 29 prepubertal children (group C).InterventionsParticipants' vaginal or cervical specimens were tested for HPV with the CLART HPV 2 assay (Clinical Array Technology, Genomica, Madrid, Spain) and for cytological abnormalities with liquid-based cytology.Main Outcome MeasuresDifferences in prevalence of low- and high-risk HPV infections among the 3 groups.ResultsGenital HPV was detected in 37.9% (36/95) of all participants; 47.4% (18/38) of group A, 28.6% (8/28) of group B, and 34.5% (10/29)of group C (P = .27). Multiple HPV infection was detected in 26.3% (10/38), 10.7% (3/28), and 13.8% (4/29) of groups A, B, and C, respectively (P = .21). High-risk genotypes were detected in 47.4% (18/38), 28.6% (8/28), and 24.1% (7/29) of groups A, B, and C, respectively (P = .10). Main high-risk genotypes were HPV 16 (27%, 10/37), HPV 31 (21.6%, 8/37 ), HPV 35 (13.5%, 5/37), HPV 53 (13.5%, 5/37), and low-risk HPV 6 (18.9%, 7/37). Sexual activity was associated with increased risk for genital high-risk HPV infection (odds ratio = 3.41; 95% confidence interval, 1.19-9.78); specifically with HPV 33 and HPV 51. Forty percent of sexually active adolescents with normal cervical cytology were infected with high-risk HPV types. Family history of skin HPV was positively associated with genital HPV in the sexually active group (odds ratio = 2.01; 95% confidence interval, 1.17-3.46).ConclusionTimeline and target population for HPV vaccination might need to be reappraised, in view of significant nonsexual transmission of genital HPV so early in childhood.     

Will it Hurt? The Intrauterine Device Insertion Experience and Long-Term Acceptability Among Adolescents and Young Women

Study ObjectiveTo examine how the intrauterine device (IUD) insertion experience affects long-term IUD acceptability among adolescents.DesignText to Web survey study.SettingBoston Children's Hospital and Cambridge Health Alliance in Massachusetts.Participants, Interventions, and Main Outcome MeasuresNulliparous adolescents aged 13-21 years who received an IUD or etonogestrel implant between January 2012 and May 2018.ResultsWe received survey responses from 95 adolescents (n = 46 IUD; n = 49 implant; response rate = 95/1098 (9%)). Mean current age (20.8 years) and time since device insertion (2.4 years) were similar between groups. Although a large proportion of both groups (64%) experienced moderate to severe preprocedural anxiety, IUD users expected more insertional pain compared with implant users (55.6 vs 39.6; P = .01). Compared with implant users, more IUD users experienced moderate to severe insertional pain (80% vs 18%; P < .0001), recalled that the procedure hurt more than expected (52% vs 4%; P < .0001), and endorsed lower rates of pain management satisfaction (72.4 vs 85.6; P = .04). Most respondents would recommend their method to a friend (75%) or consider getting the same device in the future (63%). When explicitly asked, more IUD users reported that dislike of the insertion procedure might or would probably prevent them from getting the same device in the future (41% vs 14%; P = .005).ConclusionCompared with implant users, IUD users reported more negative insertion experiences, although preprocedural anxiety was prevalent in both groups. Dislike of the insertion experience might negatively affect adolescents’ willingness to continue using an IUD in the future. Findings should encourage multimodal interventions to holistically improve the IUD insertion experience.     

Experience with Implanon® in a north-east London family planning clinic

Aim The primary objective of the study was to evaluate the continuation rates of a relatively new long-acting method of contraception, Implanon®. The secondary objective was to study discontinuations related to bleeding problems and their management.

Method?A retrospective review of records of women fitted with Implanon was undertaken during February 2000–January 2003.

Results?Results from the secondary objective will be the subject of a separate communication. Of the 147 implants fitted, 132 records could be retrieved; of these, 97% of the women had pre-insertion counselling by the clinician. The most common indications for Implanon usage were choice of a long-acting method, unhappy experience with other contraceptive methods and suboptimal compliance with contraceptive pills and injectables. The median age of fitting was 25 years and 36% of the women were nulliparous. No problems were experienced with fitting or removal of implants. Twenty (15%) women were lost to follow-up. Twenty-two implants were removed by the end of the study period, with 12 (60%) removals attributed to prolonged heavy/light bleeding. There were no known pregnancies during the study. Given that 15% of the women could not be followed up or contacted, the assumed lifetimes of Implanon using the Kaplan–Meier method are 0.90 (95% confidence interval 0.82–0.95) at 12 months, 0.80 (0.67–0.88) at 24 months and 0.75 (0.58–0.85) at 35 months. The confirmed lifetimes are 0.84 (0.71–0.91) at 12 months, 0.63 (0.42–0.78) at 24 months and 0.53 (0.28–0.73) at 35 months.

