Obstetrics and Gynecology Clinics

Pediatric and Adolescent Gynecology

Foreword

William F. Rayburn, MD, MBA

Consulting Editor
This issue pertaining to Pediatric and Adolescent Gynecology (PAG), edited by

S. Paige Hertweck, MD, provides expert perspectives from a multidisciplinary team,
many of whom helped define pediatric and adolescent gynecology as a specialty.
An important clinical reference, this issue combines contemporary approaches to
diagnoses with the latest management advice to address gynecologic problems in
infants, children, and adolescents.
Gynecologic problems encountered in infants and children (genital trauma, intersex
disorders, mullerian anomalies) are unique to these age groups and involve physician
skills differing from those utilized for adults. Because of these unique circumstances,
practicing obstetrician-gynecologists are often uncomfortable in evaluating and
managing these children. For this reason, pediatric gynecology was created as
a new specialty incorporating the expertise of gynecologists, pediatricians, urologists,
pediatric surgeons, endocrinologists, and geneticists.
The American College of Obstetricians and Gynecologists recommends that the
initial reproductive health visit to the obstetrician-gynecologist occurs as early as
age 13. This initial visit would not include a pelvic examination unless indicated by
the medical history. Instead, this encounter would provide an opportunity for the
obstetrician-gynecologist to begin a physician-patient relationship, counsel patients
and parents or guardians regarding health behaviors and dispel myths and fears. It
also will assist an adolescent in building trust into the health care system when she
has a specific need.
Health care of the adolescent female should include a review of normal menstruation, diet and exercise, healthy sexual decision-making, relationships, immunizations,
and injury prevention. Preventive counseling is beneficial for parents, guardians, or
other supportive adults, and can include discussions about physical, sexual, and
emotional development; signs and symptoms of common conditions affecting adolescents; and encouragement of lifelong health choice behaviors.
This issue highlights differences between adolescents and adults about certain
gynecologic disorders (endometriosis, polycystic ovarian syndrome, abnormal cervical
cytology, menstrual disorders, contraception and intrauterine devices). Several articles
cover topics emphasized by the American College of Obstetricians and Gynecologists
Obstet Gynecol Clin N Am 36 (2009) xiiixiv

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0889-8545/09/$ see front matter 2009 Elsevier Inc. All rights reserved.
obgyn.theclinics.com
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Foreword
Committee on Adolescent Health Care. The risks of exposure to violence, substance

use, sexually transmitted disease, and unintended pregnancy threaten the health and
well-being of adolescents. Additional research is needed to determine the best care
for adolescents, especially in defining optimal treatment. Unfortunately, there exists
confusion about adolescents participating in research because of uncertainty about
the need for parental permission and what constitutes appropriate protection as
research subjects. We look to the distinguished group of contributors in this issue
to carry this agenda forward.
William F. Rayburn, MD, MBA
Department of Obstetrics and Gynecology
University of New Mexico School of Medicine
MSC10 5580; 1 University of New Mexico
Albuquerque, NM 87131-0001, USA
E-mail address:
[email protected]
Pediatric and Adolescent Gynecology
Preface
S. Paige Hertweck, MD
Guest Editor
Pediatric and adolescent gynecology (PAG) is a unique subspecialty of gynecology

that encompasses reproductive healthcare of young women under the age of 22.
The spectrum of conditions that a gynecologist may see present in young women
between the newborn period and adolescence is wide and varied. Many conditions
are an overlap between the fields of gynecology and pediatrics, pediatric endocrinology, hematology, urology, pediatric surgery, dermatology, psychiatry, public health
medicine and genetics.
As past president of the North American Society for Pediatric and Adolescent Gynecology (NASPAG), I have had the opportunity to interact with PAG experts across the
United States and Canada. This issue of Obstetrics and Gynecology Clinics provides
a collection of PAG topics presented by some of those physicians who have been
recognized as experts in each chosen area. These authors have been hand-selected
based on their expertise, their history, and their ability to make a complex topic understandable by all health care providers.
I am pleased to begin this issue with a written summary of one of my favorite
lectures given at NASPAG: My PAG Photo Album by Dr. Mary Anne Jamieson. In
this article, Dr. Jamieson provides a wonderful visual overview of PAG cases with
nuances and clinical pearls to assist the reader in providing the best treatment for
the presenting condition. This should stir the readers interest and enhance the reading
of the rest of the issue.
In this issue, PAG issues addressed range from disorders of sexual development,
including mullerian anomalies, to those of genital trauma and urologic conditions
that may present to the gynecologist. A helpful and practical article, The Adolescent
Sexual Health Visit, begins the latter half of this issue, and like the articles on updates
of polycystic ovarian syndrome and contraception in the adolescent, it has an overlap
with public health issues facing teens and our society today. The issue closes with
a look at hematologic conditions (both thrombophilias and bleeding disorders) that
present to the gynecologist, and dysmenorrhea and endometriosis in the adolescent.
Each author, as mentioned, was selected because of their expertise in their topic, and
by reading their articles, you should glean practical information for those young women
whom you encounter who have PAG conditions.
Obstet Gynecol Clin N Am 36 (2009) xvxvi

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Preface
Let me close with a thank you to Drs. Jamieson, Allen, Breech, Laufer, Yerkes, Merritt,
Shafi, Burstein, Lara-Torre, Pfeifer, Kives, James, Dietrich, Yee, and Templeman for
their timely adherence to a tight deadline to facilitate publication in time for the
2009 Annual Clinical Meeting of NASPAG in San Antonio, Texas, and for the 2009
Annual Clinical Meeting of the American College of Obstetricians and Gynecologists.
I would also like to acknowledge the noteworthy assistance of Carla Holloway
whose kind persistence and patient but firm demeanor has kept us on track. She is
a credit to her field. Thank you.
For those readers with further interest in PAG, please consider membership to the
North American Society for Pediatric and Adolescent Gynecology (NASPAG) or attendance at one of NASPAGs annual meetings. The mission of NASPAG is to provide
a forum for education, research, and communication among healthcare professionals
who provide gynecologic care to children and adolescents. NASPAG is a small society
of approximately 400 to 500 members making it a very collegial and interactive group.
Membership includes a subscription to the Journal for Pediatric and Adolescent Gynecology and access to a list serve to assist you with the ability to ask experts for advice
in the care of PAG patients.
I hope that you find this issue not only enjoyable, but helpful as you care for this
unique type of gynecologic patient. We have a unique role as healthcare providers
to this special population as their interaction with us is often their introduction to gynecology. A proper diagnosis, management, and positive interaction with us can
empower these young women to take charge of their own healthcare and best care
for themselves.
S. Paige Hertweck, MD
Department of Obstetrics and Gynecology
University of Louisville School of Medicine
550 South Jackson Street
Louisville, KY 40202, USA
E-mail address:
[email protected]
A Photo Album
of Pediatric a nd
Adolescent Gyne colo gy
Mary Anne Jamieson, MD, FRCSC
KEYWORDS
Images Cases Dysmenorrhea Amenorrhea
Vulvar diseases Pelvic neoplasms Pelvic mass
Mullerian ducts Pelvic pain
During the past decade as the sole pediatric and adolescent gynecology subspecialist
in a tertiary care academic center, the author has had the privilege of caring for many
patients with many problems, some common and some unique or challenging. Often
these patients and their families have allowed the author to take photographs (protecting their anonymity) with the understanding that educating health care providers is an
essential part of ensuring that other young girls who have similar conditions will
receive the care that they need. This article presents a selection of images depicting
pediatric and adolescent gynecologic conditions that, although not particularly
common, present with a relatively common complaint such as dysmenorrhea, pelvic
mass or pain, genital irritation, and amenorrhea. Health care providers who recognize
the unusual underlying condition will save patients and their families days, weeks, or
even years of misdiagnoses, frustration, fear, or even pain and suffering. When
possible, references to useful publications/articles about the particular conditions
are provided. Textbooks on pediatric and adolescent gynecology also devote full
chapters to each of these four topics.13
DYSMENORRHEA
Most cases of dysmenorrhea in adolescents represent primary dysmenorrhea; that is,

prostaglandin-mediated physiologic menstrual cramping associated with ovulatory
cycles. Because perimenarchal girls are not always ovulatory, early menstrual cycles
often are irregular and painless. Girls who do experience primary dysmenorrhea
should get relief from properly administered non-steroidal anti-inflammatory drugs
(NSAIDS), and for those who still suffer, the combined use of oral contraceptives
and NSAIDS usually suffices. When these strategies fail, or when severe pain accompanies early cycles, other underlying conditions, such as obstructive Mullerian
congenital anomalies (see the article by Breech in this issue), endometriosis (see
Pediatric & Adolescent Gynecology, Obstetrics & Gynecology (and Pediatrics), Queens University, Victory 4, Kingston General Hospital, 76 Stuart Street, Kingston, Ontario, Canada
E-mail address: [email protected]
Obstet Gynecol Clin N Am 36 (2009) 124
doi:10.1016/j.ogc.2009.01.004
Jamieson
the article by Templeman in this issue), constipation, and pelvic adhesions, should be
considered.418
Case 1: Obstructed Non-Communicating Uterine Horn (Figs. 1A, 2)
A 12-year-old complained of predominantly right-sided dysmenorrhea beginning with

