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A laparoscopic approach was used in four infants with antenatally diagnosed ovarian cysts requiring surgical intervention. Operating time ranged from 60 to 90 minutes, there were no intraoperative or postoperative complications, and all infants were discharged within 23 hours after surgery. If performed by experienced practitioners, microendoscopy is an alternative to laparotomy in neonates requiring surgical intervention for ovarian cysts.

Background: Pelvic pain is a common complaint encountered in pediatric and adolescent gynecology. Etiologies are similar to those found in adult women, but the incidence and presentations vary with age. The purpose of this study is to review musculoskeletal (MS) pelvic pain in a pediatric and adolescent gynecology setting. Methods: A retrospective review of charts of 63 patients presenting to a private practice pediatric and adolescent gynecologist between 7/1/97 and 6/30/99 was performed. To be included in analysis, patients had a diagnosis of pelvic pain which could not be explained by standard gynecologic history, physical exam, laboratory, and ultrasound evaluation or did not respond to standard treatments for known endometriosis. A history of laparoscopy was not required, but when it was performed it could be used to exclude patients from analysis if a reason for the pain was identified. All patients who fulfilled these criteria had been screened for MS etiologies of pelvic pain using the leg lift (Carnett test) and/or head lift. Results: Sixty-three patients aged 9-23 (mean 15.21, SD 2.71) fulfilled the criteria for evaluation. Diagnoses included irritable bowel syndrome (N = 4, 6.35%), interstitial cystitis (N = 1, 1.56%), unexplained (N = 7, 11.11%), endometriosis not responding to ablation & GnRH agonists (N = 2, 3.17%), endometriosis not responding to ablation & GnRH agonists & MS pain (N = 7, 11.11%), and MS pain (N = 42, 66.67%). Mean age of those with MS pain was 15. 27 (SD 2.94), and mean duration of symptoms prior to diagnosis was 17.97 mo (SD 20.90, range 1 week-7 yr). On physical exam, trigger points were identified as causative factors in 5 (10.20%), and 40 (81.63%) had a + Carnett test. Of those with a final diagnosis of MS pain, only 5/31 (16.31%) responded to nonsteroidal anti-inflammatory agents, 6/30 (20.0%) responded to OCPs, and 3/11 (27.27%) responded to DMPA-2/3 also had a diagnosis of endometriosis. Nineteen (38.78%) had been surgically explored for the pain in the past, 1 by laparotomy & 18 by laparoscopy. Only 3 (15.79%) had symptomatic improvement after surgery. Physical therapy resulted in resolution of symptoms in 20/21 (95.24%) who completed treatment. Four of 5 (80%) who underwent trigger point injections responded.Conclusions: MS etiologies of pelvic pain are common in the adolescent age group and respond well to physical therapy. Physical therapy might be employed as an early intervention prior to surgery in adolescent girls with unexplained pelvic pain.

Breast disorders in the pediatric and adolescent population cover a wide range of complaints, and although very few are life- threatening, they may be a source of considerable distress to the girl concerned. These patients may present to family practice physicians, surgeons, pediatricians, and gynecologists, all of whom may play a role in the diagnosis and management of the underlying complaint. All practitioners involved in the care of patients in this population must have an understanding of the common breast disorders, including their presentation and options for management. With the ever-expanding field of molecular biology and genetic diagnosis, it is likely that the daughters of women who have had breast cancer, or who are genetic carriers of the disease, are seeking medical advice regarding appropriate medical options. This article addresses the management of breast disorders with these concerns in mind.

Nancy Sokkary MD , Roshi Mansouri MD, Jennie Yoost MD , Mariel Focseneanu MD, Tania Dumont MD , Meera Nathwani BHSc , Lisa Allen MD, FRCSC , S. Paige Hertweck MD , Jennifer E Dietrich MD, MSc 1,2 1 Baylor College of Medicine, Houston, TX 2 Texas Children's Hospital, Houston, TX 3 University of Louisville, Louisville, KY 4 Washington University School of Medicine, St. Louis, MO 5 The Hospital for Sick Children, Toronto, Ontario

We wish to report the results of a chart review of adolescents using depomedroxyprogesterone (DMPA) for contraception. The specific aims of this study were to examine weight-gain patterns and time to amenorrhea between two groups of adolescent girls receiving differing dosing regimes of DMPA. (excerpt)

