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Study Objective: To estimate the 1-year continuation rate of the levonorgestrel-releasing intrauterine device (LNG-IUD) in adolescents with endometriosis, and the frequency at which additional systemic hormonal treatment (HT) is utilized., Methods: A retrospective cohort study was performed of patients aged 12 - 21 years who underwent laparoscopy for endometriosis and LNG-IUD insertion at a single tertiary care institution between 2018 and 2021., Results: We evaluated 224 adolescents (mean age=17.0, SD=1.8 years) who underwent LNG-IUD placement during laparoscopic evaluation for endometriosis. Stage I endometriosis was most common (84.4%), followed by stage II (13.0%). Of 221 with follow-up, 208 (94.1%) had HT added or continued post-surgery. The most common additional HT was norethindrone acetate (42.5%), followed by combined hormonal contraceptives (34.8%). The 1-year LNG-IUD continuation rate was 92.0%. There were 18 IUD removals (8%) by 1 year, and the median time to removal was 118 days (IQR=159; range 8-293). Use of additional HT was associated with a lower hazard of IUD removal within the first year of use (HR = 0.19, 95% CI: 0.06-0.56, p<0.001)., Conclusion: The majority of adolescents used the LNG-IUD with additional systemic HT for endometriosis management. While overall continuation was high, adolescents who were using LNG-IUD and HT were more likely to continue LNG-IUD than those who were not utilizing additional HT., Competing Interests: Declaration of competing interest Authors 1 and 3 receive author royalties from UpToDate. Author 2 does not have any potential conflicts to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Importance: Malnourished adolescents and young adults with anorexia nervosa (AN) are at high risk for skeletal deficits., Objective: To examine whether low-magnitude mechanical signals (LMMS) could preserve bone mineral density (BMD) throughout 6 months in adolescents and young adults with AN., Design, Setting, and Participants: This double-blind, sham-controlled randomized clinical trial, conducted in a hospital-based specialty clinic, assessed female adolescents and young women without medical comorbidity or medication use that would compromise bone health. A total of 837 female adolescents were screened from January 1, 2012, to December 31, 2019, of whom 317 met the study criteria. Data analysis was performed from 2020 to 2024., Intervention: Platform delivering low-magnitude mechanical signals (LMMS) (0.3 g at 32-37 Hz) or sham (ie, placebo) signals for 10 minutes daily for 6 months., Main Outcomes and Measures: The primary outcome was trabecular volumetric BMD (vBMD) as measured by peripheral quantitative computed tomography of the tibia at baseline and 6 months. Secondary outcomes included cortical vBMD, cross-sectional area (CSA), areal BMD and body composition measured by dual-energy x-ray absorptiometry, and serum bone turnover markers., Results: Forty female adolescents and young women (median [IQR] age, 16.3 [15.1-17.6] years; median [IQR] percentage median BMI for age, 87.2% [81.0%-91.6%]) completed the trial. Total bone vBMD changes were nonsignificant in both groups (95% CI for difference in median change between groups, -57.11 to 2.49): in the LMMS group, vBMD decreased from a median (IQR) of 313.4 (292.9-344.6) to 309.4 (290.4-334.0) mg/cm3, and in the placebo group, it increased from a median (IQR) of 308.5 (276.7-348.0) to 319.2 (309.9-338.4) mg/cm3. Total CSA at the 4% tibia site increased from a median (IQR) of 795.8 (695.0-844.8) mm2 to 827.5 (803.0-839.4) mm2 in the LMMS group, whereas in the placebo group, it decreased from 847.3 (770.5-915.3) mm2 to 843.3 (828.9-857.7) mm2 (95% CI for difference in median change between groups, 2.94-162.53). Median (IQR) trabecular CSA at the 4% tibia site increased from 616.3 (534.8-672.3) mm2 to 649.2 (638.0-661.4) mm2 in the LMMS group but decreased in the placebo group from 686.4 (589.0-740.0) mm2 to 647.9 (637.3-661.9) mm2 (95% CI for difference in median change between groups, 2.80-139.68 mm2). Changes in cortical vBMD, cortical section modulus, and muscle CSA were not significant between groups. The 6-month changes in trabecular and total bone CSA at the tibia 4% site (weight-bearing trabecular bone) were significantly different between groups (these measures increased in the LMMS group but decreased in the placebo group; total bone CSA: 95% CI, 2.94-162.53; P = .01; trabecular CSA: 95% CI, 2.80-139.68; P = .02). Greater increases in body mass index were seen in the placebo group (median [IQR] gain, 0.5 [-0.3 to +2.1]) than in the LMMS group (median [IQR] gain, +0.4 [-0.3 to +2.1]), perhaps due to differences in fat mass accrual. No adverse events occurred related to the LMMS intervention., Conclusions and Relevance: In this randomized clinical trial of female adolescents and young women with AN, a 6-month LMMS intervention did not yield improvement in tibial trabecular vBMD. However, LMMS led to increases in total and trabecular CSA at the tibia. These results suggest an early positive response of increased bone turnover and trabecular bone quantity due to the LMMS intervention. Future studies should use a longer duration of intervention, consider strategies to optimize adherence, and potentially focus on a more profoundly malnourished patient population., Trial Registration: ClinicalTrials.gov Identifier: NCT01100567.

Abstract: Chronic pelvic pain is heterogeneous with potentially clinically informative subgroups. We aimed to identify subgroups of pelvic pain based on symptom patterns and investigate their associations with inflammatory and chronic pain-related comorbidities. Latent class analysis (LCA) identified subgroups of participants (n = 1255) from the Adolescence to Adulthood (A2A) cohort. Six participant characteristics were included in the LCA: severity, frequency, and impact on daily activities of both menstruation-associated (cyclic) and non-menstruation-associated (acyclic) pelvic pain. Three-step LCA quantified associations between LC subgroups, demographic and clinical variables, and 18 comorbidities (10 with prevalence ≥10%). Five subgroups were identified: none or minimal (23%), moderate cyclic only (28%), severe cyclic only (20%), moderate or severe acyclic plus moderate cyclic (9%), and severe acyclic plus severe cyclic (21%). Endometriosis prevalence within these 5 LCA-pelvic pain-defined subgroups ranged in size from 4% in "none or minimal pelvic pain" to 24%, 72%, 70%, and 94%, respectively, in the 4 pain subgroups, with statistically significant odds of membership only for the latter 3 subgroups. Migraines were associated with significant odds of membership in all 4 pelvic pain subgroups relative to those with no pelvic pain (adjusted odds ratios = 2.92-7.78), whereas back, joint, or leg pain each had significantly greater odds of membership in the latter 3 subgroups. Asthma or allergies had three times the odds of membership in the most severe pain group. Subgroups with elevated levels of cyclic or acyclic pain are associated with greater frequency of chronic overlapping pain conditions, suggesting an important role for central inflammatory and immunological mechanisms., (Copyright © 2024 International Association for the Study of Pain.)