menarche. She visited the emergency department with each of her first three
menstrual cycles. A routine ultrasound did not identify any abnormality, but the MRI
was classic for a non-communicating right-sided obstructed uterine horn adjacent
to a normal left hemi-uterus with patent outflow tract. After excision of the noncommunicating horn, the patient experienced only mild central dysmenorrhea that
responded well to NSAIDS. Although this horn was removed by laparotomy, laparoscopic excision is possible, depending on the junction and the surgeons comfort
and skill. Removal of the horn did leave a bed of myometrium on the left uterus that
required layered closure. Although the recommendation is controversial, the patient
was advised to discuss elective cesarean with any future obstetrics care provider
(see Case 4 and references listed regarding myomectomy and future obstetric uterine
rupture). (For a list of useful references, see the discussion of dysmenorrhea in the
previous paragraph.)
Case 2: Obstructed Hemi-Vagina with Right Hematocolpos (Figs. 1B, 36)
A precoital 17-year-old girl did not experience dysmenorrhea until 3 years after
she began menstruating. She was thought to have primary dysmenorrhea, but
instead of improving with treatment with NSAIDS and an oral contraceptive pill,
the problem seemed to be worsening. The patient began to notice intermenstrual
A
= Ovary
Fig.1. (A) Noncommunicating R uterine horn (Case 1). (B) Obstructed R Hemivagina (Case 2)
often associated with Ipsilateral Renal Agenesis (OHVIRA). (C) Uterine Didelphys with
complete longitudinal vaginal septum (Case 3).
A Photo Album of Pediatric, Adolescent Gynecology
Fig. 2. (Case 1) Non-communicating right uterine horn (RH) with unobstructed left hemiuterus (LH) with right and left ovaries (RO and LO, respectively) and normal left tube
(long arrow) with attenuated hypoplastic right tube (short arrow) to fibria remnant.
Fig. 3. (Case 2) Bulging obstructed right hemi-vagina with hematocolpos (long arrow). Short
arrow indicates the hymen.
Fig. 4. (Case 2) Evacuation of clotted hematocolpos from obstructed right-sided hemivagina.
Jamieson
Fig. 5. (Case 2) Septum (S) excision in progress.
Fig. 6. (Case 2) Two cervices (left, LC, and right, RC) at the apex of the vagina. Often at least
one cervix looks a little atypical. Note the excision suture line (arrow) is taken up as high as
possible between the two cervices.
pelvic pressure and new-onset difficulty with tampon insertion. Although an MRI
was performed, the pelvic ultrasound (done transabdominally) and gentle singledigit vaginal examination were enough to make the diagnosis of non-communicating right-sided hemi-vagina. The vagina has a capacity to expand with the
slow accumulation of menstrual blood, and symptoms and therefore diagnosis
can be delayed several months to a couple of years. Especially because the left
side of this uterine didelphys and duplicated vagina are not obstructed, early
menstrual cycles can seem quite normal. The vaginal septum was excised in
the operating room under regional or general anesthetic (Figs. 36), and every
effort was made to wedge out the base to avoid leaving a ridge of uncomfortable
remnant. The lines of excision need to be oversewn with absorbable suture in
a hemostatic fashion. After this outpatient procedure the patient had no menstrual
or coital complaints, and a single tampon sufficed. (For a list of useful references,
see the earlier discussion of dysmenorrhea.)
Case 3: Uterine Didelphys with Complete Longitudinal Vaginal Septum (Figs. 1C, 7)
In contrast to the patient in Case 2, the patient shown in Fig. 7 has a complete longitudinal vaginal septum and must wear a tampon in both sides unless she chooses to
Fig. 7. (Case 3) Introital image of complete longitudinal vaginal septum (S) with right and
left vaginas identified by arrows.
have the septum removed (performed in the same fashion as that described in Case 2).
Patients who have this condition can have obstructed hemi-vagina and ipsilateral renal
anomaly (OHVIRA) syndrome.13
Patients who have a complete longitudinal vaginal septum most often have duplication of their Mullerian anatomy. Unless they have some type obstruction of menstrual
outflow at the uterine/cervix level, they experience only primary dysmenorrhea. They
may be asymptomatic or may present with perceived tampon overflow, perceived
menorrhagia, difficulty with tampon insertion, or difficulty with intercourse. Sometimes
they present to the emergency department after intercourse has resulted in tearing of
the septum, which can bleed quite briskly and require urgent surgical repair (or
removal). It often takes an astute clinician to find the septum during the gynecologic
examination, but for patients in whom Pap smears and cervix swabs are indicated,
both cervices need to be sampled. This particular patient had two separate Mullerian
systems and had a total of two pregnancies, one in each horn. Each uterus will have an
ipsilateral fallopian tube and ovary. (For a list of useful references, see the earlier
discussion of dysmenorrhea.)
Case 4: Leiomyoma (Rare in This Age Group) (Figs. 8, 9)
A precoital 15-year-old presented with worsening dysmenorrhea that did not respond
to standard medical therapies. A single-digit gynecologic examination was limited,
and a rectal examination was normal. The transabdominal pelvic ultrasound identified an isolated 4- to 5-cm intramural fibroid, but in her age group this finding was
completely unexpected. After the myomectomy menstrual cycles were much more
tolerable. This surgery was performed by laparotomy, based on surgeons comfort
and skill, with meticulous hemostasis, layered closure, and minimal use of cautery.
Some surgeons would have chosen a laparoscopic approach. Although the recommendation is controversial, the patient was advised that future childbirth probably
should be by elective cesarean section. The medical literature has several case
reports and case series regarding laparoscopic myomectomy and the risk of uterine
rupture during subsequent pregnancies. The reported rates of rupture are low, but
they tend to be rates of prelabor uterine rupture, because many patients in the series
do undergo elective cesarean section.1929
Jamieson
Fig. 8. (Case 4) Open myomectomy in 15-year-old girl. L, leiomyoma; U, uterus.
Fig. 9. (Case 4) Leiomyoma after removal.
PELVIC MASS/PAIN
Children and teenaged girls can present with abdominal pain and abdominal masses
(Fig. 10). Ovarian masses are relatively common in this context, and the differential
diagnosis of an ovarian mass is quite broad. Most often, in this age group, the ovarian
mass represents a functional ovarian cyst (with our without hemorrhage), benign teratoma, cystadenoma, or even an unrecognized pregnancy; malignancy is far less
common.3034 When surgery is necessary, laparoscopy should be considered, and
efforts should be made to salvage/preserve ovarian tissue, even when the mass is
quite large (assuming that it is benign). The following two cases were chosen because
the first represents a relatively common cause of ovarian enlargement/mass/pain, and
the second is far rarer. They can be difficult to distinguish, but the treatment is
different.
Fig. 10. Abdomen distended by ovarian dermoid in an adolescent.
Case 5: Benign Dermoid (Teratoma) (Figs. 1114)
A peripubertal girl presented with an abdominal mass and worsening pain. An ultrasound reported a large complex mass arising out of the pelvis. One ovary was identified, but the other was not. Although removal of small dermoids is controversial, and
the surgical approach to large dermoids (laparoscopy versus laparotomy) is similarly
controversial, this patient was taken to laparotomy for dermoid cystectomy. She
did, in fact, have ovarian torsion as well (Fig. 11). The pedicle was untwisted, and
the ovarian tissue surrounding the mass and the ipsilateral fallopian tube were
preserved (Fig. 12). The ovarian bed was closed in layers with a final result similar
to the image in Fig. 13.35 Fig. 14 depicts typical contents of a benign ovarian teratoma,
including skin, hair, and a tooth.
Fig.11. (Case 5) Peripubertal child with large left ovarian dermoid (O) at laparotomy. Uterus
(U) and torted ovarian pedicle and fallopian tube (arrow).
Jamieson
Fig. 12. (Case 5) Ovarian cystectomy salvaging ovarian cortex in progress.
Fig.13. Similar to the final result achieved in Case 5, this image depicts the completion of the
ovarian cortex preservation. Closure was performed in layers (long arrow). Short arrow indicates Fallopian tube.
Fig. 14. (Case 5) Contents of typical dermoid showing skin (S), hair (H), and a tooth (T).
Case 6: Massive Ovarian Edema (Fig. 15)
A perimenarchal 11-year-old presented with abdominal pain, but she was overweight
and, in the office, no mass was appreciated. The ultrasound reported a solid-appearing mass arising out of the pelvis. Only one distinct ovary could be identified, and the
impression was that the mass represented some type of atypical ovarian neoplasm/
tumor. Under that assumption the patient was taken to laparotomy. Tumor markers
(alpha fetoprotein, lactate dehydrogenase, human chorionic gonadotropin) were all
negative.31,32 When a linear incision was made in the outer layer of this ovarian
mass and no distinct inner cyst or tumor could be identified, a small wedge excision
was made, and tissue was sent for frozen section. The report was of very edematous
but otherwise normal ovarian stroma. There was no sign of torsion. The other ovary
was entirely normal. The ovarian defect was closed, and the massive ovary was returned to the pelvis. The child was followed, and within 6 weeks an ultrasound revealed entirely normal ovaries bilaterally. A review the medical literature found
several publications describing massive ovarian edema.3644 Although some have
postulated intermitted torsion with only lymphatic and venous (not arterial) obstruction, no definite cause or etiology is known. The treatment, however, is conservative,
and efforts should be made to avoid the natural instinct to remove the gonad. This
patient did have irregular and subjectively heavy menstrual periods and was given
a combined contraceptive pill postoperatively. Whether the relative ovarian suppression aided in the regression of the edema is unclear.
GENITAL IRRITATION
Genital irritation from contact irritants/allergens, agglutination, infections, dermopathy, and other causes is quite common in childhood and adolescence. The following
cases depict less common causes of genital pain or irritation. For a review of vulvovaginal irritation in childhood, the reader can refer to any of the pediatric and adolescent
gynecology texts listed at the beginning of this article. (Although Candida is a common
cause of vulvovaginitis in women of reproductive age, it does not tend to be the culprit
for genital irritation in children. There are exceptions, such as children who have diabetes, who are immunocompromised, who have been treated recently with antibiotics, or who are in diapers. Topical antifungals can cause further irritation to the
childs vulnerable genital skin.)45,46
Fig. 15. (Case 6) Massive ovarian edema at laparotomy showing right ovary (RO), right tube
(RT), and left ovary (LO).
10
Jamieson
Case 7: Labial Hypertrophy (Figs. 16A, 16B. See also Case 13 Figs. 23, 24)
In North America today, gynecologists and plastic surgeons are seeing more and more
young females concerned about and dissatisfied with the appearance of their external
genitalia and in particular with the size of their labia minora. The natural history is for
the labia minora to enlarge and become more pigmented at puberty. There is quite
a large variation of normal size. In a small number of cases, this process is extreme,
and the redundant skin tends to trap secretions and cause pruritus or soreness.
The skin can be problematic in certain athletic activities, tampon insertion, intercourse,
and in wearing some styles of clothing. The indications for labial reduction are controversial, but when deemed necessary the procedure involves either simple linear
excision with oversewing of the cut edge (Fig. 16Aii), or segmental excision and
a pull-down swing repair (Figs. 16Ai, 16B). With the latter technique, it is extremely
Fig. 16. (Case 7) (A) Schematics showing labial hypertrophy surgical techniques. (B) Planned
right-sided V-shaped wedge excision for surgical management of symptomatic labial hypertrophy (short arrow) and completed left-sided medial suture line (long arrow). (Note:
Figs. 23 and 24 depict unilateral labial hypertrophy in conjunction with imperforate hymen.)
important to retain the blood supply by transilluminating a section before removal and
also to reapproximate medial surface to medial surface and lateral surface to lateral
surface with good hemostasis of the labial core tissue.47 If the closure imbricates
the outer labial surfaces, the repair will not take. (Note: In Case 13, Figs. 23, 24 depict
unilateral right-sided labial hypertrophy in a peripubertal, premenarchal patient. This
patient also had an imperforate hymen, but since becoming menstrual and as puberty
has progressed, she has become more symptomatic from the redundant labial tissue.
Labial reduction is being deferred until pubertal labial growth is complete, presumably
after Tanner 5 thelarche/pubarche.)
Case 8: Vaginal Foreign Body (Figs. 17, 18)
This childs presenting complaint was of vulvar burning with associated vulvar excoriation (Fig. 17). Upon questioning, there had in fact been foul-smelling vaginal
discharge for the past 4 months. Well-intentioned but somewhat misguided health
care providers had prescribed repeated courses of topical antifungals. The child
also had been given a single course of a broad-spectrum antibiotic and, although
the discharge did improve during the course of therapy, it returned quickly thereafter.
There was no history to support victimization. The child did undergo an office vaginal
lavage using a pediatric feeding tube and warm saline, but nothing was retrieved. She
gave no history of inserting anything into her vagina, and an index finger rectal examination was negative. The child was taken for examination under anesthetic, and an old
fragment that was assumed to be paper towel was removed (Fig. 18). All her symptoms resolved very quickly.
Fig.17. (Case 8) Mild vulvar excoriation (arrows) seen in a prepubertal child who had genital
burning and foul-smelling vaginal discharge refractive to conservative strategies.
11
12
Jamieson
Fig. 18. (Case 8) Old fragment of presumed paper towel retrieved from the vagina of the
child pictured in Fig. 17.
Case 9: Psoriasis of the Vulva (Fig. 19)
A prepubertal child complained of chronic external vulvar itching. Good vulvar hygiene
with daily soaks, avoidance of irritants, and other conservative measures had been
instituted, but the problem persisted. Again, antifungals were of no benefit. A trial of
over-the-counter, low-potency corticosteroid had reduced the symptoms, but treatment was sporadic. Although the child would not agree to a photograph of the vulva,
she gladly agreed to this anonymous photograph of the skin lesion behind her ear,
which was instrumental in making the diagnosis of vulvar psoriasis. The vulvar dermopathy was not quite as obvious, with less marked scaling and a shinier appearance,
but upon close examination there was patchy texturing to the labia majora. Higherpotency corticosteroid tapered to a lower-potency product for maintenance, along
with bland emollients, has eliminated her symptoms. Werlingers48 review article
and Caseys45 textbook chapter provide more information on vulvar psoriasis and
other dermatologic conditions.
Fig. 19. (Case 9) Psoriasis discovered during assessment of child who had chronic vulvar
pruritus who ultimately was found to have vulvar psoriasis.
GENITAL ULCERS
Genital ulcers in children and teens tend to cause a great deal of anxiety among the
patients, their families, and the health care providers who are called upon to assess,
diagnose, and treat the condition. Certainly Herpes simplex type I and II come to mind,
as do other sexually transmitted infections (eg, chancroid) and autoimmune conditions
(eg, Behcets disease).4955 The following three cases depict ulcers caused by vulvar
apthosis, Varicella, and Crohns disease.
Case 10: Vulvar Apthosis (Fig. 20)
In recent years a nonspecific, nonsexually transmitted condition referred to as vulvar

apthosis has been reported in children and teens. This condition probably represents
a condition reported almost a century ago and referred to as Lipchutz ulcers. A
variety of viral infections have been blamed, such as Epstein-Barr virus, Cytomegalovirus, and influenza A. This peripubertal child presented with extreme genital pain,
vulvar ulcers with associated edema, and erythema of the labia minora (Fig. 20).
She was premenarchal, precoital, and there was no history of victimization. The
outbreak was preceded by fever and malaise. The ulcers lasted 2 to 3 weeks, and
the severe pain was present for the first 10 to 14 days. She was treated with analgesics, topical xylocaine jelly, and regular tub soaks. Initially ice packs were soothing and
were thought to reduce swelling. Urinary retention was avoided by having the patient
void while soaking in warm water. Despite the look of cellulitis, antibiotics were not
used in this particular patient. It remains to be seen whether antivirals or corticosteroids will prove helpful, because current reports of their use are anecdotal and case
based.4951,5457
Fig. 20. (Case 10) Vulvar apthosis of about 5 days duration showing early eschar (long
arrow) associated labial edema and erythema (short arrow).
13
14
Fig. 21. (Case 11) Varicella zoster infection in an 8-year-old girl who had no history of chicken
pox. Note the left-sided dermatome distribution.
Case 11: Vulvar Varicella (Fig. 21)
An 8-year-old girl presented with a 5-day history of increasing pain and pruritus
involving her left vulva, buttock, and lower left limb. Her symptoms were accompanied
by fever, lethargy, and decreased appetite. Examination revealed a vesiculobulbous
rash in the left-sided vulvar and sacral dermatomes. A diagnosis of Herpes zoster/
shingles was made.
She was treated with intravenous antivirals, analgesics, and local care strategies (as
described earlier in Case 10) and was well enough for discharge 4 days later. History
revealed that the patient had never had chicken pox, but her mother had had primary
chicken pox at 36 weeks during the pregnancy. Although Herpes zoster infections are
well known, and management, as for recurrent Herpes simplex, is well described, the
medical literature contains little information summarizing strategies for treating children who have such a severe case of genital zoster.52,53,5860
Case 12: Crohns Disease Fistula (Fig. 22)
An 18-year-old had been unwell for more than 3 years. She had had biopsyproven classic ulcerative colitis and had undergone colectomy. She did have
Fig. 22. (Case 12) Crohns ulcer/fistula.
a rectal stump, and re-anastomosis was planned in the future. Unfortunately, she
continued to suffer intermittent abdominal pain and weight loss despite the colectomy and presented with a painful introital swelling that initially resembled a Bartholins abscess. The abscess began to drain spontaneously, and the site became
more ulcerated. She has subsequently been diagnosed with a Crohns rectovaginal (introital) fistula. Crohns disease is a recognized cause of genital ulcers and
fistulas. The management of these fistulas usually involves antibiotics, immunomodulators, and biologic agents before consideration of conservative surgical
repair.6164
Case 13: Imperforate Hymen (Figs. 2325)
Although imperforate hymen is not usually a cause of genital irritation, it can present
with the sensation of a vulvar or introital uncomfortable pressure or bulge (Fig. 23).
If the condition is not identified with a mini-genital examination during the newborn
or childhood period, teens tend to present with the symptoms of mucocolpos or hematocolpos (ie, pelvic pressure or pain, an abdominal mass, or urinary retention). In this
case, an astute clinician noticed that the girl had begun puberty but had not experienced her first menstrual bleed. Hymenotomy was performed in the operating room
under anesthetic. This patient presented in urinary retention because of a very large
liquefied mucocolpos (Fig. 24), but old menstrual blood is found more often. Fig. 25
depicts completion of the hymenal resection. As mentioned in the discussion of
Case 7, this patient had unilateral right-sided labial hypertrophy.
Fig. 23. (Case 13) (A) Right labial hypertrophy and (B) imperforate hymen.
15
16
Jamieson
Fig. 24. (Case 13) Draining liquefied mucocolpos. Stay sutures on imperforate hymen. Hypertrophied right labia minora (arrow).
Fig. 25. (Case 13) After hymenotomy with excision of imperforate hymen, leaving a squareshaped rim and oversewing the edge with absorbable suture for hemostasis (long arrow).
Short arrow indicates urethral meatus.
AMENORRHEA
Case 14: Acquired Colpoclesis (Fig. 26)
Unfortunately, an 16-year-old female who had factitious disorder and self-harm

demonstrated escalating behaviors and douched her vagina with a bathroom cleaning
product.65,66 Because of her mental illness, she was treated as an inpatient with daily
vaginal irrigation, estrogen vaginal cream, and a soft stent. The entire vaginal mucosa
sloughed, and she was discharged (23 weeks later) only when new, healthy vaginal
surfaces were present and the cervix could be seen clearly at the apex of the vagina.
Unfortunately she did the same thing within 24 hours of discharge and ultimately had
Fig. 26. (Case 14) Caustic vaginal douche injury with sloughing of vaginal mucosa. A, apex; I,
introitus.
a complete mid-vaginal colpoclesis similar to that performed in patients who have

graft-versus-host disease of the vagina.67 This patient was a type I diabetic and
died at age 18 years.
Case 15: Complete Androgen Insensitivity (Figs. 27, 28; Table 1)
A 16-year-old presented with primary amenorrhea. She gave no history to suggest an

endocrinopathy and gave no history of lower abdominal pain. She claimed that
secondary sexual characteristics had occurred normally, and she admitted to past
intercourse. The physical examination revealed a female with a height of 58 and
a weight of 200 pounds with Tanner 5 breasts (Fig. 27). Surprisingly, she had no pubic
hair and no axillary hair. When asked, she claimed to shave, but later recanted this
statement. The labia majora and minora were normal bilaterally, and the urethral
meatus was at 12 oclock in the vestibule under a very normal appearing clitoris
(Fig. 28). Palpation of the inguinal areas was negative; no masses were present. There
was a distensible vaginal pouch with no sign of genital ambiguity, but no cervix and no
uterus were present on either speculum examination or bimanual examination. A
presumptive diagnosis of complete androgen insensitivity was made. As expected,
her genotype was 46XY, and her testosterone level was in the normal male range.
Fig. 27. (Case 15) Full Tanner V breast development.
17
18
Jamieson
Fig. 28. (Case 15) Introitus of a patient who had complete androgen insensitivity. Note mons
with no pubic hair (M), no sign of clitoromegaly (large arrow), and normal female positioning of urethral meatus (small arrow).
Several visits took place thereafter to educate both the patient and her family about
her condition and the implications. Ultimately full disclosure took place. She was
offered counseling for the emotional, sexual, and psychologic ramifications and was
educated about the fertility/reproductive implications. She underwent laparoscopic
bilateral gonadectomy and, at least for a while, took exogenous estrogen therapy.
The patient was seen informally approximately 5 years later. She was married,
comfortably coital, and planned to adopt a child. She seemed quite well
adjusted.6878 Table 1 presents a very basic comparison of complete androgen insensitivity and Mayer-Rokitansky-Kuster-Hauser syndrome (presented in Case 16), two
Table 1
Complete androgen insensitivity versus Mayer-Rokitansky-Kuster-Hauser syndrome
Feature
Complete Androgen
Insensitivity
Mayer-RokitanskyKuster-Hauser Syndrome
Thelarche
Tanner 5
Tanner 5
Pubarche
Tanner 1
Tanner 5
Vagina (dilator
or vaginoplasty)
Blind pouch or absent

