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Limited data exist on the reproductive hormone dynamics that govern the transition from menarche to the establishment of the mature ovulatory cycles of a fertile young woman. It is also unclear how environmental and lifestyle factors could modulate this transition in contemporary girls. Here, we introduce A Girl's First Period Study, an ambitious longitudinal study aimed at charting the early post-menarchal course of a cohort of healthy girls in the Triangle region of North Carolina.

Throughout the 20 century, in developed countries there has been a secular trend toward earlier menarche. Over the past 2 decades, however, there has been an apparent stabilization in the average age of menarche age in most Western countries.The objective of this study was to analyze the mean age of menarche in a cohort of Italian girls, to analyze the mean age of breast button appearance (B2), and to correlate the B2 developmental stage and age at menarche with the most important clinical and auxological parameters.We retrospectively evaluated the data of 1458 Italian girls born between 1995 and 2003. We collected the main auxological and clinical parameters, including age at B2, age at menarche, height, weight, and body mass index (BMI) at B2 and menarche and, when possible, adult/near adult height.The mean age of B2 was 10.16 ± 1.00 years, significantly earlier than previously reported for Italian girls (P.05); the mean age of menarche was 12.07 ± 0.99 years, also significantly earlier than previously reported (P.0001). Age at B2 and menarche inversely correlated with BMI standard deviation score (SDS) (P.0001). The mean adult/near adult height of the girls in the study cohort was not statistically different from previously reported data for Italian women.Our results suggest a new trend for an earlier appearance of thelarche and menarche in Italian girls. Our data confirm a significant relationship between BMI and age of B2 and menarche. The girls' final height seems to be in line with average height for the Italian female population.

STUDY OBJECTIVE: To characterize typical menstrual characteristics in a large sample of secondary school girls, as well as knowledge of typical (ie, normal) menstruation, endometriosis awareness, and educational needs. To establish whether self-reported atypical period symptoms indicate menstrual characteristics suggesting the need for further clinical review for a specialist opinion. DESIGN: Cross-sectional survey. SETTING: Secondary schools in West Midlands, England. PARTICIPANTS: A total of 442 girls, aged 15-19 years. INTERVENTIONS AND MAIN OUTCOME MEASURES: The questionnaire determined demographic characteristics, age at menarche, menstrual cycle patterns and experiences, awareness of endometriosis, and preferences for learning about it. RESULTS: Period pain was common (94%), with pain reported as moderate/severe (86%). Girls reported missing school due to their menstrual periods (23%), mainly because of pain. Most believed their period was typical (63%); however, 27% were unsure, and 30% did not know whether it was regular. Self-report of atypical periods was associated with symptoms suggesting need for clinical review and with consulting a doctor [χ²(2) = 36.272, P < .001)]. Only 8% could describe endometriosis, although 86% wanted to learn more about it. CONCLUSION: Most secondary school girls report dysmenorrhea. Although most girls reporting atypical periods had seen a doctor, more than one-fourth did not know whether their period was typical or regular. The majority do not have knowledge of endometriosis, contrasting with adolescents' familiarity with other common chronic conditions such as diabetes and epilepsy. We suggest menstrual health education (MHE) to improve knowledge of typical menstruation and pain treatment, aiding earlier identification of problematic period symptoms that might indicate underlying pathology.

Study Objective Evaluation of acute abdominal pain in an adolescent female patient should include consideration of all potential sources of pain, including gynecologic etiologies. The goal of our study was to determine the frequency of evaluation of gynecologic causes of abdominal pain in adolescent girls seen in a pediatric emergency department. Study Design A retrospective review was performed of girls between 12 and 21 years of age presenting to the emergency department or urgent care centers at a single pediatric institution with the chief complaint of abdominal pain during 2016. Frequency analyses of demographic and clinical characteristics are presented. Results A total of 1082 girls presented with a chief complaint of abdominal pain. Menarche was documented in 85% of patients, sexual history in 52% of patients, and assessment of contraception use in 28%. Pregnancy testing was performed in 77%. Sexually transmitted infection (STI) testing was performed in 31%, and in only 73% of patients who reported being sexually active. Imaging was performed in 52%. In the subgroup of patients who reported being sexually active and presented with abdominal pain and vaginal discharge, only 37% had a pelvic examination performed. In multivariable modeling, Black patients were significantly more likely than White patients to have STI testing performed (adjusted risk ratio [aRR] = 1.39; confidence interval [CI] = 1.13-1.70) and to undergo a pelvic examination (aRR = 2.45; CI = 1.34-4.50), and less likely to undergo imaging (aRR = 0.69; CI = 0.59-0.81). Conclusion The assessment of abdominal pain in adolescent girls should include gynecologic etiologies. Our results raise concerns that there are deficiencies in the evaluation of gynecologic sources of abdominal pain in girls treated at pediatric facilities, and evidence of potential racial disparities.

Study Objective This study analyzed the relationship between household food security and variation in age at menarche, as well as the connections between food insecurity, nutritional status, and allostatic load, among girls aged 12-15 years from the 2009-2014 United States National Health and Nutrition Examination Survey (NHANES). Methods Data analysis included mean comparisons of age at menarche among household food security groups (high, marginal, low, and very low) as well as categorical variables known to associate with age at menarche (ethnicity, poverty status, body mass index [BMI], allostatic load, and milk consumption). χ2 Analyses were used to test the associations between household food security and additional categorical variables. Univariate and multivariate regression models were used to test the relationship between variation in age at menarche and household food security, ethnicity, BMI, and allostatic load categories while controlling for age. Results Non-Hispanic Black and Hispanic/Mexican American girls had earlier mean ages at menarche, higher mean BMIs, and disproportionately experienced household food insecurity when compared to non-Hispanic White-identifying girls. In the univariate analyses, marginal household food security, Hispanic/Mexican American and Black ethnicities, overweight and obese BMI categories, and marginal-high allostatic load were each associated with lower age at menarche compared to reference categories. These associations were maintained in the multivariate analysis, although only Hispanic/Mexican American ethnicity predicted earlier menarche when compared to that of non-Hispanic White girls. Conclusions Marginal household food security, particularly for girls who identified as non-White, predicted earlier age at menarche independent of nutritional status and allostatic load. At the same time, having more energetic resources (ie, higher BMI) also significantly predicted earlier menarche.

Study Objective To explore key aspects of menstrual health literacy and menstrual management in young women at school or in tertiary education. Design Cross-sectional online survey. Setting Australia-wide. Participants A total of 4202 adolescent and young women (13-25 years of age; median age 17 years), having reached menarche, living in Australia and currently attending school (n = 2421) or tertiary education (n = 1781). Interventions Online survey hosted by Qualtrics between November 2017 and January 2018. Data were collected on contraceptive use, management strategies, sources of information, and knowledge of menstruation. Main Outcome Measures Information on prevalence and effectiveness of different management strategies, health-seeking behavior, knowledge about menstruation, and common menstrual disorders such as endometriosis. Results The majority of young women did not seek medical advice for their menstrual symptoms, but used information from the Internet (50%) and engaged in self-management, most commonly with over-the-counter medications such as paracetamol (51%) or ibuprofen (52%). Oral contraceptive use was relatively common (35%), and mostly for reduction of menstrual pain (58%). Despite having significant dysmenorrhea, approximately one-half of the participants (51%) thought that their period was normal. Women with higher pain scores were more likely to rate their period as “abnormal” (P Conclusion Self-management of menstrual symptoms is common, but a significant minority of women are underdosing or choosing ineffective methods. Most women do not seek medical advice even when symptoms are severe, and cannot identify symptoms suggestive of secondary dysmenorrhea. Improved education on menstruation is vital.

