Gynecology_Novak

Gynecology_Novak. Valerian, kava, ginseng, and St. John’s wort are among the more commonly used botanicals that may prolong the effects of anesthetic agents. Valerian has sedative effects that are believed to be mediated by benzodiazepine and γ -aminobutyric acid (GABA) receptors. For patients who use valerian on a daily basis, it is suggested that it be tapered off over the weeks preceding the surgery. Kava is mediated by GABA receptors and potentiates the sedative effects of anesthetics. The general recommendation is to discontinue its use 24 hours before surgery. St. John’s wort induces cytochrome P450 enzymes (cyclosporin, indinavir, and warfarin). It modulates the GABA receptor and inhibits the reuptake of serotonin, dopamine, and noradrenaline. The recommendation is to discontinue it 5 days preoperatively.


Gynecology_Novak

Gynecology_Novak. The following botanicals are associated with hepatotoxicity: kava, red yeast rice (which contains the ingredient in lovastatin), chaparral, valerian, and echinacea. In terms of endocrinologic effects, both chromium and ginseng can cause hypoglycemia. Table 13.13 highlights some of the more commonly used botanicals and vitamins and their possible effects in the surgical patient. Complementary and The two domains in which there is the most research and the most promise with regard to surgical Alternative Medicine patients are mind–body-based therapies and approaches based in complete systems, specifically Approaches that May oriental medicine and acupuncture. Benefit the Surgical Patient


Gynecology_Novak

Gynecology_Novak. A review of the use of acupuncture as the sole source of anesthesia for patients undergoing cesarean delivery in China reviewed 12 years of experience with success rates of 92% to 99%. Blood pressure, heart rate, and respiratory rate remained stable throughout the surgery, which is a significant advantage over pharmaceutical anesthesia (113). Although it is unlikely that acupuncture will readily be used as the only source of anesthesia in this country, it demonstrates the effectiveness of this approach and encourages its consideration as an adjunct. In one randomized controlled trial in patients undergoing upper-and lower-abdominal (gastrointestinal) surgery, acupuncture was given 2.5 cm lateral to the spine before induction. Postoperatively, patients who received the acupuncture had decreased postoperative pain, nausea and vomiting, analgesic requirement, and sympathoadrenal responses. Supplemental morphine use dropped by 50%, and postoperative nausea was reduced by 30%. Cortisol and


Gynecology_Novak

Gynecology_Novak. postoperative pain, nausea and vomiting, analgesic requirement, and sympathoadrenal responses. Supplemental morphine use dropped by 50%, and postoperative nausea was reduced by 30%. Cortisol and epinephrine levels were reduced 30% to 50% during the recovery phase and the first postoperative day (114). Several studies specifically looking at nausea and vomiting in women undergoing gynecologic surgeries showed benefit in both acupuncture and acupressure (115–117).


Gynecology_Novak

Gynecology_Novak. Table 13.13 Commonly Used Botanicals and Vitamins and Their Possible Effects in the Surgical Patient In a sham-controlled trial, the intensity of transcutaneous acupoint electrical stimulation (TAES) was studied in women undergoing lower-abdominal surgery. In patients receiving high-intensity TAES (9–12 mA), there was a 65% decrease in analgesia requirement, decreased duration in patient-controlled anesthesia therapy, and decrease in nausea, vomiting, and pruritus (118). In Germany, auricular electrically stimulated anesthesia is frequently used. Review of one randomized controlled trial in patients anesthetized with desﬂurane with and without auricular acupuncture revealed significantly reduced anesthetic requirement (the amount of anesthesia required to prevent purposeful movements) (119).


Gynecology_Novak

Gynecology_Novak. Acupuncture warrants further investigation as an adjunct to anesthesia in gynecologic patients. Even simple adjuncts, such as the use of acupressure bands or electroacupressure bands, are reasonable to support as they are safe and showed some efficacy in decreasing nausea and vomiting postoperatively.


Gynecology_Novak

Gynecology_Novak. Mental preparation for surgery results in psychological, physiologic, and economic benefit. Higher levels of anxiety are associated with a greater risk of complications, depression, and increased need for anesthesia, decreased immune function, and a longer time to heal. Many different physiologic aspects are affected, including decreased chemotaxis and phagocytosis and decreased inﬂammatory factors such as cytokines. One study examining wound healing took healthy dental students and made a standardized scalpel incision in the palate at two times: one right before examinations and one during summer vacation. The incisions in these healthy students took 3 days (40%) longer to heal during times of stress versus times of decreased stress (120). The power of the spoken word was explored as long ago as 1964, when a study randomized patients to a preoperative visit characterized by sympathetic, caring, and informative communication versus an interchange characterized by cursory remarks. The


Gynecology_Novak

Gynecology_Novak. ago as 1964, when a study randomized patients to a preoperative visit characterized by sympathetic, caring, and informative communication versus an interchange characterized by cursory remarks. The patients receiving the sympathetic preoperative visit required half the pain medicines and had a two-and-a-half-day decreased hospital stay (121).


Gynecology_Novak

Gynecology_Novak. A meta-analysis of mind–body interventions and surgery included 191 studies and more than 8,600 patients. The use of mind–body approaches, including such interventions as hypnosis, imagery, and relaxation, was associated with reduced blood loss, decreased pain, decreased medication use, increased return of bowel function, decreased psychological stress, and decreased hospital stay by 1.5 days. In a study of 241 patients undergoing invasive medical procedures randomized to standard care versus structured attention versus self-hypnosis, the hypnosis has the most pronounced effects on pain and anxiety and improved hemodynamic stability (122). In a study designed to examine the impact of preoperative instructions, patients undergoing spinal procedures involving fusions or instrumentation (surgeries associated with significant blood loss) were enrolled. All subjects received a 15-minute interaction with a psychologist. The subjects were randomized into one of three groups receiving either


Gynecology_Novak

Gynecology_Novak. associated with significant blood loss) were enrolled. All subjects received a 15-minute interaction with a psychologist. The subjects were randomized into one of three groups receiving either direct simple information alone, information plus instruction in muscle relaxation, or information plus instruction in previsualization of the blood moving away from the surgical site during surgery. Controlling for the length of surgery and incision length, the estimated blood loss in the first two groups averaged 900 mL and in the third group was 500 mL (123).


Gynecology_Novak

Gynecology_Novak. In a study of ambulatory surgery patients receiving spinal anesthesia, patients who were randomized to listening to soothing music had decreased sedative requirements both during the surgery and in the perioperative period (124). Patients undergoing cataract surgery were randomized to receive a 5-minute hand massage preoperatively or to the control group. When compared with the control group, the intervention group had significantly decreased levels of anxiety, systolic blood pressure, diastolic blood pressure, heart rate, and epinephrine and norepinephrine (125).


Gynecology_Novak

Gynecology_Novak. In a study of women undergoing hysterectomy, patients received standardized anesthesia and were randomized to music during surgery, music plus positive suggestions, or the sounds of the operating room. On the day of surgery, both the music group and the music-plus-suggestion groups received significantly less rescue anesthesia. On postoperative day 1, the patients who had heard music during surgery had more effective analgesia and early mobilization. At the time of discharge, both intervention groups had less fatigue. There was no change in nausea and vomiting, bowel function, or length of stay (126).


Gynecology_Novak

Gynecology_Novak. In another study with patients undergoing abdominal hysterectomy, patients were randomized to listen intraoperatively to one of four tapes: positive suggestions regarding pain, or nausea and vomiting, or both, or white noise. The positive suggestions had no beneficial effects in reducing nausea and vomiting or the consumption of analgesics or antiemetics (127). In another randomized controlled trial in patients undergoing thyroidectomy under general anesthesia, patients were randomized to listen to taped positive suggestions during surgery versus a blank tape. The group receiving the suggestions had less nausea and vomiting (47% vs. 85%), and less antiemetic treatment (30% vs. 68%) (128). In a study exploring the timing of listening to taped suggestions, patients who received the suggestions preoperatively had a 30% decrease in estimated blood loss. Patients receiving the suggestions both pre-and perioperatively had a 26% decrease in blood loss, and in the group listening to the


Gynecology_Novak

Gynecology_Novak. preoperatively had a 30% decrease in estimated blood loss. Patients receiving the suggestions both pre-and perioperatively had a 26% decrease in blood loss, and in the group listening to the suggestions only intraoperatively, there was a 9% decrease in blood loss. The authors suggest that the preoperative suggestions may be the critical factor (129).


Gynecology_Novak

Gynecology_Novak. In a retrospective study examining the use of hypnosis plus conscious sedation for plastic surgery, the patients who received hypnosis had better pain and anxiety relief, decreased nausea and vomiting, and a significant reduction in midazolam and alfentanil requirements and patient satisfaction was significantly increased (130). Although the studies and interventions in mind–body approaches in the surgical patient are varied, these interventions are low cost and low risk and may offer very real benefits for the patient, as well as a greater sense of empowerment.


Gynecology_Novak

Gynecology_Novak. As physicians driven by our desire and commitment to provide the best possible care, we have a responsibility to inform our patients of all therapies that can be of benefit, regardless of their system of origin. In practice this is challenging, because there are many unanswered questions in the use of complementary and alternative modalities, and because there is no established standard of care. Each physician, together with his or her patient, needs to form his or her own opinions regarding the appropriate integration of CAM therapies. Many patients will want conclusive evidence of any therapy before using it. Others, assured of the relative safety of a therapy, may require less conclusive evidence. Illustrating this dilemma, in a systematic review of randomized trials regarding CAM approaches to PMS, the authors concluded that “despite some positive findings, the evidence was not compelling for any of these therapies, with most trials suffering from various methodological


Gynecology_Novak

Gynecology_Novak. CAM approaches to PMS, the authors concluded that “despite some positive findings, the evidence was not compelling for any of these therapies, with most trials suffering from various methodological limitations. On the basis of current evidence, no complementary or alternative therapy can be recommended as a treatment for premenstrual syndrome” (131). Although this concept certainly is appealing in its simplicity, it may not be in the best interest of patients. We need to be consistent in our requirement of evidence, using the same levels of evidence for incorporating interventions from CAM as from conventional approaches. As with many clinical decisions we are forced to make with incomplete data, many factors must be considered. The potential risks and benefits must be weighed carefully, and primum non nocere must certainly be our guide.


Gynecology_Novak

Gynecology_Novak. In many regards, we are in the most challenging time as it relates to integrating appropriate CAM approaches into the practice of gynecology. As more research is done and as medical schools and residency programs incorporate education about these approaches, the gap between our patients’ desires and our standard practices will decrease as appropriate therapies are seamlessly incorporated and ineffective and fraudulent ones are discarded. 1. Eisenberg DM, Davis RB, Ettner SL, et al. Trends in alternative medicine use in the United States, 1990–1997: results of a follow-up national survey. JAMA 1998;280:1569–1575. 2. Eisenberg DM, Kessler RC, Foster C, et al. Unconventional medicine in the United States. Prevalence, costs, and patterns of use. N Engl J Med 1993;328:246–252. 3. Barnes PM, Powell-Griner E, McFann K, et al. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004;343:1–19. 4.