(often)
Absent (often)
Uterus
Absent
Variable
Gonads (gonadectomy) Testes Leydig cell replete

Sertoli-cell only (yes, after puberty)
Normal ovaries
(No)
Testosterone level
Normal male
Normal female
Karyotype
46XY
46XX
Associated anomalies
No
Yes: vertebral/renal
Fertility implications
No childbearing
Egg retrieval with surrogate
conditions with absent vagina and no genital ambiguity. (See also the article in this
issue by Allen on intersex disorders.)
Case 16: (Utero) Vaginal Agenesis: Mayer-Rokitansky-Kuster-Hauser
Syndrome (Figs. 2931)
A 16-year-old presented with primary amenorrhea. She was a figure skater, and
she, her family, and her health care provider always had thought she had an
element of hypothalamic delay. On the other hand, she had full pubertal development but no first menses. She did describe a monthly 1- to 2-day episode of mild
to moderate pelvic pain, usually but not always left-sided. Upon examination, no
vagina could be identified. The introital skin appeared relatively normal, and there
was an element of distensibility to that area, although she had never attempted
intercourse (Figs. 29, 30). Neither a rectal examination nor an ultrasound revealed
a uterus, but an MRI identified bilateral small masses along each pelvic sidewall
just below the pelvic brim, consistent with rudimentary uterine horns. Ovaries
also were identified in the same vicinity.
Although mittleschmertz ovulatory pain was considered a possible cause for her
pain, a 3-month course of cyclic oral contraceptives precipitated the pain reproducibly during the pill-free interval. Therefore, despite the rudimentary appearance
of the horns on MRI, the patient underwent laparoscopic bilateral uterine horn
removal, under the assumption that one or both might harbor endometrium and
that the monthly pain was a consequence of cryptomenorrhea (Fig. 31). A small
nidus of endometrium was identified on histopathology of the left horn but not
the right. She did experience minimal premenstrual syndrome molimina and occasional ovulatory pain but had no further episodes of the presumed cryptomenorrhea. The ovarian cyst seen in these pictures was not identified during the
earlier imaging; therefore it was assumed to be functional and was expected to
involute. It was left in situ.
The patient was diagnosed as having Mayer-Rokitansky-Kuster-Hauser syndrome.
She was educated, counseled, and her renal/vertebral systems were imaged. She was
instructed on the use of vaginal dilators and ultimately became coital. A very normalappearing and functional vagina was the end result. Unfortunately, a couple years later
she experienced torsion of the right ovary, and the diagnosis was missed. The ovary
became completely infarcted and since has been removed laparoscopically. Ovarian
Fig. 29. (Case 16) A patient who has vaginal agenesis. Arrow indicates urethral meatus.
19
20
Jamieson
Fig. 30. (Case 16) Distensible introitus in a patient who has vaginal agenesis. Dilator
therapy would involve a similar maneuver.
Fig. 31. (Case 16) Pelvis in a patient who has vaginal agenesis showing bilateral non-communicating horns (and right ovarian cyst). The normal left ovary (arrow) is only partially visible.
LH, left horn; LT, left fallopian tube; RH, right horn; RO, right ovary with cyst; RT, right fallopian tube.
torsion has been reported in patients who have vaginal agenesis (see the article by
Breech elsewhere in this issue).7982 Several other references on anomalies of the
reproductive tract are listed in the discussion of dysmenorrhea early in this article,
and Table 1 presents a very basic comparison of complete androgen insensitivity
and Mayer-Rokitansky-Kuster-Hauser syndrome as two conditions with absent
vagina.
SUMMARY
Although dysmenorrhea, pelvic mass/pain, genital irritation, and amenorrhea are relatively common complaints, the astute clinician needs a broad differential diagnosis to
avoid missing uncommon underlying etiologies such as: Mullerian anomalies and
cryptomenorrhea, ovarian teratomas and torsion, labial hypertrophy, vaginal foreign
bodies, dermopathies, genital ulcers, imperforate hymen, and the absent vagina.
The author hopes that these images will assist health care providers, their students,
and their patients.
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Disorder s of Sexual
Development
Lisa Allen, MD, FRCSC
KEYWORDS
Disorders of sexual development Gender assignment
Feminizing genitoplasty and surgical outcomes
Gender identity Quality of life Disclosure
Disorders of sex development (DSDs) are medical conditions in which the development of chromosomal, gonadal, or anatomic sex varies from normal and may be
incongruent with each other.1 The term DSD arose from a conference sponsored by
the Lawson Wilkins Pediatric Endocrine Society and the European Society for Pediatric Endocrinology and replaces previous terminology such as intersex disorders or
hermaphroditism, terms which in the past were part of cumbersome and/or confusing
classification systems and often not well accepted by patients and families.1 Disorders
of sexual development is a more inclusive concept, incorporating medical diagnoses
which would not traditionally have been included with intersex conditions, ie, Mullerian
agenesis.
This article primarily addresses the medical conditions where infants may be born
with ambiguous genitalia leading to decisions with regard to gender assignment.
The approach to investigations and diagnosis in the newborn period will be stressed
within an interprofessional team. Policies with regard to surgery have developed, with
techniques evolving and data emerging from long-term outcome studies. Current
medical and surgical management are reviewed. Finally, a developmental approach
to disclosure is presented.
The management of patients with DSD diagnoses requires a thoughtful contemplative health care provider. The development of gender identity may not be consistent
with the gender assigned in the newborn period and gender dsyphoria may manifest.
This awareness must be incorporated into any strategy of care. Ideally, treatment,
especially surgery (if appropriate), should be undertaken by individuals with specific
experience and training. Given the relative rarity of these conditions, an overall incidence of intersex conditions is 1:55002 (the incidence of DSD diagnoses will be slightly
higher than 1:5500, as it includes conditions not previously classified with intersex
terminology), referral of newborns, children, and adolescents for care to multidisciplinary gender teams in large centers can assist in addressing medical, surgical,
and psychosocial challenges.
Section of Pediatric Gynecology, Division of Endocrinology, The Hospital for Sick Children, 555
University Avenue, Toronto, ON Canada, M5G 1X8
doi:10.1016/j.ogc.2009.02.001
26
Allen
DISORDERS OF SEX DEVELOPMENT CLASSIFICATION AND ETIOLOGIES
Disorders of sex development may result from a heterogeneous group of etiologies.

The DSD nomenclature divides these etiologies into categories of 46XX DSD, 46XY
DSD, Sex Chromosome DSD, Ovotesticular DSD, and 46XX Testicular DSD. Within
each category specific diagnoses are made when possible (Table 1).
APPROACH TO DIAGNOSIS
In the newborn period, in particular, when an infant is born with ambiguous genitalia reflecting a possible diagnosis of a DSD, there is felt a sense of urgency to provide the
family with not only the specific diagnosis but in conjunction a gender assignment.
This urgency arises from the cultural pressures that necessitate the usual announcement of Its a boy or Its a girl to friends, family, and colleagues. However, the
complexities of diagnosis and gender assignment require time; it is extremely important
to avoid unfounded early judgments that may not be consistent with final diagnoses.
The first contacts families have with health care providers are extremely important
and are remembered. Within those first meetings the principal issue is to reassure
the family upfront about their childs overall health and well-being. It is acceptable to
acknowledge the uncertainty that exists in assigning the gender of their child. The
genital examination should be reviewed with the parents, along with providing an
education with regard to the basic embryology pertaining to sexual development.
Educational tools can be invaluable to complement verbal explanations such as developmental Web sites (http://www.sickkids.ca/childphysiology, http://dsdguidelines.
org/). Health care providers should explain the process that will be involved to investigate their child. As information becomes available, the results should be shared with
families in a timely fashion, actively involving them in the decision-making process.
Families may wish to record information sessions with the health care providers to
assist them in recall. It is important to find out who the family would like to have to
meet with the team. In some family cultures, the grandparents or aunts and uncles
may be important to include. Recommendations on the optimal management of
newborns and individuals with DSDs suggest a multidisciplinary team involvement.1,3
These interprofessional teams consist of care providers from pediatric endocrinology,
urology, gynecology, genetics, psychology, psychiatry, social work, and nursing. Each
team may function differently in consultation processes, but it is advisable to have one
individual function as a coordinator, assisting families to move through the process with
the team, providing consistency of care and information. In our center, social work and
endocrinology are often the first contacts for the family. If all team members are not able
to consult together, social work may be able to be present at most consults, helping
families to clarify information, particularly if conflicting. It is crucial to give parents the
support at this time, to decide with whom they should share information about their
babys health, outside of the parental dyad and what information to share. Ideally, all
members of the team will consult before diagnoses are made and gender assignment
suggested.
The diagnosis of DSDs involves the usual process of history, physical examination,
and investigations.
The history begins with a perinatal history inquiring to determine if there were symptoms of maternal virilization or maternal medication use in pregnancy suggesting an
exogenous (maternal) source of androgen. Antenatal karyotyping may be available if
amniocentesis or chorionic villus sampling was performed. Occasionally the diagnosis
of a DSD may occur antenatally with the discovery of a discrepancy between the
prenatal karyotype and genital anatomy on routine ultrasonography or from suspicion
Disorders of Sexual Development
Table 1
Classification and etiologies of disorders of sexual development
Category
Etiology
Diagnosis
46XX DSD
Increased fetal
adrenal androgen
production
Congenital adrenal hyperplasia

(21 hydroxylase deficiency, 11 B
Hydroxylase deficiency,
3B-Hydroxysteroid dehydrogenase
deficiency, P450 Oxidoreductase)
Androgen-secreting tumor
Ovotesticular DSD (both ovarian and
testicular tissue)
46XX SRY1 testicular DSD (SRY
translocation)
Placental aromatase deficiency
Oxidoreductase deficiency
Maternal androgen secreting tumor or
Luteoma of pregnancy
Exogeneous androgens (eg, danazol)
Dysmorphic syndromes
Mullerian agenesis
Cloacal exstrophy
Fetal gonadal
androgen
production
Fetoplacental source
Transplacental
passage of maternal
androgens
Other
46XY DSD
Testicular dysgenesis/
malfunction
Biosynthetic
defectdecreased
androgen synthesis
Deficient synthesis
or action of AMH
End organ
unresponsiveness
Other
Pure gonadal dysgenesis (XY)

Mixed gonadal dysgenesis (often 45X/46XY)
Testicular regression
Ovotesticular DSD
5 alpha reductase deficiency
Leydig cell hypoplasia or aplasia
Nonvirilizing CAH (StAR, 3 betaHydroxysteroid dehydrogenase,
17OHD/17-20 lyase, Smith-Lemli-Opitz
Syndrome)
Persistent Mullerian duct syndrome
Androgen receptor defects (complete or
partial AIS)
Dysmorphic syndromes
Hypospadius
Micropenis
Cloacal exstrophy
Persistent Mullerian duct syndrome
Sex-Chromosome
DSD
45XO Turner Syndrome

47XXY Kleinfelter syndrome
Ovotesticular
DSD
46XX/46XY
45X/46 XY (mixed gonadal dysgenesis)
Abbreviations: AIS, androgen insensitivity syndrome; AMH, antimullerian hormone; CAH, congenital adrenal hyperplasia; DSD, disorders of sexual development; SRY, sex-determining region Y.
of genital ambiguity such as a reduction in penile size, absence of a phallus, scrotal

phallic malposition, labial fusion, or indeterminate sex on second trimester ultrasound.4 A family history of other individuals affected with DSDs may allow more
detailed directed imaging or specific testing for prenatal diagnosis, ie, DNA analysis
for CYP21 (21-hydroxylase) gene in congenital adrenal hyperplasia (CAH).
The family history, as alluded to in the preceding paragraph, can assist with diagnosis. Questioning should cover not only family members such as siblings or relatives
27
28
Allen
with ambiguous genitalia (ie, X-linked conditions such as androgen insensitivity

syndrome [AIS] but also early neonatal death, or relatives with amenorrhea or infertility).
Early neonatal death in a male sibling may reflect an undiagnosed CAH condition with
salt wasting crisis. Families may not share the diagnosis of DSD with relatives but may
disclose issues of infertility. Consanguinity in the parents increases the risk of disorders
associated with an autosomal recessive pattern of inheritance such as CAH, testosterone biosynthetic defects, Leydig cell hypoplasia, and 5 alpha reductase deficiency.
On physical examination it is important to assess for features that may suggest
a dysmorphic syndrome as opposed to an isolated variation in genital anatomy. A
general assessment of health should include an assessment for dehydration, although
salt-wasting crises with CAH generally occur between the 4th and 15th day of life.
Examination of the external genitalia cannot provide a diagnosis, nor determine
gender assignment; however, it can provide evidence to exclude some diagnosis
(ie, with a palpable labioscrotal gonad, CAH in a female infant is unlikely) and is one
factor that will be considered in gender assignment.
One of the important features to assess on examination is the presence or absence
of unilateral or bilateral palpable gonads. Gonads may need to be milked down into the
labioscrotal folds, and a careful examination sweeping from the internal ring along the
inguinal canal is necessary (Fig. 1).5 Gonads that are bilaterally palpable are generally
testes, albeit they may be dysgenetic.6 In the algorithm for diagnosis (Fig. 2), the presence or absence of palpable gonads along with knowledge of karyotype will help
determine further aspects of investigation.
The further examination of the external genitalia can assist with determining the
Prader staging of the individual. The Prader scale is a determination of the degree
of virilization of the external genitalia on a scale from 1 to 5 reflecting progressive virilization of the external genitalia and the urogenital sinus. By accurately assessing the
genitalia and using descriptive terminology such as a Prader scale, health care
providers have a consistent vocabulary when making management decisions (Fig. 3).
Features to be assessed on the physical examination include phallus size, fusion of
labioscrotal folds, rugosity of labioscrotal folds, presence of a persistent urogenital
sinus, presence of a vaginal opening, and position of the urethral meatus. The phallus
should be measured for both length and width of the corporal bodies, from the base to
the tip of the glans. The full-term newborn penis should measure at least 2 cm and is
usually 3.5 0.4 cm, a phallus less than 2.3 to 3.6 cm is consistent with
Fig. 1. Palpation for gonads, milking down from inguinal canal into labioscrotal folds.
History
Perinatal
Past Medical
Family
Physical examination
Including assessment of Palpable Gonads
Karyotype
Karyotype
XX
(FISH
DX1)
Rule out CAH (17 OH progesterone)

