Adams Hillard, Paula J.
Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, USA
Correspondence to Paula J. Adams Hillard, MD, Professor, Department of Obstetrics and Gynecology, Associate Chair for Medical Student Education, 300 Pasteur Dr HH333, Stanford, CA 94305-5317, USA. E-mail: firstname.lastname@example.org
This section of Current Opinion in Obstetrics and Gynecology focuses on the gynecologic issues of prepubertal girls and adolescents. The topics that I have selected include a range of problems – from those that are all too common, like pelvic inflammatory disease (PID) – to those that are rare, such as primary ovarian insufficiency (POI). These topics have in common the characteristic that they each significantly impact a young girl's life, with the overarching theme that a girl's quality of life is critically important to her overall health and well-being. As the section editor, it is my privilege to select topics that are important and relevant to the practice of gynecology, and to select authors who are world experts on these topics. The authors who have so graciously agreed to write reviews for this issue are generally well known in the field of pediatric and adolescent gynecology, although some are better known in our sister fields of pediatrics and adolescent medicine. Other authors typically write about their topics from the perspective of adult gynecology or reproductive endocrinology and infertility. Let me introduce each author to you.
The first gynecologic examination is a milestone for most women and can be an event that is empowering, or, alternatively, can bring memories or flashbacks of previous sexual abuse, coercion, or violence. Drs Barbro Wijma and Karin Siwe review this topic from their perspectives in Sweden. Dr Wijma has studied victimization among women, and she and Dr Siwe have previously written about the first pelvic exam and its impact on young women . Dr Wijma is a physician and psychotherapist, and Professor of Gender and Medicine of Linkoping University in Sweden. She has explored the interdisciplinary ways of bridging the gap between science and ethics, philosophy, and sociology. She has collaborated with Dr Wijma in writing about medical students’ experiences in learning to perform the pelvic examination, the topic of Dr Siwe's PhD thesis . In this issue of Current Opinion in Obstetrics and Gynecology, they review (pp. 357–369) the topic of the first pelvic examination for an adolescent, and explore the US and Swedish perspectives on this examination. They address the concept that this examination may not be living up to its potential utility as a positive and empowering rite of passage for young women.
Dr Maria Trent is the director of the Interdisciplinary Training-Leadership in Adolescent Health program at the Johns Hopkins University School of Medicine. A major focus of her research and scholarship has been on fertility preservation in adolescent girls . She has written previously about care delivery for PID in pediatric ambulatory settings . In the review (pp. 350–356) published in this issue of Current Opinion in Obstetrics and Gynecology, she provides an ‘alternative look’ at the published data on adolescents with PID, and concludes that there is limited evidence to guide the best practice strategies for young and middle adolescents with PID. The evidence supports the fact that adolescents and adult women receive suboptimal treatment for PID; large database reviews demonstrate that only 30–40% of patients received care according to the U.S. Centers for Disease Control (CDC) treatment guidelines [5,6]. Because adolescents are at increased risk for poor adherence to treatment regimens, and at increased risk of sexually transmitted disease (STD) reacquisition, they risk adverse reproductive health outcomes including infertility, recurrent PID, and chronic pelvic pain. Dr Trent argues for additional research to determine the cost-effective, evidence-based treatments for PID in adolescents that will prevent reacquisition of STDs and PID, and thus benefit their quality of life and health.
The topic of intimate partner violence (IPV) is now well established as an important focus for screening during annual gynecologic visits for adults. The US Preventive Services Task Force now recommends that clinicians screen women of childbearing age for IPV as a Grade B recommendation: that there is ‘high certainty that the net benefit (of screening) is moderate or there is moderate certainty that the net benefit is moderate to substantial’ . The US Centers for Disease Control and Prevention estimates that nearly 36% of women report experiencing some form of interpersonal violence (rape, physical violence, and stalking) in their lifetime . IPV in adolescents has not been studied as extensively as IPV among adult women, but Dr Elizabeth Miller, Chief of the Division of Adolescent Medicine at the Children's Hospital of Pittsburgh, is a true expert on this difficult topic. She has studied sex trafficking among adolescents, teen dating abuse, the link between IPV and unintended pregnancy, and interventions to prevent violence and reproductive coercion . Dr Miller's co-author, Heather McCauley, is a fellow in the division of Adolescent Medicine. She is a social epidemiologist whose research focuses on the health impacts of sex-based violence as well as the protective factors that mitigate the health impacts of exposure to violence . These two authors review (pp. 364–369) the topic of relationship abuse and reproductive and sexual coercion among teens for this issue of Current Opinion in a thorough and eye-opening manner. It is clear that for our patients’ safety and reproductive health, we need to be aware of the possibility of reproductive coercion and adolescent relationship abuse.
Although many textbooks still define primary amenorrhea as no menses by age 16, it is statistically quite uncommon for an adolescent not to have achieved menarche by age 15 . In addition, the lack of the onset of breast development by age 13 is also rare, and thus should be evaluated, as it may be associated with gonadal dysgenesis or POI . Although there are many causes of primary amenorrhea, POI must be considered. POI may also be discovered when menses have not occurred by age 15 or during an evaluation for infrequent menses.