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Gynecology_Novak. 3. Barnes PM, Powell-Griner E, McFann K, et al. Complementary and alternative medicine use among adults: United States, 2002. Adv Data 2004;343:1–19. 4. Bair YA, Gold EB, Greendale GA, et al. Ethnic differences in use of complementary and alternative medicine at midlife: longitudinal results from SWAN participants. Am J Public Health 2002;92:1832– 1840. 5. Hollyer T, Boon H, Georgouis A, et al. The use of CAM by women suffering from nausea and vomiting during pregnancy. BMC Complement Altern Med 2002;2:5. 6. Shen J, Andersen R, Albert PS, et al. Use of complementary/alternative therapies by women with advanced-stage breast cancer. BMC Complement Altern Med 2002;2:8. 7. Newton KM, Buist DS, Keenan NL, et al. Use of alternative therapies for menopause symptoms: results of a population-based survey. Obstet Gynecol 2002;100:18–25. 8. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998;279:1548–1553. 9.


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Gynecology_Novak. 8. Astin JA. Why patients use alternative medicine: results of a national study. JAMA 1998;279:1548–1553. 9. Adler SR, Fosket JR. Disclosing complementary and alternative medicine use in the medical encounter: a qualitative study in women with breast cancer. J Fam Pract 1999;48:453–458. 10. U.S. Food and Drug Administration (USFDA). Dietary supplements. www.fda.gov/food/dietarysupplements. 11. National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM). http://www.nccaom.org/. 12. Gouveia LO, Castanho P, Ferreira JJ. Safety of chiropractic interventions: a systematic review. Spine (Phila Pa 1976) 2009;34:E405– E413. 13. National Certification Board for Theraputic Massage and Bodywork (NCBTMB). www.ncbtmb.org/. 14. American Society of Clinical Hypnosis (ASCH). www.asch.net. 15.


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Gynecology_Novak. 13. National Certification Board for Theraputic Massage and Bodywork (NCBTMB). www.ncbtmb.org/. 14. American Society of Clinical Hypnosis (ASCH). www.asch.net. 15. Cho ZH, Chung SC, Jones JP, et al. New findings of the correlation between acupoints and corresponding brain cortices using functional MRI. Proc Natl Acad SciUSA 1998;95:2670–2673. 16. National Institutes of Health Consensus Panel. Acupuncture. http://consensus.nih.gov/1997/1997acupuncture107html.htm. 17. National Center for Complementary and Alternative Medicine. Acupuncture for pain. Available online at: http://nccam.nih.gov/ health/acupuncture/acupuncture-for-pain.htm. Accessed Sept. 18, 2009. 18. Accreditation Commission for Acupuncture and Oriental Medicine (ACAOM). http://www.acaom.org/. 19. American Board of Medical Acupuncture. http://www.dabma. org/. 20. Council on Naturopathic Medical Education. http://www.cnme. org/. 21.


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Gynecology_Novak. http://www.acaom.org/. 19. American Board of Medical Acupuncture. http://www.dabma. org/. 20. Council on Naturopathic Medical Education. http://www.cnme. org/. 21. Federation of State Medical Boards. Model Guidelines for the Use of Complementary and Alternative Therapies in Medical Practice. Available online at: http://www.fsmb.org/pdf/2002 grpol Complementary Alternative Therapies.pdf. 22. Whelan AM, Jurgens TM, Naylor H. Herbs, vitamins and minerals in the treatment of premenstrual syndrome: a systematic review. Can J Clin Pharmacol 2009;16:e407–e429. 23. Proctor M, Murphy PA. Herbal and dietary therapies for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2001;3:CD002124. 24. Thys-Jacobs S, Starkey P, Bernstein D, et al. Calcium carbonate and the premenstrual syndrome: effects on premenstrual and menstrual symptoms. Premenstrual Syndrome Study Group. Am J Obstet Gynecol 1998;179:444–452. 25.


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Gynecology_Novak. 25. Bertone-Johnson ER, Hankinson SE, Bendich A, et al. Calcium and vitamin D intake and risk of incident premenstrual syndrome. Arch Intern Med 2005;165:1246–1252. 26. Fugh-Berman A, Kronenberg F. Complementary and alternative medicine (CAM) in reproductive-age women: a review of randomized controlled trials. Reprod Toxicol 2003;17:137–152. 27. Walker AF, DeSouza MC, Vickers MF, et al. Magnesium supplementation alleviates premenstrual symptoms of ﬂuid retention. J Womens Health 1998;7:1157–1165. 28. Facchinetti F, Borella P, Sances G, et al. Oral magnesium successfully relieves premenstrual mood changes. Obstet Gynecol 1991;78:177–181. 29. London RS, Murphy L, Kitlowski KE, et al. Efficacy of alphatocopherol in the treatment of the premenstrual syndrome. J Reprod Med 1987;32:400–404. 30. Ziaei S, Zakeri M, Kazemnejad A. A randomised controlled trial of vitamin E in the treatment of primary dysmenorrhoea. BJOG 2005;112:466–469. 31.


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Gynecology_Novak. 30. Ziaei S, Zakeri M, Kazemnejad A. A randomised controlled trial of vitamin E in the treatment of primary dysmenorrhoea. BJOG 2005;112:466–469. 31. Kleijnen J, Ter Riet G, Knipschild P. Vitamin B6 in the treatment of the premenstrual syndrome—a review. Br J Obstet Gynaecol 1990;97:847–852. 32. Wyatt KM, Dimmock PW, Jones PW, et al. Efficacy of vitamin B-6 in the treatment of premenstrual syndrome: systematic review. BMJ 1999;318:1375–1781. 33. Dell DL, Svec C. The PMDD phenomenon: breakthrough treatments for premenstrual dysphoric disorder (PMDD) and extreme premenstrual syndrome (PMS). New York: McGraw-Hill, 2002. 34. Berger D, Schaffner W, Schrader E, et al. Efficacy of Vitex agnus castus L. extract Ze 440 in patients with pre-menstrual syndrome (PMS). Arch Gynecol Obstet 2000;264:150–153. 35. Schellenberg R. Treatment for the premenstrual syndrome with agnus castus fruit extract: prospective, randomised, placebo controlled study. BMJ 2001;322:134–137. 36.


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Gynecology_Novak. 35. Schellenberg R. Treatment for the premenstrual syndrome with agnus castus fruit extract: prospective, randomised, placebo controlled study. BMJ 2001;322:134–137. 36. Loch EG, Selle H, Boblitz N. Treatment of premenstrual syndrome with a phytopharmaceutical formulation containing Vitex agnus castus. J Womens Health Gend Based Med 2000;9:315–320. 37. Atmaca M, Kumru S, Tezcan E. Fluoxetine versus Vitex agnus castus extract in the treatment of premenstrual dysphoric disorder. Hum Psychopharmacol 2003;18:191–195. 38. Meier B, Berger D, Hoberg E, et al. Pharmacological activities of Vitex agnus-castus extracts in vitro. Phytomedicine 2000;7:373–381. 39. Stevinson C, Ernst E. A pilot study of Hypericum perforatum for the treatment of premenstrual syndrome. BJOG 2000;107:870–876. 40. Tamborini A, Taurelle R. Value of standardized ginkgo biloba extract (EGb 761) in the management of congestive symptoms of premenstrual syndrome). Rev Fr Gynecold Obstet 1993;88:447–457. 41.


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Gynecology_Novak. 40. Tamborini A, Taurelle R. Value of standardized ginkgo biloba extract (EGb 761) in the management of congestive symptoms of premenstrual syndrome). Rev Fr Gynecold Obstet 1993;88:447–457. 41. Ashton AK. Antidepressant-induced sexual dysfunction and ginkgo biloba. Am J Psychiatry 2000;157:836–837. 42. Saldeen P, Saldeen T. Women and omega-3 fatty acids. Obstet Gynecol Surv 2004;59:722–730; quiz 745–746. 43. Kidd PM. Omega-3 DHA and EPA for cognition, behavior, and mood: clinical findings and structural-functional synergies with cell membrane phospholipids. Altern Med Rev 2007;12:207–227. 44. Walsh MJ, Polus BI. A randomized, placebo-controlled clinical trial on the efficacy of chiropractic therapy on premenstrual syndrome. J Manipulative Physiol Ther 1999;22:582–585. 45. Proctor ML, Hing W, Johnson TC, et al. Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2006;3:CD002119. 46.


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Gynecology_Novak. 45. Proctor ML, Hing W, Johnson TC, et al. Spinal manipulation for primary and secondary dysmenorrhoea. Cochrane Database Syst Rev 2006;3:CD002119. 46. Goodale IL, Domar AD, Benson H. Alleviation of premenstrual syndrome symptoms with the relaxation response. Obstet Gynecol 1990;75:649–655. 47. Girman A, Lee R, Kligler B. An integrative medicine approach to premenstrual syndrome. Am J Obstet Gynecol 2003; 188[Suppl]:S56–S65. 48. Habek D, Habek JC, Barbir A. Using acupuncture to treat premenstrual syndrome. Arch Gynecol Obstet 2002;267:23–26. 49. Jing Z, Yang X, Ismail KM, et al. Chinese herbal medicine for premenstrual syndrome. Cochrane Database Syst Rev 2009;1: CD006414. 50. Witt CM, Reinhold T, Brinkhaus B, et al. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. Am J Obstet Gynecol 2008;198: e1–e8. 51.


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Gynecology_Novak. 51. Zhu X, Proctor M, Bensoussan A, et al. Chinese herbal medicine for primary dysmenorrhoea. Cochrane Database Syst Rev 2008; 2:CD005288. 52. Domar AD, Seibel MM, Benson H. The mind/body program for infertility: a new behavioral treatment approach for women with infertility. Fertil Steril 1990;53:246–249. 53. Poehl M, Bichler K, Wicke V, et al. Psychotherapeutic counseling and pregnancy rates in in vitro fertilization. J Assist Reprod Genet 1999;16:302–305. 54. Levitas E, Parmet A, Lunenfeld E, et al. Impact of hypnosis during embryo transfer on the outcome of in vitro fertilization-embryo transfer: a case-control study. Fertil Steril 2006;85:1404–1408. 55. Gerhard I, Postneek F. Auricular acupuncture in the treatment of female infertility. Gynecol Endocrinol 1992;6:171–181. 56. Smith C, Coyle M, Norman RJ. Inﬂuence of acupuncture stimulation on pregnancy rates for women undergoing embryo transfer. Fertil Steril 2006;85:1352–1358. 57.