11 deoxydrotisol
ACTH
Renin
Aldosterone
Serum and urine electrolytes
ACTH stimulation test
Karyotype
46XY
(FISH SRY)
All patients:
Gonadotropins (FSH, LH)
Androgens (Testosterone,
DHEAS,
Androstenedione)
Imgaging of genital tract
(Ultrasound and
Sinogram)
Other investigations
AMH
HCG stimulation test
ACTH stimulation test
GnRh stimulation test
Gonadal Skin biopsies
DNA mutational analysis
Other Investigations
DNA Mutational Analysis
Fig. 2. Algorithm of investigations for disorders of sexual development.
a micropenis.7,8 Clitoral size in term newborns ranges from 2.0 to 8.5 mm in length,
with width from 2.0 to 6.0 mm.9 A single opening on the perineum may suggest
a persistent urogenital sinus; imaging such as a genitogram is required to determine
the level of the confluence relative to the perineum. Fusion of the labioscrotal folds
Fig. 3. Prader scale reflecting the degree of virilization of the external genitalia. The internal
genitalia reflect the changes in the urogenital sinus that may be seen with a 46XX DSD such
as congenital adrenal hyperplasia.
29
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is evident if the distance measured from the anus to the posterior fourchette is more
than 50% of the distance measured from the anus to the phallus (clitoris). Labioscrotal
fusion and a urogenital sinus is a reflection of earlier in utero exposure to androgens,
as these events occur before 14 weeks of gestational age. In hypospadius patients, it
is important to assess the location of the urethral meatus along the ventral aspect of
the penile shaft and the degree of chordee. Hyperpigmentation of the genital skin and
nipples may reflect the excess ACTH (adrenocorticotropic hormone) and proopiomelanocortin in infants with CAH.
In preterm infants, caution must be applied in the interpretation of the findings on
external genital examination to avoid overdiagnosis of DSD, as the clitoris may appear
prominent in female infants, and descended testes do not occur before 34 weeks of
gestational age (Fig. 4).10,11
Some investigations will be applied to all individuals with DSD to assist with diagnosis, others are more specifically ordered based on results of earlier testing and
physical examination. All individuals require karyotyping on peripheral blood, initial
rapid testing is available using fluorescence in situ hybridization for X and Y chromosomes (DX1 for X, sex determining region Y [SRY] for Y) but careful assessment of the
full karyotype must be performed for definitive assessment especially to rule out
mosaicism. Imaging of the internal genital tract usually involves both ultrasound to
assess for the presence of a uterus and intra-abdominal or inguinal gonads and
also a genitogram of the urogenital sinus, to determine presence of vagina, impression
of cervix, and length of confluence (high or low urogenital sinus). Gonadotropins,
testosterone, and dihydrotestosterone are part of initial investigations.
CAH is both the most common cause of ambiguous genitalia in the newborn, with
a worldwide incidence of 1:14,50012 and is potentially life threatening, therefore
biochemical screening should be performed in any suspected 46XX DSD newborn.
Basal 17 hydroxyprogesterone will be elevated in the most common form of CAH,
21 Hydroxylase deficiency, but may not be elevated until 48 hours following birth.
Salt-wasting crises will have hyponatremia, hyperkalemia, and dehydration; therefore,
serum and urine electrolytes, renin, and aldosterone are important additional testing.
Less common forms of CAH account for only 5% of CAH and will require more definitive testing, ie, 11 deoxycortisol for 11 beta hydroxylase deficiency or elevated
17 hydroxypregnenolone and dehydroepiandrosterone for 3 beta hydroxysteroid
dehydrogenase deficiency. Borderline results may require ACTH stimulation testing.
Fig. 4. Ambiguous genitalia in an infant. Relevant clinical findings: rugation and hyperpigmentation of fused labioscrotal folds. Enlarged phallus and solitary perineal opening consistent with urogenital sinus.
More specific testing will generally be guided by the DSD teams caring for these
newborns such as gonadal or skin biopsies to determine gonadal mosaicism, androgen
receptor binding assays, and analysis of 5 alpha reductase activity. Human chorionic
gonadotropin (HcG) stimulation testing will assist with detecting defects in testosterone
biosynthesis. Antimullerian hormone measurement can indicate presence of testicular
tissue and specifically presence of Sertoli cells. Stimulation with exogeneous testosterone may determine the capacity of the phallus to respond to androgens. Molecular
genetic testing for mutations in genes involved in sex development can be performed:
CYP21A2 for CAH, androgen receptor gene for AIS, SRY gene for XY gonadal dysgenesis, and mutations in SOX 9 and WT1 gene, which are associated with dysgenetic
gonadal development and syndromes such as campomelic dysplasia and DenysDrash syndrome, respectively.3,10 Specific genetic testing is not routinely available
except in specialized centers. Despite completion of these investigations, a definitive
diagnosis may not be able to be reached in the newborn period. In one study, just under
half of DSD cases (48.7%) had no definitive diagnosis provided to newborns.13
MANAGEMENT: GENDER ASSIGNMENT
Before discussing assignment of gender, one must understand the three components
of psychosexual development. Gender identity refers to the intrinsic sense of oneself
as female or male. Gender role refers to the set of behaviors typical of one gender or
another, these will vary with context such as the surrounding culture. Sexual orientation refers to an individuals erotic responsiveness, that is the gender or genders to
whom one is attracted (homosexual, heterosexual, bisexual). Gender identity, gender
role and sexual orientation are each components and yet may be distinct.14
When assigning gender to a newborn or child, the hope is that the assigned gender
will be consistent with the developed internal sense of gender, ie, gender identity. It
should be emphasized that a variation in gender role or differences in sexual orientation does not reflect an incorrect gender assignment. For example, in young women
with CAH, gender role behaviors have been found to differ from control girls in
a more masculinized fashion, however gender identity does not differ substantially
from non-CAH control girls.1517
There are many aspects of the child that must be taken into account when assigning
gender: karyotype, gonadal function, phenotype (body habitus, Prader staging of
external genitalia), internal genitalia (ie, presence of uterus), potential for fertility and
sexuality, risk of future malignancy, and prenatal androgen influences on target tissue
(including the brain).18 In addition, information on known quality of life from long-term
outcome studies should be discussed and accounted for when assigning gender as
a newborn.
Although gender assignment should be solely based on the expected gender identity that an individual will develop over his or her lifetime, international studies indicate
that the influence of the society that the individual will be raised in plays a role. Families
living in societies that are matrilineal will be more accepting of female gender assignment than those raised in patriarchal societies. The reasons may be cultural, traditional, or economic (ie, lines of inheritance) as to why one gender may be more
acceptable to a family than the other and may reflect how men and women are treated
within that society. Even within a country, different ethnic groups may have different
views on gender assignment.19,20 These cultural, religious, and family values are additional considerations for the team before gender assignment.
Gender assignment has evolved over time. The concept of gender neutrality was
advocated in the 1950s by John Money21 who believed that an infant remained gender
31
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neutral until the age of 2, and that gender assignment along with feminizing genitoplasty surgery and an unequivocable commitment from family and health care
providers would result in formation of an internal sense of gender consistent with
that assigned. Recent awareness and knowledge indicates that whereas most individuals will be content with the gender assigned, gender dysphoria in individuals with
DSD does exist. Gender dysphoria may be sufficiently intense to result in self reassignment of gender, especially as adolescence and adulthood approach. The challenge
remains that gender assignment and accompanying medical and surgical treatments
that are applied in infancy and childhood are often disconnected from the care of individuals in adolescence and adulthood. Pediatric health care providers must manage
infants and children with DSDs with the awareness of the emerging long-term data
related to quality of life, sexuality, and psychosocial outcomes. Factors predicting
gender dysphoria have not yet been elucidated, gender identity has not consistently
been associated with genital appearance, predictors of prenatal androgen exposure
(Prader staging), nor age at surgical procedures.15,22
The prenatal androgen environment of the fetus and the acceptance of the brain as
a gendered organ have started to be taken into account in gender assignment. As an
example, in the past, individuals with a diagnosis of 46XY cloacal exstrophy were
previously assigned to a female gender because of the absence of functional male
genitalia despite normally functioning testes and androgen response in target tissues.
Current knowledge that gender identity evolves in these individuals and that 35% to
55% experience either gender dysphoria and/or have self-declared as a male identity,
has altered the practice of gender assignment.23,24 A survey of urologists indicated
that 70% would choose a male gender assignment, mostly guided by the belief of
the likelihood of brain imprinting by prenatal androgen exposure.25 However, animal
studies suggest that differences between male and female brains are not solely a result
of the prenatal androgen exposure during critical periods of brain development but
may also be influenced by sex-determining genes even before gonadal function.26
Differentiation of the human brain cells may be under sex-specific transcriptional
control mechanisms.27 Hence, the gender identity that develops in 46XY cloacal exstrophy can differ from the gender identity that develops in 46XX CAH despite prenatal
androgen exposure in both conditions.
The traditional gender assignment for some medical conditions leading to DSDs is
listed in Table 2.28
Once a diagnosis is rendered and a gender assigned, a developmental approach to
care should ensue continuing with the multidisciplinary team. An interprofessional
Table 2
Gender assignment in DSD conditions
Diagnosis
Typical Gender Assignment
46XX CAH
Female (advanced Prader stages, late diagnosis consideration

to male gender assignment)
Complete AIS
Female
XY cloacal exstrophy
Male
PAIS
Male or female
MGD
Male or female
Ovotesticular DSD
Male or female
Abbreviations: AIS, androgen insensitivity syndrome; CAH, congenital adrenal hyperplasia; DSD,
disorders of sexual development; MGD, mixed gonadal dysgenesis; PAIS, partial androgen insensitivity syndrome.
comprehensive approach will ensure that all aspects of care are addressed: medical
and surgical management, gender issues, conveyance of information, disclosure, and,
importantly, psychosocial issues. Before the introduction of an interprofessional clinic,
one center found that these issues were not addressed with consistency. Patients
previously involved with individual services had errors in diagnosis in 21% of cases,
and had gaps in care: 10% in medical/surgical management, 13% in gender issues,
33% in information and disclosure, and 38% in psychosocial issues (unpublished
data).29
SURGERY
When undertaken, feminizing genital surgery includes some or all of the following:
clitoral surgery for clitoral hypertrophy, urogenital sinus mobilization if present, labioplasty, neovaginal construction, and possible gonadectomy in XY containing
karyotypes.
Clitoral surgery has evolved considerably. Originally surgery to reduce the size of
the clitoris involved clitoral resection, owing to its obvious severe impact on sexuality,
clitoral recession replaced resection in the 1980s.29,30 Clitoral recession was technically easy, preserved full clitoral sensation but could be associated with painful erectile tissue and the presence of visible bulging corpora upon arousal. The most
commonly performed surgery presently is clitoroplasty, removing the enlarged
corpora cavernosum of the clitoris while sparing the neurovascular bundle to the
glans. Recent reports of further possible enhancement such as the corporal sparing
dismembered clitoroplasty are appearing. The latter technique splits the corpora in
the midline after detaching them from the glans, and rather than removing this erectile
tissue, buries the bodies within the labia bilaterally.31
The management of the urogenital sinus varies depending on the level of confluence. For the low urogenital sinus, where the separation of the urethra and vagina
occurs within millimeters from the introitus, a simple Y-V flap vaginoplasty can be performed (Fortunoff flap) (Fig. 5).32 Mobilization of the entire urogenital sinus is performed if the urogenital sinus confluence is within 3 cm from the perineum.33 The
excess mucosa of the mobilized urogenital sinus is used to partially construct the
posterior and lateral walls of the vagina.34 Those extremely high urogenital sinuses,
higher than 3 cm from the perineum, where the vagina may enter the urogenital sinus
proximal to the external urethral sphincter may require neovaginal reconstruction.33
The trend with feminizing genitoplasty procedures is to perform single-stage surgical
procedures, where both clitoral surgery and urogenital sinus surgery is completed at
the same point in care. Genitoplasty also involves refashioning the tissues to create
labia minora and labia majora.
Although the goals of feminizing genitoplasty are to restore anatomy achieving
a more feminine appearance with a patent vagina for menstruation and sexual function, to preserve sensation and promote sexuality, to preserve reproductive capacity,
and to prevent urologic sequelae, it is also anticipated that one of the aims is to
develop a more stable gender identity, and to promote better psychosocial and
psychosexual outcomes.13,35
It is clear that the newborn infant may not consent to decisions related to surgery in
infancy or childhood. Surgery in infancy and childhood is generally irreversible and
may impact on sexual functioning later in life.36,37 Most health care professionals
will advise deferring surgery with Prader 1 and 2 stages, as well as for neovaginal creation. It is recognized that some variations of the genitalia may never require corrective
surgery, and as a vagina is nonessential to health during the childhood ages, deferring
33
34
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Fig. 5. (A) Flap location for Y-V vaginoplasty in low urogenital sinus surgery. Adult patient
with 5 alpha reductase deficiency. (B) Initial incision for flap. (C) Further dissection of
flap. (D) Flap will then be advanced into apex of a vertical incision made in the posterior
wall of the vagina. Postoperative dilating of the blind-ended vagina will create further
length and width of the vagina.
treatment to adolescence or adulthood is logical when decisions may be made by the

individual rather than for that individual. Assessments of trends in genital surgery over
time indicate that parents are choosing to defer surgery in childhood, which in the past
was not common.28
The dilemma with regard to surgery lies with the more advanced Prader stages (III, IV,
and V) and in conditions with potential ongoing androgen action on the external
genitalia (Partial androgen insensitivity syndrome or PAIS) where female gender assignment is made (yet gender identity may not develop congruently with assigned gender).
Arguments have been made to defer surgery until an age where individuals may provide
their own informed consent (full consent policy). However, little information is yet available on the long-term outcomes of individuals where surgery is not undertaken with
respect to the influence of discordant genitalia on psychosexual and quality-of-life
measures. Most surgery in DSD children still occurs within the first year of life; in one
study, 63% of the population had surgery before the age of 6 months.38
Consent for surgery from families must include a discussion of the risks of feminizing
genitoplasty on genital function later in life (ie, adverse clitoral sensory function), risks
of gender self-reassignment, and the high likely need for further revision surgery in
adolescence or adulthood, which will be reviewed later in this article.
Most centers caring for newborns and children with DSDs practice on a spectrum of
policy between the optimal gender policy and the full consent policy with regard to
decisions for surgery, applying an individualized, family-centered, culturally sensitive,
and open-minded approach. Although surgery may be performed, a supportive environment allows families to choose to defer surgery. Several guidelines on surgery have
been published: the Consensus Statement on Management of Intersex Disorders
reflects recommendations from the Lawson Wilkins Pediatric Endocrine Society and
the European Society for Pediatric Endocrinology, the statement of the British Association of Pediatric Surgeons Working Party on the Surgical Management of Children
Born with Ambiguous Genitalia can be found at www.baps.org.uk.1
GONADECTOMY
Gonadectomy is required in some 46XY DSD conditions for two main reasons: risk of
malignancy and risk of ongoing virilization with continued androgen exposure (with
female gender assignment).
Dysgenetic gonads or intra-abdominal testes carry a varying risk of malignancy.
DSD patients are at increased risk of developing seminomas of the testes and dysgerminomas in dysgenetic gonads.39 Gonadoblastomas may occur in the dysgenetic
gonads of children.40 Less frequent gonadal malignancies include Sertoli cell tumor,
yolk sac tumor, teratoma, embryonal carcinoma, choriocarcionoma, and unclassified
sex cord stromal tumor.4145 Tumor risk can be considered as high, intermediate, or
low. The highest risk of malignancy is associated with the dysgenetic intra-abdominal
gonad, or in PAIS with nonscrotal gonads where tumor risk may range from 15% to
50%. The lowest risk is in the patient diagnoses of complete androgen insensitivity
syndrome (CAIS) and ovotesticular DSD at 2% to 3%. An example of an intermediate
risk would be a dysgenetic or PAIS intrascrotal gonad.39 The general recommendation
is to remove streak gonads where any Y-containing chromosomal material is present
in childhood including in Turners mosaicism. Turners mosaicism with a Y-containing
karyotype carries a malignancy risk of 12%.39
In women with CAIS, deferring removal of testes until after the natural process of
pubertal development avoids the need for estrogen induction of secondary sexual
characteristics for most women and allows the patient to decide about removal after
a full consent process. Malignancy risk is not only influenced by the dysgenetic nature
of the gonads and by gonad location, but also by age. The tumor risk in DSD patients
with Y chromatin material in their genetic makeup increases with age. This is particularly relevant in women with CAIS where the possibility of deferral of gonadectomy to
postpuberty is considered. In CAIS the risk of tumor formation is initially low (3.6% at
age 25) and rises to 33% at age 50.40 Rare tumors are reported young, there is a case
35
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report of a 17-month-old girl with CAIS, diagnosed with a yolk sac tumor;44 however,
rare tumors can occur in gonads of non-DSD children. Tumor risk is sufficiently low in
the first 2 decades of life for CAIS to allow postpubertal timing of gonadectomy.
The other concern with regard to retained gonads is the potential for ongoing virilization of children/adolescents assigned a female gender, ie, with PAIS and 5 alpha
reductase deficiency. In these scenarios, gonadectomy during the early neonatal
period, before the peak of gonadal function with PAIS or before puberty with 5 alpha
reductase deficiency will prevent further masculinizing genital anatomic change.
In some individuals with DSDs the gonad is contained within a hernial sac, if the
hernia requires surgical repair, gonadectomy may occur concurrently.
Gonadectomy for intra-abdominal gonads may be approached laparoscopically,
whereas for inguinal gonads, the approach is typically via an inguinal incision
(Table 3).46
MEDICAL
The discussion of the steroid management of the most common cause of ambiguous
genitalia, congenital adrenal hyperplasia, is beyond the scope of this article. Principles
of hormone replacement therapy will be presented for DSD diagnoses with female
gender. The goals of hormone replacement therapy are not only to initiate and maintain secondary sexual characteristic development (including uterine growth) but also
to allow for psychosexual development. Bone health will benefit from sex steroid
initiation and prevention of osteopenia/osteoporosis is an additional important
consideration.47
The group of DSD patients who require hormone therapy are those who are hypogonadal, ie, patients postgonadectomy, or in those with Turners syndrome and/or
premature ovarian failure. In women with CAIS who did not undergo early gonadectomy, spontaneous pubertal development will usually occur through peripheral
aromatization of androgens to estradiol, although no pubic or axillary hair will develop
owing to the androgen resistance. The presence or absence of a Mullerian structure
(ie, uterus) will determine if estrogen therapy alone is required or a combination of
Table 3
Recommendations for timing of gonadectomy in DSD conditions
DSD
Timing of Gonadectomy
PAIS (with female gender assignment)
At diagnosis, often in first 6 months of life