Conclusion?Although not free of side-effects, Implanon can be a good choice for women who are properly informed and counselled and seek long-term ‘forgettable’ contraception.     

Surgical margin status and recurrence pattern in invasive vulvar Paget’s disease: A Japanese Gynecologic Oncology Group study

ObjectiveTo examine the association between surgical margin status and recurrence pattern in invasive vulvar Paget’s disease.MethodsThis is a preplanned secondary analysis of a previously organized nationwide retrospective study in Japan (JGOG-1075S). Women with stage I-IV invasive vulvar Paget’s disease who received surgical treatment from 2001-2010 were examined (n=139). Multivariable analysis was performed to assess local-recurrence, distant-recurrence, and all-cause mortality based on surgical margin status.ResultsThe median age was 70 years. The majority had stage I disease (61.2%), and the median tumor size was 5.0cm. Nodal metastasis was observed in 15.1%. Simple vulvectomy (46.0%) was the most common surgery type followed by radical vulvectomy (28.1%). More than half received vulvar reconstructive surgery (59.0%). Positive surgical margin was observed in 35.3%, and close margin <1cm was observed in 29.5%. Vulvectomy type was not associated with surgical margin status (P=0.424). The median follow-up was 5.8 years. Positive surgical margin was associated with increased local-recurrence (5-year cumulative rates for positive versus negative margin: 35.8% versus 15.0%, P=0.010) but not distant-recurrence (18.3% versus 16.0%, P=0.567). Positive surgical margin was also associated with increased all-cause mortality (5-year overall survival rates for positive versus negative margin: 72.6% versus 88.2%, P=0.032). In multivariable analysis, positive surgical margin remained an independent factor associated with increased risk of local-recurrence (hazard ratio 2.80, 95% confidence interval 1.18-6.63) and all-cause mortality (hazard ratio 2.87, 95% confidence interval 1.20-6.83).ConclusionPositive surgical margin appears to be common in invasive vulvar Paget’s disease that is associated with increased local-recurrence and all-cause mortality risks. Role of alternative surgical technique or adjuvant therapy merits further investigation to improve local disease control.     

Menstruation in Adolescents: What Do We Know? and What Do We Do with the Information?

The menstrual cycle has been recognized as a vital sign that gives information about the overall health of an adolescent or young adult female. Significant deviations from monthly cycles can signal disease or dysfunction. This review highlights the evidence based parameters for normal puberty, menarche, cyclicity, and amount of bleeding. The review addresses sources of information available online, noting inaccuracies that appear in web sites, even and especially those targeting adolescents. The review includes a call to action to provide accurate information about the menstrual cycle as a VITAL SIGN.     

The Efficacy and Safety of Ospemifene in Treating Dyspareunia Associated with Postmenopausal Vulvar and Vaginal Atrophy: A Systematic Review and Meta‐Analysis

IntroductionOspemifene, a novel selective estrogen receptor modulator, has been developed for the treatment of vulvovaginal atrophy and dyspareunia in postmenopausal women.AimWe carried out a systematic review and meta‐analysis to assess the efficacy and safety of the drug for treating dyspareunia associated with postmenopausal vulvar and vaginal atrophy.MethodsA literature review was performed to identify all published randomized double‐blind, placebo‐controlled trials of ospemifene for the treatment of vulvovaginal atrophy and dyspareunia. The search included the following databases: MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. The reference lists of the retrieved studies were also investigated. A systematic review and meta‐analysis was conducted.Main Outcome MeasuresSix publications involving a total of 1,772 patients were used in the analysis, including three randomized controlled trials (RCTs) that were short‐term (12 weeks) comparisons of ospemifene with placebo and three RCTs that were long‐term (1 year) comparisons of ospemifene with placebo.ResultsFor the comparison of short‐term ospemifene with placebo, parabasal cells (the standardized mean difference [SMD] = −37.5, 95% confidence interval [CI] = −41.83 to −33.17, P < 0.00001), superficial cells (SMD = 9.24, 95% CI = 7.70 to 10.79, P < 0.00001), vaginal PH (SMD = −0.89, 95% CI = −0.98 to −0.80, P = 0.00001), and dyspareunia (SMD = −0.37, 95% CI = −0.43 to −0.30, P = 0.00001) indicated that ospemifene was more effective than the placebo. For the comparison of long‐term ospemifene with placebo, endometrial thickness (SMD = 0.90, 95% CI = 0.58 to 1.23, P = 0.00001), treatment emergent adverse event, discontinuations due to adverse event, and serious adverse event indicated that ospemifene was generally safe.ConclusionsThis meta‐analysis indicates that ospemifene to be an effective and safe treatment for dyspareunia associated with postmenopausal vulvar and vaginal atrophy. Cui Y, Zong HT, Yan HL, Li N, and Zhang Y. Treating dyspareunia associated with postmenopausal vulvar and vaginal atrophy: A systematic review and meta‐analysis. J Sex Med 2014;11:487–497.     