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.

To assess emergent changes in the age at menarche and investigate associated factors in Israeli adolescents in 2003 and 2016.Cross-sectional study.Two national representative school-based surveys (first and second "Mabat Youth").Both surveys included female students in 7th-12th grades (ages 11-19 years). The first (N = 3328) was conducted between the years 2003 and 2004, and the second (N = 2535) from 2015 to 2016.The survey questionnaire was self-administered and anthropometric measurements were performed by trained personnel.The current age at menarche in Israeli girls was determined and independent factors (demographic, clinical, and lifestyle) examined. Changes that occurred since the past national survey more than a decade ago were documented.The estimated median age at menarche declined from 13.0 (interquartile range, 12.0-14.0) years in 2003-2004 to 12.5 (interquartile range, 12.0-13.0) years in 2015-2016 (P .0001). Jewish girls reached menarche earlier than Arab girls, but both populations experienced a similar downward trend in the past approximately 14 years. Greater body mass index, higher socioeconomic status, and immigrant status were associated with younger menarche onset (P .001). Age at menarche remained lower in 2015-2016 vs 2003-2004, even after adjustment for these potential confounders, with a high hazard ratio (HR), which decreased as a function of survival time (t): HRThis study confirms the decline in age at menarche in Israel. Findings were associated with body mass index and population group but also indicated that other factors are likely involved.

Study Objective To explore the prevalence and impact of dysmenorrhea, pelvic pain and menstrual symptoms on young women at school or in tertiary education. Design and Setting Cross-sectional online survey in Australia. Participants A total of 4202 adolescent and young women (13-25 years of age; median age 17 years), having reached menarche, living in Australia and currently attending school (n = 2421) or tertiary education (n = 1781). Interventions Online survey hosted by Qualtrics between November 2017 to January 2018. Data were collected on sociodemographic data, menstrual cycle characteristics, dysmenorrhea, pelvic pain, and educational and social impact. Main Outcome Measures Information on menstrual and pelvic pain impact, academic absenteeism and presenteeism, impact on non-academic activities and interactions with teaching staff. Results and Conclusions Dysmenorrhea was reported by 92% of respondents. Dysmenorrhea was moderate (median 6.0 on a 0-10 numeric rating scale) and pain severity stayed relatively constant with age [rs(3804) = 0.012, P = .477]. Noncyclical pelvic pain at least once a month was reported by 55%. Both absenteeism and presenteeism related to menstruation were common. Just under half of women reported missing at least one class/lecture in the previous three menstrual cycles. The majority of young women at school (77%) and in tertiary education (70%) reported problems with classroom concentration during menstruation. Higher menstrual pain scores were strongly correlated with increased absenteeism and reduced classroom performance at both school and in tertiary education. Despite the negative impact on academic performance the majority of young women at school (60%) or tertiary education (83%) would not speak to teaching staff about menstruation.

Study Objective To identify and examine the key areas of need and explore the experiences of adolescent girls with heavy menstrual bleeding and/or dysmenorrhea. Design and Setting Qualitative interview study using semi-structured interviews. Gynaecology outpatient clinic at The Royal Children's Hospital, Melbourne, Australia. Participants Adolescent girls (12-18 years; mean age, 14.8 ± 1.5 years) presenting with heavy menstrual bleeding and/or dysmenorrhea at the clinic (N = 30). Interventions and Main Outcome Measures In-depth semi-structured interviews were conducted between May and August 2018. Interview data were thematically analyzed using a grounded theory approach. Themes covered experiences and unmet needs of adolescent girls with heavy menstrual bleeding and/or dysmenorrhea. Results A total of 12 themes were identified, and covered the impact of symptoms, experiences, and/or unmet needs of these adolescents. Key themes highlighting experiences and unmet needs related to (1) coordination of healthcare, (2) day-to-day coping, (3) school, and (4) information surrounding menstrual issues. From these themes, 7 unmet needs emerged and were organized under 3 key areas of need: (1) treatment, management, and care, (2) improvements in the school environment, and (3) menstrual health as a gendered issue. Conclusion Menstrual concerns can have a profound physical and psychosocial impact on adolescents. Effective school-based menstrual education programs may be key in reducing stigma, fear, and shame surrounding menstruation, in teaching positive management strategies and in encouraging adolescents to seek help for their menstrual concerns.

To characterize and compare sex hormone concentrations, and uterine and ovarian volumes in adolescent girls born small for gestational age (SGA) who had experienced catch-up growth and girls born at a size appropriate for gestational age (AGA), and to investigate the association between these parameters and glucose metabolism, perinatal factors, and early growth.A prospective, longitudinal, observational study from birth until adolescence.Mean age at final assessment was 12.7 ± 0.1 years.We followed 55 girls (20 SGA, 35 AGA).Sex hormone concentrations (gonadotropins, estradiol, testosterone, and sex hormone binding globulin) were analyzed, and the oral glucose tolerance test conducted. Uterine and ovarian sizes were assessed using pelvic ultrasound.Uterine and ovarian volumes were smaller in SGA-born compared with AGA-born girls (P = .013 and P = .039, respectively). SGA girls had lower sex hormone binding globulin levels (P = .039) and higher testosterone levels (P = .003), free androgen index (P .001), and glycemia 2 hours post glucose load (P = .005) compared with AGA-born girls. Birth weight and early infancy height velocity explained 37.4% of variation in ovarian volume (P = .004), and body mass index at birth, increase in peripheral skinfold thickness during second year of life, and early childhood height velocity explained 43.2% of variation in testosterone levels in adolescence (P = .006).SGA-born girls who experienced catch-up growth remain at risk of biochemical hyperandrogenism in adolescence, and have reduced uterine and ovarian volumes, which might influence future reproductive function. Ovarian size and androgen levels in adolescence might be influenced by early growth and subcutaneous fat deposition.

Study Objective The purpose of this prospective study was to assess the effectiveness of norethisterone (NET) in the management of abnormal uterine bleeding (AUB) in adolescents in a tertiary care center. Design This was a prospective audit focused on administering high doses of NET in female adolescents with complaints of AUB. Setting We included female adolescents who presented to our Emergency Gynecological Department or Adolescent Gynecological Outpatient Department from October 2016 to January 2019. Participants The study included 29 female adolescents aged 11-17 (mean, 13.14) years. Interventions Patients were administered a daily dose of 10-30 mg, depending on the severity of the condition, bleeding duration, and patient weight. Main Outcome Measures Cessation of vaginal bleeding. Results Mean age at menarche of our patient sample was 11.4 years (range, 10.7-14 years). AUB presented at a mean time of 24.6 months after menarche (range, 0-79 months). Blood transfusion was deemed necessary in 9 patients. Bleeding stopped at a mean of 46.1 (range, 8-120) hours after onset of treatment with NET. No serious adverse events were reported with NET administration, with only 3 cases of minor side effects. Conclusion The use of NET is an effective and reliable treatment option among adolescents for whom control of AUB is desired in the acute setting.