Study Objective: Telemedicine for long-acting reversible contraception (LARC) care is understudied given the rapid implementation of these services in response to the COVID-19 pandemic. We compared outcomes over 1 year of adolescents and young adults (AYAs) attending a LARC post-insertion visit via telemedicine vs in person., Design: Longitudinal cohort study., Setting: Four academic adolescent medicine clinics in the United States., Participants: AYAs (ages 13-26 years) who received LARC between 4/1/20 and 3/1/21 and attended a post-insertion visit within 12 weeks., Interventions: none., Main Outcome Measures: Outcomes over 1 year were compared between AYAs who completed this visit via telemedicine vs in person. We analyzed the data using descriptive statistics, bivariate analyses, and regression models., Results: Of 194 AYAs (ages 13.9-25.7 years) attending a post-insertion visit, 40.2% utilized telemedicine. Menstrual management (odds ratio (OR) = 1.02; confidence interval (CI): 0.40-2.60), acne management (P = .28), number of visits attended (relative risk (RR) = 1.08; CI: 0.99-1.19), and LARC removal (P = .95) were similar between groups. AYAs attending via telemedicine were less likely than those attending in person to have STI testing (P = .001). Intrauterine device expulsion or malposition and arm symptoms with implant in situ were rare outcomes in both groups., Conclusion: Roughly 40% of AYAs attended a post-insertion visit via telemedicine during the first year of the COVID-19 pandemic and had similar 1-year outcomes as those attending in person. The decreased likelihood of STI testing for those using telemedicine highlights the need to provide alternative options, when indicated, such as asynchronous or home testing. Our results support the use of telemedicine for AYA LARC post-insertion care and identify potential gaps in telemedicine care which can help improve clinic protocols., Competing Interests: Conflicts of Interest S.P. and A.D. were co-PIs for a grant through the Investigator-Initiated Studies Program of Organon which supported data management and analysis for this study. C.M. received funding through this grant to support their involvement in the project. C.B., S.M., and S.G. were the directors of the Collaborative at their respective sites when this study was conducted and received funding for data management through this grant. A.B. and M.E. have nothing to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Objective: Anti-Müllerian hormone is a reliable measure of ovarian reserve associated with menopause timing and fertility. Previous studies have observed that individuals with endometriosis have lower anti-Müllerian hormone levels than those without. However, sample sizes have been small and information is limited regarding the long-term influence of endometriosis on anti-Müllerian hormone levels among the general population, which may have important implications for menopause timing and chronic disease risk., Methods: Among 1961 premenopausal women in the Nurses' Health Study II who provided a blood sample and had not been pregnant in the last 6 months, we used generalized linear models to determine the association between laparoscopically-confirmed endometriosis and log-transformed plasma anti-Müllerian hormone level, adjusted for age (continuous and squared) and other potential confounding variables., Results: Participants were on average 40 years old (interquartile range 37-42 years) at blood draw. Women with endometriosis diagnosed prior to blood draw (n = 119) had a lower mean anti-Müllerian hormone level (1.6 ng/mL [SD = 2.3]) than women without known endometriosis (n = 1842) (2.8 ng/mL [SD = 3.0]). In multivariable adjusted models, women with endometriosis had 29.6 % lower anti-Müllerian hormone levels (95 % CI: -45.4, -9.2 %) than women without. This association was greater among women with a body mass index of 25 kg/m 2 or more (percent difference: -44.0 % (-63.7, -13.8)), compared to those with a body mass index of under 25 kg/m 2 (percent difference: -19.8 % (-41.7, 10.4)), but did not vary by parity or infertility history., Conclusions: Lower anti-Müllerian hormone levels in women with endometriosis may be one mechanism through which endometriosis influences risk of infertility, younger age at menopause, and cardiovascular disease., Competing Interests: Declaration of competing interest The authors declare that they have no competing interest., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: Over four million women in the US alone have been diagnosed with endometriosis. For those living with this disease, surgery and hormonal treatment reduce associated pelvic pain in some, while others continue to experience life impacting pain. Therefore, identification of accessible and cost-effective methods of pain reduction to compliment current treatment is urgently needed. Our objective was to quantify the prevalence of complementary and alternative methods used to manage acyclic pelvic pain and their reported benefit among women of different age groups living with endometriosis., Methods: We used baseline questionnaire data from laparoscopically-confirmed endometriosis cases who completed a WERF EPHect compliant questionnaire in the longitudinal cohort of The Women's Health Study: From Adolescence to Adulthood (A2A). Participants with acyclic pelvic pain were asked to indicate specific methods or activities that either helped or worsened their pelvic/lower abdominal pain. Differences among age groups [adolescent (<18 years), young adult (18-25 years), and adult (>25 years)] were assessed using Fisher's exact test., Results: Of the 357 participants included in analysis, sleep for coping was reported more frequently among adolescents ( n  = 59, 57.3%) compared to young adults ( n  = 40, 44.0%) and adults ( n  = 19, 31.1%; p  = 0.004). Adolescents also reported more frequent use of music ( n  = 29, 21.2%) than young adults ( n  = 10, 7.0%) and adults ( n  = 7, 9.1%; p  = 0.001). Exercise worsened pain most commonly among adolescents ( n  = 82, 59.9%), followed by younger adults ( n  = 67, 46.9%), and adults ( n  = 27, 35.1%; p  = 0.002)., Discussion: Our analysis of participants in the A2A cohort showed that the prevalence of complementary and alternative methods used for coping with endometriosis-associated acyclic pelvic pain varied by age group. Future studies should aim to provide information that will further inform decisions in making care plans for managing endometriosis-associated pain that is effective, accessible, and tailored to the preferences of the patient., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Mongiovi, Wallace, Goodwin, Vitonis, Karevicius, Shafrir, Sasamoto, DiVasta, Sieberg, Terry and Missmer.)

Objective: This study aimed to estimate and compare continuation rates of hormonal intrauterine devices (IUDs) when placed for contraceptive or menstrual management indications in adolescents and young adults., Study Design: We conducted a secondary analysis of a prospectively collected database of all hormonal IUD insertions from January 1, 2017 through December 31, 2020, with at least 1-year follow-up, across four Adolescent Medicine practices. IUD insertions without known indication were excluded., Results: A total of 936 IUD insertions were attempted, 45% for contraception only, 18% for menstrual management only, and 37% for both indications. Insertion was successful in 868 (93%) attempts, and success did not differ by indication (p = 0.74). The mean age at insertion was 18.9 years (SD = 2.4 years), with no difference by indication. Of the completed insertions, 650 (75%) had at least one follow-up during the data analysis period. Excluding those without follow-up, the overall continuation rates were 77% at 1 year, 66% at 2 years, and 54% at 3 years. While continuation rates did not differ by indication at 1 year, at 3 years, continuation was highest among those who sought the device for menstrual management only (contraception = 53%, menstrual = 57%, both = 53%, p < 0.01) Malposition was rare (4.0%), as was device expulsion (2.5%), and these did not differ by indication., Conclusion: IUD continuation rates were high among adolescents and young adults and did not significantly differ when placed for contraceptive or non-contraceptive indication in the first year of use., Implications: Adolescents and young adults may seek the hormonal IUD for contraception and/or menstrual management. Our study found that IUD continuation rates were high at 1 year regardless of the indication for utilization., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Abstract: Abdominal pain is a common symptom of several debilitating conditions (eg, inflammatory bowel disease, irritable bowel syndrome, and endometriosis) and affects individuals throughout their lifespan. Quantitative sensory testing (QST) reference values exist for many body sites but not the abdomen. Using a QST battery adapted from the German Research Network on Neuropathic Pain, we collected QST data on the upper and lower abdomen in 181 pain-free participants, ages 12 to 50 years, to establish reference values by age and biological sex. The normative values are presented as medians for each QST measure by sex (male, n = 63; female, n = 118) and across 3 age categories (adolescents: 12-19 years, n = 48; young adults: 20-30 years, n = 87; and adults: 31-50 years, n = 46). Evaluating the sensory functioning of the abdomen and characterizing ranges of QST measures is an essential first step in understanding and monitoring the clinical course of sensory abnormalities in patients with underlying diseases affecting the abdomen and pelvis. The impact of age and development on sensory functioning is necessary, given age-related changes in pain perception and modulation., (Copyright © 2023 International Association for the Study of Pain.)

Adolescents and young adults (AYA) with anorexia nervosa (AN) frequently have co-occurring anxiety and depression, which can negatively impact prognosis. To inform treatment of co-occurring anxiety and depression, we assessed the association of nutritional intake and hunger/stress hormones on anxiety and depression using a six-month longitudinal study of 50 AYA females receiving care for AN. At baseline and six months, we measured anxiety (Spielberger State/Trait Anxiety Inventory [STAI]), depression (Beck Depression Inventory [BDI]), body mass index (BMI), 3-day dietary intake (total calories and proportion of fat, carbohydrate, protein), and serum cortisol, leptin, and adiponectin. We performed mixed effects linear regression analyses, adjusting for age, duration of AN, and percentage of median BMI (%mBMI). At baseline, median age was 16.3 (interquartile range [IQR]=2.5) years, duration of AN was 6 (IQR=8.8) months and %mBMI was 87.2 (IQR=10.5)%. Fifty-six percent had clinically significant anxiety; 30% had depression. Over 6 months, participants had significant improvements in %mBMI (+2.2[IQR=9.2]%, p<.01), STAI (-9.0[IQR=25.0], p<.01), and BDI (-5.0[IQR=13.8], p<.01) scores. Participants with larger improvements in caloric intake had greater improvements in STAI (p=.03) and BDI scores (p=.04). Larger improvement in BDI was significantly associated with increased fat intake (p<.01), but not carbohydrate or protein intake. Change in STAI was not associated with changes in fat, carbohydrate, or protein intake. Changes in STAI or BDI scores were not associated with changes in cortisol, leptin, or adiponectin. Increased caloric intake may augment treatment of co-occurring anxiety and depression, and increased fat intake may improve depression for AYA with AN., Competing Interests: Declarations of interest: None

Objectives: Widespread use of telemedicine for contraceptive care, including long-acting reversible contraception (LARC), was adopted in the United States in response to the COVID-19 pandemic. Given the rapid implementation of these services, little is known about the use of telemedicine for adolescent and young adult (AYA) contraceptive care. This study examined the routine use of telemedicine for LARC post-insertion care by comparing visit attendance between AYAs receiving LARC before and after the COVID-19 pandemic onset., Methods: This analysis included LARC insertions 3/1/19-11/30/19 (pre-pandemic onset cohort) and 4/1/20-12/31/20 (post-pandemic onset cohort) from three Adolescent Medicine subspecialty clinics in the United States. De-identified data were collected via review of the electronic health record. Descriptive statistics, χ 2 tests, and t-tests described and compared groups. Adjusted logistic regression models examined factors associated with attending a post-insertion visit and attending this visit via telemedicine., Results: This analysis included 525 LARC insertions (279 pre- and 246 post-pandemic onset). The proportion of AYAs attending a post-insertion visit increased after the COVID-19 pandemic onset (pre 30 % vs. post 46 %; p≤0.001). Adjusted models revealed that the post-pandemic onset cohort was nearly twice as likely to attend a post-insertion visit as the pre-pandemic onset cohort (OR=1.90; 95 % CI=1.68-2.15). Of those attending this visit in the post-pandemic onset cohort (n=112), 42 % utilized telemedicine., Conclusions: AYAs were more likely to attend post-insertion visits after the COVID-19 pandemic onset than before. Telemedicine may have influenced this change in visit attendance., (© 2023 Walter de Gruyter GmbH, Berlin/Boston.)