(concern of virilization/malignancy)
Gonadal dysgenesis with Y containing

chromosomal material, includes mixed
gonadal dysgenesis with streak gonad
(intra-abdominal)
Childhood (concern of risk of malignancy)
Androgen biosynthetic defects,

ie, 5 alpha reductase deficiency
(female gender assignment)
Prepuberty (concern of virilization at puberty)
CAIS
At diagnosis, at time of hernia repair or defer

to postpuberty for spontaneous pubertal
development (low risk of malignancy)
Gonadal dysgenesis (scrotal testis)

(male gender assignment)
Consider biopsy at puberty, may consider

sperm banking if feasible
Abbreviations: CAIS, complete androgen insensitivity syndrome; DSD, disorders of sexual development; PAIS, partial androgen insensitivity syndrome.
estrogen-progestin replacement. As hormone replacement therapy will be prescribed

consistent with previous gender assignment, its introduction to an individual should
serve as a developmental milestone where the contentedness of that individual with
their sex of rearing should be assessed. A reluctance by the adolescent to begin
hormone replacement therapy may indicate gender dysphoria with the assigned sex
and warrants a thorough, sensitive discussion.48
The timing of prescribing sex steroids will depend on the natural age of spontaneous
puberty and the influence of the surrounding peer group. Many young women will wish
to begin thelarche at a similar age to their classmates.
Final predicted adult heights should be followed. For individuals with impaired
height potential, ie, those with advanced bone ages (ie, poorly controlled CAH) or
with restricted genetic potential (Turners syndrome), benefit may result from a slight
delay in introduction of estrogen therapy. Hence, not only chronologic age but bone
age should be considered. Endocrinologists in North America most frequently base
introduction of hormone replacement therapy (HRT) on a bone age of older than 12,
and would consider a chronologic age range of 12 to 14 as appropriate.49 Newer information on final heights obtained for young women with Turners syndrome indicate no
adverse effect on final heights with low-dose transdermal estrogen regimens started
at early ages (12 to 13), and better psychoscocial outcomes than the traditional
delayed regimens (older than age 15).50,51 Estrogen replacement may be oral (estradiol or conjugated equine estrogen) or transdermal (patch or gel). The general process
is to begin at a low dose, gradually increasing over a period of several years toward the
final adult replacement regimen. The optimal young adult dose of estrogen is not clear;
our institution uses the doses of HRT in Table 4, a higher amount than for bone protection derived from studies in postmenopausal women. These doses are generally
accepted as appropriate for young adults in the premature ovarian insufficiency literature.52 The timing of incremental increase in estrogen is guided by tissue response,
ie, Tanner staging of breasts and side effects/tolerance to therapy but is generally
every 6 months. An example of a regimen of HRT is to begin with oral estradiol at
0.5 mg/day increasing by 0.5 mg/day every 6 months to a maximum dose of 2 mg/
day. Progestin therapy, if required, is introduced at 2 years of unopposed estrogen
therapy or with any spontaneous uterine bleeding. Recent concerns with regard to
HRT in postmenopausal women have resulted in increased flexibility in dosing regimens, with newer lower dose formulations available. This marketing change has
been advantageous for pubertal induction regimens. Transdermal estradiol patches
for example are now available in strengths of 25.0, 37.5, 50.0, 75.0, and 100.0 mg.
Table 4
Hormone replacement therapy in DSD conditions
Type
Final Maintenance Dose
Estrogens
Oral conjugated equine estrogen
Oral estradiol
Transdermal patch estradiol
1.25 mg/d
2.0 mg/d
100 mg/24 h (100-mg patch applied twice weekly)
Progestins (if Mullerian

structurespecifically uterus present)
Medroxyprogesterone acetate
Micronized progesterone
10 mg/d cyclically 1014 d/mo

200 mg cyclically 1014 d/mo
37
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With adolescents and young adults, switching to a combined hormonal contraceptive method may be preferable. This allows an aspect of privacy and anonymity
especially if in college/university or other shared accommodation situations where
a contraceptive method may not require explanation to peers but hormone replacements may (Table 4).
OUTCOMES
The ideal information to guide policies on the management of individuals with DSD is
long-term outcome data covering all aspects of quality of life, sexuality, fertility, and
psychosocial functioning. There are challenges with regard to interpreting the information that is beginning to become available. The most marked is that management has
evolved; surgical techniques have changed; and interprofessional teams recognizing
the importance of psychological support, family-centered care, education, and disclosure have now become the standard of care. It will be a while before we see if
improved outcomes related to these altered care plans will be evident in adult populations. It is important however not to disregard the evidence that is currently available,
recognizing that in some areas research remains sparse. These long-term outcomes
must be reflected back to the pediatric health care professionals caring for infants and
children where most management decisions are made. Many aspects may influence
long-term outcomes, including the family and culture in which the child lives, as well
as the specific diagnosis. Information on long-term outcomes has suggested that
different diagnoses may carry different prognoses in quality-of-life measures.
GENDER IDENTITY
Gender dysphoria is present in 46XY DSD conditions with normal gonadal function
and less commonly in 46XX DSD medical conditions including CAH and in other
DSD conditions. Gender dysphoria is more common with female gender assignment
than male gender assignment, although dissatisfaction with male sex of rearing can be
seen.2022
Several studies have assessed the degree of gender dysphoria and gender change
in adolescent and adult women with CAH.20,22,53 This group of individuals would have
experienced prenatal androgen exposure but not the possible gene-related sexual
dimorphism of the brain. Zucker and colleagues53 reported 5.7% (3/53) of 46XX
CAH women living in a male social role; only one of the three had self-declared
male identity, the remaining 2 individuals were assigned male gender at birth. Dessens
and colleagues20 reviewed multiple studies, comprising 250 46XX CAH individuals assigned female gender at birth, of which 5.2% experienced gender dsyphoria and 1.6%
changed gender. Gender dysphoria and gender change were not found to be related
to Prader staging. Although the rates of gender dysphoria are lower than that seen in
some 46XY DSD conditions with normal gonadal function, the reported rates are
higher than in non-DSD populations. Another study (not included in Dessens and
colleagues,20 review) included a population of patients studied in a psychosexual
development clinic, that may overestimate the incidence of gender identity issues. It
reported five of nine individuals assigned female gender at birth had self-declared
male identities for a rate of 55%.22 Information on gender dysphoria for mixed/partial
gonadal dysgenesis (22% to 55%)22,54 similarly reinforces that all individuals diagnosed with a DSD should have access to psychological counseling and follow-up,
asking questions related to gender identity, and assisting those individuals whose
self-declared gender identity is different from the assigned gender identity with their
dsyphoria especially as adulthood approaches. This may include assisting with

gender transition. A trend to more gender dsyphoria as an individual ages exists.21
Although gender dysphoria may develop with the gender assigned as a newborn to
varying degrees with different diagnoses, most individuals overall do not exhibit
gender dsyphoria; hence, in addition to genetic factors and prenatal hormone exposure, other factors such as the social environment may influence gender outcome.
When discussing generally irreversible surgical procedures with families, part of the
counseling must include awareness of the potential for gender dysphoria, with its
inherent risk of self reassignment later in life.
SURGICAL OUTCOMES
In the past several years, an increasing number of international clinics and DSD
teams have published on the outcomes of childhood surgery for the women they
care for. Recognition exists that the cosmesis of external genitalia may not reflect
the function of the genitalia. Studies that look at interim results, with only short-term
follow-up into childhood may not reflect or correlate with longer term results but at
the present time are the only measures available for assessing newer surgical techniques.29,55 Caution must be advised on interpreting these early results. The best
studies will take into account objective measures of sexual functioning at an age
where the vagina and clitoris are part of a womans sexuality as well as qualityof-life measures. The lack of rigorous definitions of complications or outcomes
along with differing medical and surgical techniques may be responsible for sometimes conflicting results.
Different surgical groups report disparate cosmetic outcomes of feminizing genitoplasty surgeries. Dissatisfaction with cosmesis from a patient perspective or objective
assessments of poor cosmetic results by health care providers ranges from 30% to
100%.56,57 Alizai and colleagues58 reported on 14 girls with CAH who were formally
assessed by an examination under anesthesia with a urologist, plastic surgeon, and
gynecologist and found in 46% the clitoral appearance was deemed to be unsatisfactory because of atrophy or absence. This value is similar to the 41% poor cosmetic
results reported by Creighton and colleagues59 in the United Kingdom after assessment of genital proportion and objective aspects of clitoris, labia, vagina, pubic hair,
and skin. The Australian experience reported by Lean and colleagues60 was more
favorable, cosmesis was reported (consistent with the Creighton and colleagues
study) as good if appearance was normal and unlikely to be judged abnormal by nonmedically trained individuals, satisfactory if there were up to two minor abnormalities
but still unlikely to be judged abnormal by nonmedically trained individuals, and poor if
they appeared abnormal or had three or more abnormal features. Using this assessment scheme, 72% had good genital appearance; however, in the detailed description
of abnormality, 25% of clitori were small, absent, or large and 38% had a small vaginal
introitus.
Repeat surgical procedures, often more minor than initial genitoplasty or vaginal
dilation, are commonly required at puberty, even with planned single-stage feminizing
genitoplasties. The results from the previous study by Creighton and colleagues59
found that 98% of their adult population required treatment, of which 77% would be
major surgical revisions. Other groups report lesser operative intervention at puberty;
major revision surgery was required in only 2 of the 32 patients assessed in an Australian DSD population; however, an additional 49% required minor introital surgery or
vaginal dilation. The most frequent reason for further therapy is vaginal stenosis,
and while not always defined in studies, stenosis implies a vagina not acceptable
39
40
Allen
for vaginal intercourse. Stenosis occurred in 11%, 36%, and 100% of the following
studies assessing outcomes of childhood feminizing genitoplasty: Eroglu and
colleagues,57 Krege and colleagues,61 and Alizai and colleagues.58
The most important message in the evolving surgical literature regarding feminizing
vaginoplasty surgery is that the outcomes are not related to the age at which surgery is
performed but are influenced by the experience of the surgeon; therefore, referrals to
centers with DSD teams and subspecialty surgeons should be mandatory before
considering feminizing surgery.60
Recent clitoral surgery has evolved to spare the neurovascular bundle when performing clitoroplasty. The clitoris is an intensely innervated structure, with capacity
to perceive light pressure, vibration, temperature, and pain.35 Unfortunately, there is
little data on the sexual function of the clitoris following surgery. There is preliminary
evidence that clitoral surgery may result in sexual dysfunction, even with newer clitoroplasty techniques. Sexual dysfunction was evident overall in a group of adult women
with DSD; however, when clitoral surgery had been performed compared with no
clitoral surgery a significantly higher rate of difficulties in sensuality and orgasm
subscales of a standardized questionnaire were evident.37 Objective assessment of
genital sensation following feminizing genitoplasty revealed abnormal results for
both cold and warm extremes of temperature when applied to the clitoris in women
with CAH compared with nonsurgical controls.36 Further evaluation of sexual function
following surgical procedures is extremely important, especially objective assessments with newer surgery techniques.
Incorporating the current knowledge of outcomes of genital surgery in childhood
into counseling of families of newborns and children with DSDs may allow families
to feel comfortable with choices to avoid surgery on lesser degrees of genital ambiguity knowing that impairment to function and sensation may occur.
In CAIS and Mullerian agenesis (MRKH syndrome), although feminizing genitoplasty
is not required, most patients will desire creation of a neovagina. The technique of
active vaginal dilatation of the existing vaginal dimple is preferred over all surgical
techniques. Although surgical procedures involving split thickness skin grafting (McIndoe procedure), colonic interposition, and laparoscopic-assisted peritoneal vaginoplasty are available, these should be reserved for the rare circumstance of failed
vaginal dilation owing to the potential for both surgical complications and stenosis,
which may occur with any surgical procedure.
PSYCHOSEXUAL OUTCOMES/QUALITY OF LIFE MEASURES
Quality of life for women includes aspects of intimacy with partners, arousal and
sexual function, as well as self-esteem, social functioning, and mental health.
Recently, quality-of-life studies are being reported on women with DSD diagnoses
compared with either illness controls or population controls. Women with DSD may
report delayed sexual milestones, fewer partnerships and sexual experiences, and
a lower level of arousal.53,54,62 Overall lower quality of life, higher anxiety, higher
frequency of suicidal thoughts, and lower self-esteem may be more frequent than in
population or illness controls.48,63 Similar to other outcome information, this cannot
be generalized to all women with DSD but may be more common with certain diagnoses, ie, CAH, mixed gonadal dysgenesis (MGD) compared with CAIS.63 Importantly,
patients may not feel comfortable bringing these issues to their health care providers
for discussion.54 Hence, psychosocial care provided by mental health staff comfortable with expertise in DSD should be integrated into the interprofessional care
team. This will allow not only recognition of challenges but can provide therapy
including addressing interpersonal relationships. Sexual therapy may be a valuable