Study Objective Risks associated with precocious puberty might be observed in the rapidly progressive form of borderline early puberty (BEP). Differentiating the rate of progression is important for deciding treatment with gonadotropin-releasing hormone analogue (GnRHa). The aim was to examine the treatment characteristics and effect of treatment on predicted adult height (PAH). Design Retrospective observational study. Setting Single-center, a pediatric endocrinology unit. Participants A total of 135 girls, pubertal findings starting between 7-10 years of age. Interventions Data were collected via chart review. Patient groups were defined as treated with GnRHa (n = 63) or untreated (n = 72) girls. Main Outcome Measures Referral characteristics and anthropometric and pubertal findings of the patients with BEP, effect of treatment on PAH, and final height of the groups were compared. Results The mean (±SD) age of the patients at admission and for the first appearence of pubertal findings was 8.8 ± 1.0 and 8.0 ± 0.8 years, respectively. Target height and PAH-target height values at admission were similar. At initiation of treatment, PAH of the treated girls (157.8 ± 7.2 cm) were significantly lower compared with untreated girls (160.7 ± 6.5 cm). The age at menarche of patients in the treated and untreated groups were 12.3 ± 1.0 and 11.3 ± 1.1 years, respectively. The final height of the groups were similar (157.1 ± 6.6 vs 157.0 ± 5.9 cm; P = .922) despite a lower PAH of the treated group. Conclusion GnRHa treatment resulted in an increase in PAH and normalized the age of menarche in patients with BEP. In selected girls with rapidly progressive BEP, GnRHa treatment may be considered.

Irregular menstrual cycles due to anovulation are well described in the first few years after menarche, but the normal developmental trajectory from anovulatory to mature ovulatory cycles during adolescence remains undefined. In this article we review the very limited understanding of this final stage of female reproductive axis development and discuss why additional research in this area is critical to the health of women.

Study Objective To report on the rate of amenorrhea among adolescents and young adults with a bleeding diathesis after insertion of the 52mg levonorgestrel intrauterine system (LNG-IUS). Design Retrospective chart review. Setting Tertiary care, multidisciplinary Gynecology-Hematology Clinic or Adolescent Gynecology clinic. Participants The cohort included 35 females aged 12-25 years presenting from January 2010-January 2020 with heavy menstrual bleeding (HMB); 23 with an inherited blood disorder and 12 with Ehlers-Danlos Syndrome. Interventions 52mg LNG-IUS. Main Outcome Measures Primary outcome was bleeding profile after LNG-IUS insertion. Secondary outcomes included rates of amenorrhea, IUD expulsion, discontinuation, and unplanned pregnancy. Results Mean age at menarche was 11.6 years, with mean age at insertion of 16.9 (range 11-23). Majority of participants were white (n=26,74.3%). Von Willebrand Disease was present in 16 patients (45.7%) and EDS in 12 (34.3%). A majority (91.4%) had tried at least one hormonal regimen prior to LNG-IUS. Most participants (81.8%) reported improvement in bleeding, with 60.6% reporting spotting or amenorrhea. LNG-IUS expulsion occurred in 3 participants (9.1%) within the first 21 days, despite hemostatic agents at time of insertion. Mean continuation was 5.08 years (95% CI 4.24-5.92), with 79% likelihood that participants kept their IUD in place for at least 2.5 years, and some up to 6 years. Conclusion The 52-mg LNG-IUS is an effective treatment option for adolescents and young adults with HMB and a bleeding diathesis, with high rates of amenorrhea. Rates of IUD expulsion appear higher during the first 30 days, but long-term continuation remains high.

To characterize the patient population with cognitive or physical impairments that presents for anticipatory guidance of puberty, evaluate caregiver concerns with respect to puberty, and describe chosen management strategies and outcomes following menarche.Retrospective cohort study SETTING: Academic tertiary care women and children's hospital PARTICIPANTS: Eligible female patients with special needs up to age 26 years presenting for anticipatory guidance from 2009 to 2018 MAIN OUTCOME MEASURES: Primary outcomes included characterization of patients presenting for anticipatory guidance and their reasons for menstrual management. Secondary outcomes were satisfaction with menstrual management and bleeding patterns.A total of 61 patients presented for anticipatory guidance of puberty, on average 13.5 months prior to menarche. Compared to the overall adolescent population with special needs who presented for gynecologic care, patients who had autism spectrum disorder (ASD), were nonverbal, or had attention-deficit/hyperactivity disorder (ADD/ADHD) were more likely to present for a pre-menarchal visit to discuss anticipated pubertal development (P.001, P = .009, and P = .04, respectively). More than half of families described potential behavioral changes as their main concern. The majority of post-menarchal patients (80%) desired hormonal management of menses, including 30% of patients who had placement of a levonorgestrel intrauterine device. In all, 96% of patients were satisfied with their final menstrual bleeding pattern; 50% achieved amenorrhea or light spotting.This study describes the important role of pre-menarchal reproductive counseling for girls with disabilities. Anticipation of puberty causes great anxiety in families and patients, especially those with ASD, ADD/ADHD, and non-verbal status. Providers should consider initiating these conversations early in pubertal development.

Study Objective To establish the gynecological and reproductive outcomes for girls born with a cloacal anomaly, seen in a pediatric specialist cloaca clinic. Design Local approval was granted to conduct this review. Outcomes were retrospectively identified using healthcare records. Participants Girls with known cloacal anomaly, seen in the cloaca clinic between 2009 and 2019, who had attained menarche or received gynecological input. Results Nine females met the inclusion criteria, who were 12-30 years old. The mean age of menarche was 12 years (SD = 1.29). Two developed obstructed menstruation, requiring surgical intervention. Vaginal stenosis affected all women. Three women underwent revision surgery, and 1 is awaiting surgery. None of the women have attempted a pregnancy, to our knowledge. Conclusion Cloacal anomaly is a rare complex condition. Female individuals with cloacal anomaly require multidisciplinary gynecology specialist care throughout adolescence and adulthood. Provision of a dedicated gynecological service could improve the quality of life of these women.

Study Objective Polycystic ovarian syndrome (PCOS) is a common endocrine disorder characterized by hyperandrogenism and chronic anovulation, which affects 5%-10% of reproductive-age women. Diagnosis of adult patients with PCOS is made easily with clinical and laboratory methods and the anti-Mullerian hormone (AMH) level are accepted as a good indicator. However, there is still no complete consensus on the diagnosis of PCOS in adolescents. Design and Setting Prospective cohort study, December 2013 to November 2014. Participants The study was conducted on adolescent girls with oligomenorrhea, with at least 2 years since menarche. The study group consisted of adolescent girls with complete PCOS and incomplete PCOS. A control group was formed of healthy adolescent girls. Complete PCOS was diagnosed according to the Rotterdam criteria, as the presence of all the following characteristics: oligomenorrhea, hyperandrogenism, and polycystic ovarian morphology on ultrasound image. Incomplete PCOS was accepted as “oligomenorrhea and polycystic ovarian morphology,” or “oligomenorrhea and hyperandrogenism.” Interventions and Main Outcome Measures All patients underwent a physical examination and the anthropometric assessments, insulin resistance, and acanthosis nigricans were recorded. It was also noted whether or not the patient had an acne score. The Ferriman-Gallwey score was applied to evaluate hirsutism. Results The results of this study showed that no statistically significant difference was found between the PCOS and incomplete PCOS groups and the control group with respect to AMH levels. Conclusion The use of adult-specific diagnostic methods in adolescence might result in an incomplete diagnosis and inadequate treatment plan. Although the serum AMH level clearly facilitates the diagnosis of PCOS, the use of the AMH level in adolescence in PCOS diagnosis is still controversial and further studies are needed.