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Gynecology_Novak. 56. Smith C, Coyle M, Norman RJ. Inﬂuence of acupuncture stimulation on pregnancy rates for women undergoing embryo transfer. Fertil Steril 2006;85:1352–1358. 57. Dieterle S, Ying G, Hatzmann W, et al. Effect of acupuncture on the outcome of in vitro fertilization and intracytoplasmic sperm injection: a randomized, prospective, controlled clinical study. Fertil Steril 2006;85:1347–1351. 58. Westergaard LG, Mao Q, Krogslund M, et al. Acupuncture on the day of embryo transfer significantly improves the reproductive outcome in infertile women: a prospective, randomized trial. Fertil Steril 2006;85:1341–1346. 59. Paulus WE, Zhang M, Strehler E, et al. Inﬂuence of acupuncture on the pregnancy rate in patients who undergo assisted reproduction therapy. Fertil Steril 2002;77:721–724. 60.


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Gynecology_Novak. 68. Amato P, Christophe S, Mellon PL. Estrogenic activity of herbs commonly used as remedies for menopausal symptoms. Menopause 2002;9:145–150. 69. Wuttke W, Seidlova-Wuttke D, Gorkow C. The Cimicifuga preparation BNO 1055 vs. conjugated estrogens in a double-blind placebo-controlled study: effects on menopause symptoms and bone markers. Maturitas 2003;44[Suppl 1]:S67–S77. 70. Wong VC, Lim CE, Luo X, et al. Current alternative and complementary therapies used in menopause. Gynecol Endocrinol 2009;25:166–174. 71. Briese V, Stammwitz U, Friede M, et al. Black cohosh with or without St. John’s wort for symptom-specific climacteric treatment— results of a large-scale, controlled, observational study. Maturitas 2007;57:405–414. 72. Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic Guide to Herbal Medicines. Austin, TX, American Botanical Council; 1998. 73.


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Gynecology_Novak. 82. Grube B, Walper A, Wheatley D. St. John’s wort extract: efficacy for menopausal symptoms of psychological origin. Adv Ther 1999;16:177–186. 83. Uebelhack R, Blohmer JU, Graubaum HJ, et al. Black cohosh and St. John’s wort for climacteric complaints: a randomized trial. Obstet Gynecol 2006;107[Pt 1]:247–255. 84. Waynberg J, Brewer S. Effects of Herbal vX on libido and sexual activity in premenopausal and postmenopausal women. Adv Ther 2000;17:255–262. 85. Dennehy CE. The use of herbs and dietary supplements in gynecology: an evidence-based review. J Midwifery Womens Health 2006;51:402–409. 86. Nedstrand E, Wijma K, Wyon Y, et al. Applied relaxation and oral estradiol treatment of vasomotor symptoms in postmenopausal women. Maturitas 2005;51:154–162. 87. Irvin JH, Domar AD, Clark C, et al. The effects of relaxation response training on menopausal symptoms. J Psychosom Obstet Gynaecol 1996;17:202–207. 88.


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Gynecology_Novak. 87. Irvin JH, Domar AD, Clark C, et al. The effects of relaxation response training on menopausal symptoms. J Psychosom Obstet Gynaecol 1996;17:202–207. 88. Freedman RR, Woodward S. Behavioral treatment of menopausal hot ﬂushes: evaluation by ambulatory monitoring. Am J Obstet Gynecol 1992;167:436–439. 89. Ganz PA, Greendale GA, Petersen L, et al. Managing menopausal symptoms in breast cancer survivors: results of a randomized controlled trial. J Natl Cancer Inst 2000;92:1054–1064. 90. Zaborowska E, Brynhildsen J, Damberg S, et al. Effects of acupuncture, applied relaxation, estrogens and placebo on hot ﬂushes in postmenopausal women: an analysis of two prospective, parallel, randomized studies. Climacteric 2007;10:38–45. 91. Jones CR, Czajkowski L. Evaluation and management of insomnia in menopause. Clin Obstet Gynecol 2000;43:184–197. 92. Cho SH, Whang WW. Acupuncture for vasomotor menopausal symptoms: a systematic review. Menopause 2009;16:1065–1073. 93.


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Gynecology_Novak. 92. Cho SH, Whang WW. Acupuncture for vasomotor menopausal symptoms: a systematic review. Menopause 2009;16:1065–1073. 93. Lee MS, Shin BC, Ernst E. Acupuncture for treating menopausal hot ﬂushes: a systematic review. Climacteric 2009;12: 16–25. 94. Borud EK, Alraek T, White A, et al. The Acupuncture on Hot Flushes Among Menopausal Women (ACUFLASH) study, a randomized controlled trial. Menopause 2009;16:484–493. 95. Borud E, Grimsgaard S, White A. Menopausal problems and acupuncture. Auton Neurosci 2010;157(1-2):57–62. 96. Porzio G, Trapasso T, Martelli S, et al. Acupuncture in the treatment of menopause-related symptoms in women taking tamoxifen. Tumori 2002;88:128–130. 97. Frisk J, Carlh¨all S, K¨allstr¨om AC, et al. Long-term follow-up of acupuncture and hormone therapy on hot ﬂushes in women with breast cancer: a prospective, randomized, controlled multicenter trial. Climacteric 2008;11:166–174. 98.


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Gynecology_Novak. 98. Takahashi K, Okada M, Ozaki T, et al. Safety and efficacy of oestriol for symptoms of natural or surgically induced menopause. Hum Reprod 2000;15:1028–1036. 99. Itoi H, Minakami H, Sato I. Comparison of the long-term effects of oral estriol with the effects of conjugated estrogen, 1-alphahydroxyvitamin D3 and calcium lactate on vertebral bone loss in early menopausal women. Maturitas 1997;28:11–17. 100. Lyytinen H, Pukkala E, Ylikorkala O. Breast cancer risk in post-menopausal women using estrogen-only therapy. Obstet Gynecol 2006;108:1354–1360. 101. Raz R, Stamm WE. A controlled trial of intravaginal estriol in post-menopausal women with recurrent urinary tract infections. N Engl J Med 1993;329:753–756. 102. Palacios S, Castelo-Branco C, Cancelo MJ, et al. Low-dose, vaginally administered estrogens may enhance local benefits of systemic therapy in the treatment of urogenital atrophy in postmenopausal women on hormone therapy. Maturitas 2005;50:98–104. 103.


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Gynecology_Novak. 103. Gerbaldo D, Ferraiolo A, Croce S, et al. Endometrial morphology after 12 months of vaginal oestriol therapy in post-menopausal women. Maturitas 1991;13:269–274. 104. The Writing Group for the PEPI Trial. Effects of estrogen or estrogen/progestin regimens on heart disease risk factors in post-menopausal women. The Postmenopausal Estrogen/Progestin Interventions (PEPI) trial. JAMA 1995;273:199–208. 105. Ryan N, Rosner A. Quality of life and costs associated with micronized progesterone and medroxyprogesterone acetate in hormone replacement therapy for nonhysterectomized, postmenopausal women. Clin Ther 2001;23:1099–1115. 106. Fitzpatrick LA, Pace C, Wiita B. Comparison of regimens containing oral micronized progesterone or medroxyprogesterone acetate on quality of life in postmenopausal women: a cross-sectional survey. J Womens Health Gend Based Med 2000;9:381–387. 107.


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Gynecology_Novak. 107. Komesaroff PA, Black CVS, Cable V, et al. Effects of wild yam extract on menopausal symptoms, lipids and sex hormones in healthy menopausal women. Climacteric 2001;4:144–150. 108. Benster B, Carey A, Wadsworth F, et al. Double-blind placebo-controlled study to evaluate the effect of pro-juven progesterone cream on atherosclerosis and bone density. Menopause Int 2009;15:100–106. 109. Leonetti HB, Longo S, Anasti JN. Transdermal progesterone cream for vasomotor symptoms and postmenopausal bone loss. Obstet Gynecol 1999;94:225–228. 110. Leung JM, Dzankic S, Manku K, et al. The prevalence and predictors of the use of alternative medicine in presurgical patients in five California hospitals. Anesth Analg 2001;93:1062–1068. 111. Tsen LC, Segal S, Pothier M, et al. Alternative medicine use in presurgical patients. Anesthesiology 2000;93:148–151. 112.


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Gynecology_Novak. 111. Tsen LC, Segal S, Pothier M, et al. Alternative medicine use in presurgical patients. Anesthesiology 2000;93:148–151. 112. Kaye AD, Clarke RC, Saber R, et al. Herbal medicines: current trends in anesthesiology practice—a hospital survey. J Clin Anesth 2000;12:468–471. 113. Wang DW, Jin YH. Present status of cesarean section under acupuncture anesthesia in China. Fukushima J Med Sci 1989;35: 45–52. 114. Kotani N, Hashimoto H, Sato Y, et al. Preoperative intradermal acupuncture reduces postoperative pain, nausea and vomiting, analgesic requirement, and sympathoadrenal responses. Anesthesiology 2001;95:349–356. 115. Frey UH, Scharmann P, L¨ohlein C, et al. P6 acustimulation effectively decreases postoperative nausea and vomiting in high-risk patients. Br J Anaesth 2009;102:620–625. 116.


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Gynecology_Novak. 115. Frey UH, Scharmann P, L¨ohlein C, et al. P6 acustimulation effectively decreases postoperative nausea and vomiting in high-risk patients. Br J Anaesth 2009;102:620–625. 116. Streitberger K, Diefenbacher M, Bauer A, et al. Acupuncture compared to placebo-acupuncture for postoperative nausea and vomiting prophylaxis: a randomised placebo-controlled patient and observer blind trial. Anaesthesia 2004;59:142–149. 117. Turgut S, Ozalp G, Dikmen S, et al. Acupressure for postoperative nausea and vomiting in gynaecological patients receiving patient-controlled analgesia. Eur J Anaesthesiol 2007;24:87–91. 118. Wang B, Tang J, White PF, et al. Effect of the intensity of transcutaneous acupoint electrical stimulation on the postoperative analgesic requirement. Anesth Analg 1997;85:406–413. 119. Greif R, Laciny S, Mokhtarani M, et al. Transcutaneous electrical stimulation of an auricular acupuncture point decreases anesthetic requirement. Anesthesiology 2002;96:306–312. 120.