Measuring Quality in Minimally Invasive Gynecologic Surgery: What,How, and Why?

In healthcare, the goal of maximizing value by improving the quality of care and lowering costs has been notoriously challenging to achieve. The fee-for-service model in gynecology and other fields has historically promoted the reduction of nonsurgical or minimally invasive approaches in favor of complex, often morbid procedures. In this review, we seek to define quality and value in the healthcare field and describe strategies that promote quality over production. We then discuss national, non–specialty-based efforts in the context of Surgical Care Improvement Project measures to improve quality of care. Finally, we present a case study through the Kaiser Permanente Minimally Invasive Hysterectomy Initiative, one such model that successfully built on the quality metrics of the foregoing strategies to improve patient care.     

Psychosexual Development in Adolescents and Adults with Disorders of Sex Development—Results from the German Clinical Evaluation Study

IntroductionBoth biological and psychosocial factors influence psychosexual development. High levels of pre‐ and postnatal androgens lead to more male‐typical behavior. So far, the influence of androgens on gender identity and sexual orientation is unclear. Disorders of sex development (DSDs) are heterogeneous genetic conditions with different levels of prenatal androgens resulting in variations of genital development. Through DSD, the role of the different factors, especially androgen exposure, on psychosexual development can be evaluated.AimThe purpose of the study was to assess psychosexual development in adolescents and adults with different forms of DSD.MethodsFor the examination of psychosexual development of 66 adolescents and 110 adults with DSD, the authors used the Utrecht Gender Dysphoria Scale for adolescents, the Questionnaire of Gender Identity for adults, and a condition‐specific DSD study questionnaire. Individuals were analyzed in four subgroups reflecting the karyotype, absence/presence of androgen effects, and gender of rearing.Main Outcome MeasuresMain outcome measures used were gender identity, friendships, love and sexual relationships, and sexual orientation in adolescents and adults with DSD.ResultsIndividuals with DSD did not show increased gender dysphoria. However, partnership and sexuality were identified to be difficult areas of life. Both adolescents and adults with DSD reported fewer experiences regarding love or sexual relationships compared with unaffected individuals. Especially men with DSD and undervirilization and women with DSD and androgen effects less often had a love relationship. Adult women with DSD and androgen effects more frequently engaged in love and sexual relationships with individuals of the same gender compared with women without DSD.ConclusionIndividuals with DSD experience atypical hormonal influences (higher levels of androgens in girls/women and lower levels in androgens in boys/men); however, they did not show increased gender dysphoria in this study. However, partnership and sexual relationships are difficult areas of life for adolescents and adults with DSD. We recommend that individuals with DSD should get support from a multiprofessional team with competency in assessing and counseling issues regarding relationships and sexuality. Contact to other individuals with DSD can be helpful for nonprofessional support and exchange of experiences. Jürgensen M, Kleinemeier E, Lux A, Steensma TD, Cohen‐Kettenis PT, Hiort O, Thyen U, Köhler B, and the DSD Network Working Group. Psychosexual development in adolescents and adults with disorders of sex development—Results from the German Clinical Evaluation Study. J Sex Med 2013;10:2703–2714.     

Amniocentesis or chorionic villus sampling in multiple gestations? Experience with 500 cases

500 women with multiple pregnancies underwent amniocentesis or chorionic villus (CV) sampling at our department between January 1988 and July 1997. The aim of this retrospective study was to evaluate the laboratory aspects and the consequences of discordant results in these pregnancies in relation to the method of sampling. Uncertain results in one or both samples, requiring further investigation were more frequent in CV samples (eight times in 163 paired samples, 5 per cent) than in amniotic fluid (AF) samples (once in 298 paired samples, 0.3 per cent). Sampling one fetus twice (erroneous sampling) was seen only once among 163 pregnancies with two CV samples in our study. Cross contamination due to mixed sampling was discovered in two of seven pregnancies that underwent DNA diagnosis in CV and might be a rather regular occuring phenomenon. In none of the 500 pregnancies mixed sampling caused diagnostic dilemmas. A third sampling problem, maternal cell contamination caused a diagnostic problem once among the AF samples. Selective fetal reduction appeared safer after CV sampling than after amniocentesis. Subsequently, CV sampling instead of amniocentesis has become the method of choice for prenatal diagnosis in multiple pregnancies in our department.