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Study Objective To describe features of menstruation, menstrual-related symptoms, and menstrual management in females with Rett syndrome (RTT) to help develop a clinical approach to these parameters in RTT. Design Retrospective cross-sectional chart review and prospective survey. Setting Cincinnati Children's Hospital Medical Center, Rett Syndrome and Related Spectrum Disorders Clinic. Participants Females with RTT (12-55 years of age) and their caregivers. Main Outcome Measures Descriptive data on features of menstruation and menstrual-related symptoms in individuals with Rett syndrome; prevalence, types, reason for use/discontinuation, and efficacy of hormonal treatment in females with RTT. Results Age at menarche, menstrual cycle length, and menstrual period length in females with RTT are comparable to those in typically developing females and females with other neurodevelopmental disabilities. Dysmenorrhea and emotional lability are common menstrual cycle−related changes among females with RTT; 22.1% of participants also reported catamenial seizures. Oral progestin, combined oral contraceptive pill, and depot-medroxyprogesterone acetate (DMPA) were effectively used to suppress or regulate menstruation and to manage menstrual-related symptoms. Conclusions Characteristics of menstruation in females with RTT are comparable to those of typically developing females, with the exception of increase in catamenial seizure activity. Hormonal treatments are used for management of menstruation, dysmenorrhea, and seizures. Choice of hormonal treatment is influenced by bone health and immobility in females with RTT.

Study Objective To describe knowledge and use of contraceptive methods among pregnant teens in Brazil. Design A cross-sectional survey. Setting A tertiary care center in Bahia, Brazil. Participants Pregnant teens 10-19 years old. Interventions Participants were asked about contraceptive knowledge and previous contraceptive use. Main Outcome Measures Contraceptive knowledge, previous contraceptive use, and contraceptive intentions for after pregnancy. Other survey topics included demographic characteristics, school attendance, and sexual history. Results A total of 90 participants wereincluded in the study, with an average age of 15.4 ± 1.7 years, and a mean age at first sexual intercourse of 13.8 ± 1.2 years. Most participants were unmarried (58/90), of mixed race (57/90), had a household income below minimum wage (59/83), lived with their parents (54/90), and unemployment (81/90). More than 80% were not using contraception or were using it irregularly whenthey became pregnant. Most participants reported knowledge of condoms (82/90), of the combined oral contraceptive pill (75/90) and of injectable contraceptives (68/90). However, less than half reported knowledge oflong-acting reversible contraceptive methods. In terms of contraceptive intentions after pregnancy, the most commonly cited methods were the contraceptive injection (36/90), the intrauterine device (17/90) and the combined pill (9/90). Conclusion In this study we found a low level of knowledge of contraceptive methods, and especially of long-acting reversible contraceptive methods, among pregnant teens in Northeast Brazil. Low socioeconomic status and high rates of unplanned pregnancy might be reasons for insufficient sexual and reproductive health counseling in this population.

Study Objective The purpose of this study was to assess whether variability exists in the management of acute abnormal uterine bleeding (AUB) in adolescents between pediatric Emergency Department (ED) physicians, pediatric gynecologists, and adolescent medicine specialists. Design Retrospective chart review. Setting Tertiary care medical center ED. Participants, Interventions, and Main Outcome Measures We included girls aged 9-22 years who presented from July 2008 to June 2014 with the complaint of acute AUB. Patients were identified using the International Classification of Diseases, ninth revision codes for heavy menstrual bleeding, AUB, and irregular menses. Exclusion criteria included pregnancy and current use of hormonal therapy. One hundred fifty patients were included. Results Among those evaluated, 61% (n = 92) were prescribed hormonal medication to stop their bleeding by providers from the ED, Adolescent Medicine, or Pediatric Gynecology. ED physicians prescribed mostly single-dose and multidose taper combined oral contraceptive pills (85%; n = 24), compared with Adolescent Medicine (54%, n = 7), and Gynecology (28%, n = 13). Pediatric gynecologists were more likely than ED physicians to treat patients with norethindrone acetate, either alone or in combination with a single dose combined oral contraceptive pill (61%, n = 33 vs 7%, n = 2; P Conclusion Variations in treatment strategies for adolescents who present with acute AUB exist among pediatric specialties, which reflects a lack of standardized care for adolescents. Prospective evaluation of the shortest interval to cessation of bleeding, side effects, and patient satisfaction are valuable next steps.