Study Objective To determine the cross-sectional characteristics of menstruating girls, dysmenorrhea, and the frequencies of related problems. Design Descriptive, cross-sectional study. Setting Randomly selected primary, junior, and high schools in the city center of Kayseri. Participants Two thousand female adolescents of ages between 9 and 18 years. Main Outcome Measures We used a questionnaire addressing the epidemiological characteristics of menstruation, such as age at menarche, duration of menstrual intervals, average days of bleeding, and any menstrual problems and their frequencies. Results This study consists of a sufficient number of participants from all age groups. Of the participant (n = 2000) girls, 63.7% (n = 1274) had started menstruating. The mean age at menarche was 12.74 (±1.03) years. With a prevalence of 84.8% (n = 1080), dysmenorrhea was the most prevalent menstrual problem and the average pain score was 5.87 (±2.45). Of the menstruating girls, 34% (n = 439) used painkillers, the most commonly used was acetaminophen; during their period the prevalence of nonmedical methods to relieve pain was 35.2%; the rate of seeking medical help for dysmenorrhea was 9.3% (n = 119). In menstruating participants, 90.8% discussed their menstrual problems with their mothers. The rate of school absenteeism in menstruating girls was 15.9% in general and 18% in those with dysmenorrhea. Conclusion Problems related to menstruation are common in adolescents and these problems affect their social life. In adolescent girls, the most common menstrual problem is dysmenorrhea and it affects school performance and attendance. Girls with menstrual problems showed a low rate of seeking medical help.

Study Objective To assess the clinical course of obstructive Mullerian anomalies found in girls after menarche. Design A retrospective case series of adolescents who, between 2009 and 2016, were treated for vaginal or uterine obstructive malformations diagnosed after menarche. Setting Division of Gynecology, Poznan University of Medical Sciences, Poznan, Poland. Participants and Interventions Twenty-two patients who, at the age range between 11.4 and 18.2 (median, 13.1) years, between 2 and 74 (median 7.5) months after menarche, underwent surgical repair of obstructive genital anomaly. Main Outcome Measures Mullerian defect type, presentation, radiologic findings, pre- and postoperative course. Results Eighteen patients (18 of 22; 81.8%) were diagnosed with obstructed hemivagina ipsilateral renal anomaly syndrome. One patient (1 of 22; 4.5%) was diagnosed with uterus didelphys and unilateral cervical atresia. Three patients (3 of 22; 13.6%) had unicornuate uterus with a cavitated, noncommunicating rudimentary horn. The right side was affected in 13 patients (13 of 22; 59.1%), and the left side in 9 patients (9 of 22; 40.9%; P > .05). All but 1 patient had renal agenesis on the side of obstruction. Before repair of the obstructive genital anomaly, 4 patients underwent unnecessary surgeries for misdiagnosed ovarian cysts. Serious complications (pelvic inflammatory disease, vesicovaginal fistula) occurred in 2 patients with microperforated pyocolpos. Pelvic endometriosis was found in 4 of our patients. Conclusion Our case series suggests that obstructed hemivagina ipsilateral renal anomaly syndrome is the most common obstructive Mullerian anomaly diagnosed in adolescents after menarche. The differential diagnosis for unilateral kidney agenesis accompanied by dysmenorrhea in adolescent girls should include obstructive genital tract anomaly. Accurate diagnosis of an obstructive genital anomaly early after menarche might help prevent unnecessary surgeries and infection-related complications. Meanwhile, prompt surgical correction of an obstructive genital tract anomaly results in relief of symptoms and might reduce the risk of endometriosis.

Background Over 95% of girls with Turner syndrome (TS) who lack all or part of the X chromosome will experience premature ovarian insufficiency and will require estrogen replacement therapy to initiate and maintain puberty. However, the optimal protocol that mimics physiologic puberty while preserving growth potential is not yet known. Current recommendations to start with low dose estrogen increased incrementally over two to three years will typically result in thelarche within six months and menarche after an average of two years. Here we present three patients with TS who experienced rapid progression of puberty, with menarche occurring shortly after initiating the lowest dose of transdermal estrogen. Our institutional review board deemed this retrospective case series exempt from the need for IRB approval. Case Three 12-year-old females with mosaic TS (Table 1) presented for pubertal induction. On exam, the patients had tanner stage I breasts and pubic hair. Labs were consistent with ovarian insufficiency with elevated levels of follicle stimulating hormone (FSH) and undetectable levels of estradiol. They were each started on estradiol 14 ucg transdermal patch weekly for pubertal induction and experienced menarche within five months. Breast and pubic hair progressed to tanner stage II and III. Cases 1 and 2 subsequently had regular monthly menses with moderate flow. The dose of their transdermal estradiol patch was decreased by half to 7 ucg weekly. Case 3 developed heavy, irregular bleeding, which caused her to stop using the transdermal estrogen patch. Four months later, she reinstated estrogen use with half of her prior dose at 7 ucg weekly. At one year follow up, all three cases continued with the ultra low dose estradiol 7 ucg transdermal patch weekly without further episodes of vaginal bleeding. On imaging bone age was within normal limits. Comments These cases highlight the importance of starting estrogen replacement therapy at the lowest available dose in girls with Turner syndrome. Given the possible advancement of bone age with pubertal levels of estrogen, rapid progression to menarche could further impair the final growth potential in these patients who are already susceptible to short stature. Thus girls with TS should be monitored closely when initiating estrogen therapy and should be re-evaluated if they experience vaginal bleeding with low dose therapy.

Background Heavy menstrual bleeding (HMB) is a common problem among adolescent girls, exacerbated by Inherited Bleeding Disorders (IBD) and Joint Hypermobility (JH), including Ehlers-Danlos Syndrome (EDS). Studies have examined use of the levonorgestrel intrauterine system (LNG-IUS) in adult women with IBDs, showing reduction in menstrual blood loss and high continuation rates, but questions remain regarding rates of IUS expulsion and need for hemostatic agents with insertion. A few studies have addressed teens with IBDs or JH and LNG-IUS, reinforcing positive outcomes. However, study sizes were small, limiting conclusions regarding bleeding profiles, IUS expulsion, and long-term continuation. The objective of this study was to report on our patients with HMB and a bleeding diathesis using the LNG-IUS, including post-IUS bleeding profiles, rates of IUS expulsion and long-term continuation. Methods After IRB approval, we conducted a retrospective review of females, ages 12-25, who presented to our multidisciplinary bleeding clinic with HMB. Charts were selected using ICD-10 codes for HMB and diagnosis of an IBD or JH Disorder, treated with the LNG-IUS. Data was extracted from the chart by a single provider, including demographics, bleeding diagnosis, bleeding profiles before and after insertion, medications prescribed, continuation rate, and complications. Primary outcome was bleeding pattern after insertion. Secondary outcomes included rates of IUD expulsion and continuation. Descriptive statistics were reported as means, ranges and frequencies. LNG-IUS continuation rates were recorded and used to construct a survival graph. Results 35 patients met inclusion criteria. Mean age at menarche was 11.6. Mean age at insertion was 16.9 (range 11-23); majority were Caucasian (73.3%). Von Willebrand Disease was present in 16 patients (45.7%) and JH Disorders in 12 (34.3%, Table 1). Majority (91.4%) had tried at least one hormonal regimen prior to LNG-IUS. Follow up bleeding data was available on 33 patients (Table 1); one patient was excluded for same-day removal and one for removal at 2 weeks for cramping. Majority (81.8%) reported improvement in bleeding, with 60.6% reporting spotting or amenorrhea. IUS expulsion occurred in 3 patients (9.1%) despite hemostatic agents administered at insertion. Mean continuation was 5.08 years (95% CI 4.24-5.92), with 79% likelihood that patients kept their IUD in place for at least 2.5 years, and some up to 6 years (Figure 1). Conclusions The LNG-IUS is an effective treatment for adolescents and young adults with HMB and a bleeding diathesis, with high rates of amenorrhea. Rates of IUD expulsion appear higher than the general population during first 30 days, but long-term continuation rates remain high.