Objectives: This study aimed to describe the clinical experience of gender-diverse adolescents and young adults receiving long-acting reversible contraception (LARC)., Study Design: This was a secondary analysis of prospectively collected quality improvement data among gender-diverse adolescents and young adults receiving LARC in four adolescent medicine clinics., Results: Most attempted insertions (59/63) were successful. A majority (54%) chose LARC for both contraception and menstrual management. Pelvic pain/cramping and unsatisfactory bleeding were reported side effects. One known expulsion and six known LARC removals occurred., Conclusions: Gender-diverse adolescents and young adults had high rates of successful LARC insertion and demonstrated a side effect profile similar to a broader adolescent and young adult population seeking LARC care., Implications: LARC is an important and well-tolerated method of menstrual management and contracention in gender-diverse adolescents and young adults, although more investigation is needed to understand how gender-affirming testosterone therapy may impact the LARC experience in this population., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To explore the use duration of a gonadotropin-releasing hormone agonists (GnRHa) plus add-back in adolescents with laparoscopically confirmed endometriosis and the treatment course before and after GnRHa therapy., Design: Retrospective cohort study., Materials and Methods: We identified 51 subjects with laparoscopically confirmed endometriosis who had participated in a randomized trial of a GnRHa plus add-back as adolescents between 2008 and 2012. Electronic medical records were reviewed to obtain demographic data, clinical characteristics, and treatment outcomes after trial completion. The study was deemed IRB exempt., Results: The average age of participants during trial enrollment was 17.9 ± 1.7 years. Thirty-three participants had stage I endometriosis (65%). The most common treatments trialed before GnRHa therapy were combined oral contraceptives (n = 47, 92%) and progestin-only pills (n = 23, 45%). The average duration of GnRHa use during the trial was 9.5 ± 3.5 months; 34 subjects (67%) completed the 1-year trial. After trial completion, 23 subjects (45%) continued to use a GnRHa with add-back therapy. The mean duration of additional GnRHa use was 31.7 ± 28.6 months, and the longest identified duration was an additional 96 months. Twenty-four subjects switched to other hormonal treatments after trial participation, most commonly oral progestins (n = 15) or combined oral contraceptives (n = 6). Thirteen participants (25%) returned to a therapy that had been trialed before GnRHa use., Conclusion: Almost half the participants in this cohort continued to use a GnRHa with add-back for treatment of endometriosis beyond the 12-month recommended duration. Treatment varied widely after discontinuation of GnRHa, with many participants returning to previously trialed medical therapies., (Copyright © 2023 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Reduction mammaplasty is increasingly common in younger patients with macromastia. Unfortunately, a recent surge in mental health disorders has been documented in this population. It is unknown how mental health disorders affect patients undergoing reduction mammaplasty. This study examines the impact of concurrent mental health conditions on health-related quality of life outcomes after reduction mammaplasty., Methods: A prospective cohort study was performed on patients aged 12-21 years undergoing reduction mammaplasty. Patients were assigned to unaffected or affected (baseline mental health condition) cohorts based on psychological history. Patients completed the Short-form-36, Rosenberg Self-esteem Scale, Eating Attitudes Test 26, and Breast-related Symptoms Questionnaire at baseline and postoperatively., Results: A total of 250 patients were included (81 affected and 169 unaffected). Mean age at surgery was 17.9 ± 2.0 and 18.1 ± 1.8 years for affected and unaffected patients, respectively. Anxiety (n = 59, 23.6%) and depression (n = 38, 15.2%) were the most prevalent conditions. Affected patients were outscored by controls at baseline and postoperatively in most measures. However, significant score improvements were also reported in the affected cohort. In fact, the magnitude of score improvements observed in both cohorts were similar ( P > 0.05, all)., Conclusions: Baseline mental health conditions are common in young patients presenting for reduction mammaplasty. After surgery, health-related quality of life in affected patients remains below unaffected peers; however, significant and similar gains are achieved. We advise providers to recommend mental health treatment to affected patients, but not preclude otherwise appropriate candidates from surgery., Competing Interests: The authors have no financial interest to declare in relation to the content of this article. This work was supported in part by the Plastic Surgery Foundation (grant no.: 192776; July 2011). The Plastic Surgery Foundation had no involvement in the study design; collection, analysis, and interpretation of data; the writing of this article; or the decision to submit this article for publication.Disclosure statements are at the end of this article, following the correspondence information., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Purpose: To identify factors associated with bothersome implant-associated uterine bleeding, and to evaluate the impact of bleeding management on implant discontinuation., Methods: We analyzed a quality improvement database of implant insertions (n = 825) at three adolescent/young adult programs and described individuals with and without reported bothersome bleeding. We utilized logistic regression to assess for factors associated with bleeding., Results: Implant recipient mean age was 18.9 ± 2.6 years, and 27% reported having subsequent bothersome uterine bleeding. Recipients had increased odds of reporting such bleeding if they had previously irregular menses (odds ratio [OR] = 1.36; 95% confidence interval [CI]: 1.11-1.68 irregular and infrequent, OR = 1.41; 95% CI: 1.07-1.86 irregular and frequent) or sought the implant for menstrual management purposes exclusively (OR = 1.67; 95% CI 1.42-1.96) or in combination with contraceptive need (OR 1.65; 95%: CI 1.57-1.72). Prior use of the progestin injection or implant was associated with lower odds of subsequent bleeding report (OR = 0.63; 95% CI: 0.54-0.73; OR = 0.54; 95% CI: 0.39-0.75, respectively). Medication management of bleeding was associated with the likelihood of implant discontinuation at 1 year compared to those with untreated bleeding (hazard ratio 1.98 times, 95% CI: 1.39-2.81). The implant was continued for 3 years in over 50% of recipients with ever-managed bothersome bleeding., Discussion: Individuals with historically irregular menses and those seeking the implant for menstrual management more often reported bothersome bleeding. Treating such bleeding with medication was associated with higher 1-year discontinuation rates, although many continued implant use for 3 years. Such findings may influence implant preinsertion counseling and/or postinsertion bleeding management., (Copyright © 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Abstract: We described trends in pelvic pain characteristics over 2 years of follow-up among adolescents and adults with and without endometriosis participating in the longitudinal observational cohort of the Women's Health Study: From Adolescence to Adulthood, using data reported at baseline and at years 1 and 2 of follow-up. Participants completed a questionnaire at baseline (between November 2012 and May 2019) and annually thereafter that included validated measures of severity, frequency, and life interference of dysmenorrhea, acyclic pelvic pain, and dyspareunia. Our study population included 620 participants with surgically confirmed endometriosis (rASRM stage I/II = 95%) and 671 community-based and hospital-based controls, with median age = 19 and 24 years, respectively. The proportion reporting hormone use varied across the 3 years ranging from 88% to 92% for cases and 56% to 58% for controls. At baseline, endometriosis cases were more likely to report severe, frequent, and life-interfering dysmenorrhea, acyclic pelvic pain, and dyspareunia compared with controls. Among cases, frequency and severity of dysmenorrhea and dyspareunia were relatively static across 2 years. However, acyclic pelvic pain improved. Severe acyclic pain decreased from 69% at baseline to 46% at year 2. Daily pain decreased from 28% to 14%, and life interference from 68% to 38%. Trends among controls remained fairly stable across 2 years. Among endometriosis cases who completed the questionnaire at all 3 time points, 18% reported persistent, severe acyclic pelvic pain at all 3 time points. Over time, different trends were observed by pelvic pain type among endometriosis cases and controls, supporting the importance of assessing multidimensional features of pelvic pain., (Copyright © 2022 International Association for the Study of Pain.)

Study Objective: To describe adolescent and young adult (AYA) long-acting reversible contraception (LARC) follow-up care via telemedicine in the year following the COVID-19 pandemic onset DESIGN: Longitudinal cohort study SETTING: Three academic adolescent medicine clinics in the United States PARTICIPANTS: AYAs using LARC INTERVENTIONS: None MAIN OUTCOME MEASURES: The main outcome measures were patient characteristics, visit information (frequency, timing, and modality), patient-reported symptoms, and outcomes for those presenting for LARC follow-up care between April 1, 2020, and March 31, 2021. Descriptive statistics were used to describe the sample. χ 2 tests and t tests were used to compare groups. Adjusted logistic regression models using general estimating equations were applied to assess factors associated with telemedicine visits and to examine visit outcomes., Results: Of the 319 AYAs (ages 13.6-25.7 years), 40.1% attended at least one LARC telemedicine visit. Patients attending any telemedicine encounter vs only in-person visits had similar demographic and clinical characteristics. Of the 426 follow-up visits, 270 (63.4%) were conducted in person and 156 (36.6%) were performed via telemedicine. Most visits (62.7%) occurred within 12 months of device insertion. Reports of bothersome uterine bleeding beyond patient expectations (OR = 1.26; 95% CI, 0.80-1.96), any symptom (OR = 1.40; 95% CI, 0.94-2.10), or 2 or more symptoms (OR = 1.22; 95% CI, 0.67-2.22) at follow-up was not associated, positively or negatively, with mode of follow-up. Management of bleeding (OR = 1.27; 95% CI, 0.56-2.89), management of acne (P = .46), and need for rapid follow-up (P = .33) were similar between follow-up modalities., Conclusions: Patient demographic/clinical characteristics and visit outcomes were similar between telemedicine and in-person LARC follow-up. Telemedicine could play an important role in AYA LARC care., (Copyright © 2022. Published by Elsevier Inc.)