Study Objective To evaluate the efficacy of continuous norethisterone acetate (NET-A), 5 mg (group N) vs cyclical combined oral contraceptive pill (COC) consisting of drospirenone 3 mg/ethinyl estradiol 20 μg pills (group P) in treating dysmenorrhea in young adult women. Design, Setting, and Participants This prospective, open-label, nonrandomized study included 38 Jordanian patients: 20 patients in group N and 18 patients in group P. Interventions Continuous NET-A 5 mg daily or cyclical COC. Main Outcome Measures Pain scores, adverse effects, analgesic use, school absence, and cost. Results Thirty-eight patients used NET-A or COC for 6 months. All participants had almost the same starting levels of visual analogue scale (VAS) scores. Both drugs were similar in suppressing dysmenorrhea at the 3-month follow-up visit; VAS score mean (±SD) in group N and P were 1.30 ± 1.22 and 1.28 ± 0.83 (P = .22), respectively, and after 6 months, with mean VAS scores (±SD) of 1.30 ± 1.22 and 1.28 ± 0.83, respectively (P = .95). The cost of the treatment in the N group was much less than in the P group. Participants in the N group were less likely to use pain killers: 20% and 44% in the N and P groups, respectively (P = .006) in the first month and only 5% and 17% (P = .019) in the N and P groups, respectively, at the 3-month follow-up, and none of them used any analgesics at the 6-month follow-up. Conclusion A continuous NET-A regimen is a well tolerated, effective, and inexpensive option for dysmenorrhea treatment and was as good as COC.

The approach to menstrual suppression for adolescents with developmental disabilities has evolved considerably over the years due to changing philosophies and evolving treatment options. We review the medical management options available for menstrual suppression with a focus on the needs and treatment of adolescents with developmental disabilities.

Background: The causative factor in the majority of cases of adolescent heavy menstrual bleeding is anovulatory dysfunctional uterine bleeding while inherited bleeding disorders contribute to approximately 10% of cases in adolescents at our institution. The principles of initial severe menstrual bleeding management in the adolescent patient include aggressive fluid replacement, coagulopathy reversal, fibrinolytic therapy, and hormone administration. Once aggressive, standard medical management has been exhausted, interventional radiology or surgical approaches may be required to aid in stopping ongoing losses. The ultimate long-term goal of therapy in this age group is to maintain reproductive potential. We report two cases involving non-medical management which achieved bleeding cessation without, presumably, compromising fertility. Cases: Intrauterine balloon tamponade A 13-year old female with prolonged heavy menstrual bleeding and a past medical history significant for remote, cured Stage IV neuroblastoma. She received cyclophosphamide and cisplatin as part of her treatment. Diagnostic hysteroscopy identified the site of bleeding which was subsequently tamponaded with a large caliber Foley catheter. The severe menstrual bleeding resolved and hormonal therapies were weaned to a combined oral contraceptive pill (COCP). Investigations did not reveal any evidence of a bleeding disorder, and the etiology of the bleeding was thought to be due to ovulatory dysfunction secondary to previous chemotherapy. Uterine artery embolization (UAE) A 15-year old female with regular menstrual cycles presented with severe menstrual bleeding. Initial management at a regional hospital resulted in stabilization for transfer to a tertiary level pediatric hospital. Angiography with non-occlusive, selective bilateral UAE using an absorbable material (Gelfoam) was undertaken to rule out a vascular malformation and provide temporary control for hysteroscopic assessment. Diagnostic hysteroscopy confirmed the presence of a thick polypoid endometrium which was found to be secretory on sampling. The bleeding subsided and menstrual control was afforded with a COCP. There was no confounding bleeding disorder. Comments: Non-occlusive, selective bilateral UAE with an absorbable material and hysteroscopy-guided intrauterine balloon tamponade are non-destructive therapeutic modalities which should not impact on future reproductive and obstetrical outcomes. Neither of the patients presented here have attempted pregnancy so this statement still awaits confirmation. Invasive options may be considered as an adjunct to medical management in refractory cases. These cases highlight that medical therapy should be initiated early and aggressively as adolescents may remain hemodynamically stable in the face of significant blood loss and decompensation may occur rapidly.