Background Access to reproductive healthcare for adolescent girls with medical conditions requiring use of mycophenolate mofetil or sodium (MMF), a teratogenic immunosuppressant, is important to prevent unintended pregnancy and birth defects in offspring. Highly effective long acting reversible contraception (LARC), intrauterine devices (IUDs) and contraceptive implants, is recommended for this population. The aim of this study is to describe the girls prescribed MMF at a children's hospital and the reproductive healthcare they received. Methods We searched electronic health records (EHR) to identify females aged 10 through 20 years prescribed MMF at our children's hospital from January 2010 through December 2019. Of the 225 patients identified, we excluded 64 who initiated MMF before January 2010. We reviewed the EHRs of 161 subjects starting with the first visit, either inpatient or outpatient, when the MMF was prescribed and prospectively reviewed all subspecialty, and reproductive health visit notes thereafter. We entered the date and type of each health visit as well as EHR documentation of menarche, coitarche, sexual activity, pregnancies, and contraceptive use into an online database, REDCap. Results Of the 161 subjects: 50% had systemic lupus erythematosus (SLE), 25% solid organ or bone marrow transplant, 25% other disease; 39% were Hispanic, 32% Black. At MMF initiation, mean age was 15.2 ± 3.9 years; 89% were post-menarchal; 19% had coitarche. We recorded subjects’ EHR data for a mean of 5 ± 3 years after MMF initiation. 42% ever had sex, with mean time to EHR documentation of sexual activity of -0.7 ± 2.4 years since MMF initiation. Of the 68 subjects who ever had sex, a higher proportion had SLE v. transplant v. other disease, [66% v. 19% v. 15%, p Conclusions We found that adolescent girls prescribed the teratogenic immunosuppressant mycophenolate need reproductive health care; a majority were post-menarchal and more than 40% were sexually active, especially those with SLE. We also found a high uptake of LARC methods of contraception in those who attended a reproductive health visit suggesting that increasing access to contraceptive services for these high-risk adolescent girls may reduce their risk of adverse pregnancy outcomes.

Background Polycystic Ovarian Syndrome (PCOS) and Pilonidal Disease (PD) have been associated with a number of dermatologic conditions such as hirsutism, acne, seborrheic dermatitis, androgenetic alopecia, psoriasis and hidradenitis suppurativa. These conditions share similar risk factors including obesity, elevated androgens and metabolic syndrome. There is scant evidence about association between PCOS and PD. Prevalence of PD in adolescents is 0.7% and of PCOS is 8 to 13%. Pilonidal disease and PCOS are associated with significant morbidity and decreased quality of life, thus early diagnosis and treatment are important. We sought to determine whether pilonidal disease is associated with PCOS and whether severity of PD is greater in patients with concurrent PCOS and whether treatment of PCOS reduces pilonidal disease severity. Methods This was a retrospective chart review approved by the Institutional Review Board. Inclusion criteria was all girls aged 12 to 21 receiving a diagnosis of PCOS or PD from 2012-2019 at a tertiary medical center. Variables analyzed included age, race/ethnicity, BMI, menarche, tobacco use, payer status, treatment of PCOS and PD, serum markers of hyperandrogenism and metabolic syndrome. Data was analyzed with Student's t-test, chi-squared test, and multiple logistic regression Results In total, 100, 043 patients presented to an urban tertiary medical center with 769 patients diagnosed with PD of which 209 patients were diagnosed with both PD and PCOS. Patients with both diagnoses were more likely to have a higher BMI (31.4 v. 27.4, p Conclusions There is a higher prevalence of PCOS among adolescent girls diagnosed with PD. PCOS treatment appears to confer a protective effect in reducing risk of intervention for PD. Increased awareness of the association between PCOS and PD among providers taking care of female adolescents with PD should result in lower threshold for screening for PCOS and/or referral to adolescent gynecology for further evaluation. If future studies involving diverse population show replicability of these findings, formalized practice guidelines aimed at screening for PCOS in girls presenting with PD should be developed. This approach may improve early detection and ultimately treatment of PCOS.

Background Long term follow up of straddle injuries (SI) in prepubertal females is not well documented in current literature. It is unclear how these patients should be counseled about how prepubertal SI could affect pubertal development of genital structures. We present a case of post pubertal asymmetric right labial hypertrophy in a patient with prepubertal SI. Case Our patient initially presented at 8 years old (YO) to our emergency department (ED) after sustaining a SI from falling on a playground beam. Evaluation in the ED showed a hemostatic shallow right labial laceration at 9 o'clock. Repair was not indicated and she was discharged home. Follow up in the office 2 weeks later showed the area had healed well, no anatomic abnormalities noted. At 13 YO, she presented to the office for evaluation of abnormal right labia minora (LM), discovered after getting a hair tourniquet on the area. At her visit, she reported normal pubertal development and menarche at 12 YO. In addition to the hair tourniquet, she reported the area of abnormal tissue was causing discomfort, frequently catching on underwear and clothes. On physical exam, she was noted to have Tanner stage IV pubic hair. The bilateral labia majora were normal and symmetric. The left LM was normal in shape and appearance, and approximately 1 cm in length. The right LM was abnormal, having a pedunculated length of tissue measuring 6 cm in length and 1 cm in width, with the base of the LM extending from the clitoral hood to approximately 9 o'clock, below which there was no identifiable LM tissue. There was no visible scar in the area of her prior SI, however that was the location where the right LM tissue ended. The patient and her parents elected for surgical correction of the abnormal area. She underwent right labiaplasty, and the excess pedunculated right LM tissue was removed without complications. On post operative follow up, the area was well healed. Comments Most studies on prepubertal SI only include short term follow up, typically until healing of the injury has occurred. There is a paucity of data regarding long term outcomes. Though most SI are minor and will likely have no long term effect, our case demonstrates how even a seemingly minor prepubertal SI with no visible scarring in the area can lead to abnormal development of the genitalia with puberty.

Background There are many reasons for choosing the etonogestrel subdermal implant (hereafter “implant”). Limited data exists on outcomes of implant use in adolescents, and specifically, on the management of abnormal uterine bleeding (AUB). The goals of this study include characterize the purpose of implant placement in adolescents, describe rates and management of side effects, and identify reasons for early discontinuation of the implant. Methods This is a retrospective cohort study of females less than 18 years who had the implant placed from 2013-2018, identified using Current Procedural Terminology codes. Data were collected on contraceptive history, bleeding profiles, side effects, and outcomes. Descriptive statistics, analysis of variance tests, Fisher's exact test, and chi-square test data are reported. This study was IRB approved. Results A total of 272 patients were included in this study. The average age of menarche was 12 years and average age at insertion was 16 years. The majority of patients (90%) were nulliparous, 65% had been sexually active prior to implant placement, and 84% desired the implant for contraception. Of 241 patients who had at least one follow up visit, 187 reported AUB. On average, adolescents reported AUB starting 2.7 months after placement, which they managed expectantly for 10.3 months prior to desiring removal or trial of medication to resolve AUB. Of the 187 patients who reported AUB, 59% had no documented discussion of options for management and 24% had only one option offered. Trials of different medications for the treatment of AUB had varying effects on bleeding patterns (Table 1). Average time of removal for those with AUB was 22.1 months after implant placement, similar to 21.5 months for those without AUB. Most patients (76%) had the implant in place for at least 12 months. Adolescents with frequent or prolonged bleeding were more likely to have the implant removed prior to 12 months than those with other bleeding patterns (p=0.001). Patients complaining of weight gain and mood issues were also more likely to have early removal (p Conclusions Adolescents mostly chose the implant for contraceptive efficacy and, although AUB was common, three-quarters chose to continue for at least 12 months. Prolonged or heavy bleeding, mood issues, and perceived weight gain were associated with earlier removal. Several options exist to treat implant-related AUB, and improved use of these medications may make bleeding patterns more tolerable. Additional studies are needed to optimize treatment of AUB and address other bothersome side effects.