Background: Macromastia is common among adolescents and young women and has well-documented negative physical and psychosocial effects. The pathogenesis of idiopathic macromastia has been attributed to increased end organ sensitivity to circulating gonadal hormones. Despite the known negative effects of macromastia, there is a paucity of literature examining the clinical risk factors associated with macromastia severity in this age group., Methods: In this cross-sectional study, standardized clinical forms were administered to patients between the ages of 12 and 21 years undergoing reduction mammaplasty. Data were collected pertaining to patient demographics, biometrics, breast symptoms, medical and family history, and breast tissue resection mass at the time of reduction. Resection mass was normalized to patient body surface area in analyses., Results: A total of 375 patients were included in analyses. Mean age at surgery was 18.1 years. The following risk factors were positively associated with macromastia severity in both univariate and multivariate logistic regression models: overweight or obesity, racial or ethnic minority status, patient-reported gynecologic or endocrine complaints, and early menarche ( p < 0.05, all). More severe cases of macromastia were associated with approximately three times the odds of being overweight or obese or achieving menarche before 11 years old., Conclusions: In our sample, overweight or obesity, racial or ethnic minority status, early menarche, and patient-reported gynecologic or endocrine complaints were all positively associated with macromastia severity. Awareness of these factors can empower physicians to identify and address modifiable risk factors to prevent progression to more severe disease. Macromastia itself should prompt screening for gynecologic or endocrine complaints with referral as indicated., Clinical Question/level of Evidence: Risk, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: The combined oral contraceptive pill, containing both estrogen and progestin, is commonly prescribed to adolescents for numerous health benefits. However, there is concern among patients and providers that its use may exacerbate breast growth. This retrospective, case-control study examined the association between combined oral contraceptive pill use and macromastia-related breast hypertrophy and symptoms in adolescents., Methods: A total of 378 patients undergoing reduction mammaplasty between the ages of 12 and 21 years were assessed for baseline and postoperative breast symptoms and combined oral contraceptive pill use. In addition, the medical records of 378 female controls of the same age range were retrospectively reviewed., Results: Although a lower proportion of the macromastia cohort used any hormonal contraception compared to controls (37.8 percent versus 64.8 percent; OR, 0.33; 95 percent CI, 0.24 to 0.44; p < 0.001), they were more often prescribed combined oral contraceptive pills (82.5 percent versus 52.7 percent; OR, 1.93; 95 percent CI, 1.29 to 2.68; p < 0.001). Participants with macromastia who used combined oral contraceptive pills had a smaller median normalized amount of breast tissue resected during reduction mammaplasty than those who never used hormonal contraception (639.5 g/m 2 versus 735.9 g/m 2 ; p = 0.003). Combined oral contraceptive pills were not associated with breast-related symptoms or clinical impairment, or postoperative breast growth ( p > 0.05 for all)., Conclusions: Combined oral contraceptive pill use during adolescence may be associated with developing less severe breast hypertrophy. Combined oral contraceptive pills do not appear to exacerbate macromastia-related symptoms or impact postoperative growth in young women following reduction mammaplasty. Although additional research is needed, providers are encouraged to consider combined oral contraceptive pills for their patients with macromastia when indicated and appropriate., Clinical Question/level of Evidence: Risk, III., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Endometriosis affects reproductive-aged females and varies considerably in terms of symptom presentation, morphologic features, and treatment response. Most studies investigating symptom recurrence after an endometriosis-related surgery have been conducted among adults. The Endometriosis pain QUality aftEr Surgical Treatment (EndoQUEST) Study was established to assess characteristics and biomarkers that are associated with pain remediation and improved quality of life after an endometriosis-related surgery among adolescents and young adults. This paper describes the EndoQUEST methodology, summarizes baseline descriptive factors, and compares characteristics by participant retention status. We enrolled 100 surgically-confirmed endometriosis participants aged 12-23 years who provided questionnaire data on reproductive and behavioral factors, pain characteristics and quality of life at three time points; before surgery, 6 weeks to 26 weeks after surgery, and 1 year after surgery. Among these 100 participants, 88 provided blood and/or saliva at all three time points, while 12 provided blood and/or saliva samples only before surgery and 6 to 26 weeks after surgery. There was little evidence of lost to follow-up at 1 year after surgery due to pain symptoms, as pain and quality of life characteristics were similar between participants who completed the questionnaire 1 year after surgery and those who did not. Analyses utilizing these longitudinal data will advance personalized treatment decision making for adolescents and young adults with endometriosis., Competing Interests: S.A.M. serves as an advisory board member for AbbVie and Field Chief Editor for Frontiers in Reproductive Health; neither are related to this study and these do not alter our adherence to PLOS ONE policies on sharing data and materials. No other authors have a conflict of interest to report.