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Gynecology_Novak. 119. Greif R, Laciny S, Mokhtarani M, et al. Transcutaneous electrical stimulation of an auricular acupuncture point decreases anesthetic requirement. Anesthesiology 2002;96:306–312. 120. Marucha PT, Kiecolt-Glaser JK, Favagehi M. Mucosal wound healing is impaired by examination stress. Psychosom Med 1998;60:362–365. 121. Egbert LD. Reduction of postoperative pain by encouragement and instruction of patients. A study of doctor-patient rapport. N Engl J Med 1964;270:825–827. 122. Lang EV, Benotsch EG, Fick LJ, et al. Adjunctive non-pharmacological analgesia for invasive medical procedures: a randomised trial. Lancet 2000;355:1486–1490. 123. Bennett HL, Benson DR, Kuiken DA. Preoperative instructions for decreased bleed during spine surgery. Anesthesiology 1986;65:A245. 124. Lepage C, Drolet P, Girard M, et al. Music decreases sedative requirements during spinal anesthesia. Anesth Analg 2001;93:912– 916. 125.


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Gynecology_Novak. 124. Lepage C, Drolet P, Girard M, et al. Music decreases sedative requirements during spinal anesthesia. Anesth Analg 2001;93:912– 916. 125. Kim MS, Cho KS, Woo H, et al. Effects of hand massage on anxiety in cataract surgery using local anesthesia. J Cataract Refractive Surg 2001;27:884–890. 126. Nilsson U, Rawal N, Unestahl LE, et al. Improved recovery after music and therapeutic suggestions during general anaesthesia: a double-blind randomised controlled trial. Acta Anaesthesiol Scand 2001;45:812–817. 127. Dawson P, Van Hamel C, Wilkinson D, et al. Patient-controlled analgesia and intra-operative suggestion. Anaesthesia 2001;56:65– 69. 128. Eberhart LH, Doring HJ, Holzrichter P, et al. Therapeutic suggestions given during neurolept-anaesthesia decrease post-operative nausea and vomiting. Eur J Anaesthesiol 1998;15:446–452. 129.


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Gynecology_Novak. 128. Eberhart LH, Doring HJ, Holzrichter P, et al. Therapeutic suggestions given during neurolept-anaesthesia decrease post-operative nausea and vomiting. Eur J Anaesthesiol 1998;15:446–452. 129. Enqvist B, von Konow L, Bystedt H. Pre-and perioperative suggestion in maxillofacial surgery: effects on blood loss and recovery. Int J Clin Exp Hypn 1995;43:284–294. 130. Faymonville ME, Fissette J, Mambourg PH, et al. Hypnosis as adjunct therapy in conscious sedation for plastic surgery. Reg Anesth 1995;20:145–151. 131. Stevinson C, Ernst E. Complementary/alternative therapies for premenstrual syndrome: a systematic review of randomized controlled trials. Am J Obstet Gynecol 2001;185:227–235. Benign Diseases of the Female 14 Reproductive Tract Paula J. Adams Hillard The causes of abnormal bleeding vary by age, with anovulatory bleeding most likely in adolescents and perimenopausal women.


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Gynecology_Novak. Paula J. Adams Hillard The causes of abnormal bleeding vary by age, with anovulatory bleeding most likely in adolescents and perimenopausal women. Pelvic masses in adolescents are most commonly functional or benign neoplastic ovarian masses, whereas the risks of malignant ovarian tumors increase with age. Although pelvic ultrasonography is an excellent technique for imaging pelvic masses and ultrasonographic characteristics may suggest reassuring characteristics of an ovarian mass, the possibility of malignancy must be kept in mind. Vulvovaginal symptoms of any sort in a young child should prompt the consideration of possible sexual abuse. Most uterine leiomyomas are asymptomatic, although bleeding, pressure symptoms, or pain may necessitate medical or surgical management.


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Gynecology_Novak. Benign gynecologic conditions can present with a variety of signs and symptoms that vary by age. In this chapter, the most likely causes of specific signs and symptoms, as well as diagnosis and management, are described for each age group: prepubertal, adolescent, reproductive age, and postmenopausal women. The common gynecologic problems include those that cause pain, bleeding, pelvic masses (which may be symptomatic or asymptomatic), as well as vulvar and vaginal symptoms. Benign conditions of the female genital tract include anatomic lesions of the uterine corpus and cervix, ovaries, fallopian tubes, vagina, and vulva. A classification of benign lesions of the vulva, vagina, and cervix appears in Table 14.1. Leiomyoma, polyps, and hyperplasia are the most common benign conditions of the uterus in adult women. Benign uterine leiomyoma (uterine fibroids) are presented in Chapter 15. Benign tumors of the ovaries are listed in Table 14.2. Malignant diseases are presented in Chapters


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Gynecology_Novak. the uterus in adult women. Benign uterine leiomyoma (uterine fibroids) are presented in Chapter 15. Benign tumors of the ovaries are listed in Table 14.2. Malignant diseases are presented in Chapters 35–40.


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Gynecology_Novak. Prepubertal Bleeding Prior to menarche, which normally does not occur before nine years of age, any bleeding requires evaluation. To appropriately evaluate a young girl with vaginal bleeding, a practitioner should understand the events of puberty (1–4). The hormonal changes that control the Table 14.1 Classification of Benign Conditions of the Vulva, Vagina, and Cervix Mesonephric, paramesonephric, and urogenital sinus cysts Adenosis (related to in utero diethylstilbestrol exposure) Pelvic organ prolapse/Disorders of pelvic support Table 14.2 Benign Ovarian Tumors


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Gynecology_Novak. Adenosis (related to in utero diethylstilbestrol exposure) Pelvic organ prolapse/Disorders of pelvic support Table 14.2 Benign Ovarian Tumors Differential Diagnosis of Prepubertal Vaginal Bleeding cyclic functioning of the hypothalamic–pituitary–ovarian axis are described in Chapter 7. An understanding of the normal sequence and timing of these events is critical to an appropriate assessment of a girl at the onset of bleeding (see Chapter 29). Menarche typically occurs when an adolescent has reached Tanner stage 3 or 4 of breast development (Fig. 14.1). Bleeding in the absence of breast development must be evaluated.


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Gynecology_Novak. Slight vaginal bleeding can occur within the first few days of life because of withdrawal from exposure to high levels of maternal estrogen. New mothers of female infants should be informed of this possibility to preclude unnecessary anxiety. After the neonatal period, a number of causes of bleeding should be considered in the prepubertal age group (Table 14.3). Menses rarely occur before breast budding (5,6). Vaginal bleeding in the absence of secondary sexual characteristics should be evaluated carefully.


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Gynecology_Novak. The causes of bleeding in this age group range from the medically mundane to malignancies that may be life threatening. The source of the bleeding is sometimes difficult to identify, and parents who observe blood in a child’s diapers or panties may be unsure of the source— whether from the urinary tract, the vagina, or the rectum. Pediatricians usually look for urinary causes of bleeding, and gastrointestinal factors such as constipation and or anal fissure or inﬂammatory bowel disease should be considered. The possibility of abuse should always be considered in girls with any vulvovaginal symptoms, particularly if bleeding is present. Failure to diagnose sexual abuse may leave a child in significant danger.


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Gynecology_Novak. Vulvar Lesions Vulvar irritation can lead to pruritus with excoriation, maceration of the vulvar skin, or fissures that can bleed. Other visible external causes of bleeding in this age group include urethral prolapse, condylomas, lichen sclerosus, or molluscum contagiosum. Urethral prolapse can present acutely with a tender mass that may be friable or bleed slightly; it is most common in African American girls and may be confused with a vaginal mass (Fig. 14.2). The classic presentation is a mass symmetrically surrounding the urethra. This condition can be managed medically with the topical application of estrogens (7). The presence of condyloma should prompt questioning about abuse, although it was suggested that condyloma that appears during the first 2 to 3 years of life may be acquired perinatally from maternal infection with human papillomavirus (Fig. 14.3) (8,9). Excoriation and subepithelial hemorrhage (“blood blisters”) into the skin can cause external bleeding in the presence


Gynecology_Novak

Gynecology_Novak. perinatally from maternal infection with human papillomavirus (Fig. 14.3) (8,9). Excoriation and subepithelial hemorrhage (“blood blisters”) into the skin can cause external bleeding in the presence of prepubertal lichen sclerosus; this finding may mistakenly be identified as abuse, and the conditions are not mutually exclusive (Fig. 14.4) (10). Although most gynecologists recognize the appearance of lichen sclerosus in postmenopausal women, the condition can occur in prepubertal girls and may not be recognized by clinicians who are unfamiliar with this condition. As with adults, the cause of lichen sclerosus remains uncertain; a familial incidence was identified (11).


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Gynecology_Novak. Figure 14.1 Tanner breast stage at menarche. Foreign Body A foreign body in the vagina is a common cause of vaginal discharge, which may appear purulent or bloody. Young children explore all orifices and may place all varieties of small objects inside their vaginas (Fig. 14.5). An object, such as a small plastic toy, can sometimes be palpated on rectal examination, and occasionally “milked” toward the vaginal introitus to allow removal. The most common foreign bodies found in the vagina are small pieces of toilet paper (12). Although it was suggested that the presence of vaginal foreign bodies might be a marker for sexual abuse, this is not always the case; but the possibility of abuse should always be considered.


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Gynecology_Novak. Precocious Puberty Vaginal bleeding in the absence of other secondary sexual characteristics may result from precocious puberty (see Chapter 29), although as with normal puberty, the onset of breast budding or pubic hair growth are more likely to occur before vaginal bleeding. A large observational study suggested that the onset of pubertal changes—breast budding and pubic hair—might occur earlier than previously thought (2). Evaluation for precocious puberty was recommended for girls with pubertal development younger than age 8 years. Guidelines proposed evaluation of white girls younger than age 7 years and African American girls younger Table 14.3 Causes of Vaginal Bleeding in Prepubertal Girls Vulvitis with excoriation Trauma (e.g., accidental injury [straddle injury] or sexual abuse) Trauma (abuse, penetration) Figure 14.2 Urethral prolapse in prepubertal girl. Figure 14.3 Perianal condyloma in prepubertal girl.


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Gynecology_Novak. Trauma (abuse, penetration) Figure 14.2 Urethral prolapse in prepubertal girl. Figure 14.3 Perianal condyloma in prepubertal girl. than age 6 years who have either breast development or pubic hair, rather than the traditional age of 8 (13). An expert panel concluded that there is reasonable evidence that pubertal milestones are occurring at a younger age in girls (3).


Gynecology_Novak

Gynecology_Novak. Trauma Trauma can be a cause of genital bleeding. A careful history should be obtained from one or both parents or caretakers and the child herself, because trauma caused by sexual abuse often is not recognized. Trauma can be characterized as accidental or nonaccidental, which is described as child abuse. Physical findings that are inconsistent with the description of the alleged accident should prompt consideration of abuse and appropriate consultation or referral to an experienced social worker or sexual abuse team. All states impose a mandatory legal obligation to report suspected child physical abuse; most states specifically require reporting child sexual abuse, but even in those that do not, the laws are broad enough to encompass sexual abuse implicitly (14,15). Notification is required even with the suspicion of sexual abuse. In general, a straddle injury occurring with accidental trauma affects the anterior and lateral vulvar area, whereas penetrating injuries with lesions of


Gynecology_Novak

Gynecology_Novak. even with the suspicion of sexual abuse. In general, a straddle injury occurring with accidental trauma affects the anterior and lateral vulvar area, whereas penetrating injuries with lesions of the fourchette or lesions that extend through the hymenal ring are less likely to occur as a result of accidental trauma (Fig. 14.6) (16).