Background Vulvar lichen sclerosus is a benign dermatologic condition marked by inflammation and epithelial thinning. It is thought to mostly occur in low estrogen states, though a few studies have shown that symptoms may persist following puberty. The purpose of this study is to characterize a cohort of pediatric and adolescent females with lichen sclerosus and compare age of symptom onset, documented symptoms and duration, and exam findings. Methods This is an IRB exempt retrospective cohort study of females aged 0-21 years seen between 2000 and 2020 with the diagnosis of lichen sclerosus by ICD-9 or 10 code. Study variables included age at symptom onset, age at diagnosis, presenting symptoms, exam findings, and presence of symptoms before and after menarche. Groups were compared using the chi square test of independence and Fisher's exact test. Data were analyzed using SPSS Version 27. Results One hundred patients met inclusion criteria. Forty patients noted presence of symptoms following menarche; 26 (65%) reported first symptom onset after age 13, while 14 (35%) had symptoms that started in childhood and persisted after menarche. Eleven patients with childhood onset of symptoms had no documented report of symptoms following menarche. Of the remaining 49 patients, 25 are still under age 13 and 24 were lost to follow-up. After excluding the 7 patients with reported childhood onset of symptoms that were not seen until adolescence, the patients with onset of symptoms at age 13 or older (n=26) were less likely to present with vaginal bleeding (3.8% vs 25.4%, p=0.02), dysuria (15.4% vs 32.8%, p=0.09), and constipation or painful defecation (0% vs 14.9%, p=0.05) than the younger cohort (n=67). Vulvar itching (61.5% vs 71.6%) and pain (38.5% vs 44.8%) were similar in both groups. Seven patients (26.9%), ranging in age from 17-21 years, presented with dyspareunia. On initial physical exam, the patients with symptom onset at age 13 or older were more likely to have clitoral adhesions (19.2% vs 3%, p=0.02), loss of labia minora (38.5% vs 3.0%, p Conclusions This study suggests that lichen sclerosus can present or persist after menarche in at least 40% of patients. It can cause architectural vulvar changes that interfere with sexual function, which may be the presenting complaint. It is important for providers to consider lichen sclerosus as a new diagnosis in both pre and postmenarchal patients as well as monitor for progression of disease throughout the pubertal transition and adolescence.

Study Objective Paratubal cysts (PTCs) occur in 7%-10% of women, regardless of age. Although common, PTCs often are found incidentally because of the potential for these cysts to be asymptomatic. The specific aims of the study were to determine if PTC number and size correlated with signs of hyperandrogenism and obesity, as well as to investigate the molecular profiles of these PTCs in samples derived from female adolescents. Design, Setting, Participants, Interventions, and Main Outcome Measures A prospective cohort study was performed in a single children's hospital. Girls 18 years of age or younger who underwent surgery for PTC suspected on the basis of the presence of a persistent adnexal cyst on imaging or a concern for adnexal torsion involving a cyst were consented to participate in the study. Results Nineteen patients met enrollment criteria with a mean age at menarche of 11.2 ± 1.3 years. Most of the patients (84%; n = 16/19) had adnexal torsion at the time of diagnosis of PTC. Irregular menses and hirsutism was found in 52.6% (n = 10/19) of the patients, among whom 36.8% (n = 7/19) were obese. The mean PTC size was 10.4 ± 4.3 cm with 57.9% (n = 11/19) of the cohort having more than 1 PTC. When patients were compared on the basis of their body mass index, the size of PTCs was significantly larger in the overweight/obese group. The wingless-type (WNT) signaling members catenin beta 1 (CTNBB1) and wingless-type MMTV integration site family, member 7A (WNT7A) were upregulated in 86% (n = 12/14) and 79% (n = 11/14) of the patients, respectively. WNT7A was significantly upregulated in girls with 1 cyst and low body mass index. Conclusion A correlation exists between obesity, cyst size, and hyperandrogenism. Activation of the WNT/CTNBB1 pathway via WNT7A might play a role in PTC development.

Turner syndrome (TS) is one of the most common sex chromosome disorders and is characterized by short stature and gonadal dysgenesis. A few patients with TS achieve normal sexual development, menarche, and even pregnancy. We encountered two cases of Turner syndrome with spontaneous sexual development and menstruation. The patients had different karyotypes, 45,X monosomy and 45,X/47,XXX mosaic TS, and presented with severe anemia due to excessive menstrual bleeding. Abnormal uterine bleeding patterns are expected in patients with primary ovarian insufficiency; however, the menstrual patterns of patients with TS have not been well described in the literature. Here, we describe these cases along with a brief review of the relevant literature.

Study Objective Puberty is a normal process for adolescents, and the first signs may include change in body odor, breast development, or pubic hair growth. This is then followed by menarche approximately 2 years later. Vaginal bleeding in pre-pubertal female individuals is rare. The aim of this study was to investigate causes of pre-pubertal bleeding in a group of patients. Design, Setting, Method, and Main Outcome Measures Seventeen patients who presented with pre-pubertal recurrent vaginal bleeding with no other signs of precocious puberty were investigated, to determine the cause of this symptom. Results The mean age for the onset of vaginal bleeding was 7.4 years, ranging from 4 to 9.67 years. Gonadotrophin-releasing hormone (GnRH) stimulation tests showed a pre-pubertal response in all cases. Pelvic ultrasound scans showed a pre-pubertal uterus in all patients. Two patients were found to have foreign bodies identified during a genital examination under anesthetic, and in both cases removal of the foreign bodies terminated the vaginal bleeding. Conclusion In conclusion, recurrent vaginal bleeding was not associated with GnRH response, raised estradiol levels, or abnormal pelvic ultrasound findings. In cases of recurrent vaginal bleeding with normal hormonal investigations in pre-pubertal girls, it is recommended that a genital examination under anesthetic be undertaken to rule out undiagnosed causes of the presenting symptom.