Background: Persistent adolescent gynecomastia negatively affects health-related quality of life. Surgery results in psychosocial improvements, but the effects of postoperative complications on health-related quality of life are unknown. The authors examined whether complications following adolescent gynecomastia surgery impact postoperative health-related quality of life., Methods: Patients aged 12 to 21 years who underwent surgical correction of unilateral/bilateral gynecomastia between 2007 and 2019 were enrolled (n = 145). Relevant demographic and clinical data were obtained from medical records. Fifty-one patients completed the following surveys preoperatively, and at 6 months and 1, 3, 5, 7, 9, and 11 years postoperatively: 36-Item Short-Form Health Survey (Version 2), Rosenberg Self-Esteem Scale, and the 26-item Eating Attitudes Test., Results: Within a median period of 8.6 months, 36 percent of breasts experienced at least one complication. The most common were residual tissue (12.6 percent), contour irregularities (9.2 percent), and hematomas (7.8 percent). Patients reported significant postoperative improvements in self-esteem and in seven health-related quality-of-life domains (Physical Functioning, Role-Physical, Bodily Pain, Vitality, Social Functioning, Role-Emotional, and Mental Health) at a median of 33.3 months. Postoperative survey scores did not vary by grade or procedure, or largely by body mass index category or complication status. However, patients aged younger than 17 years at surgery scored significantly higher than older patients in the Short-Form Health Survey Vitality and Mental Health domains postoperatively., Conclusions: Health-related quality-of-life improvements are achievable in adolescents through surgical correction of persistent gynecomastia. Postoperatively, patients largely experienced similar health-related quality-of-life gains irrespective of complication status, grade, surgical technique, or body mass index category. Minor postcorrection complications are but do not appear to limit postoperative health-related quality-of-life benefits., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background: Adolescence is a challenging time, and an increasing number of young people are seeking plastic surgery. With the rise of health-related quality of life studies in plastic surgery, it is critical to understand the natural variation and changes in health-related quality of life for this population., Methods: In this longitudinal, cohort study validated surveys were administered to cisgender participants aged 12-21 years: Short-Form 36v2, Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26. Surveys were administered at baseline and up to 9 years follow-up. At the time of enrollment, participants were in a current state of good health with no considerable past or current medical, surgical, or psychological history., Results: A total of 149 female and 75 male participants were included, with a median (interquartile range) baseline age of 16.0 (4.4) years and follow-up time of 3.3 (4.1) years. Over the study period, girls who were not overweight or obese experienced significant declines in five SF-36 domains (general health, vitality, social functioning, role-emotional, and mental health) and on the Rosenberg Self-Esteem Scale, Breast-Related Symptoms Questionnaire, and Eating-Attitudes Test-26 ( P < 0.05). In contrast, boys' and overweight/obese girls' health-related quality of life largely remained stable ( P > 0.05)., Conclusions: Adolescence is a challenging time, on which plastic surgery-related concerns are superimposed. Our findings suggest that girls may be more at risk for developing psychosocial deficits that worsen over adolescence and young adulthood. This observation is critical for the interpretation and contextualization of health-related quality of life in adolescent plastic surgery patients., (Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Objective: To determine if women with endometriosis experience lower urinary tract symptoms (LUTSs) more often than those without., Design: Cross-sectional analysis at enrollment in a longitudinal cohort., Setting: Enrollment at 2 academic hospitals and from the local community., Patient(s): This analysis included 1,161 women with (n = 520) and without (n = 641) surgically confirmed endometriosis who were enrolled in the Women's Health Study: from Adolescence to Adulthood between 2012 and 2018., Intervention(s): Not applicable., Main Outcome Measure(s): Prevalence of LUTSs, including stress incontinence, urgency and frequency, straining with urination, incomplete bladder emptying, hematuria, dysuria, and bladder pain using standardized questionnaires., Result(s): The primary outcomes were that women with endometriosis reported the following more often than those without: difficulty passing urine (7.9% vs. 2%; crude odds ratio [OR], 4.14 [95% confidence interval {CI}, 2.19-7.80]; adjusted OR [aOR], 4.31 [95% CI, 2.07-8.95]); still feeling full after urination (18.8% vs. 4.7%; crude OR, 4.73 [95% CI, 3.08-7.25]; aOR, 4.67 [95% CI, 2.88-7.56]); having to urinate again within minutes of urinating (33.1% vs. 17.0%; crude OR, 2.41 [95% CI, 1.83-3.18]; aOR, 2.49 [95% CI, 1.81-3.43]), dysuria (11.7% vs. 4.9%; crude OR, 2.55 [95% CI, 1.62-4.01]; aOR, 2.38 [95% CI, 1.40-4.02]); and pain when the bladder is full (23.0% vs. 4.9%; crude OR, 5.79 [95% CI, 3.82-8.78]; aOR, 6.04 [95% CI, 3.74-9.76]). For the secondary outcomes, among female participants with endometriosis, we observed that the odds of LUTS did not differ by the revised American Society for Reproductive Medicine stage (I/II vs. III/IV) or duration of endometriosis-associated symptoms., Conclusion(s): Women with surgically confirmed endometriosis were more likely to report LUTS than those without., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To report on long-acting reversible contraception (LARC) experience and continuation rates in the Adolescent Medicine LARC Collaborative., Study Design: LARC insertion data (682 implants and 681 intrauterine devices [IUDs]) were prospectively collected from January 1, 2017, through December 31, 2019, across 3 Adolescent Medicine practices. Follow-up data through December 31, 2020, were included to ensure at least 1 year of follow-up of this cohort. Continuation rates were calculated at 1, 2, and 3 years, overall and by Adolescent Medicine site, as were descriptive statistics for LARC procedural complications and patient experience., Results: Implant and IUD insertion complications were uncommon and largely self-limited, with no IUD-related uterine perforations. Uterine bleeding was the most frequently reported concern at follow-up (35% implant, 25% IUD), and a common reason for early device removal (45% of implant removals, 32% of IUD removals). IUD malposition or expulsion occurred following 6% of all insertions. The pooled implant continuation rate at 1 year was 87% (range, 86%-91% across sites; P = .63), 66% at 2 years (range, 62%-84%; P = .01), and 42% at 3 years (range, 36%-60%; P = .004). The pooled IUD continuation rate at 1 year was 88% (range, 87%-90% across sites; P = .82), 77% at 2 years (range, 76%-78%; P = .94), and 60% at 3 years (range, 57%-62%; P = .88)., Conclusions: LARC is successfully provided in Adolescent Medicine clinical settings, with continuation rates analogous to those of well-resourced clinical trials. Uterine bleeding after LARC insertion is common, making counselling imperative. Future analyses will assess whether the medical management of LARC-related nuisance bleeding improves continuation rates in our Adolescent Medicine patient population., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: The aim of this study is to examine age at menarche across sexual orientation groups., Methods: Data were obtained from 131,090 female participants, born 1947-2001, in 3 longitudinal studies-the Growing Up Today Study and Nurses' Health Study 2 and 3. We estimated the association between sexual orientation and age at menarche using regression models adjusted for age, race/ethnicity, birthweight, height, and body mass index., Results: Compared to heterosexual participants, sexual minorities were younger at menarche. Sexual minorities were more likely to have early menarche (≤11 years) and less likely to have late menarche (≥14 years) compared to heterosexual girls. As an example of this pattern, Nurses' Health Study 3 bisexual participants were >30% more likely than heterosexuals to have early versus average menarche (odds ratio 1.37, 95% confidence interval 1.09-1.72)., Conclusion: Sexual minority girls have a younger age at menarche than heterosexual girls and may benefit from screening for adverse outcomes associated with early menarche., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Endometriosis is generally histopathologically defined as the presence of at least 2 of the following: endometrial stroma, Müllerian epithelium, and/or hemosiderin-laden macrophages (HLM). Despite clinically evident endometriotic lesions, biopsies are frequently nondiagnostic. In this study, we conducted a large-scale review of biopsies of lesions clinically thought to represent endometriosis and correlate the histologic findings with clinical appearance to expand sensitivity of the pathologic definition of endometriosis, particularly in patients on hormonal therapy. In all, 112 biopsies from 78 patients (mean age=25, range 18-39 yr) were reviewed for histopathologic features suggestive of or diagnostic for endometriosis including the presence of endometrial stroma, Müllerian epithelium, dystrophic calcifications, HLM, chronic inflammation, adhesions, and vascular proliferation. Endometriosis was confirmed by pathologic criteria in 37 of 78 patients (47%). Biopsies from patients on hormonal therapy (n=62, 80%) were significantly less likely to meet pathologic criteria for endometriosis (P=0.01). Nondiagnostic biopsies (70/112; 63%) frequently displayed HLM (20%), chronic inflammation (29%), dystrophic calcifications (26%), vascular proliferation (20%), or adhesions (20%) and were significantly more likely to have a vascular clinical appearance (P=0.01). Diagnostic biopsies (42/112; 38%) were more likely to have a blue/black clinical appearance (P=0.03), demonstrate HLM (P=0.004), and display pseudodecidualization (P=0.05). Patients with a high clinical suspicion of endometriosis have a range of histologic findings, with less than half meeting the current histopathologic criteria for diagnosing endometriosis. Given the heterogeneous histopathologic appearance, revision of the histologic criteria may be warranted with further exploration, particularly for lesions with predominantly vascular features., Competing Interests: The authors declare no conflict of interest., (Copyright © 2020 by the International Society of Gynecological Pathologists.)

Objective: To estimate the efficacy and safety of a novel nonhormonal therapeutic agent, cabergoline, compared with that of the standard clinical therapy, norethindrone acetate (NETA), for the treatment of endometriosis-associated pain in young women with endometriosis., Design: Randomized, double-blind, placebo-controlled pilot study., Setting: Tertiary care center., Patients: Women (n = 9) with surgically confirmed endometriosis., Interventions: A random, double-blind assignment to either NETA (5 mg/day) + placebo twice weekly or cabergoline (0.5 mg) twice weekly + placebo daily for 6 months., Main Outcome Measures: We collected the measures of pelvic pain and laboratory parameters every 3 months., Results: We observed a decrease in pain scores and increase in pain relief in women randomized to receive cabergoline, who appeared to show similar or more improvements than women treated with NETA. The serum measures of vascular endothelial growth factor receptor 1 declined over 6 months in those who received cabergoline. Cabergoline was well tolerated, and no serious adverse events occurred., Conclusions: Safe, effective adjunct treatments are lacking for patients with endometriosis who do not respond to standard care. Because the growth of endometriosis requires angiogenesis, blood vessel growth is an attractive therapeutic target. This pilot study suggests that cabergoline, a vascular endothelial growth factor pathway inhibitor, is an effective therapeutic option for women with chronic pain due to endometriosis. Building upon this investigation, we will conduct larger, randomized trials of cabergoline, advancing research on the best treatments for endometriosis-particularly disease resistant to hormonal therapies., Clinical Trial Registration Number: clinicaltrials.gov; registration number NCT02542410., (© 2021 The Authors.)