Background: Von Willebrand’s Disease (VWD) is the most common inherited bleeding disorder affecting women and produces significant menorrhagia as its main symptom. Though combined oral contraceptive pills (OCP’s) are the most common treatment modality for menorrhagia, randomized controlled studies to assess their efficacy are lacking. Data on response rates to different doses and combinations of estrogens and progestins in OCP’s, and data on response rates to combined therapy of OCP’s with desmopressin acetate (DDAVP) and/or aminocaproic acid (Amicar) are sparse. Methods: The patient population consisted of 80 patients aged 9–19 years, who were primary referrals to a combined Hematology/Gynecology clinic for evaluation of menorrhagia. A retrospective chart review was done on these patients following an IRB approval. Collected data included age of menarche, onset of menorrhagia, follow up duration, severity of menorrhagia including PBAC score, co-morbidities, family history of bleeding or clotting disorders, blood group, factor VIII coagulant activity, ristocetin cofactor activity, and VW Ag level. VWD was defined as ristocetin cofactor activity

potential. Surgical management: Decision to perform feminizing vs. masculinizing surgery is influenced by the degree of masculinization of the external genitalia and the projected effectiveness of sex assignment including functionality and potential for future fertility. In XY gonadal dysgenesis, surgery should be considered in cases of severe virilization and be performed in conjunction, when appropriate, with repair of the common urogenital sinus. A second surgery to create a functional vagina should be performed after puberty when the patient is motivated to self-dilate and/or is sexually active. FSH and hCG stimulation tests suggestive of ovotestes avoid gonadal biopsy; dysgenetic gonads can be removed after puberty when the risk of malignant transformation is relevant. Hormone replacement therapy: HRT should mimic endogenous hormone production in normal adolescent females. Initiate therapy around age 12 to achieve breast development, support maturation of secondary sex characteristics, and attain optimal bone density. Start with a low dose estrogen; double dose at 3 to 6 months and again 3 months later. After 2 years of unopposed estrogen therapy, add progesterone to achieve optimal breast development irrespective of the presence or absence of a uterus. Treatment should continue until the expected age of menopause. Androgen therapy is not indicated. Discussion: XY gonadal dysgenesis invariably leads to female sex assignment however, the cases presented illustrate potential diagnostic and management difficulties. Systematic laboratory testing and imaging allow early diagnosis and minimize patient and parental frustration. Appropriately timed surgeries minimize the need for additional corrective procedures so that functionality is maximized. Non-surgical diagnostic modalities are consistent with new approaches that seek less invasive interventions. Appropriately timed HRT results in satisfactory development of secondary sex characteristics and minimizes the psychosocial stressors patients face.

In the last 15 years, seven cases of deep vaginal lacerations after the so-called water-skiing douche have been reported.1-4 We report the first such case in the premenarcheal girl. CASE REPORT A 9-year-old girl, Tanner stage 2, in otherwise excellent health, was transferred to Kosair Children's Hospital (Louisville, KY) after falling while water skiing and sustaining an injury producing persistent vaginal bleeding. This young girl was on her fifth trial of being up on water skis. She was wearing a single-layer, one-piece cloth bathing suit. The boat was traveling approximately 40 to 50 mph. She never was able to reach a full standing position.