This study aimed to investigate the association between age at menarche (AAM) and adverse health indicators in adolescent girls.A retrospective cohort study.Population-based survey data.A total of 319,437 female participants aged 12-18 years from the Korea Youth Risk Behaviour Web-based Survey.We assessed associations between AAM (categorized as ≤10, 11, and ≥12) and health indicators (poor self-rated health, high psychological stress, unhappiness, sexual initiation, and pregnancy). Covariates were individual-level (bodyweight, living with family, parent's education, household wealth, and presence of parents and siblings) and community-level factors (year of birth, single-sex education and level of school, urbanization level of school area, year of survey, and regional deprivation). Odds ratios (ORs) for each adverse health indicator were examined by each AAM group using multivariable regression analyses. For pregnancy, we calculated relative risks (RRs) using a log-binomial regression model.Age at menarche was12 in 42% of our study population. Nearly one-half of the girls born in the early 2000s went through menarche before the age of 12 years, whereas only one-third of girls born in the early 1990s went through menarche before the age of 12 years. Girls who experienced menarche at age ≤10 or age 11 years were more likely to show self-rated poor health (AAM ≤ 10: OR, 1.28; 95% confidence intervals [CI], 1.22-1.34; AAM = 11: OR, 1.16; 95% CI, 1.12-1.21), high stress (OR, 1.19; 95% CI, 1.14-1.23, and OR, 1.10; 95% CI, 1.06-1.14), and sexual initiation (OR, 2.21; 95% CI, 2.05-2.38, and OR, 1.32; 95% CI, 1.23-1.41) compared to those with AAM ≥12 years when data were adjusted for all covariates. AAM ≤10 years was associated with consistently higher odds for poor health than AAM ≥12 years. The ORs of sexual initiation increased with earlier AAM. Risk of pregnancy was similar across AAM groups when individual- and community-level covariates were controlled for.Early menarche, defined as12 years, can be still a useful indicator in adolescent health interventions to identify high-risk groups in the setting of declining AAM.

Study Objective To examine prevalence and risk factors associated with primary dysmenorrhea among Chinese female university students in Hunan province, China. Design A cross-sectional study. Setting Female university students in Changsha city, Hunan province, China. Participants Four thousand six hundred six female individuals selected using a multistage cluster random sampling method. Interventions A self-administered questionnaire, which included sociodemographic information, lifestyle habits, emotional characteristics, and menstruation pattern, was used to collect data. Main Outcome Measures Information about menarche, body mass index, cycle length and regularity, primary dysmenorrhea, physical exercise, depression, and anxiety. Results The prevalence of primary dysmenorrhea was 41.7% (1921/4606) among Chinese female university students. Multivariate binary logistic regression indicated that being a minority (odds ratio [OR], 1.335; 95% confidence interval [CI], 1.083-1.646), underweight (OR, 1.249; 95% CI, 1.08-1.42), annual household income less than 80,000 CNY (OR, 1.169; 95% CI, 1.018-1.342), maternal history of dysmenorrhea (OR, 2.553; 95% CI, 2.236-2.915), age at menarche younger than 12 years (OR, 1.161; 95% CI, 1.013-1.329), irregular menstrual cycle (OR, 1.216; 95% CI, 1.063-1.391), and skipping breakfast (OR, 1.294; 95% CI, 1.124-1.490) were associated risk factors of primary dysmenorrhea. Conclusion The prevalence of primary dysmenorrhea among Chinese university students is relatively high. Various risk factors were identified that associated with primary dysmenorrhea. More effort and attention should therefore be directed toward this health problem in China.

To investigate the relationships between premenstrual syndrome (PMS) and lifestyle, sleep, and dietary habits among Japanese high school students.Cross-sectional study.Two public high schools in Sendai, the largest city in northeastern Japan.A school-based survey was conducted among 1818 female Japanese high school students in 2015, and 1022 students with regular menstrual cycles (25-38 days) completed the questionnaire.Relationships between PMS and lifestyle, sleep, and dietary habits.The rates of moderate to severe PMS and premenstrual dysphoric disorder were 9.7% (99/1022) and 2.2% (22/1022), respectively. A total of 121 students (11.9%) were classified as having PMS-the PMS(+) group. Significant differences were observed between the PMS(+) group and those without PMS-the PMS(-) group-in age at menarche (P = .022), menstrual pain (P .001), hypnagogic disorder (P .001), long Internet use time (P .001), eating breakfast (P = .018), chewing well (P = .037), and belonging to a sports club (P = .046). Multivariate analysis revealed that the risk factors for PMS were menstrual pain (odds ratio [OR], 4.74; 95% confidence interval [CI]: 2.83-7.95), hypnagogic disorder (OR, 2.22; 95% CI, 1.47-3.35), stress fracture (OR, 2.19; 95% CI, 1.21-3.98), and Internet use time (OR, 1.003; 95% CI, 1.001-1.005). Belonging to a sports club decreased the risk of PMS (OR, 0.57; 95% CI, 0.35-0.91).Sleep, dietary habits, belonging to a sports club, and screen time affect PMS among high school students.

Study Objective Girls with Turner syndrome with Y-chromosome material (TS + Y) are assumed to have nonfunctional gonads with increased tumor risk, therefore prophylactic gonadectomy is recommended at diagnosis. In this study we aimed to determine rates of spontaneous thelarche (ST) and spontaneous menarche (SM), and prevalence of gonadal tumor and malignancy in girls with TS + Y, to further inform discussions about gonadectomy. Design Retrospective review of clinical and pathology data. Setting Multicenter study involving 4 United States children's hospitals. Participants Patients included those with a genetically proven diagnosis of TS + Y and phenotypically female genitourinary exam. Interventions Demographic characteristics, pubertal development, and gonadal pathology data were abstracted from clinical records. Data for ST were analyzed for patients aged 13 years and older and SM for patients older than 15 years. Main Outcome Measures ST, SM, prevalence of gonadal tumor, and malignancy. Results Forty-four patients met inclusion criteria. Nineteen patients were 13 years or older; 8/19 (42%) had ST and reached Tanner stages 2-4 and 2 (11%) had normal ovarian pathology. Nineteen patients were 15 years or older; 2/19 (11%) had SM. Thirty-seven patients underwent gonadectomy; 35 had available pathology results. Gonadoblastoma was identified in 35/7 patients (19%), 1 in situ germ cell neoplasia, and 1 dysgerminoma (3%). One patient with bilateral gonadoblastoma had ST and SM. Conclusion In this multicenter cohort, 42% of girls with TS + Y entered puberty spontaneously and 11% had SM, supportive of gonadal function. Risk of tumor was similar to previous reports. To achieve informed decision-making, discussions about gonadectomy should incorporate potential for gonadal function and tumor risk.

Study Objective To assess pubertal events in a Hispanic female population and to create normograms of puberty. Design Longitudinal. Setting University facility. Participants Five hundred forty-nine girls from the Growth and Obesity Chilean Cohort study. Interventions Follow-up twice a year beginning at age 6 years. Main Outcome Measures Breast development, pubic hair development, and age. Breast development (B2, B3, and B4) and pubarche (P2) were determined. Age at menarche was obtained from the adolescents and their mothers. Age and growth velocity at peak height velocity were calculated. Results In girls, B2, B3, and B4 occur at median ages of 9.2, 10.2, and 10.9 years, respectively. The median age at P2 was 9.7 years. The mean age at peak height velocity and the growth velocity were 10.6 years (SD = 1.1) and 8 cm/y, respectively. The mean age at menarche was 11.9 years (SD = 1.1); only 2.8% (15 /530) of girls experienced menarche after 14 years and 1.9% before 10 years. The mean interval time between B2 and menarche was 2.5 ± 1.0 years. Transient thelarche occurred in 8.6% of girls. Conclusion This longitudinal cohort shows that thelarche occurred 1.2 months later than previously reported in cross-sectional studies. Conversely, we found that pubic hair appeared 12 months earlier and menarche occurred 9 months earlier than previously reported. These findings are important in setting normalcy data and avoiding unnecessary clinical consultations.