Problem: Associations between immune dysfunction conditions (eg, systemic lupus erythematous, rheumatoid arthritis) and endometriosis have been observed in adult women, but not assessed among a younger population. We investigated the association between immune-mediated conditions and endometriosis among young women., Method of Study: This cross-sectional analysis in the Women's Health Study: From Adolescence to Adulthood included 551 participants with surgically diagnosed endometriosis (median age=19) and 652 controls without endometriosis (median age=24). Participants completed an expanded Endometriosis Phenome and Biobanking Harmonization Project questionnaire. We used logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) to investigate the associations between autoimmune/inflammatory, atopic, chronic pain/fatigue, and endocrine disorders with endometriosis, adjusting for confounders., Results: Participants with any autoimmune and/or inflammatory condition had an increased odds of co-occurring endometriosis (OR: 1.87; CI: 0.92-3.80), as did participants with allergies (OR: 1.76; CI: 1.32-2.36), asthma (OR: 1.35; CI: 0.97-1.88), chronic fatigue syndrome and/or fibromyalgia (OR: 5.81; CI: 1.89-17.9), or previous mononucleosis (OR: 1.75; CI: 1.14-2.68). Odds of endometriosis were lower among participants with eczema (OR: 0.68; CI: 0.44-1.04). We observed a positive trend between the number of immune-mediated conditions and the odds of endometriosis (p-trend=0.0002). Endocrine disorders were not associated with endometriosis., Conclusions: Among this population of adolescents and adult women, endometriosis was more likely among participants with autoimmune and/or inflammatory diseases, allergies, asthma, previous mononucleosis infection, and chronic fatigue and/or fibromyalgia. We observed that an increasing number of immune-mediated conditions were positively associated with endometriosis risk. It is important for clinicians who care for adolescents and women with these conditions to consider endometriosis as a comorbidity., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Study Objectives: Hypothalamic amenorrhea is common in adolescents and young adults (AYAs) with anorexia nervosa (AN), and ovarian reserve is not routinely assessed. AN increases rates of fertility problems, but how or when AN negatively influences future fertility is unclear. We sought to determine whether biomarkers of ovarian reserve were impacted in AYA with AN., Design: Cross-sectional study., Setting: Tertiary care center., Participants: Females with AN and amenorrhea (n = 97) at the pre-intervention visit of a clinical trial, n = 19 females without an eating disorder or menstrual dysfunction., Main Outcome Measures: Serum anti-Müllerian hormone (AMH) concentrations., Results: AMH levels were higher in AYA with AN than unaffected adolescents (4.7 vs. 3.2 ng/mL; P = .03). Neither FSH nor inhibin B differed between groups. In 19.6% of participants with AN, AMH levels were elevated above the normal range (>6.78 ng/mL). These subjects had a longer disease duration than those with normal AMH levels (9 vs. 3 mos; P = .03); age or degree of malnutrition did not differ between AN subjects with normal or elevated AMH., Conclusions: AMH levels appear to be normal or elevated in AYA with AN. Low AMH in a patient with AN should raise clinical concern regarding ovarian reserve, and should not be attributed to degree of malnutrition alone. Currently, AMH is not regularly assessed during routine AN clinical care. However, our findings suggest some clinical utility in identifying those patients with reduced ovarian reserve. Potential links between the hypothalamic amenorrhea suffered by patients with AN and PCOS should be explored., (Copyright © 2021 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Background & Aims: Gastroenterologic symptoms often are reported by adults with endometriosis, leading to unnecessary diagnostic tests or complicated treatment. We investigated associations between endometriosis and irritable bowel syndrome (IBS) in adolescents and whether concurrent pain disorders affect these., Methods: We collected data from within The Women's Health Study: Adolescence to Adulthood, which is a US longitudinal study of premenopausal females with and without endometriosis. Our study cohort included participants younger than 21 years enrolled from 2012 to 2018. Participants completed an extensive health questionnaire. Those with IBS based on a self-reported diagnosis or meeting Rome IV diagnostic criteria were considered cases and those without IBS were controls. Subjects without concurrent gastrointestinal disorders or missing pain data (n = 323) were included in the analyses. We calculated adjusted odds ratios using unconditional logistic regression., Results: More adolescents with endometriosis (54 of 224; 24%) had comorbid IBS compared with adolescents without endometriosis (7 of 99; 7.1%). The odds of IBS was 5.26-fold higher among participants with endometriosis than without (95% CI, 2.13-13.0). In girls with severe acyclic pelvic pain, the odds of IBS was 35.7-fold higher in girls without endometriosis (95% CI, 4.67-272.6) and 12-fold higher in girls with endometriosis (95% CI, 4.2-36.3), compared with no/mild pain. For participants with endometriosis, each 1-point increase in acyclic pain severity increased the odds of IBS by 31% (adjusted odds ratio, 1.31; 95% CI, 1.18-1.47)., Conclusions: In an analysis of data from a longitudinal study of girls and women with and without endometriosis, we found significant associations between endometriosis and IBS, and a linear relationship between acyclic pelvic pain severity and the odds of IBS. Increased provider awareness and screening for IBS and endometriosis will improve patient outcomes and increase our understanding of these complex disorders., (Copyright © 2021 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine contraceptive methods used by adolescent/young adult women of diverse sexual orientations., Study Design: We collected data from 12,902 females, born 1982-1995, from the longitudinal Growing Up Today Study., Results: Compared to heterosexuals, lesbians were half as likely to use contraceptives; other sexual minority subgroups (e.g., bisexuals) were more likely to use contraceptives, particularly long-acting reversible contraceptives., Conclusions: Many sexual minority women use contraception throughout adolescence/young adulthood, though use is low among lesbians., Implications: With limited contraception use, lesbians miss opportunities for care and need to be brought into the healthcare system in other ways., (Copyright © 2020. Published by Elsevier Inc.)

Progestin-only contraception has become increasingly popular among adolescents. However, patients, parents, and providers share concerns regarding the potential impact that progestin-only contraception may have on breast growth. We sought to explore the impact of progestin-only contraception on breast hypertrophy and symptomatology in adolescents with macromastia., Methods: Patients between the ages of 12 and 21 years undergoing reduction mammaplasty were prospectively assessed for baseline and postoperative breast symptomatology and medication use. The medical records of female controls within the same age range were retrospectively reviewed., Results: A total of 378 participants with macromastia and 378 controls were included in analyses. A higher proportion of controls used progestin-only methods compared with participants with macromastia (28.0% versus 5.3%, P < 0.001). The most commonly prescribed methods were the depot medroxyprogesterone acetate injection (31.0%), levonorgestrel-containing intrauterine device (31.0%), and subdermal implant (26.2%). Patients with macromastia who used progestin-only contraception had a greater amount of breast tissue resected during reduction mammaplasty ( P = 0.04), reported greater musculoskeletal pain ( P = 0.008), and were roughly 500% more likely to experience breast pain (odds ratio, 4.94; 95% confidence interval, 1.58-15.47; P = 0.005) than those with macromastia who never used hormonal contraception., Conclusions: Adolescents with macromastia who use progestin-only contraception may have greater breast hypertrophy and worse breast and musculoskeletal pain. When appropriate, providers may wish to consider other contraception methods for patients who are at-risk for breast hypertrophy or those who suffer from macromastia-related symptoms., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Study Objective: To analyze clinical, metabolic, hormonal, and ultrasound characteristics of adolescents with polycystic ovary syndrome phenotypes., Design: We performed a retrospective analysis of quality improvement data. We divided patients according to phenotype on the basis of clinical or biochemical diagnosis of hyperandrogenism (HA), irregular menstruation (IM), and presence or absence of polycystic ovarian morphology (PCOM) on pelvic ultrasound (PUS) images, if obtained. The 5 resulting groups were: (1) HA/IM/normal PUS, n = 28; (2) HA/PCOM, n = 10; (3) IM/PCOM, n = 18; (4) HA/IM/PCOM, n = 40; and (5) HA/IM/no PUS obtained, n = 80. We compared parameters between groups using the nonparametric Wilcoxon rank sum test., Setting: Boston Children's Hospital, 2012-2016., Participants: One hundred seventy-six girls and young women aged 11-25 years., Interventions: None., Main Outcome Measures: (1) Clinical, metabolic, and hormonal characteristics; and (2) PUS measurements., Results: Groups with HA had significantly higher acne scores, Ferriman-Gallwey scores, and total and free testosterone concentrations than groups without HA. Significant differences in hemoglobin A1c were found between the IM/PCOM and HA/IM/PCOM groups (5.1% vs 5.3%; P = .01) and the IM/PCOM and HA/IM/no PUS groups (5.1% vs 5.3%; P < .01). In patients who had ultrasound performed, 49/94 (52.1%) met PCOM criteria on the basis of ovarian size, 37/94 (39.4%) on the basis of follicle number, and 27/94 (28.7%) on both; 10/94 (10.5)% had incidental findings on ultrasound, with 2 patients requiring further management., Conclusion: Limited differences in clinical, metabolic, and hormonal characteristics exist between adolescents with different phenotypes of polycystic ovary syndrome, and are mostly related to the presence or absence of HA. Of patients with ultrasound examinations, only 2 had clinically actionable incidental findings., (Copyright © 2020 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Background: Reduction mammaplasty effectively alleviates symptoms and restores quality of life. However, operating on adolescents remains controversial, partly because of fear of potential postoperative breast growth. This cross-sectional study provides surgeons with a method to predict the optimal timing, or biological "sweet spot," for reduction mammaplasty to minimize the risk of breast regrowth in adolescents., Methods: The authors reviewed the medical records of women aged 12 to 21 years who underwent reduction mammaplasty from 2007 to 2019. Collected data included symptomology, perioperative details, and postoperative outcomes., Results: Four hundred eighty-one subjects were included in analyses and were, on average, 11.9 years old at first menses (menarche) and 17.9 years old at surgery. Six percent of subjects experienced postoperative breast growth. Breast size appears to stabilize considerably later in obese adolescents compared to healthy-weight and overweight patients, and breast growth in obese macromastia patients may not end until 9 years after menarche. Operating on obese women before this time point increased the likelihood of glandular breast regrowth by almost 120 percent (OR, 1.18; 95 percent CI, 1.11 to 1.26). Surgery performed less than 3 years after menarche, the commonly regarded end of puberty, increased the likelihood of glandular regrowth by over 700 percent in healthy-weight and overweight subjects (OR, 7.43; 95 percent CI, 1.37 to 40.41)., Conclusions: Findings suggest that reduction mammaplasty age restrictions imposed by care providers and third-party payors may be arbitrary. Surgical readiness should be determined on an individual basis incorporating the patient's biological and psychological maturity, obesity status, potential for postoperative benefit, and risk tolerance for postoperative breast growth., Clinical Question/level of Evidence: Risk, III.