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Gynecology_Novak. Abuse The medical evaluation of suspected child sexual abuse is best managed by individuals who have experience in assessing the physical findings, laboratory results, and the children’s statements and behaviors. Genital findings are categorized as follows (17): 1. Normal, normal variants, and other conditions 2. Nonspecific findings that may be the result of abuse, depending on the timing of the examination, but that may be due to other causes 3. Concerning for abuse or trauma, including findings that were noted with documented abuse and that may be concerning for abuse, but for which insufficient data exist to determine that abuse is the only cause 4. Clear evidence of blunt force or penetrating trauma. The overall classification of the likelihood for abuse can be categorized as follows (17): 1. No evidence of abuse 2. 3. 4. Definitive evidence of abuse or sexual contact. Figure 14.4 Prepubertal lichen sclerosus.


Gynecology_Novak

Gynecology_Novak. No evidence of abuse 2. 3. 4. Definitive evidence of abuse or sexual contact. Figure 14.4 Prepubertal lichen sclerosus. Most cases of child sexual abuse do not come to light with an acute injury and instead are associated with normal or nonspecific genital findings (17,18). Forms of abuse such as fondling or digital penetration may not result in visible genital lesions. Other Causes Other serious but rare causes of vaginal bleeding include vaginal tumors. The most common tumor in the prepubertal age group is a rhabdomyosarcoma (sarcoma botryoides), which is associated with bleeding and a grapelike clustered mass (see Chapter 36). Other forms of vaginal tumor are rare but should be ruled out with a thorough examination under anesthesia with vaginoscopy if no other obvious external source of bleeding is found. Figure 14.5 Foreign body (plastic toy) in the vagina of an 8-year-old girl. Figure 14.6 Straddle injury—vulvar hematoma in a 13-year-old girl.


Gynecology_Novak

Gynecology_Novak. Figure 14.5 Foreign body (plastic toy) in the vagina of an 8-year-old girl. Figure 14.6 Straddle injury—vulvar hematoma in a 13-year-old girl. Figure 14.7 Pelvic ultrasound (transabdominal) of a premenarchal 10-year-old girl. Diagnosis of Prepubertal Bleeding Hormonally active ovarian tumors can cause endometrial proliferation and bleeding. Likewise, exogenously administered estrogens can result in bleeding. Rarely, bleeding can result from the prolonged use of topical estrogens prescribed as therapy for vulvovaginitis or labial adhesions or from accidental ingestion of prescription estrogens.


Gynecology_Novak

Gynecology_Novak. Examination A careful examination is indicated when a child has genital symptoms. The technique of examining the prepubertal child is described in Chapter 1. If no obvious cause of bleeding is visible externally or within the distal vagina, an examination can be performed using anesthesia with vaginoscopy to completely visualize the vagina and cervix. This examination should be performed by a clinician who has experience in pediatric and adolescent gynecology.


Gynecology_Novak

Gynecology_Novak. Imaging If an ovarian or vaginal mass is suspected, a transabdominal pelvic ultrasonographic examination can provide useful information. The appearance of the ovaries (normal prepubertal size and volume, follicular development, cystic, or solid) can be noted, as well as the size and configuration of the uterus. The prepubertal uterus has a distinctive appearance, with equal proportions of cervix and fundus and a size of approximately 2 to 3.5 cm in length and 0.5 to 1 cm in width (Fig. 14.7). The uterine fundus enlarges with estrogen stimulation, resulting in the postmenarchal appearance in which the uterine fundus is larger than the cervix (19). An ultrasonographic examination should be the first imaging study performed; more sophisticated imaging techniques, such as magnetic resonance imaging (MRI) or computed tomography (CT) scanning, are rarely indicated as initial diagnostic modalities, and they add unnecessary expense and radiation exposure with CT.


Gynecology_Novak

Gynecology_Novak. Management of Prepubertal Vaginal Bleeding The management of bleeding in prepubertal-age girls is directed toward the cause of bleeding. If bloody discharge believed to result from nonspecific vulvovaginitis persists despite therapy, further evaluation may be necessary to rule out the presence of a foreign body. Skin lesions (chronic irritation) and lichen sclerosus may be difficult to manage but can be treated with a course of topical steroids; lichen sclerosus often requires the use of ultrahigh-potency topical steroids and ongoing maintenance therapy. Vaginal and ovarian tumors should be managed in consultation with a gynecologic oncologist. Table 14.4 Causes of Pelvic Mass by Approximate Frequency and Age Functional cyst Functional cyst Functional cyst Functional cyst Fibroids Ovarian tumor (malignant of benign) Presentation of Prepubertal Pelvic Masses


Gynecology_Novak

Gynecology_Novak. The probable causes of a pelvic mass found on physical examination or through radiologic studies are vastly different in prepubertal children than they are in adolescents or post-menopausal women (Table 14.4). A pelvic mass may be gynecologic in origin, or it may arise from the urinary tract or bowel. The gynecologic causes of a pelvic mass may be uterine, adnexal, or more specifically ovarian. Because of the small pelvic capacity of a prepubertal child, a pelvic mass very quickly becomes abdominal in location as it enlarges and may be palpable on abdominal examination. Ovarian masses in this age group may be asymptomatic, associated with chronic pressure-related bowel or bladder symptoms, or may present with acute pain caused by rupture or torsion. Abdominal or pelvic pain is one of the most frequent initial symptoms. The diagnosis of ovarian masses in prepubertal girls is difficult because the condition is rare in this age group and, consequently, there is a low index of suspicion.


Gynecology_Novak

Gynecology_Novak. most frequent initial symptoms. The diagnosis of ovarian masses in prepubertal girls is difficult because the condition is rare in this age group and, consequently, there is a low index of suspicion. Many symptoms are nonspecific, and acute symptoms are more likely to be attributed to more common entities such as appendicitis. Abdominal palpation and bimanual rectoabdominal examination are important in any child who has nonspecific abdominal or pelvic symptoms. An ovarian mass that is abdominal in location can be confused with other abdominal masses occurring in children, such as Wilms’ tumor or neuroblastoma. Acute pain is often associated with torsion. The ovarian ligament becomes elongated as a result of the abdominal location of ovarian tumors, thus creating a predisposition to torsion. Adnexal torsion is more likely to occur with an ovarian mass than with a normal size ovary. While torsion of a normal ovary is rare in adolescents and adults, it is more likely to occur in


Gynecology_Novak

Gynecology_Novak. torsion. Adnexal torsion is more likely to occur with an ovarian mass than with a normal size ovary. While torsion of a normal ovary is rare in adolescents and adults, it is more likely to occur in prepubertal girls.


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Gynecology_Novak. Diagnosis of Prepubertal Ultrasonography is the most valuable tool for diagnosing ovarian masses. The characteristics Pelvic Masses of a pelvic mass can be determined. Whereas both unilocular and multilocular cysts frequently resolve with observation, the finding of a solid component mandates surgical assessment because of the high risk of a germ cell tumor (20). Additional imaging studies, such as CT scanning, MRI, or Doppler ﬂow studies, may be helpful in establishing the diagnosis (21).


Gynecology_Novak

Gynecology_Novak. Differential Diagnosis Fewer than 2% of ovarian malignancies occur in children and adolescents (22). Ovarian tumors account for approximately 1% of all malignant tumors in these age groups. Germ cell tumors make up one-half to two-thirds of ovarian neoplasms in individuals younger than 20 years of age. A review of studies conducted from 1940 until 1975 concluded that 35% of all ovarian neoplasms occurring during childhood and adolescence were malignant (23). In girls younger than 9 years of age, approximately 80% of the ovarian neoplasms were malignant. Germ cell tumors account for approximately 60% of ovarian neoplasms in children and adolescents compared with 20% of these tumors in adults (23). Epithelial neoplasms are rare in the prepubertal age group; thus, data usually are reported from referral centers. Some reports include only neoplastic masses, whereas others include nonneoplastic masses; some series combine data from prepubertal and adolescent girls. One community survey of


Gynecology_Novak

Gynecology_Novak. referral centers. Some reports include only neoplastic masses, whereas others include nonneoplastic masses; some series combine data from prepubertal and adolescent girls. One community survey of ovarian masses revealed that the frequency of malignancy was much lower than previously reported; of all ovarian masses confirmed surgically in childhood and adolescence, only 6% of patients with ovarian enlargement had malignant neoplasms, and only 10% of neoplasms were malignant (24). Surgical decision making inﬂuences the statistics on incidence; the surgical excision of functional masses that would resolve in time inﬂates the percentage of benign masses. In one series, nonneoplastic masses in young women and girls younger than 20 years of age constituted two-thirds of the total (25). Even in girls younger than 10 years of age, 60% of the masses were nonneoplastic, and two-thirds of the neoplastic masses were benign. Authors of older case series were less aware of the benign and functional


Gynecology_Novak

Gynecology_Novak. younger than 10 years of age, 60% of the masses were nonneoplastic, and two-thirds of the neoplastic masses were benign. Authors of older case series were less aware of the benign and functional masses that are now found incidentally with routine sonographic images. Functional, follicular cysts can occur in fetuses, newborns, and prepubertal children (26). Rarely, they may be associated with sexual precocity.


Gynecology_Novak

Gynecology_Novak. Management of A plan for the management of pelvic masses in prepubertal age girls is shown in Figure 14.8. Prepubertal Pelvic Masses Unilocular cysts are virtually always benign, even in this age group, and will regress in Figure 14.8 Management of pelvic masses in premenarchal and adolescent girls.


Gynecology_Novak

Gynecology_Novak. Figure 14.8 Management of pelvic masses in premenarchal and adolescent girls. 3 to 6 months; thus, they do not require surgical management with oophorectomy or oophorocystectomy. Close observation is recommended, and there is a risk of ovarian torsion that must be discussed with the child’s parents (27). Recurrence rates after cyst aspiration (either ultrasonographically guided or with laparoscopy) may be as high as 50%. Attention should be directed to long-term effects on endocrine function and future fertility; preservation of ovarian tissue is a priority for patients with benign tumors. Oophorectomy should be avoided if at all possible for benign masses (28). Premature surgical therapy for a functional ovarian mass can result in ovarian and tubal adhesions that can adversely affect future fertility. Solid masses, those larger than approximately 8 cm, and enlarging masses require surgical intervention, as the likelihood of neoplasm is high.