Background Depot medroxyprogesterone acetate (Depo Provera ® ) is a popular contraceptive method among adolescents. Little is known, however, about the long term effects of Depo Provera ® on bone mineral density in adolescent females. This ongoing study prospectively evaluates the effects of Depo Provera ® and oral contraceptive pills on bone mineral density, compared to normally menstruating adolescents receiving no hormonal contraception. Methods From March 1, 1995 to December 31, 1997, 55 patients aged 12 to 17 presenting for new start hormonal contraception (Depo Provera ® : n = 30, oral contraceptive pills: n = 25) received baseline lumbar vertebral bone mineral density evaluation by dual energy x-ray absorptiometry (DEXA). Patients continuing with their original contraceptive method received bone mineral density evaluation every six months. Patients who subsequently discontinued hormonal contraception, became, pregnant or switched to an alternative contraceptive method were removed from the study. Exclusion criteria included prior use of hormonal contraception, previous pregnancy, and pre-existing risk factors for osteoporosis. Results Baseline DEXA scans revealed no significant difference in bone mineral density between the three groups. After 1 year, bone mineral density decreased from baseline by 0.017 gm/cm 2 or 1.8% in the Depo Provera ® group (n = 15), and increased by 0.030 gm/cm 2 or 3.0% in the oral contraceptive group (n = 8), p = 0.013. Bone mineral density increased by 0.0093 gm/cm 2 or 1.2% in the normally menstruating group over 1 year. After 18 months, bone mineral density decreased from baseline by 0.036 gm/cm 2 or 3.8% in the Depo Provera ® group (n = 10), and increased by 0.062 gm/cm 2 or 6.1% in the oral contraceptive group (n = 4), p 2 (2.0%) in the same time period. A subset of patients receiving Depo Provera ® over 24 months (n = 5) experienced a decrease of 0.222 gm/cm 2 or 4.8% in bone mineral density from baseline. There were no significant differences between the Depo Provera ® and oral contraceptive groups with respect to body mass index, race, smoking, alcohol consumption, or osteoporosis risk factors. Conclusions Depo Provera ® administration in adolescent females appears to be associated with a decrease in bone mineral density which becomes more pronounced with long term use. This is particularly significant as peak bone mineral density is accrued during the adolescent years. Further research is needed to determine whether decreased skeletal bone mineralization induced by Depo Provera ® is reversible on discontinuation of Depo Provera ® , or may be prevented by the concurrent administration of anti resorptive/bone forming agents.

Background Congenital absence of the uterus and vagina (CAUV) is a well known syndrome in which a phenotypic females lack mullerian derived structures. Identification of the genes responsible for this disorder has been hampered because in general patients with CAUV cannot reproduce, and inheritance patterns of mutations cannot be traced. De novo translocation break points have been used successfully to aid in identifying genes responsible for a wide variety disorders and does not rely on a reproductive history for identifying the genes. Methods Chromosomal studies utilizing high-resolution banding were performed on peripheral leukocytes and fibroblast cultures from various sites on a patient with CAUV. Results We have identified tissue specific mosaicism in a patient with CAUV and de novo balanced translocations from leukocyte and tissue fibroblast cultures by GTG banding techniques. Chromosome analysis from leukocyte on the patient's parents showed normal karyotypes while the patient herself had a more complex pattern. Studies on leukocyte cultures from this patient identified a 46, XX, t(8;13) q22.1;q32.1) de novo balanced reciprocal translocation. Analysis of metaphase spreads from fibroblasts cultures of the buttock region revealed a second set of chromosome mosaicism. One cell line was similar to the leukocyte culture with a 46, XX, t(8:13)(q22.1;q32.1) karyotype. The other cell line had three balanced translocations showing a 46, XX, t(1;12)(q23;q24.3), t(6;6)(q15;p25), t(8;13)(q22;q32) karyotype. These two cell lines were in a ratio of 20: 5 respectively. Chromosome analysis of fibroblast cultures from the breast region shows cells with both the simple and more complex translocation. Conclusion These results indicate the importance of analyzing multiple tissue samples in the process of locating de novo break points for gene identification. It also suggests that somatic mosaicism may be a mechanism in the pathogenesis of uterovaginal agenisis. Identification of the genes at the specific break points of these translocations is in progress.

Background Several case reports have been published in the dermatologic literature demonstrating resolution of verruca plana, otherwise knows as “common warts”, with the use of oral Cimetidine.(Orlow et al. J Am Acad Dermat, 1993;28(5)) The mechanism of this effect has not been fully elucidated. We report complete disappearance of extensive vulvar/introital condyloma acuminata in an adolescent. Case An 18 y.o. female with congenital adrenal hyperplasia presented with multiple recurrent genital warts only 1 month after complete laser ablation. (Photo #1) Cimetidine, 400 mg P.O. Q.I.D. was prescribed and, when evaluated after 5 weeks of therapy, all condyloma had completely disappeared.(Photo #2) No untoward side-effects were noted. Conclusions We propose that there may be a role for Cimetidine in the treatment of extensive genital warts.