adjunct in adulthood.
DISCLOSURE
Disclosure begins with the family at the time of the diagnosis and assessment of their
newborn with a DSD and should be considered a lifelong ongoing process that evolves
along a developmental time line. The diagnosis of DSD is both challenging to understand and challenging to explain; however, the health care team should consider
themselves as having a role in preparing the family and the child/adolescent to receive
this diagnosis when they are cognitively and psychologically prepared. In health care
teams who care for many DSD patients, the responsibility for disclosure may be
shared among team members in conjunction with the family. Guidance around disclosure may be provided by social work or other team members who have developed the
expertise to work with the family from infancy.
Helping families to correctly understand the childs diagnosis is the first step on the
road to disclosure; families should be encouraged to gather information that can later
be used to help them explain to their child decisions that were made with regard to
management. Audio files of initial consultations with physicians may prevent inaccuracies in recollection. These audio recordings can be used with the patient at a later
age when they have questions about the decisions that were made around their
medical care. Parents can be encouraged to practice telling the story of their childs
diagnosis out loud to them when they are a newborn. This practice allows for a growing
comfort level on behalf of the parents with what they may perceive as difficult information, at a time when a child cannot remember. As childrens questions arise, they
should be answered truthfully although in a developmentally appropriate way. Some
milestones in a child/adolescents life may be natural points to disclose in a stepwise
fashion about their medical history, ie, with peers onset of puberty, with sex education
in primary school, biology classes in high school, or with parenting classes. The family
should be encouraged to keep the health care team apprised of what has and has not
been disclosed to the patient. Parents may need separate appointments with the
health care team to explore and rehearse how to disclose information, as well as to
assess their own reaction to the process. It is not uncommon for parents to experience
a sense of sadness and guilt at new developmental stages of their childs life. It is
important for them to get professional mental health support if these feelings become
overwhelming. It is a myth to believe that patients are better off not being aware of their
diagnosis. The absence of disclosure can lead to angry, alienated patients who feel
betrayed by the health care team and their families.
It is very important throughout this process to offer contact with patient support
groups. Parents often feel alone and alienated, as do patients as they learn about their
conditions. The connection with a group of patients with conditions the same or
similar, is key in decreasing the sense of isolation and difference that is reported
from these populations.
SUMMARY AND FUTURE DIRECTION
Patients with DSD are infrequently encountered with an incidence 1:5500.2 Their
complex management must address medical, surgical, and psychosexual needs of
the individual patient. Evolving information suggests that thoughtful, flexible, familycentered care by specialized interprofessional teams may provide the optimal environment for care. The awareness that current management cannot eliminate all adverse
outcomes (eg, gender dysphoria, surgical complications) should drive ongoing
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research and continual reflection into the optimal care decisions. Long-term outcome
studies of newer surgical techniques, the decisions of families to not proceed with
surgery, and quality-of-life measures should continue to be objectively assessed to
further our knowledge base regarding appropriate management of DSD patients.
Continued listening to and dialoguing and collaborating with DSD patients, families,
and support/advocacy groups will also add to our understanding of this complex
condition. A developmental approach to disclosure of diagnosis to the affected individual is advocated, with age-appropriate teaching materials and educational Web
sites as useful adjuncts. Lifelong care should be offered by knowledgeable care
providers, with smooth transitions from pediatric to adult health care facilities. The
education that the health care team provides to the patient and family should be supplemented with advocacy in the public arena.
ACKNOWLEDGMENT
I acknowledge the dedicated team of health care professionals who make up the
Multidisciplinary Urogenital Clinic at The Hospital for Sick Children from whom I have
learned so much: Riyanna Babul-Hirji, MS, Darius Bagli, MD, Susan Bradley, MD, David
Chitayat, MD, Walid Farhat, MD, Genevieve Kilman, BA, CCLS, Armando Lorenzo, MD,
Barb Neilson, MSW RSW, J.L. Pippi Salle, MD, PhD, Dianne Wherret, MD, and Ken Zukker, PhD. A special thank you to Barb Neilson for her comments on the article.
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54. Szarras-Czapnik M, Lew-Starowicz Z, Zucker KJ. A psychosexual follow-up study
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45
Mlleria n Anomalies
Lesley L. Breech, MDa,*, Marc R. Laufer, MDb
KEYWORDS
Mullerian anomalies Utero-vaginal anomalies
Vaginoplasty Vaginal reconstruction
Vaginal anomalies
The diagnosis and management of girls and young women with Mullerian anomalies
requires not only knowledge of embryologic development, but an awareness of the
known associations of structural anomalies of the female reproductive tract with other
congenital anomalies, including renal anomalies and anorectal malformations. Recognition of such associations appropriately guides the diagnostic evaluation and allows
potential simultaneous operative treatment. Because reproductive anomalies are not
rare, most clinicians will encounter these abnormalities within routine gynecologic
practice and an organized discussion is advantageous for appropriate diagnosis,
management, and possible referral. Familiarity with the anomalies, associations
and optimal treatment allows providers to offer the recommended clinical care in
a timely way, avoiding unnecessary delays and potential compromise to reproductive
success.
EMBRYOLOGY
The reproductive organs in the female consist of external genitalia, gonads, and an
internal duct system, the Mullerian ducts. These three components originate embryologically from different primordia and in close association with the urinary system and
hindgut. Thus, the developmental history is quite complex. The Mullerian (paramesonephric) duct system is stimulated to develop preferentially over the Wolffian (mesonephric) duct system, which regresses in early female fetal life. The cranial parts of
the Wolffian ducts can persist as the epoophoron of the ovarian hilum; the caudal parts
can persist as Gartners ducts. The Mullerian ducts persist and, with complete development, form the fallopian tubes, the uterine corpus and cervix, and a portion of the
vagina.
About 37 days after fertilization, the Mullerian ducts first appear lateral to each Wolffian duct as invaginations of the dorsal coelomic epithelium. The site of origin of the
invaginations remains open and ultimately forms the fimbriated ends of the fallopian
Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati Childrens

Hospital Medical Center, 3333 Burnet Avenue, ML 4000, Cincinnati, OH 45229, USA
b
Childrens Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
* Corresponding author.
E-mail address: [email protected] (L.L. Breech).
doi:10.1016/j.ogc.2009.02.002
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Breech & Laufer
tubes. At their point of origin, each of the Mullerian ducts forms a solid bud. As the
solid buds elongate, a lumen appears in the cranial part, beginning at each coelomic
opening. The lumina extend gradually to the caudal growing tips of the ducts.
The paired Mullerian ducts continue to grow in a medial and caudal direction until
they eventually meet in the midline and become fused together in the urogenital
septum. A septum between the two Mullerian ducts gradually disappears, leaving
a single uterovaginal canal lined with cuboidal epithelium. Failure of reabsorption of
this septum can result in a septate uterus. The most cranial parts of the Mullerian ducts
remain separate and form the fallopian tubes. The caudal segments of the Mullerian
ducts fuse to form the uterus and part of the vagina. The cranial point of fusion is
the site of the future fundus of the uterus. Variations in this site of fusion can result
in an arcuate or bicornuate uterus. Complete failure of fusion can result in a didelphic
uterus. Although isolated case reports continue to challenge established embryologic
mechanisms of Mullerian development, additional reports are necessary to fully evaluate potential variations in embryologic development.
The vagina is formed from the lower end of the uterovaginal canal, which developed
from the Mullerian ducts and the urogenital sinus. The point of contact between the
two is the Mullerian tubercle. A solid vaginal cord results from proliferation of the cells
at the caudal tip of the fused Mullerian ducts. The cord gradually elongates to meet
the bilateral endodermal evaginations (sinovaginal bulbs) from the posterior aspect
of the urogenital sinus below. These sinovaginal bulbs extend cranially to fuse with
the caudal end of the vaginal cord, forming the vaginal plate. Subsequent canalization
of the vaginal cord occurs, followed by epithelialization with cells derived mostly from
endoderm of the urogenital sinus. Most investigators suggest that the vagina develops
under the influence of the Mullerian ducts and estrogenic stimulation. There is general
agreement that the vagina is a composite formed partly from the Mullerian ducts and
partly from the urogenital sinus.
At about the 20th week, the cervix takes form as a result of condensation of stromal
cells at a specific site around the fused Mullerian ducts. The mesenchyme surrounding
the Mullerian ducts becomes condensed early in embryonic development and eventually forms the musculature of the female genital tract. The hymen is the embryologic
septum between the sinovaginal bulbs above and the urogenital sinus proper below. It
is lined by an internal layer of vaginal epithelium and an external layer of epithelium
derived from the urogenital sinus (both of endodermal origin), with mesoderm between
the two. It is not derived from the Mullerian ducts.
CONGENITAL HYMENAL ABNORMALITIES
The normal hymen can have multiple configurations including annular, crescentic, and
fimbriated/redundant. However, failure of the hymen to perforate completely in the
perinatal period can result in varying anomalies including imperforate, microperforate,
cribiform (sievelike), navicular (boatlike), or septated (Fig. 1). Such anomalies are
ideally recognized at birth as part of the newborn examination or seen in childhood
as part of well-child genital examinations. An abnormal hymen that results in a small
orifice may preclude the use tampons, insertion of vaginal cream or suppositories,
or the ability to have vaginal intercourse. Providers should be aware that there have
been reports of familial occurrences of hymenal abnormalities, and thus alert young
women that their daughters may have a similar abnormality.1
Imperforate hymen (Fig. 2) has an incidence of 1 in 1000 and may present in
the neonatal period as hydrocolpos or mucocolpos, resulting from stimulation of the
vaginal epithelium. Significant amounts of mucous can be secreted during the
Mullerian Anomalies
Fig. 1. Septate hymen in menarchal female.
perinatal period secondary to maternal estradiol stimulation.2 The newborn may

have a bulging, translucent yellow-gray mass at the vaginal introitus. Most
hydro/mucocolpos is asymptomatic and resolves as the mucous is reabsorbed and
estrogen levels decrease. However, large hydro/mucocolpos may obstruct the
ureters, resulting in hydronephrosis or even respiratory distress. Neonatal ultrasound
Fig. 2. Imperforate hymen. Notice the thin, transparent hymen stretched over the darkcolored accumulated menstrual blood.
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can demonstrate the fluid collection. Resection of the hymen is recommended in the
symptomatic infant. Aspiration, without definitive enlargement or a vaginostomy for
continued drainage, should be avoided owing to the risks of reaccumulation with
recurrence of a mass or ascending infection. Asymptomatic girls with an imperforate
hymen can be monitored throughout childhood and avoid the risks of surgery in
infancy. The optimal time for surgery is after the onset of puberty (as evidenced by thelarche) but before menarche. The hymen should then be resected to prevent the development of hematocolpos, pain, and possible retrograde menstruation. Pubertal timing
allows adequate resection with less risk of scarring and a decrease in the potential
need for repeat procedures, given the presence of adequate on-going endogenous
estrogen. In the unestrogenized state of childhood it may be difficult to differentiate
vaginal agenesis and an imperforate hymen.
Unfortunately, the most common presentation of imperforate hymen is in a pubertal
girl with cyclic or persistent pelvic pain and an abdominal mass or perineal bulging
with a translucent bluish-tinged hymen secondary to significant hematocolpos, and
in severe cases, additional hematometra. Less commonly, mass-effect symptoms
including urinary retention or constipation are the patient complaints leading to evaluation. Hematocolpos may become quite large because the vagina is distensible and
the obstruction is so distal.
Definitive surgery should take place only after the appropriate evaluation. This
should always include an examination of the external genitalia, and a digital rectal
examination, if indicated, with radiographic imaging only as necessary to confirm
the diagnosis. Pelvic and abdominal ultrasonography will confirm a distal obstruction.
The goal of hymenotomy/hymenectomy is to open the hymenal membrane to allow
the egress of menstrual flow, tampon use, and eventually comfortable sexual intercourse. The procedure is usually performed under general anesthesia with the patient
in high lithotomy. After the usual sterile preparation and draping, a straight or Foley
catheter is used to drain the bladder and properly delineate the urethra. Stay sutures
can then be placed to provide ample traction for the hymenotomy and allow stabilization for quick insertion of a suction device to collect the copious amount of thickened,
chocolate-colored old blood and menstrual fluid. After evacuation of the hematocolpos, the hymenal orifice can be enlarged with removal of excess tissue to create an
orifice of normal size. In treatment of the imperforate hymen, puncture without definitive surgical repair should be avoided, because the viscous fluid may not drain
adequately and the small perforations will allow ascension of bacteria and the possibility of infection, such as pelvic inflammatory disease or tuboovarian abscess.
Other hymenal anomalies with some degree of perforation are rarely clinically significant in childhood. A navicular configuration may be associated with postvoid dribbling and complaints of incontinence or, in rare circumstances, recurrent urinary
tract infections. Most young women present after menarche with complaints of difficulty inserting or removing a tampon or, less commonly, with significant dyspareunia
with penetration (Fig. 3). These are also usually surgically corrected with a simple
outpatient excision.
ANOMALIES OF THE UTERUS, CERVIX, AND VAGINA
Anomalies of the female reproductive tract may result from one of several developmental abnormalities, including agenesis/hypoplasia, vertical fusion (canalization
abnormalities resulting from abnormal contact with the urogenital sinus), lateral fusion
(duplication), or resorption (septum). Clinicians should be cognizant that patients with
each abnormality will present with different symptoms, and will require specific
Mullerian Anomalies
Fig. 3. Redundant posterior hymen causing difficulty with tampon use.
individualized therapy. Common symptoms seen in uterine and vaginal malformations