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Gynecology_Novak. Various developmental and congenital vulvovaginal abnormalities occur in the neonatal age group. Whereas an extensive discussion of these abnormalities is beyond the scope of this text, obstetrician-gynecologists will recognize that they must be prepared to deal with the parents and family when an infant is born with ambiguous genitalia. The etiology of these problems, and intersex disorders (now termed disorder of sex development [DSD]) that may be discovered in an older child can be complex (29). Chromosomal abnormalities, enzyme deficiencies (including 17-or 21-hydroxylase deficiency as causes of congenital adrenal hyperplasia), or prenatal masculinization of a female fetus resulting from maternal androgen-secreting ovarian tumors or, rarely, drug exposure can all result in genital abnormalities that are noted at birth. These abnormalities are described in Chapter 31


Gynecology_Novak

Gynecology_Novak. Ambiguous genitalia represent a social and potential medical urgency that is best handled by a team of specialists, which may include urologists, neonatologists, endocrinologists, and pediatric gynecologists (30). The first question parents ask after a baby is born “is it a boy or a girl?” In the case of ambiguous genitalia, the parents should be informed that the baby’s genitals are not fully developed and, therefore, a simple examination of the external genitalia cannot determine the actual sex. The parents should be told that data will be collected but that it may take several days or longer to determine the baby’s intended sex. In some situations, it may be best to state simply that the baby has some serious medical complications. The issues of sex assignment and appropriateness or timing of surgical therapy are controversial and should be managed by clinicians with extensive experience in this area (29,30).


Gynecology_Novak

Gynecology_Novak. Other genital abnormalities may be noted at birth, although few obstetricians or pediatricians carefully examine the external genitalia of female neonates. It is argued that careful inspection of the external genitalia of all female infants should be performed, with gentle probing of the introitus and anus to determine the patency of the hymen or a possible imperforate anus. If patency is in doubt, a rectal thermometer may be used to gently test the patency. It is suggested that this examination should be performed on all female infants in the delivery room (31,32). Various types of hymenal configurations in the newborn are described, ranging from imperforate to microperforate, to cribriform, to hymenal bands, and to hymens with central anterior, posterior, or eccentric orifices (33). An examination during the neonatal period would prevent the discovery of an imperforate hymen or vaginal septum after a young woman experiences periodic pelvic and abdominal pain with the development of


Gynecology_Novak

Gynecology_Novak. examination during the neonatal period would prevent the discovery of an imperforate hymen or vaginal septum after a young woman experiences periodic pelvic and abdominal pain with the development of a large hematometra or hematocolpos (34).


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Gynecology_Novak. Congenital vulvar tumors may include strawberry hemangiomas, which are relatively superficial vascular lesions, and large cavernous hemangiomas. Treatment is controversial; many lesions will spontaneously regress. Some clinicians have used interferon-α therapy (35,36).


Gynecology_Novak

Gynecology_Novak. Vulvar and vaginal symptoms, such as burning, dysuria, itching, or a rash, are common initial symptoms among children that are reported to gynecologists. It may be difficult for a young child to describe vulvar sensations. Parents may notice the child crying during urination, scratching herself repeatedly, or complaining of vague symptoms. Often, the child’s pediatrician will have evaluated the child for urinary tract infection. Evaluation for pinworms is warranted, because pinworms can cause severe itching in the vulvar as well as perianal area. Vulvovaginitis is the most common gynecologic problem of childhood. Prepubertally, the vulva, vestibule, and vagina are anatomically and histologically vulnerable to bacterial infection, with the bacteria typically present in the perianal area. The physical proximity of the vagina and vestibule to the anus can result in overgrowth of bacteria that can cause primary vulvitis and secondary vaginitis. Yeast infections are rare in prepubertal


Gynecology_Novak

Gynecology_Novak. The physical proximity of the vagina and vestibule to the anus can result in overgrowth of bacteria that can cause primary vulvitis and secondary vaginitis. Yeast infections are rare in prepubertal children who are toilet trained and out of diapers (37).


Gynecology_Novak

Gynecology_Novak. Figure 14.9 A: Labial adhesions B: Cotton-tipped applicator placed inside the labial adhesions shown in (A). The clinician should be familiar with normal prepubertal genital anatomy and hymenal configuration (38,39). The unestrogenized vulvar vestibule is mildly erythematous and can be confused with infection. In addition, smegma around and beneath the prepuce may resemble patches of candida vulvitis. In prepubertal girls, the vulvar area is quite susceptible to chemical irritants.


Gynecology_Novak

Gynecology_Novak. Chronic skin conditions such as lichen sclerosus, psoriasis, seborrheic dermatitis, and atopic vulvitis may occur in children (40). Lichen sclerosus, the cause of which is not well established, has a characteristic “cigarette paper” appearance in a keyhole distribution (around the vulva and anus) (Fig. 14.4). Lichen sclerosus should be treated in pediatric patients as it is in adults; there is some evidence that the condition may regress as the child progresses through adrenarche and menarche, although this appears to be infrequent. The use of ultrapotent steroids topically has been successful in children and adults (41).


Gynecology_Novak

Gynecology_Novak. Labial agglutination or adhesions may occur as a result of chronic vulvar inﬂammation from any cause (Fig. 14.9A). The treatment of labial adhesions consists of a brief course (2 to 6 weeks) of externally applied estrogen cream. The area of agglutination (adhesion) will become thin as a result, and separation can usually be performed in the office with the use of a topical anesthetic (e.g., lidocaine jelly) (Fig. 14.9B). Manual separation in the office without pretreatment with topical estrogen and without anesthesia is discouraged, as this practice may be so traumatic to the child that she will not allow subsequent examination. In the absence of a previously traumatic examination or previous surgical separation with recurrence, surgical separation frequently is not required (42). Treatment with a topical emollient (such as petrolatum) is indicated after lysis to prevent recurrent adhesions. Urethral prolapse may cause acute pain or bleeding, or the presence of a mass may be noted


Gynecology_Novak

Gynecology_Novak. with a topical emollient (such as petrolatum) is indicated after lysis to prevent recurrent adhesions. Urethral prolapse may cause acute pain or bleeding, or the presence of a mass may be noted (Fig. 14.2).


Gynecology_Novak

Gynecology_Novak. Vulvovaginal symptoms of any sort in a young child should prompt the consideration of possible sexual abuse. Sexually transmitted infections may occur in prepubertal children (43). Although vulvar condyloma presenting before age 2 to 3 years can be transmitted during vaginal delivery from the mother or from warts on caretakers’ hands, the possibility of abuse should be considered in all children with genital warts (44,45). Condyloma in older girls may be spread in a nonsexual manner, but was classified as “indeterminant” in classification findings that may be associated with sexual abuse (44). Sensitive, but direct, questioning of the parent or caretaker and the child should be a part of the evaluation; if sexual abuse is suspected, the incident must be reported to the appropriate social services agency.


Gynecology_Novak

Gynecology_Novak. Nonsexually transmitted vulvar ulcers can occur in peripubertal and adolescent girls, often in association with systemic symptoms suggestive of a viral illness (46). Herpes simplex virus, syphilis, and Behcet’s disease can cause vulvar ulcers, and they may occur as a form of genital aphthosis (Fig. 14.10). Figure 14.10 Vulvar aphthosis in prepubertal girl.


Gynecology_Novak

Gynecology_Novak. The symptom of vaginal discharge in the prepubertal age group is almost always caused by inﬂammation and irritation. In prepubertal girls, the primary site typically is the vulva, with vaginitis following secondarily, whereas in adolescents and adults, vaginitis typically is the primary finding with vulvitis occurring secondarily. Sexual abuse should always be considered in prepubertal children with vaginal discharge or a foreign body (47). Although the routine use of cultures to detect sexually transmitted diseases (STDs) in girls with a history of sexual abuse was questioned, vaginal culture for gonorrhea and chlamydia should be performed in girls who have symptoms that include vaginal discharge (48). In prepubertal girls, vulvovaginitis is usually caused by multiple organisms that are present in the perineal area, although a single organism such as Streptococcus, or even rarely Shigella, may be causative (49). When the cause is related to poor perineal hygiene, cultures often


Gynecology_Novak

Gynecology_Novak. are present in the perineal area, although a single organism such as Streptococcus, or even rarely Shigella, may be causative (49). When the cause is related to poor perineal hygiene, cultures often reveal a mixture of bacterial organisms. In this situation, the typical history is intermittent symptoms of irritation, itching, discharge, and odor over many months to years. Treatment should be initiated with a focus on hygiene and cleansing measures (40). A short-term (less than 4 weeks) course of treatment with topical estrogens and broad-spectrum antibiotics may be necessary. The problem is frequently recurrent. In girls who have a relatively acute onset of vaginal discharge and vulvovaginal symptoms, a single bacterial organism is more likely to be the cause of their symptoms.


Gynecology_Novak

Gynecology_Novak. Pokorny and Stormer described a technique for obtaining vaginal cultures and for performing vaginal irrigation (50). A catheter within a catheter can be fashioned using the tubing from an intravenous butterﬂy setup within a sterile urethral catheter. Nonbacteriostatic saline (1–3 mL) can be injected, aspirated, and sent for culture (Fig. 14.11). Cultures taken in this manner are almost always better tolerated than cultures obtained using a cotton-tipped applicator. A larger quantity of saline can be used to irrigate the vagina while the catheter is still within the vagina. Small foreign bodies can often be ﬂushed from the vagina in this manner. The most common foreign body is a small piece of toilet paper, although children will place other objects (toys, beans, coins) within their vaginas (Fig. 14.5). A persistent vaginal discharge after treatment or a discharge that is bloody or brown in color without other obvious external lesions should prompt vaginal irrigation or vaginoscopy to


Gynecology_Novak

Gynecology_Novak. (Fig. 14.5). A persistent vaginal discharge after treatment or a discharge that is bloody or brown in color without other obvious external lesions should prompt vaginal irrigation or vaginoscopy to rule out a foreign body (12).


Gynecology_Novak

Gynecology_Novak. Figure 14.11 Catheter technique for obtaining vaginal culture and irrigation. The adolescent’s experience and expression of illness and pain should be viewed within the context of her life experiences. Most adolescents have limited life experiences with problems such as pain, discomfort, or bleeding. An adolescent may state that she is experiencing the “worst pain of her life” and yet may appear to be reasonably comfortable. She may well be stating the truth about this experience, which the clinician must still interpret differently from the symptoms of an adult woman who, for instance, may be in active labor. It should be remembered that an individual’s response to illness and pain is to some extent a learned behavior.