Purpose: The purpose of this study is to quantify the prevalence of dyspareunia and its impact on quality of life (QOL) in adolescent and young adult women (AYA) diagnosed with endometriosis., Methods: Eligible participants from the Women's Health Study: From Adolescence to Adulthood, a longitudinal cohort study, were AYA 18-25 years who reported having had sexual intercourse. We included n = 151 AYA with a surgical diagnosis of endometriosis and n = 287 without known endometriosis. Participants completed a questionnaire including the Short Form-36 (SF-36) QOL survey, on which lower scores indicate impairment. Dyspareunia was defined as answering "yes" to having had pain during/within 24 hours following sexual intercourse. Normative-based scores for SF-36 subscales were calculated and compared between groups using linear regression adjusted for age, body mass index, educational level, and race., Results: Participants with endometriosis experienced dyspareunia twice as often (79%) than AYA without endometriosis (40%, p < .0001). In participants with and without endometriosis, all SF-36 subscale scores were significantly lower in AYA with dyspareunia than without. For six subscales, the negative impact was significantly stronger in AYA with endometriosis than those without, and mean scores were all less than the normative score, indicating impairment., Conclusions: More than three quarters of AYA with endometriosis and two thirds without experience dyspareunia that negatively impacts both physical and mental health QOL scores. This impairment is stronger in those with endometriosis. Given the importance of relationships and peer engagement for identity formation during adolescence, dyspareunia could be particularly impactful. Clinicians should ask patients not only about contraception and prevention of sexually transmitted infections, but inquire about how dyspareunia may impact mental and physical well-being., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Young women with congenital breast asymmetry have impaired psychological well-being and self-esteem. However, little is known regarding the effects of surgical intervention in this population. This cohort study aims to assess postoperative changes in health-related quality of life following surgical treatment of breast asymmetry in young women using a prospective, longitudinal study design., Methods: From 2008 to 2018, 45 young women undergoing surgical correction of breast asymmetry of benign cause and 101 unaffected, female controls completed the following surveys: Short-Form 36v2, Rosenberg Self-Esteem Scale, and Eating-Attitudes Test-26. Surveys were administered at baseline and at up to 9-year follow-up., Results: Participants with breast asymmetry scored significantly worse than controls at baseline on the Rosenberg Self-Esteem Scale and in two Short-Form 36v2 domains: Social-Functioning and Role-Emotional. Asymmetry participants experienced significant postoperative improvements on the Rosenberg Self-Esteem Scale, and in three Short-Form 36v2 domains: Role-Physical, Social Functioning, and Mental Health. These improvements were sustained for a minimum of 5 years. Postoperatively, asymmetry participants' quality of life was comparable to controls and did not vary by age at the time of surgery, asymmetry severity, or diagnosis., Conclusions: Surgical treatment of breast asymmetry in young women yields significant and sustained improvements in psychosocial quality of life. Postoperatively, patients returned to a level of functioning commensurate with their peers., Clinical Question/level of Evidence: Therapeutic, IV.

Objective: Endometriosis is a common gynecologic disorder often associated with severe pelvic pain and infertility with few known modifiable risk factors. We investigated whether in utero and early life exposures are associated with surgically diagnosed endometriosis among adolescents and young adults., Study Design: This case-control study, including 295 laparoscopically-confirmed endometriosis cases and 309 population-based controls aged <25 years, was conducted using data from The Women's Health Study: From Adolescence to Adulthood which enrolled participants from 2012 to 2018. Information on in utero and early life factors were collected using a modified WERF EPHect questionnaire at enrollment, including their mother's age at delivery, birthweight, gestation length, exposure to smoking in utero and secondhand smoke during childhood up to age 13, and if the participant was breastfed., Results: Median age at enrollment was 17 years (range 12-24) in cases and 22 years (range 7-24) in controls, with 83 % and 68 % non-Hispanic whites, respectively. The majority of cases (95 %) were rASRM stage I or II at diagnostic surgery. Exposure to breastfeeding in early life was associated with lower odds of endometriosis diagnosis (OR = 0.39, 95 % CI = 0.21-0.74). Exposure to secondhand smoke during childhood due to maternal smoking was associated with increased odds of endometriosis diagnosis (OR = 2.70, 95 % CI = 1.11-6.60)., Conclusions: Among adolescents and young adults, our data suggest exposures to breastfeeding in early life and secondhand smoke during childhood may be associated with endometriosis risk, providing insight into etiologic pathways to be explored in this young population., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose of Review: Long-acting reversible contraception (LARC) is increasingly used by adolescents and young adults (AYAs). Subsequent to LARC insertion, AYAs are presenting to their primary care providers with LARC concerns. This article seeks to equip primary care clinicians with the tools necessary to assess and manage common LARC-associated side effects., Recent Findings: Side effects are common with progestin-only LARC, and can precipitate early discontinuation of an otherwise effective, low-maintenance form of contraception. Abnormal uterine bleeding, pelvic pain, acne, and weight change are often cited as progestin-only LARC side effects, yet the causes are poorly understood despite extensive research. While most side effects improve with time, therapeutic interventions are available for patients with undesirable side effects that prefer medical management. Research emphasizes the importance of proper patient counseling and clinical follow-up., Summary: Counseling remains essential in the management of LARC-associated side effects. However, options are available to temporarily mitigate such side effects and increase LARC satisfaction. While these therapeutic options are prescribed based on expert opinion, such regimens remain inadequately studied in AYA populations.

Background: Adolescents with endometriosis are a particularly underserved population who struggle with chronic pain. Despite widespread use, there are no published trials examining the individual effects of vitamin D and omega-3 (n-3) fatty acid supplementation on endometriosis-associated pain in adolescents., Objectives: We aimed to determine whether supplementation with vitamin D or ω-3 fatty acids remediates pain, changes frequency of pain medication usage, or affects quality of life in young women with endometriosis., Methods: Women (aged 12-25 y) with surgically confirmed endometriosis and pelvic pain enrolled in a double-blind, randomized, placebo-controlled trial. The primary outcome was pain measured by the visual analog scale (VAS). Secondary outcomes were quality of life, pain catastrophizing, and pain medication usage. Participants were randomly assigned to receive 2000 IU vitamin D3, 1000 mg fish oil, or placebo daily for 6 mo., Results: A total of 147 women were screened and 69 were randomly assigned as follows: 27 to vitamin D3; 20 to fish oil; and 22 to placebo. Participants in the vitamin D arm experienced significant improvement in VAS pain [mean (95% CI) worst pain in the past month, from baseline to 6 mo: 7.0 (6.2, 7.8) to 5.5 (4.2, 6.8), P = 0.02]; however, an improvement of nearly identical magnitude was observed in the placebo arm [6.0 (5.1, 6.9) to 4.4 (3.0, 5.8), P = 0.07]. A more modest improvement was observed in the fish oil arm [5.9 (4.8, 7.0) to 5.2 (3.7, 6.8), P = 0.39]. Neither of the intervention arms were statistically different from placebo., Conclusions: In young women with endometriosis, supplementation with vitamin D led to significant changes in pelvic pain; however, these were similar in magnitude to placebo. Supplementation with fish oil resulted in about half of the VAS pain reduction of the other 2 arms. Studies are needed to better define the physiology underlying the observed reduction in pain score in the placebo arm that persisted across 6 mo.This trial was registered at clinicaltrials.gov as NCT02387931., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2020.)

Study Objective: To examine how the intrauterine device (IUD) insertion experience affects long-term IUD acceptability among adolescents., Design: Text to Web survey study., Setting: Boston Children's Hospital and Cambridge Health Alliance in Massachusetts., Participants, Interventions, and Main Outcome Measures: Nulliparous adolescents aged 13-21 years who received an IUD or etonogestrel implant between January 2012 and May 2018., Results: We received survey responses from 95 adolescents (n = 46 IUD; n = 49 implant; response rate = 95/1098 (9%)). Mean current age (20.8 years) and time since device insertion (2.4 years) were similar between groups. Although a large proportion of both groups (64%) experienced moderate to severe preprocedural anxiety, IUD users expected more insertional pain compared with implant users (55.6 vs 39.6; P = .01). Compared with implant users, more IUD users experienced moderate to severe insertional pain (80% vs 18%; P < .0001), recalled that the procedure hurt more than expected (52% vs 4%; P < .0001), and endorsed lower rates of pain management satisfaction (72.4 vs 85.6; P = .04). Most respondents would recommend their method to a friend (75%) or consider getting the same device in the future (63%). When explicitly asked, more IUD users reported that dislike of the insertion procedure might or would probably prevent them from getting the same device in the future (41% vs 14%; P = .005)., Conclusion: Compared with implant users, IUD users reported more negative insertion experiences, although preprocedural anxiety was prevalent in both groups. Dislike of the insertion experience might negatively affect adolescents' willingness to continue using an IUD in the future. Findings should encourage multimodal interventions to holistically improve the IUD insertion experience., (Copyright © 2019 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)