include primary amenorrhea, acute and/or chronic pelvic pain, abnormal vaginal
bleeding, or a foul-smelling vaginal discharge (often worse at the time of menses).
Non-obstructive anomalies may even be found incidentally on routine examination.
Young women with obstructive anomalies are more likely to present with acute symptoms of pain and discomfort.
Genetics
The etiology of anatomic defects of the female genital tract is not fully understood.
Most forms of isolated Mullerian duct and urogenital sinus malformations are inherited
in a polygenic/multifactorial fashion. Mendelian forms of inheritance with a single gene
mutation have been described to explain specific syndromes including the McKusickLaufman syndrome (MKS), which uncommonly includes vaginal atresia and more
commonly includes transverse vaginal septa and the hand-foot-genital syndrome.1
Hand-foot-genital syndrome includes bilateral great toe and thumb hypoplasia and
small hymenal opening with various degrees of incomplete Mullerian fusion with or
without two cervices or a longitudinal vaginal septum.
Incidence
The actual incidence of Mullerian anomalies is not definitively known. Reporting issues
skew our knowledge of the true incidence. These abnormalities are relatively underreported in infants and are likely overreported in patients being evaluated for reproductive concerns, especially in adult women struggling with infertility.36 In a study of
fertile women who were evaluated for Mullerian duct anomalies at the time of tubal
ligation, an incidence of 3.2% was identified.4 Many young women may have an
underlying asymptomatic Mullerian duct anomaly; yet, since they have no pain, pelvic
mass, or reproductive compromise, they may not come to diagnosis.
Many uterine abnormalities are asymptomatic until attempts at childbearing and
thus, are often not diagnosed during adolescence. It is not until adulthood, when
patients experience multiple spontaneous pregnancy losses, persistent menstrual
abnormalities, or infertility that a definitive diagnosis is made. Patients with segmental
agenesis/hypoplasia usually present with primary amenorrhea: however, if a normally
functioning endometrium is present, significant cyclic or chronic pelvic pain may
develop. It is only if a mucocolpos significant enough to cause symptomatic
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obstruction occurs as an infant, or hematocolpos at the time of menarche, that children or adolescents with obstructive phenomenon come to diagnosis.
Diagnosis
Identification of recognizable reproductive symptoms is an important key to the diagnosis of a structural defect of the female genital tract. The symptoms include cyclic or
constant pain, pain with insertion and removal of a tampon, or the absence of menses.
A gynecologic history of amenorrhea, the inability to remove a tampon, or persistent
bleeding despite using a tampon is suspicious for a uterovaginal anomaly. Last, the
physical examination may reveal an imperforate hymen or only a vaginal dimple
with vaginal agenesis. The discovery of a blind vaginal pouch can suggest that the
Mullerian contribution to the vagina has been impaired.
Imaging Studies for Reproductive Tract Anomalies
Radiographic imaging provides much needed information to aid in making the correct
diagnosis. Delineation of the patients individual anatomy is essential to develop an
appropriate plan for surgical correction. Ultrasound is helpful in identifying the
anatomy in all cases of reproductive tract anomalies and can be used as a transabdominal, transvaginal, or transperineal approach.712 MRI can be helpful in determining
the anatomy in cases of complicated obstructive anomalies, and is often considered
the gold standard for imaging of anomalies of the reproductive tract,1316 MRI is
especially useful in determining the presence or absence of the cervix in complex
anomalies or the presence of functioning endometrium in cases of a noncommunicating obstructed rudimentary uterine horn, however, MRI may miss a rudimentary
uterine horn if it is located laterally along the psoas muscle and pelvic sidewall.17
Such a condition may be more likely in prepubertal patients who have very widely
spaced uterine horns, as seen in cloacal anomaly or cloacal exstrophy. A hysterosalpingogram (HSG) can be helpful in determining the patency of the Mullerian structures
and delineating complex communication with the urologic or colorectal system.15 An
HSG can be uncomfortable unless performed under anesthesia and should be
primarily reserved for use in older adolescents and young adults. In cases of complicated Mullerian anomalies, especially in combination with anomalies of the urologic
and colorectal systems, additional information regarding anatomy and diagnosis
may be obtained during an examination with the patient under anesthesia using
cystoscopy, vaginoscopy, laparoscopy, and/or hysteroscopy.15,18
Renal and Other Anomalies
Since the development of a normal Mullerian duct occurs in association with the
normal development of the mesonephric duct, urinary tract anomalies are the most
common abnormality associated with congenital anomalies of the female reproductive
tract.7,19 Urinary tract abnormalities in patients with Mullerian duct anomalies include
ipsilateral renal agenesis, duplex collecting systems, renal duplication, and horseshoe-shaped kidneys. In the general population, the incidence of unilateral renal agenesis has been estimated to be between 1 in 600 and 1 in 1200, on the basis of autopsy
studies.20,21 The incidence of associated genital abnormalities in female patients with
renal anomalies is estimated to be between 25% and 89%.20,22
TRANSVERSE VAGINAL SEPTUM
Transverse vaginal septa are believed to arise from a failure in fusion and/or canalization of the urogenital sinus and Mullerian ducts. Approximately 1 in 80,000 females are
Mullerian Anomalies
born with a transverse vaginal septum. The complete transverse vaginal septum may
be located at various levels (low, middle, or high) in the vagina. Approximately 46% of
vaginal septa occur in the upper vagina, 40% in the middle vagina, and 14% in the
lower vagina.23 On examination, the vagina may seem foreshortened ending in a blind
vaginal pouch. A recto-abdominal bimanual examination may elicit an abdominal/
pelvic mass. Transverse vaginal septa are rarely associated with uterine anomalies.2
The septa are usually less than 1 cm thick and may completely or incompletely
extend from one vaginal sidewall to the other. Transverse vaginal septa commonly
have a small central or eccentric perforation.24 Rarely, pyohematocolpos may be
caused by ascending infection through the small perforation. If there is no perforation
in the transverse septum, there is a resultant obstruction with hematocolpos from concealed menses; a mass is palpable above the examining finger on rectoabdominal
palpation. An obstruction with a transverse septum resulting in hematometra may
lead to endometriosis.25
Ultrasound or MRI may help define the septum and its thickness preoperatively. A
transperineal ultrasound may also confirm the thickness of the distal obstruction or
distance from the perineal skin to allow for appropriate preoperative planning. It is
also extremely important to identify a cervix, most reliably seen on MRI, to differentiate
between a high septum and congenital absence of the cervix. Management varies
between a high transverse vaginal septum and cervical agenesis, and attempts of
surgical correction of cervical agenesis have been associated with significant complications, including death.26
After menarche, patients with an obstructive anomaly present similarly; however,
patients with a high septum present more quickly with significant pain because the
uterus distends more quickly. Those adolescents with a microperforation in the transverse septum may have egress of some menstrual blood with continued discharge but
may present with pyohematocolpos secondary to ascending infection or painful
tampon insertion and dyspareunia.
Aspiration of the hematocolpos should always be avoided because of the risks of
ascending infection and pyocolpos. Definitive surgical correction is the therapy of
choice. Before surgery, some distention of the upper vagina with menstrual blood
(hematocolpos) before the development of significant hematometra may be advantageous. This allows the potential to increase the amount of upper vaginal tissue available for reanastomosis. Furthermore, preoperative dilation therapy may decrease the
thickness of the septum and increase the amount of lower vaginal tissue available.
Thin septa can then be resected followed by primary end-to-end anastomosis of
the lower and upper vagina. Thicker septa may require undermining and mobilization
of the upper and lower vaginal mucosa before anastomosis, in addition to resection of
the fibrotic septal tissue. A common complication of resection of thick septa is scar
contracture and vaginal stenosis. A circumferential Z-plasty technique allows for
scarring along the suture line to contract the incision in a longitudinal fashion rather
than a transverse one.26 Postoperatively, wearing a vaginal mold or initiating early
vaginal dilation may further decrease the risk of vaginal stenosis.27 If there is not
enough vaginal mucosa to accomplish a pull-through procedure and reanastomosis
of the vaginal mucosa, a graft may be necessary to create a patent vaginal tract.
LONGITUDINAL VAGINAL SEPTUM
Longitudinal vaginal septa may be associated with one of several uterine anomalies
including a complete septate uterus, uterine didelphi, and rarely bicornuate uteri.
Longitudinal vaginal septa have also been reported to occur in association with
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anorectal malformations, including imperforate anus with rectovestibular fistula and

cloaca.28 Septa may be partial or extend the complete length of the vagina. As
many as 20% of patients will have renal abnormalities.29 Most reproductive-age
patients present with complaints of dyspareunia and/or persistent bleeding despite
tampon use, yet many women may be asymptomatic. Prepubertal girls undergoing
evaluation and surgical management of anorectal or genitourinary anomalies are
most often asymptomatic but, because surgical exposure is best at the definitive
repair, most are treated then. The presence of a vaginal septum can usually be visualized on examination of the vaginal introitus. However, if the septum is incomplete
and does not occupy the entire vagina, vaginoscopy may be necessary to evaluate
the full extent in prepubertal patients (Fig. 4). Pelvic examination, with a speculum
examination, in reproductive-age young women is usually adequate for visualization.
Treatment is by surgical resection. Resection should be performed in childhood if
undergoing other genitourinary procedures or repair of an anorectal malformation;
however, when the vaginal septum is an isolated anomaly, it is most often corrected
after menarche owing to the later pubertal diagnosis. The septum should be
completely removed while taking care to avoid damaging the cervix or cervices, which
commonly insert along the septum at a similar level bilaterally (Fig. 5). Trauma to the
bladder, rectum, and cervical blood supply should be avoided. After resection of
the midline septum, closure of the vaginal mucosal defect is performed by suturing
the mucosal surfaces together. In reproductive-age women the use of the handheld harmonic scalpel for excision followed by reapproximation of the vaginal mucosa
with interrupted sutures is effective.
OBSTRUCTED HEMI-VAGINA WITH IPSILATERAL RENAL AGENESIS
Longitudinal vaginal septa are often present with uterine didelphis; yet in some cases an
obstructing septum is present. The association of the obstructed hemivagina with ipsilateral renal agenesis has been well described in the literature.3033 In fact, an acronym
has been proposed, OHVIRA (Obstructed Hemivagina and Ipsilateral Renal Anomaly),
to describe the syndrome.34 Patients with an obstructed hemivagina present later than
other obstructing vaginal anomalies, presumably because menstrual flow occurs normally from the nonobstructed hemiuterus.35 However, these patients also complain
Fig. 4. Vaginal septum viewed on vaginoscopy of an infant undergoing surgical repair of

a cloacal anomaly. Notice the rectal communication at the base of the vaginal septum.
Mullerian Anomalies
Fig. 5. Vaginoscopy of a prepubertal girl after repair of an anorectal malformation. She had
an associated longitudinal vaginal septum that was removed during her definitive repair.
Notice the close proximity of the two cervices and the small amount of residual septum
remaining posteriorly.
of unilateral cyclic, followed by constant, pain. There may be a microperforation allowing for communication from the obstructed to the nonobstructed side resulting in prolonged or intermenstrual discharge, or very rarely, even pyocolpos.
On physical examination, a mass is felt to bulge from the lateral wall of the vagina
toward the midline. After the pelvic examination, radiographic evaluation may also be
helpful. Ultrasound is an excellent modality to demonstrate both the uterovaginal
anomaly and the urinary anatomy.36 MRI can provide beautiful images; however, may
add significant expense (Fig. 6). Diagnostic laparoscopy is rarely necessary.34 Most
Fig. 6. MRI of the pelvis demonstrating an obstructed right hemivagina in a patient with
OHVIRA.
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patients with this anomaly can undergo resection of the obstructing septum (the
common wall of the hemivaginas) in a fashion much like that described previously for
longitudinal vaginal septa. The septal wall is resected to create a single vaginal vault.
After resection of the septal wall of the obstructed hemivagina, the patient has normal
function with a single vagina, two cervices, and two hemiuteri (uterine didelphis).
VAGINAL ATRESIA/DISTAL VAGINAL AGENESIS/SEGMENTAL VAGINAL AGENESIS
Vaginal atresia, distal vaginal agenesis, or segmental vaginal agenesis occurs when
the urogenital sinus fails to contribute to the lower portion of the vagina. The uterus,
cervix, and upper vagina develop normally, and the absent mid to lower section of
the vagina is replaced by fibrous tissue. The most common presenting symptom is
primary amenorrhea. Patients may develop cyclic or chronic pain and a pelvic or
abdominal mass as the upper vagina fills with cervical mucus secreted after puberty
or obstructed blood after concealed menarche. A physical examination confirms
normal secondary development; however, the examination of the external genitalia
reveals only a small dimple at the vaginal introitus. A rectoabdominal examination
can be helpful to determine the presence of any midline structures (a distended upper
vagina, a cervix, and/or uterus). In patients who cannot tolerate a rectoabdominal
exam, an ultrasound can provide similar information to assist in differentiating this
condition from vaginal agenesis. Ultrasonography, which should be done to assess
renal status, also can confirm the presence of an obstructed upper vagina, or the presence of a normal cervix and uterus.9 Ultrasound with a transperineal approach also will
demonstrate the thickness of the segment of agenesis which can be crucial information to guide the surgical approach; MRI is also an excellent modality to determine the
presence of a cervix and exclude the diagnosis of cervical agenesis.
In individuals with agenesis or atresia of the distal/lower vagina, an obstruction with
a hematocolpos of the upper vagina will result at the time of menarche and requires
a surgical procedure to relieve the obstruction at the time of diagnosis. This should
ideally be performed when a large hematocolpos has formed but before development
of hematometra. The hematocolpos will act as a natural tissue expander hopefully
decreasing the need for grafts. After appropriately positioning the patient, a crescentric
incision is made where the hymenal ring is or should be located. Careful dissection is
performed superiorly through the fibrous area of the absent segment taking precautions to avoid the urethra/bladder and rectum, until the bulging upper vagina is reached.
Intraoperative ultrasound guidance can be useful to identify the distended upper vagina
in difficult cases.37 The obstruction is then drained; the vaginal mucosa is identified and
a pull-through procedure brings the distended upper vaginal tissue down to the introitus. Foley catheters or urethral sounds, Hegar dilators, or simultaneous rectal examinations are all helpful to determine the limits of the vaginal dissection.
If the distance to the vagina is too great and the vagina will not reach the introitus, an
interposition graft has been used to join the introitus and upper vagina. When a bowel
graft is necessary, the technique mandates a combined abdominal and perineal
approach (Figs. 79). This surgical technique is more readily performed in childhood,
especially if it is performed in the context of more complex reconstruction, such as
genitourinary or anorectal surgery.
VAGINAL AGENESIS (MLLERIAN APLASIA)
Vaginal agenesis, Mullerian aplasia, or MRKH (Mayer-von Rokitansky-Kuster-Hauser)

syndrome all include the congenital absence of the vagina and are associated with
variable Mullerian duct development. Aplasia of the Mullerian ducts results in not
Mullerian Anomalies
Fig. 7. Intraoperative images of a patient undergoing surgical treatment of distal vaginal

agenesis. The native upper vagina would not reach to the introitus.
only absence of the uterine corpus and cervix but also the upper portion of the vagina,
which may result in near total or complete vaginal agenesis. Mullerian aplasia is estimated to occur in about 1 in 1000 to 1 in 83,000 female births, but the most widely
cited incidence is approximately 1 in 5000 female births.38 In fact, the most common
cause of vaginal agenesis is Mullerian aplasia or MRKH syndrome. Given the close
association between the genital and urinary systems throughout fetal development,
it is not surprising that approximately one third to one half of patients have associated
renal anomalies, including renal agenesis, malrotation, or ectopic kidney.3941 Other
anomalies associated with vaginal agenesis include anomalies of the skeletal and
auditory systems.
Vaginal agenesis is usually accompanied by cervical and uterine agenesis, although
approximately 7% to 10% of affected individuals may have a normal but obstructed
uterus or a rudimentary uterus with functional endometrium.4245 Vaginal agenesis
should be differentiated from vaginal atresia/distal vaginal agenesis/segmental vaginal
agenesis. Another variant, cervical agenesis or atresia, is the presence of a uterus but
agenesis of both the vagina and cervix. Approximately 90% of patients have some
degree of Mullerian development, most commonly bilateral fibromuscular uterine
Fig. 8. A segment of left colon with adequate length and blood supply was identified for use
as an interposition graft.
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Fig. 9. The colonic interposition graft was then anastomosed to the upper native vagina in
an isoperistaltic fashion to reach the introitus comfortably.
remnants located along the pelvic sidewall. However, only 2% to 7% of the uterine
remnants will have a functional endometrial lining requiring intervention.46
Most patients present with primary amenorrhea around age 15 years, given that
they have normal secondary sexual characteristics. Mullerian aplasia is the cause of
10% of cases of primary amenorrhea, second only to gonadal dysgenesis in a tertiary
care center.11 Girls with Mullerian remnants with a functional endometrium may
present with cyclic or chronic pain secondary to the accumulation of obstructed
menstrual blood.
Evaluation of the patient with near total or complete vaginal agenesis, like other
Mullerian anomalies, begins with a genital examination. Most patients will have
a vaginal dimple or very foreshortened, blind-ending vagina. The hymenal fringe is
usually present along with the small vaginal pouch, as they are both derived embryologically from the urogenital sinus (Fig. 10). A pelvic mass will usually be absent and
occasionally a peritoneal fold can be palpated on rectoabdominal bimanual examination. Transabdominal pelvic and renal ultrasound will further aid in assessing the
reproductive and urologic anatomy and frequently help to determine if a functional
Fig. 10. A view of the introitus of a patient with vaginal agenesis demonstrating the small
amount of hymenal fringe that can often be present.
Mullerian Anomalies
endometrium is present. An MRI may be more accurate in the evaluation of Mullerian