Dr Valerie Baker, one of my colleagues at the Stanford University School of Medicine, is the chief of the Division of Reproductive Endocrinology and Infertility at Stanford, and POI has been a focus of her scholarly writing [13,14]. This condition was once termed premature ovarian failure (POF) or ‘premature menopause’, but is now more appropriately termed POI, as ovarian function may wax and wane . This condition, although rare in adolescents, can have profound reproductive and health consequences. Dr Baker reminds us to consider the possibility of POI in an adolescent who is experiencing significant menstrual irregularities. She reviews (pp. 375–381) the data that support the value of measuring anti-Müllerian hormone (AMH) in addition to follicle stimulating hormone and estradiol in making this diagnosis. She also encourages the clinicians to consider the consequences for general health as well as for fertility when POI is diagnosed. Although the average clinician will see this condition only rarely, a basic awareness of its implications is critical for ensuring appropriate therapy.
Another cause of primary amenorrhea is anatomic. Vaginal agenesis, Mayer–Rokitansky–Kuster–Hauser (MRKH) syndrome, occurs in approximately 1 : 4000 births. Mr Keith Edmonds is a consultant obstetrician and gynecologist at Queen Charlotte's and Chelsea Hospital in London. He works with a multidisciplinary team to provide care for individuals with MRKH syndrome and has published a report which is the world's largest series of patients managed by nonsurgical techniques using vaginal dilators . His team has a success rate of approximately 95%. His review (pp. 382–387) of the topic of MRKH syndrome for Current Opinion provides an update on the genetic factors, new surgical options, and potential for fertility for girls and women. Clinicians should be aware of the excellent success rates with nonsurgical techniques for creation of a neovagina, but successes are highest when patients are cared for by a multidisciplinary team including, in the case of the National Centre for Adolescent and Adult Females with Congenital Abnormalities of the Genital Tract in London, a clinical nurse specialist, a clinical psychologist, a consulting radiologist and anesthetist, in addition to Mr Edmonds, the founding ob–gyn. Such excellent results can be obtained with proper attention to psychosocial support and encouragement.
Dr Lies Quint is the co-director of the pediatric and adolescent gynecology clinic at the University of Michigan, and directs the fellowship program in pediatric and adolescent gynecology. Dr Quint has extensive clinical experience in caring for girls with pediatric gynecologic conditions and has written about vulvar diseases in children . She and her fellow, Dr Melina Dendrinos, review (pp. 370–374) the dermatologic condition of lichen sclerosus of the vulva in children and adolescents. This condition, although uncommon, has a characteristic appearance, but is often not well recognized by the primary clinicians. It leads to symptoms of pain and itching, and can be a cause of dysuria and constipation. Importantly, clinicians who are unfamiliar with the condition can misdiagnose the findings as resulting from sexual abuse. Failure to recognize, diagnose, and manage the underlying cause leads to ongoing pain and itching – very troublesome symptoms for young girls. The authors review the diagnosis and management, in an effort to increase the awareness of the condition and its appropriate treatment.
This section on Pediatric and Adolescent Gynecology reviews the topics that all obstetrician–gynecologists who care for young girls and adolescents should be aware of. All of us will see and care for young women who are having their first pelvic examination. How much better might the future health of these young women be if we more appropriately helped them to feel empowered to be partners in their own healthcare with their first pelvic exam? Continuing to note the lessons learned from this issue of Current Opinion in Obstetrics and Gynecology, we should all be aware and concerned about both preventing and appropriately treating the all-too-common condition of PID in adolescents. An awareness of and reminder that interpersonal violence does not just begin in adulthood for women, but can begin during adolescence and early relationships, will allow us to appropriately consider and screen for this all-too-common condition of too many of our patients’ lives. Even those of us who have been screening for IPV in our patients for years need to be aware of the issue of reproductive coercion, which may certainly begin during adolescence for the teens we see in our offices. Although common conditions occur commonly, and most menstrual cycle irregularity in adolescence is within the defined normal menstrual parameters with menarche by age 15 and cycle length between 21 and 45 days, girls who have very irregular menses or primary amenorrhea may have something common, such as polycystic ovary syndrome or an eating disorder, but might also have the rare condition of POI. If they have primary amenorrhea, the possibility of an anatomic anomaly such as vaginal agenesis – MRKH syndrome – must be kept in mind. And finally, although vulvar burning, vulvar pain, and genital itching are not rare in the pediatric population, and frequently these symptoms are caused by the common conditions of urinary tract infections or by a mixed bacterial vulvovaginitis related to vulvar hygiene, lichen sclerosus is a condition that must be kept in mind when young girls present with these symptoms. General obstetricians and gynecologists who provide care for young girls and teens should be aware of the range of gynecologic problems from common to rare that may impact their quality of life and their current and future health.
Conflicts of interest
There are no conflicts of interest.
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