Gynecology_Novak

Gynecology_Novak. To assess vaginal bleeding during adolescence, it is necessary to understand the range of normal menstrual cycles (see Chapter 7). During the first 2 to 5 years after menarche, most cycles are anovulatory. Despite this, they are somewhat regular, within a range of approximately 21 to 45 days, in contrast to adult women, whose cycles typically range between 21 and 38 days (51–55). In more than one-fourth of girls, a pattern of plus or minus 10 days and a cycle length of 21 to approximately 45 days are established within the first three cycles; in one-half of girls, the pattern is established by the seventh cycle; and in two-thirds of girls, such a pattern is established within 2 years of menarche (53) (Table 14.5).


Gynecology_Novak

Gynecology_Novak. The mean duration of menses is 4.7 days; 89% of cycles last 7 days. The average blood loss per cycle is 35 mL, and the major component of menstrual discharge is endometrial tissue (56). An 80 mL/cycle is used as a definition of heavy menstrual bleeding and recurrent bleeding in excess of 80 mL/cycle results in anemia, although the clinical utility of the 80 mL/cycle is questioned (57,58).


Gynecology_Novak

Gynecology_Novak. The common clinical practice of asking how many pads or tampons are soaked on a heavy day or per cycle can give a rough approximation of blood loss (three to five pads per day is typical). Individual variations in fastidiousness, lack of familiarity with the volume of blood loss other than one’s own, and errors in estimation or recollection result in inaccuracies in estimations of menstrual volume. One study found that one-third of individuals who estimated their cycles to be moderate or light had bleeding in excess of 80 mL/cycle, whereas nearly one-half of those who described the bleeding as heavy had ﬂow less than 80 mL/cycle (59). In addition, the amount of menstrual blood contained in each tampon or pad may vary both within brands as well as from one brand to another (57). However, changing a pad hourly, clots larger than “50 pence size,” and requiring a change overnight are associated with a measured volume of greater than 80 mL (58).


Gynecology_Novak

Gynecology_Novak. The transition from anovulatory to ovulatory cycles during adolescence takes place during the first several years after menarche. It results from the so-called maturation of the hypothalamic–pituitary–ovarian axis, characterized by positive feedback mechanisms in which a rising estrogen level triggers a surge of luteinizing hormone and ovulation. Most adolescents have ovulatory cycles by the end of their second year of menstruation, although most cycles (even anovulatory ones) remain within a rather narrow range of approximately 21 to 42 days. Table 14.5 Parameters for Normal Menstrual Cycles in Adolescents From Hillard PJ. Menstruation in young girls: a clinical perspective. Obstet Gynecol 2002;99:655–662. Table 14.6 Conditions Associated with Anovulation and Abnormal Bleeding Androgen excess syndromes (e.g., polycystic ovary syndrome [PCOS]) Differential Diagnosis of Adolescent Abnormal Bleeding


Gynecology_Novak

Gynecology_Novak. Cycles that are longer than 42 days, bleeding that occurs more frequently than 21 days, and bleeding that lasts more than 7 days should be considered abnormal, particularly after the first 2 years from the onset of menarche. Bleeding occurring less frequently than an internal of 90 days is abnormal, even in the first gynecologic year after menarche (51). The variability in cycle length is greater during adolescence than adulthood; thus, greater irregularity is acceptable if neither significant anemia nor hemorrhage is present. However, consideration should be given to an evaluation of possible causes of abnormal menses (particularly underlying causes of anovulation such as androgen excess syndromes or causes of oligomenorrhea such as eating disorders) for girls whose cycles are consistently outside normal ranges or whose cycles were previously regular and become irregular (60,61). Conditions that are associated with abnormal bleeding are listed in Table 14.6 and more fully discussed


Gynecology_Novak

Gynecology_Novak. outside normal ranges or whose cycles were previously regular and become irregular (60,61). Conditions that are associated with abnormal bleeding are listed in Table 14.6 and more fully discussed in Chapters 29–31.


Gynecology_Novak

Gynecology_Novak. Anovulation Anovulatory bleeding can be too frequent, prolonged, or heavy, particularly after a long interval of amenorrhea. The physiology of this phenomenon relates to a failure of the feedback mechanism in which rising estrogen levels result in a decline in follicle-stimulating hormone (FSH) with subsequent decline of estrogen levels. In anovulatory cycles, estrogen secretion continues, resulting in endometrial proliferation with subsequent unstable growth and incomplete shedding. The clinical result is irregular, prolonged, and heavy bleeding.


Gynecology_Novak

Gynecology_Novak. Studies of adolescent menses show differences in rates of ovulation based on the number of months or years postmenarche. The younger the age at menarche, the sooner regular ovulation is established. In one study, the time from menarche until 50% of the cycles were ovulatory was 1 year for girls whose menarche occurred when they were younger than 12 years of age, 3 years for girls whose menarche occurred between 12 and 12.9 years of age, and 4.5 years for girls whose menarche occurred at 13 years of age or older (62).


Gynecology_Novak

Gynecology_Novak. Pregnancy-Related Bleeding The possibility of pregnancy must be considered when an adolescent seeks treatment for abnormal bleeding (Table 14.7). Bleeding in pregnancy can be associated with a spontaneous abortion, ectopic pregnancy, or other pregnancy-related complications, such as a molar pregnancy. In the United States, 30% of 15-to 17-year-old adolescent girls have had sexual intercourse, as have 70.6% of those 18 to 19 years old (63). Issues of confidentiality for adolescent health care are critical to an adolescent’s willingness to seek appropriate reproductive health care (see Chapter 1).


Gynecology_Novak

Gynecology_Novak. Exogenous Hormones The cause of abnormal bleeding that is experienced while an individual is taking exogenous hormones usually is very different from bleeding that occurs without hormonal manipulation (64). Oral contraceptive use is associated with breakthrough bleeding, which occurs in as many as 30% to 40% of individuals during the first cycle of combination pill use. In addition, irregular bleeding can result from missed pills (65,66). Strict


Gynecology_Novak

Gynecology_Novak. Table 14.7 Causes of Bleeding by Approximate Frequency and Age Group compliance with correct and consistent pill taking is difficult for many individuals who take oral contraceptives; one study reported that only 40% of women took a pill every day (67). Other studies suggest that adolescents have an even more difficult time taking oral contraceptives than do adults, missing an average of three pills per month (68). A study of urban teens reported approximately two episodes of three or more consecutive missed pills occurring during each 3-month interval (69). With this many missed pills, it is not surprising that some individuals experience irregular bleeding. The solution is to emphasize consistent pill taking; if the individual is unable to comply with daily pill use, an alternative contraceptive method may be preferable.


Gynecology_Novak

Gynecology_Novak. All forms of hormonal contraception, from combination and progestin-only minipills, to contraceptive patches, rings, intrauterine devices, and injectable and implantable contraception, can be associated with abnormal bleeding, although studies assessing bleeding have not used uniform methodologies and thus comparisons are difficult (70–72). Irregular bleeding occurs frequently in users of depomedroxyprogesterone acetate (DMPA), although at the end of 1 year, more than 50% of users will be amenorrheic (73,74). The mechanism of bleeding associated with these hormonal methods is not well established; an atrophic endometrium or factors related to angiogenesis may be involved, suggesting options for therapy (64,75). It should not be assumed that any bleeding occurring while an individual is using a hormonal method of contraception is caused by that method. Other local causes of bleeding, such as cervicitis or endometritis, can occur during use of hormone therapy and may be particularly


Gynecology_Novak

Gynecology_Novak. using a hormonal method of contraception is caused by that method. Other local causes of bleeding, such as cervicitis or endometritis, can occur during use of hormone therapy and may be particularly important to consider in adolescents who are at risk for STDs (76,77).


Gynecology_Novak

Gynecology_Novak. Hematologic Abnormalities In the adolescent age group, the possibility of a hematologic cause of abnormal bleeding must be considered. One classic study reviewed all visits by adolescent patients to an emergency room with the symptom of excessive or abnormal bleeding (75,78). The most common coagulation abnormality diagnosed was idiopathic thrombocytopenic purpura, followed by von Willebrand disease. Subsequent studies confirmed this association, particularly with excessive bleeding at the time of menarche. Von Willebrand’s disease occurs in approximately 1% of women in the United States and, in its mildest form, menorrhagia may be the only symptom (79–81). Adolescents who have severe menorrhagia, especially at menarche, should be screened for coagulation abnormalities, including von Willebrand disease.


Gynecology_Novak

Gynecology_Novak. Infections Irregular or postcoital bleeding can be associated with chlamydial cervicitis. Adolescents have the highest rates of chlamydial infections of any age group, and sexually active teens should be screened routinely for chlamydia (82). Menorrhagia can be the initial sign in patients infected with sexually transmissible organisms. Adolescents have the highest rates of pelvic inﬂammatory disease (PID) of any age group of sexually experienced individuals (see Chapter 18) (83). Other Endocrine or Systemic Problems Abnormal bleeding can be associated with thyroid dysfunction. Signs and symptoms of thyroid disease can be somewhat subtle in teens (see Diagnosis of Adolescent Abnormal Bleeding Chapter 31). Hepatic dysfunction should be considered because it can lead to abnormalities in clotting factor production. Hyperprolactinemia can cause amenorrhea or irregular bleeding.


Gynecology_Novak

Gynecology_Novak. Polycystic ovary syndrome (PCOS) can occur during adolescence, and manifestations of excess androgen (hirsutism, acne) should prompt evaluation, although the diagnostic criteria for PCOS during adolescence are not well established (84). Androgen disorders occur in about 5% to 10% of adult women, making them the most common endocrine disorders in women (see Chapter 31). Classic PCOS, functional ovarian hyperandrogenism, or partial late-onset congenital adrenal hyperplasia can occur in adolescence. These disorders often are overlooked, unrecognized, or untreated. Women with even mild disorders are candidates for intervention, including lifestyle interventions to normalize weight, and pharmacologic interventions to manage abnormal bleeding or hirsutism. These disorders may be a harbinger of type 2 diabetes, endometrial cancer, and cerebrovascular disease. Acne, hirsutism, and menstrual irregularities are often dismissed as normal during adolescence but may be manifestations of


Gynecology_Novak

Gynecology_Novak. of type 2 diabetes, endometrial cancer, and cerebrovascular disease. Acne, hirsutism, and menstrual irregularities are often dismissed as normal during adolescence but may be manifestations of hyperandrogenism (52,85). Androgen abnormality can persist beyond adolescence. Obesity, hirsutism, and acne should be evaluated to minimize the significant psychosocial costs. Androgenic changes are partially reversible if detected early and managed appropriately. Behavioral changes in lifestyle (diet and exercise) should be strongly encouraged but are often difficult to achieve. Signs of insulin resistance (acanthosis nigricans) should be evaluated and managed appropriately (86).