Background and Objective Adolescent girls perceive menstruation as a negative experience, which can affect adolescents’ physical and mental health. The aims of this study were to describe the menstrual knowledge, attitudes, and behaviors of adolescent girls in China and to examine their association with psychological stress. Design, Setting, Participants, Interventions, and Main Outcome Measures A cross-sectional study was conducted among 1349 adolescent girls aged 11-14 years in Changsha, China. Participants anonymously completed questionnaires that assessed sociodemographic characteristics, menstrual knowledge and attitudes, dysmenorrhea self-care behaviors, and perceived stress. One-way analysis of variance and Pearson r correlation and multiple linear regression analyses were conducted to examine the differences and associations among variables. Results The mean age of menarche was 11.70 (±0.82) years. A total of 1053/1349 (78.1%) of girls had a knowledge of menstruation before menarche and their mothers were the main source 931/1349 (69.0%) of their knowledge. More than half (53.4%) of adolescent girls experienced different degrees of dysmenorrhea. The mother's education, family monthly income, family type, and the girls' age, grade, menstrual status, age at menarche, sanitary napkin change frequency, menstrual restrictions, and dysmenorrhea influenced menstrual knowledge, attitudes, and practice. Psychological stress was affected by age, grade, age at menarche, sanitary napkin change frequency, menstrual restrictions, dysmenorrhea, and menstrual knowledge, attitudes, and practices. Conclusion Psychological stress management during menstruation should be a focus of health education programs for adolescent girls. During adolescence, health care providers should not only pay attention to the physical changes of adolescence girls, but also provide stress management skills to help them cope with menstrual-related concerns.

Study Objective Menarche is a significant physical and emotional experience for adolescent girls, especially in certain cultures, where it is viewed as a rite of passage, affecting the meaning of lived experiences. The purpose of the study was to explore the menarche experience among Jordanian adolescent girls when they reach menarche. Design Interpretive phenomenological analysis. Setting Az-Zarqa City, Jordan. Participants, Interventions, and Main Outcome Measures A homogenous sample of 7 Jordanian girls, ages 12-14 years, who had their first menstruation within the past 6 months. Participants were asked to narrate their experiences through journal writing; their reports to be used for interpretive phenomenological analyses by 2 independent researchers, to ensure the findings' trustworthiness. Results Three major themes emerged as: (1) menstruation as a forbidden topic; (2) keeping the “topic” to oneself; and (3) no more secrets. Each theme was characterized according to distinct sets of emotions and knowledge-seeking patterns because Jordanian culture and Islamic teachings had greatly influenced the girls' experience of menarche. Menarche was considered a social taboo; not to be openly discussed. At the first signs of menarche, participants were shocked, scared, confused, and anxious. They had limited information and support from their family or school system. Therefore, they relied on self-perceptions about menarche, and viewed the experience of menstruation with profound negative emotions. Participants hesitated to share their experiences with their mothers and close friends. They felt alone and experienced their emotional turmoil in isolation and without support. Conclusion Jordanian adolescent girls need formal health education to understand and manage the reproductive changes that occur in their bodies.

Study Objective The aim of this study was to review the efficacy of different medical modalities for menstrual suppression in the cohort of patients with disabilities who presented to the Queensland Paediatric and Adolescent Gynaecology (PAG) Service between January 2005 and December 2015. Menstrual suppression in adolescents with disabilities is an important aspect of care to support the patient and their carers in managing the complexities of menstrual hygiene, pain, and other discomfort associated with menses. It is important for general practitioners, pediatricians, and gynecologists to establish the right modality of suppression for each individual adolescent. Design, Settings, Participants, Interventions, and Main Outcome Measures The study was a retrospective case notes review of 68 adolescents who presented to the Queensland PAG Service, Brisbane, Australia with a request for menstrual suppression. The medical interventions included treatment with either combined oral hormonal contraceptive, oral medroxyprogesterone, depot medroxyprogesterone, or the levonorgestrel intrauterine system (Mirena, Bayer). The primary outcome measure was success of menstrual suppression from commencement of medical intervention to achievement of complete amenorrhea or very light bleeding described as spotting, for each medical modality. Secondary outcomes were length of time from first treatment to first observed menstrual suppression, and the number of outpatient appointments taken to achieve menstrual suppression. Results Of the 68 adolescents, 59/68 (86.8%) successfully achieved menstrual suppression, with 9/68 (13.2%) having ongoing treatment or loss to follow-up at the time of conclusion of the study; 39/68 (57.4%) were menstrually suppressed with their chosen medical modality after their initial appointment. Conclusion Medical modalities are highly effective in achieving menstrual suppression and no young women at this institution required a hysterectomy. Depot medroxyprogesterone was the most successful modality used to achieve menstrual suppression followed by the levonorgestrel intrauterine system. The combined oral hormonal contraceptive was the least successful medical treatment in achieving menstrual suppression.

Study Objective In this study, we aimed to determine the frequency of menstrual history and sexual history documentation in the inpatient setting. Design, Setting, and Participants A retrospective chart review was conducted for 307 female patients ages 11-18 years admitted from the emergency department at a single institution within a 7-month period. These charts were reviewed for documentation of menstrual and sexual history. Interventions and Main Outcome Measures Rates of menstrual and sexual history documentation were compared according to patient age, chief complaint, admitting specialty, and medical complexity. Results Sexual history documentation was noted in 158 (45.9%) of the 344 reviewed charts. Sexual history documentation rates were higher for patients with mental health symptoms (62.9%; 61 of 98 charts; P = .02) and lower for patients admitted to surgical services (30.6%; 19 of 62 charts; P = .04). At least 1 aspect of menses was documented in 113 (32.8%) of the 344 reviewed charts. Last menstrual period was the most commonly documented aspect of menstrual history, appearing in 100 (29.1%) of the 344 reviewed charts. Menarche (4.4%; 15/344), menses frequency (7.0%; 24/344), menses duration (2.6%; 9/344), flow quantity (4.9%; 17/344), and dysmenorrhea (4.4%; 15/344) were rarely documented, regardless of chief complaint or admitting service. Menstrual history documentation rates were significantly higher for patients requiring a gynecology consultation (73.3%; 11 of 15 charts; P Conclusion Menstrual and sexual history documentation rates for adolescent patients requiring inpatient admission were low, with fewer than half of patients having a documented menstrual or sexual history.

Study Objective To compare ovarian function between adolescents conceived using assisted reproductive technology (AcART) and adolescents who were conceived spontaneously (AcSP). Design Multicenter study of ovarian function in AcART because of male or tubal infertility. Setting University Hospital. Participants We evaluated 22 AcART and 53 AcSP at 1-2 years after menarche. The participants were born at term (≥37 weeks of gestation) with normal birth weights (≥2500 g) from singleton pregnancies. Interventions None. Main Outcome Measures Differences in ovulation, reproductive hormones, and ovarian morphology. Results AcART had an older age of menarche than that of AcSP, even after adjusting for maternal age at menarche, gestational age, and birth weight (P = .027). AcART had lower incidence of ovulation (P = .021) and higher luteinizing hormone serum levels (P = .01) than those of AcSP. The incidence of oligomenorrhea and the cycle length were similar between AcART and AcSP. AcART had levels of anti-Mullerian hormone, inhibin B, follicle-stimulating hormone, estradiol, and androgens similar to those of AcSP. The ovarian morphology, ovarian volume, and follicle counts were similar in both groups. Conclusion AcART had later menarche, lower ovulation rates, and higher luteinizing hormone levels than those of AcSP. Future studies should investigate whether these findings are indicative of a risk of ovarian dysfunction later in life for AcART.