Purpose: Adolescents with anorexia nervosa (AN) have decreased dehydroepiandrosterone (DHEA) and estrogen concentrations that may contribute to skeletal deficits. We sought to determine whether DHEA + estrogen replacement (ERT) prevented bone loss in young adolescents with AN., Methods: We recruited females with AN (n = 70, ages 11-18 years) into a 12-month, randomized, double-blind placebo-controlled trial. Participants were randomized to oral micronized DHEA 50 mg + 20 mcg ethinyl estradiol/.1 mg levonorgestrel daily (n = 35) or placebo (n = 35). Outcomes included serial measures of bone mineral density (BMD) by dual-energy X-ray absorptiometry (total body, hip, spine) and peripheral quantitative computed tomography (pQCT; tibia). Magnetic resonance imaging of T1-weighted images of the left knee determined physeal status (open/closed)., Results: Sixty-two subjects completed the trial. Physeal closure status was the strongest predictor of aBMD changes. Among girls with open physes, those who received DHEA + ERT showed a decline in BMD Z-scores compared with those receiving placebo, whereas there was no effect in those with at least one closed physis. Treatment did not affect any pQCT measures, regardless of physeal closure status., Conclusions: Combined DHEA + ERT did not significantly improve dual-energy X-ray absorptiometry or pQCT BMD measurements in young adolescent girls with AN, in contrast to an earlier trial showing benefit in older adolescents and young women. In girls with open physes, the mean change in the placebo arm was greater than that of the DHEA + ERT group. We conclude that DHEA + ERT is ineffective for preserving bone health in growing young adolescents with AN at the dose and route of administration described in this report., (Copyright © 2019 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine contraceptive methods used across sexual orientation groups., Study Design: We collected data from 118,462 female participants in two longitudinal cohorts-the Nurses' Health Study (NHS) 2 (founded in 1989, participants born 1947-1964) and NHS3 (founded in 2010, born 1965-1995). We used log-binomial models to estimate contraceptive methods ever used across sexual orientation groups and cohorts, adjusting for age and race., Results: Lesbians were the least likely of all sexual orientation groups to use any contraceptive method. Lesbians in NHS2 were 90% less likely than heterosexuals to use long-acting reversible contraceptives (LARCs; adjusted risk ratio [aRR]; 95% confidence interval [CI]: 0.10 [0.04, 0.26]) and results were similar for other contraceptive methods and in the NHS3 cohort. Compared to the reference group of completely heterosexual participants with no same-sex partners, those who identified as completely heterosexual with same-sex partners, mostly heterosexual, or bisexual were generally more likely to use any method of contraception. Use of LARCs was especially striking across sexual minority groups, and, with the exception of lesbians, they were more likely to use LARCs; as one illustration, NHS3 bisexuals were more than twice as likely to use LARCs (aRR [95% CI]: 2.01 [1.67, 2.42])., Conclusions: While certain sexual minority subgroups (e.g., bisexuals) were more likely than heterosexuals to use contraceptive methods such as LARCs, lesbians were less likely to use any method., Implications: Many sexual minority patients need contraceptive counseling and providers should ensure to offer this counseling to patients in need, regardless of sexual orientation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Adolescent reduction mammaplasty remains controversial because of concerns of postoperative breast growth, complications, and the effect on well-being. The authors sought to prospectively quantify early and late complications following reduction mammaplasty in adolescents and young women, and examine the intersection of surgical complications and postoperative health-related quality of life., Methods: From 2008 to 2017, female patients aged 12 to 21 years undergoing reduction mammaplasty were asked to complete the 36-Item Short-Form Health Survey (version 2), the Rosenberg Self-Esteem Scale, the Breast-Related Symptoms Questionnaire, and the Eating-Attitudes Test-26 preoperatively and postoperatively at 6 months and 1, 3, 5, and 7 years. Clinical evaluations using standardized forms assessed baseline and postoperative symptomatology, complications, and surgical outcomes., Results: In the authors' sample of 512 participants, the most common complications included hypertrophic scarring (20.0 percent) and altered sensation of the nipple (8.4 percent) or breast (7.8 percent). Patient age, body mass index category, and amount of tissue resected did not significantly increase the odds of developing a complication. Significant postoperative improvements on the Rosenberg Self-Esteem Scale, the Breast-Related Symptoms Questionnaire, the Eating-Attitudes Test-26, and in all 36-Item Short-Form Health Survey domains (i.e., physical functioning, role-physical, bodily pain, general health, vitality, social functioning, role-emotional, and mental health) were largely seen irrespective of whether complications occurred., Conclusions: Although complications following reduction mammaplasty were common, the vast majority were minor. Patients had significant postoperative improvements in their physical and psychosocial well-being regardless of whether they experienced a complication. Concerns for potential complication, especially in younger and overweight or obese patients, should not preclude otherwise healthy adolescents and young women from the benefits of reduction mammaplasty., Clinical Question/level of Evidence: Therapeutic, IV.

Purpose: While endometriosis is recognized to have a high patient burden for adults, the level of morbidity it causes for adolescents has been understudied, and may be minimized by clinicians. The purpose of this study was to determine whether endometriosis has a significant impact on quality of life (QOL) for adolescents and young adults., Methods: Five hundred and sixty-seven participants (360 cases and 207 controls) aged <25 years old who are enrolled in the Women's Health Study: From Adolescence to Adulthood longitudinal study were included in this analysis. Participants were enrolled from medical clinics and the communities surrounding Boston, MA. Participants completed an expanded World Endometriosis Research Foundation Endometriosis Phenome and Biobanking Harmonization Project standard clinical questionnaire that included the Short Form-36 (SF-36), a widely used measure of health-related QOL. We calculated SF-36 physical component summary and mental component summary scores, as well as eight subscale scores. On the SF-36, lower scores reflect greater impairment., Results: Adolescents with endometriosis had significantly lower physical component summary (mean [standard deviation]: 43.4 [11.1] vs. 53.8 [7.6], p < .0001) and mental component summary (43.3 [12.3] vs. 46.3 [10.8], p = .008) scores compared to controls, as well as lower scores on all eight subscales. More cases than controls reported mental health diagnoses, pain medication use, and avoidance of exercise during menstruation. Among cases, earlier age at menarche, more severe pelvic pain, and longer duration of diagnostic delay were associated with poorer QOL., Conclusions: Endometriosis is associated with significantly worse reports of QOL for adolescents and young women with endometriosis compared to unaffected peers. Earlier menarche was associated with poorer physical health-related QOL among cases, whereas severe pelvic pain was associated with both poorer physical and mental health-related QOL among cases. Impairment in QOL is not limited to adults with endometriosis, but affects younger patients as well., (Copyright © 2018 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Purpose: Despite the psychosocial deficits associated with gynecomastia, surgical treatment of adolescent gynecomastia remains controversial. This longitudinal cohort study measures changes in health-related quality of life following surgical treatment of gynecomastia in adolescents., Methods: The following surveys were administered to adolescents with gynecomastia and male controls, aged 12-21 years: Short-Form 36v2 (SF-36), Rosenberg Self-Esteem Scale (RSES), and Eating-Attitudes Test-26. Subjects completed surveys at baseline and postoperatively/at follow-up at 6 months, 1 year, 3 years, and 5 years., Results: From 2008 to 2017, 44 patients undergoing surgical treatment of gynecomastia and 64 unaffected male controls participated in our study. At baseline, gynecomastia patients scored significantly worse than controls on the RSES and in five SF-36 domains: general health, vitality, social functioning, role-emotional, and mental health. Scores significantly improved postoperatively on the RSES, and in four SF-36 domains: physical functioning, role-physical, bodily pain, and social functioning. Postoperatively, gynecomastia subjects scored similarly to controls in all SF-36 domains and the RSES. Young and overweight/obese patients and those with severe gynecomastia had the greatest postoperative improvement across survey measures., Conclusions: Surgical treatment of gynecomastia significantly improves the quality of life of adolescents, with measurable improvements in physical and psychosocial functioning. Postoperatively, gynecomastia patients performed comparably to unaffected controls. Surgical treatment of gynecomastia in adolescents and young men has the potential to significantly improve quality of life, particularly in younger and overweight/obese patients and those with moderate to severe gynecomastia. Concerns regarding patient age and body mass index alone should not contraindicate surgery., (Copyright © 2018 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Study Objective: To explore the potential occurrence of long-term side effects and tolerability of gonadotropin-releasing hormone agonist (GnRHa) plus 2 different add-back regimens in adolescent patients with endometriosis., Design: Follow-up questionnaire sent in 2016 to patients who participated in a drug trial between 2008 and 2012., Setting: Tertiary care center in Boston, Massachusetts., Participants: Female adolescents with surgically confirmed endometriosis (n = 51) who enrolled in a GnRHa plus add-back trial as adolescents., Interventions: Leuprolide depot 11.25 mg intramuscular injection every 3 months, plus oral norethindrone acetate 5 mg daily or oral norethindrone acetate 5 mg daily and oral conjugated equine estrogens 0.625 mg daily., Main Outcome Measures: Side effects during and after treatment, irreversible side effects, changes in pain, overall satisfaction., Results: The response rate was 61% (25 of 41; 10 subjects could not be located). Almost all (24 of 25) reported side effects during treatment; 80% (16 of 21) reported side effects lasting longer than 6 months after stopping treatment. Almost half (9 of 20) reported side effects they considered irreversible, including memory loss, insomnia, and hot flashes. Despite side effects, participants rated GnRHa plus add-back as the most effective hormonal medication for treating endometriosis pain; two-thirds (16 of 25) would recommend it to others. More participants who received a modified 2-drug add-back regimen vs standard 1-drug add-back would recommend GnRHa and believed it was the most effective hormonal medication., Conclusion: Subjects believed that GnRHa used with add-back was effective and would recommend it to others, despite significant side effects. Those who received 2-drug add-back reported more success than those who received standard add-back. A subset of patients reported side effects they consider to be irreversible., (Copyright © 2018 North American Society for Pediatric and Adolescent Gynecology. Published by Elsevier Inc. All rights reserved.)