Gynecology_Novak

Gynecology_Novak. Anatomic Causes Obstructive or partially obstructive genital anomalies typically present during adolescence. Complex m¨ullerian abnormalities, such as obstructing longitudinal vaginal septa or uterus didelphys, can cause hematocolpos or hematometra (Fig. 14.12). If these obstructing anomalies have or develop a small outlet, persistent dark-brownish discharge (old blood) may appear instead of or in addition to a pelvic mass. Many varieties of uterine and vaginal anomalies exist, and clinicians who have expertise with these anomalies should be involved in their management. Figure 14.13 illustrates situations in which abnormal bleeding can result from partially obstructing septa.


Gynecology_Novak

Gynecology_Novak. Examination A careful general physical examination can reveal signs of androgen excess such as acanthosis nigricans or facial, chest or periareolar, or abdominal terminal hair growth. Because body hair is felt by many to be culturally unacceptable in women and girls, sensitive questioning about specific hair removal techniques (bleaching, waxing, use of depilatories, shaving, plucking, threading) is warranted during an examination. A complete pelvic examination is appropriate in patients who are sexually active, are having severe pain, or may have an anatomic anomaly. Testing for gonorrhea and Chlamydia trachomatis infection is appropriate during a speculum examination if the patient is sexually active. Some young teens who have a history that is classic for anovulation, who deny sexual activity, and who agree to return for follow-up evaluation may be managed with a limited gynecologic examination supplemented with pelvic ultrasonography. Figure 14.12 Uterus didelphys.


Gynecology_Novak

Gynecology_Novak. Figure 14.12 Uterus didelphys. Figure 14.13 The types of obstructive or partially obstructive genital anomalies that can occur during adolescence. Laboratory Testing Any adolescent with abnormal bleeding should undergo sensitive pregnancy testing, regardless of whether she states that she has had intercourse. The medical consequences of failing to diagnose a pregnancy are too severe to risk missing the diagnosis. Complications of pregnancy should be managed accordingly. In addition to a pregnancy test, laboratory testing should include a complete blood count with platelet count and screening tests for coagulopathies and platelet dysfunction. An international expert panel made recommendations about when a gynecologist should suspect a bleeding disorder and pursue a diagnosis (Table 14.8). The consensus report recommends measurement of complete blood cell count (CBC), platelet count and function, prothrombin time (PT), activated partial thromboplastin time (PTT),


Gynecology_Novak

Gynecology_Novak. Table 14.8 When Should a Gynecologist Suspect a Bleeding Disorder Family history of bleeding disorder Personal history of any of the following: Epistaxis in the last year Postpartum hemorrhage, especially delayed >24 h Failure to respond to conventional management of menorrhagia From James AH, Kouides PA, Abdul-Kadir R, et al. Von Willebrand disease and other bleeding disorders in women: consensus on diagnosis and management from an international expert panel. Am J Obstet Gynecol 2009;201:12e1–e8. Management of Abnormal Bleeding von Willebrand factor (VWF) (measured with ristocetin cofactor activity and antigen, factor VIII), and fibrinogen to be assessed in collaboration with a hematologist (81).


Gynecology_Novak

Gynecology_Novak. Thyroid studies may be relevant. Testing for STDs may be performed as warranted on either a cervical or a urine specimen using DNA amplification techniques. Cervical cytology testing is generally not appropriate for adolescents, particularly at an emergency or urgent visit for excessive bleeding (87).


Gynecology_Novak

Gynecology_Novak. Imaging Studies If the pregnancy test results are positive, pelvic imaging using ultrasonography may be necessary to confirm a viable intrauterine pregnancy and rule out a spontaneous abortion or ectopic pregnancy. If a pelvic mass is suspected on examination, or if the examination is inadequate (more likely to be the case in an adolescent than an older woman) and additional information is required, pelvic ultrasonography may be helpful. Although transvaginal ultrasonographic examination can be more helpful than transabdominal ultrasonography in ascertaining details of pelvic anatomy, the use of the vaginal probe may not be possible in a young girl or one who has not used tampons or had intercourse. Direct communication between the clinician and the radiologist can be helpful in identifying patients who are appropriate candidates for transvaginal ultrasonographic examination, such as those who are sexually active, rather than a blanket prohibition against transvaginal ultrasound


Gynecology_Novak

Gynecology_Novak. patients who are appropriate candidates for transvaginal ultrasonographic examination, such as those who are sexually active, rather than a blanket prohibition against transvaginal ultrasound examination in adolescents.


Gynecology_Novak

Gynecology_Novak. Other imaging studies are not indicated as initial testing but may be helpful in selected instances. If a pelvic ultrasonographic examination does not lead to clarification of the anatomy when vaginal septa, uterine septa, uterine duplication, or vaginal agenesis is suspected, MRI can be helpful in delineating anatomic abnormalities (88). This imaging technique is useful in the evaluation of uterine and vaginal developmental anomalies, although laparoscopy can still play a role in the clarification of abnormal anatomy (89). CT scanning may be helpful in detecting nongenital intra-abdominal abnormalities.


Gynecology_Novak

Gynecology_Novak. Management of bleeding abnormalities related to pregnancy, thyroid dysfunction, hepatic abnormalities, hematologic abnormalities, or androgen excess syndromes should be directed to treating the underlying condition. Oral contraceptives can be extremely helpful in managing androgen excess syndromes, inherited bleeding disorders, and anovulation, although an appropriate evaluation should be performed prior to initiation of hormonal contraception (90–92).


Gynecology_Novak

Gynecology_Novak. Treatment with mefenamic acid and other nonsteroidal anti-inﬂammatory agents (NSAIDs) results in decreased menstrual bleeding when compared with placebo (93). Tranexamic acid, an antifibrinolytic agent, is more effective in decreasing heavy menstrual bleeding, and was approved by the U.S. Food and Drug Administration (FDA) for this indication in late 2009 (93a). After specific diagnoses are ruled out by appropriate laboratory testing, this condition can be managed either expectantly or with hormone therapy, depending on the clinical presentation and other factors, such as the need for contraception. Anovulation: Mild Bleeding


Gynecology_Novak

Gynecology_Novak. Anovulation: Mild Bleeding Adolescents who have mildly abnormal bleeding, as defined by adequate hemoglobin levels and minimal disruption of daily activities, are best managed with prospective menstrual charting, frequent reassurance, close follow-up, and supplemental iron. If the patient is bleeding heavily or for a prolonged interval, an apparent decrease in the bleeding does not necessarily mean that therapy is not required. Intermittent bleeding characterizes anovulatory bleeding and is likely to continue in the absence of therapy.


Gynecology_Novak

Gynecology_Novak. A patient who is mildly anemic will benefit from hormone therapy. If the patient is not bleeding at the time of evaluation and has no contraindications to the use of estrogen, a combination low-dose oral contraceptive can be prescribed for use in the manner in which it is used for contraception. If the patient is not sexually active, she should be reevaluated after three to six cycles to determine whether she desires to continue this regimen. Parents may sometimes object to the use of oral contraceptives if their daughter is not sexually active (or if they believe her not to be or even if they would like her not to be). These objections are frequently based on misconceptions about the potential risks of the pill and can be overcome by careful explanation of the pill’s role as medical therapy. Objections may be based on concerns that hormonal therapy for medical indications is likely to hasten the onset of coitarche or sexual debut, although no data support this fear. If the medication


Gynecology_Novak

Gynecology_Novak. Objections may be based on concerns that hormonal therapy for medical indications is likely to hasten the onset of coitarche or sexual debut, although no data support this fear. If the medication is discontinued when the young woman is not sexually active and she subsequently becomes sexually active and requires contraception, it may be difficult to explain the reinstitution of oral contraceptives to the parents. If there is no significant medical or family history that would preclude their use, combination oral contraceptives are especially appropriate for the management of abnormal bleeding in adolescents for a number of reasons: 1.


Gynecology_Novak

Gynecology_Novak. Approximately 50% of high schools juniors in the United States are sexually experienced (63). 2. Adolescents typically wait many months after initiating sexual activity to seek medical contraception. 3. At least 80% of adolescent pregnancies are unintended (94). 4. Approximately one-quarter of adolescent pregnancies end in abortion (95). 5. Approximately one in three young women will experience a pregnancy before age 20 (96). Thus, consideration should certainly be given to continuing the oral contraception use, and parents should be reassured that the medical risks are small in otherwise healthy adolescents and that there are no significant risks associated with prolonged use. Individuals may choose to continue oral contraceptives for contraception or their noncontraceptive benefits (improvement of acne, decreased dysmenorrhea, and lighter, more regular menstrual ﬂow, protective effect for endometrial and ovarian cancer).


Gynecology_Novak

Gynecology_Novak. Sometimes, providing parents with accurate information about the safety of oral contraceptives, emphasizing that currently available oral contraceptive preparations contain lower doses of estrogens and progestins than those used in the 1960s and 1970s, and emphasizing the hormonal rather than contraceptive function may not be persuasive. In such cases, cyclic progestins are an alternative. A systematic review of the use of combination hormonal therapy versus progestins alone for the treatment of anovulatory bleeding found a paucity of evidence supporting the efficacy of one management regimen over another (97). Medroxyprogesterone acetate, 5to 10 mg/day for 10 to 13 days every 1 to 2 months, prevents excessive endometrial buildup and irregular shedding caused by unopposed estrogen stimulation. This therapy should be reevaluated regularly and accompanied by oral administration of iron. Eventual maturation of the hypothalamic–pituitary–ovarian axis usually will result in the


Gynecology_Novak

Gynecology_Novak. stimulation. This therapy should be reevaluated regularly and accompanied by oral administration of iron. Eventual maturation of the hypothalamic–pituitary–ovarian axis usually will result in the establishment of regular menses unless there are underlying conditions such as hyperandrogenism.


Gynecology_Novak

Gynecology_Novak. Moderate Patients who are bleeding acutely but in a stable condition and do not require hospital admission will require doses of hormones that are higher than those in oral contraceptives to effectively stop anovulatory bleeding. An effective regimen is the use of combination monophasic oral contraceptives (every 6 hours for 4 to 7 days). After that time, the dose should be tapered or stopped to allow shedding of the dyssynchronous endometrium and withdrawal bleeding. With this therapy, the patient and her parents should be given specific written and oral instructions warning them about the potential side effects of high-dose hormone therapy—nausea, breast tenderness, and breakthrough bleeding. The patient should be instructed to call with any concerns rather than discontinue the pills, and she must understand that stopping the prescribed regimen may result in a recurrence of heavy bleeding. Both the patient and her mother should be warned to expect heavy withdrawal ﬂow for the first


Gynecology_Novak

Gynecology_Novak. she must understand that stopping the prescribed regimen may result in a recurrence of heavy bleeding. Both the patient and her mother should be warned to expect heavy withdrawal ﬂow for the first period. It will be controlled by the institution of combination low-dose oral contraceptive therapy, given once daily and continued for three to six cycles, to allow regular withdrawal ﬂow. If the patient is not sexually active, the pill may be discontinued after the recommended course of therapy and the menstrual cycles may be reassessed.