structures, but given the expense, it can be reserved for when ultrasound is indeterminate.36 Laparoscopy may be necessary if noninvasive imaging fails to make an
accurate diagnosis and it allows for the removal of obstructed uterine structures.
Furthermore, a karyotype will definitively differentiate androgen insensitivity from
Mullerian aplasia, if necessary.
Counseling
Of all the Mullerian anomalies, this diagnosis is by far the most upsetting to a girl,
young adolescent, or adult woman, and her family. Counseling by an experienced
team including nurses, social workers, psychologists and/or psychiatrists is recommended and should be strongly reinforced by the treating health care provider
when interacting with patients and families.47 Although fertility concerns, primarily
the inability to carry a pregnancy, are the overriding issue, it is also important to stress
to the young woman and her family that she has normal ovarian function with normal
production of sex steroids and normal amounts of genetic material. Emphasis on the
possibility of fertility options with assisted reproductive technologies and a gestational
carrier is crucial,46,48 in addition to confirming the ability to create a functional vagina.
Treatment
Counseling for the young woman and her family is not only the first step in treatment of
Mullerian aplasia, but likely the most important for a long-term successful outcome.
Although patients and families may be hesitant to engage in psychotherapy, attention
should be given to the psychosocial issues as well as to the correction of the anatomic
abnormality. The patients cooperation and positive attitude are vital to the ultimate
success of the creation of a functional vagina.27 The timing for the nonsurgical or
surgical creation of a vagina is purely elective, although many patients feel it is emergent at the time of diagnosis. Because this procedure is not a surgical emergency and
it is a decision with lifelong impact, surgical intervention should be delayed until the
young woman chooses to proceed with a self-selected specific treatment plan.
Because primary nonsurgical creation of a vagina requires continued vaginal dilation,
it clearly is inappropriate to consider this approach in children. Surgical procedures to
create the vagina which require postoperative dilation should not be performed during
childhood. Parents who have been instructed to dilate their daughters vagina often
present distraught and uncomfortable with the procedure. Thus, treatment should
wait until the adolescent or young woman is able to determine the treatment and
timing of the treatment. Parents may feel anxious and isolated at the time of diagnosis,
precipitating interest and inquiry regarding surgical correction. Any technique for creation of a functional vagina should be delayed until the mid to late teens when the young
woman can make her own decision, with the support of her family, and is comfortable
with and willing to participate in the process. Some women may elect never to create
a vagina. It is important to provide patients and their families with resource information
presenting all options and support regardless of the treatment selected.
Creation of a Functional Vagina
A vagina may be created by both nonsurgical and surgical approaches.49,50 A

successful outcome, using any method, is a vagina of adequate caliber (diameter
and length), with an appropriate amount of secretion or lubrication, positioned as
close as possible to an anatomic axis, to accommodate comfortable sexual intercourse. In addition, the vagina should require minimal care for maintenance. None
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of the current techniques achieves all of these goals, reinforcing the necessity to
consider advantages and disadvantages associated with each method.
Nonsurgical Repair
The nonoperative approaches attempt to use progressive invagination of the vaginal

dimple to create a vagina of adequate diameter and length. The nonoperative method
of creating a functional vagina involves the use of pressure against the vaginal dimple
to create a progressive invagination of the mucosa. The Frank approach for creation of
a vagina involves the use of graduated hard dilators.21 The use of vaginal dilators
should be offered as first line of therapy to patients with this condition. The rationale
for this approach is related to the elimination of surgery, surgical scars, and exposure
to anesthesia. Recent studies have shown that the use of dilators is greater than 85%
to 90% successful for the creation of a functional vagina.51,52 It may take months to
years to create a functional vagina depending on patient motivation and the frequency
of dilation. The Ingram modification of this technique,43 which involved sitting on
a bicycle seat stool, took an average of 11.8 months with a range of 3 to 33 months,
but more than 90% were successful in dilation.44 Although this modification is an interesting adaptation of the Frank method, many young women initially find this technique
very awkward. However, as the vagina gains length it can be helpful. The greatest
success can be achieved through a combination of education, nursing support,
mental health counseling, and a mentor program.
Surgical Repair
Surgical creation of a neovagina is another option for young women who fail nonoperative dilation therapy or who choose surgery after a thorough discussion with the
patient (and parents/guardians as indicated) regarding the advantages and disadvantages. Surgical creation of a vagina can be accomplished by one of several techniques.1,53,54 Discussion should fully describe that many surgical techniques will
require postoperative dilation to maintain vaginal adequacy. Generally, surgery should
not be used as a first-line option. Many young women are interested in a quick fix
and think that surgery will achieve this goal. The goals of surgery are to create a neovagina that is of adequate length and width and placed in an anatomically correct axis
to provide comfortable, mutually satisfying sexual intercourse. Ideally the neovagina
should not require exogenous lubrication, continued postoperative dilation, or have
significant surgical complications. Currently, there are multiple operations appropriate
for the creation of a neovagina in patients with vaginal agenesis but no consensus on
the best approach. The procedure of choice should also be determined by the
surgeons experience and success with the procedure because reoperation increases
the risks of injury to surrounding organs.
-McIndoe is the most commonly performed surgical technique
The modified Abbe
by gynecologists in the United States. It involves harvesting a split-thickness skin graft
from the patients buttocks and placing it over a vaginal mold. An incision is made at
the vaginal dimple and adequate space created to the level of the peritoneum for the
mold and graft. The labia minora are then temporarily sewn together to prevent the
mold from expulsion. The patient is then placed on strict hospital bed rest for 7
days.55 The mold is then removed and the patient wears a stent continuously for 3
to 6 months, then nightly for an additional 6 months. The patient then must perform
regular dilations, continuously wear the surgical mold, or engage in vaginal intercourse
to prevent skin-graft contracture and loss of the neovagina. This technique is felt to
have a greater than 80% functional success rate.56 However, it leaves the patient
Mullerian Anomalies
with a potentially disfiguring scar from the donor site. Other complications include
graft failure, wound infection, hematoma, and fistula formation.
-McIndoe technique but
More recently, investigators have used the modified Abbe
substituted other tissues as graft material to avoid unsightly graft site scarring. They
include artificial dermis with human recombinant basic fibroblast growth factor spray,57
autologous buccal mucosa,58 Interceed absorbable adhesion barrier (Ethicon, Inc,
Somerville, NJ),59 and human amnion.60,61
The modified laparoscopic Vecchietti procedure creates a dilationlike neovagina in
7 to 9 days. It involves placement of an acrylic 2-cm olive-shaped bead onto the
vaginal dimple that is gradually pulled superiorly by threads laparoscopically placed
that are then connected to the traction device placed on the patients abdomen.
The threads are then gradually tightened approximately 1.0 to 1.5 cm per day for
a week.62,63 Postoperatively, the patients must comply with daily vaginal dilation until
regularly sexually active.
The laparoscopic Davydov technique uses the patients own pelvic peritoneum to
line the neovagina. It involves dissection of the perineum to create a neovaginal space
while laparoscopically mobilizing the peritoneum. The peritoneum is then sutured to
the introitus and a purse-string suture closes the cranial end of the neovagina.62,64
A vaginal mold is left in situ for 6 weeks and the patient then begins daily dilation until
regularly sexually active. Complications related to laparoscopic injury and fistula
formation have occurred; however, patients report similar sexual function to women
with a native vagina.65
Patients who fail nonoperative dilation therapy or those seeking little to no postoperative upkeep may be candidates for a bowel vaginoplasty. Bowel vaginoplasty is the
preferred method of most pediatric general surgeons, given the immediate and longterm correction of the anomaly. Each bowel segment has advantages and disadvantages. Other than the consideration given to a segment of adequate length and its
ability to reach the perineum, the segment chosen should not interfere with fecal continence or the ability to perform necessary simultaneous reconstructive procedures.
Bowel vaginoplasty is performed by selecting an approximately 10-cm segment of
bowel that can be mobilized but retain an adequate vascular pedicle to reach the perineum without traction on the pedicle or graft. It may be placed in an isoperistaltic or
antiperistaltic fashion in the space dissected from the perineum to the pouch of Douglas between the bladder and rectum.66,67 Most authors advocate anchoring the proximal bowel neovagina to avoid graft prolapse.6871
Sigmoid vaginoplasty has been the most commonly used bowel segment, given its
proximity to the perineum and therefore little difficulty performing a tension-free anastomosis to the introitus. The sigmoid also produces mucous that acts as a natural
lubricant. However, some patients have found it excessive and at times malodorous
requiring postoperative neovaginal irrigation. Patients do not require routine vaginal
dilation given the large lumen, but the anastomosis at the perineum may stenose.
As long as the introitus at least retains some patency, this can be addressed after
puberty with an outpatient introitoplasty (Fig. 11). The disadvantages include the
need for a laparotomy (and the resultant scar) unless a skilled laparoscopist is available who can isolate an adequate vascular pedicle.72 Also included in this procedure
are the inherent risks of wound problems at the bowel anastomosis and graft prolapse
or even failure.
When an adequate segment of colon is not available for vaginoplasty, small bowel
has been used. It is more difficult to mobilize to the perineum, has a smaller lumen,
produces excessive mucous, and may be less durable when exposed to the potential
trauma of sexual intercourse.65 Complete stenosis has also been reported.73
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Fig. 11. An introital view after creation of colonic neovagina.
Postoperative sexual satisfaction has been assessed in a validated fashion in only

a relatively small number of patients who underwent bowel vaginoplasty. Communal
and colleagues68 administered the standardized Female Sexual Function Index to
16 patients, and Hensle and colleagues73 administered a validated Female Sexual
Dysfunction Questionnaire to 44 patients. Eight of the 11 who responded and who
were sexually active reported a 75% very satisfied rate, whereas 78% of the 36
who responded endorsed sexual satisfaction, respectively.
The Williams vulvovaginoplasty uses full-thickness skin flaps from the labia majora,
creating a neovaginal pouch.74 Vaginal dilators are then inserted daily postoperatively
for a month. Unfortunately, the kangaroolike pouch is positioned at an anatomically
odd angle and may have a relatively short length. Furthermore, the labia majora is
hair-bearing skin, which will usually result in undesirable cosmesis. Attempts to avoid
some of these concerns have included preoperative labia majora tissue expanders,
the Creatsas modification, and substituting labia minora.7578
Full-thickness skin grafts also have been performed using the myocutaneous rectus
abdominis or gracilis and pudendal thigh fasciocutaneous flaps. Although potentially
necessary in patients with more diffuse anomalies, like cloacal exstrophy, these neovaginal grafts are usually one of last resort for a diagnosis of isolated vaginal agenesis
given the disfiguring scarring and risks of harvest site wound concerns and graft
failure.
RUDIMENTARY UTERINE HORNS
Since approximately 7% to 10% of patients with vaginal agenesis (Mullerian aplasia)

may have a rudimentary uterus with some functional endometrium and no outflow
tract, it is important to maintain a high index of suspicion for an obstructed rudimentary uterine horn as a cause for recurrent pain in patients with this diagnosis. Ultrasound and/or MRI may be useful in identifying the noncommunicating uterine horn
and determining whether functional endometrium is present, as evidenced by a visible
endometrial stripe. Not uncommonly, laparoscopy is necessary to diagnose and remove the obstructed rudimentary noncommunicating uterine horn. Patients who
have any obstruction to menstrual flow, including an obstructed uterine horn, are at
Mullerian Anomalies
increased risk of endometriosis, but experts believe the endometriosis resolves after
relief of the obstruction. Early identification and excision of a blind rudimentary horn
will prevent endometriosis by eliminating reflux of menstruation. If a rudimentary is
horn is known to be present, patients should be counseled about symptoms of an
ectopic pregnancy and the need for immediate evaluation, because spontaneous
pregnancies have been reported.79
CERVICAL ATRESIA/HYPOGENESIS
Cervical agenesis and dysgenesis are rare54,8082 but are extremely important to
differentiate from diagnoses like transverse vaginal septum or vaginal atresia/
segmental vaginal agenesis. A correct diagnosis allows appropriate counseling before
surgical intervention as the classic management recommendation for this condition is
hysterectomy. Patients may present with primary amenorrhea, cyclic or chronic
abdominal or pelvic pain, and/or a distended uterus. Ultrasonography can aid in
defining the anatomy, yet an MRI allows superior identification of the presence and
integrity of the cervix.18 The adequacy of the cervix is the crucial part of the decision
to leave the uterine structure in place and anastomose to the native lower vagina or
a newly created vagina. The diagnosis and management of this Mullerian anomaly
are both challenging and controversial.
DISORDERS OF THE UTERUS
Complete Uterine Septum
The septate uterus has a smooth, normal external surface at the fundus, but the endometrial cavity is split into two by a midline septum. Most uterine fusion/duplication
abnormalities do not require surgical intervention; however, the septate uterus is
well known for the associated obstetric concerns. If patients experience pain, recurrent miscarriage, infertility, or premature labor, the abnormality should be repaired
by hysteroscopic resection.8389 The situation is more controversial in young women
in whom the diagnosis is made in late adolescence or early adulthood. The decision to
surgically intervene before attempts at pregnancy still remains unclear. The presence
of a concomitant vaginal septum may influence the timing of intervention. A combined
approach may be considered.
Bicornuate Uterus
The uterine fundus is deeply indented, often heart-shaped, in patients with a bicornuate uterus. In most cases, a single cervix is present. The level of the indentation of the
fundus can be complete, partial or arcuate. Historically, treatment in the form of a metroplasty, had been recommended. Presently, no surgical intervention is recommended and patients are followed closely for obstetric concerns. In most cases the
vagina is normal.
Unicornuate Uterus
A unicornuate uterus is a single uterine horn that has only a single round ligament and
fallopian tube, sometimes referred to as a hemiuterus. The opposite uterine horn (hemiuterus), round ligament, and fallopian tube, derived from the opposite Mullerian duct,
may be absent or underdeveloped. Variations in the degree of hemiuterine development can occur producing a noncommunicating uterine horn (hemiuterus) on the
contralateral side with or without active endometrium. A single unicornuate uterus
communicates with a single cervix and a normal vagina. As suspected with unilateral
impairment in Mullerian development, associated renal anomalies are common.
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Patients with a unicornuate uterus are at increased risk of premature labor and breech
presentation.42,90 As in other obstructive anomalies, endometriosis and subsequent
fertility issues may be significant in patients with an associated obstructed uterine
horn or hemiuterus.
PREGNANCY OUTCOME IN WOMEN WITH MLLERIAN DUCT ANOMALIES
Women with Mullerian duct anomalies seem to have an increased rate of unexplained
infertility, endometriosis, spontaneous abortion, breech presentation, and premature
delivery.5,9194 More long term outcome data are necessary to fully determine the
obstetric prognosis of women with Mullerian duct anomalies associated with other
urogenital or anorectal malformations. Women who have had vaginal atresia/lower
vaginal agenesis/segmental vaginal atresia corrected by the creation of a neovagina
are able to become pregnant and to maintain a pregnancy, if a well developed cervix
and uterus are present. Patients with vaginal agenesis always should be counseled
regarding opportunities for adoption and surrogacy. The wider use of assisted reproductive technologies also will enhance the reproductive capacity of women with
congenital abnormalities of the reproductive tract.
ADDITIONAL READING
Laufer MR, Goldstein DP, Hendren WH. Structural abnormalities of the female reproductive tract. In: Emans SJ, Laufer MR, Goldstein DP. Pediatric and Adolescent
Gynecology (Fifth Edition), Philadelphia: Lippincott Williams & Wilkins Publishing
Company, 2005. p. 334416.
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38. Pellerito JS, McCarthy SM, Doyle MB, et al. Diagnosis of uterine anomalies: relative accuracy of MR imaging, endovaginal sonography, and hysterosalpingography. Radiology 1992;183:795800.
39. Oppelt P, Renner SP, Kellermann A, et al. Clinical aspects of Mayer-RokitanskyKuester-Hauser syndrome: recommendations for clinical diagnosis and staging.
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41. Strubbe EH, Willemsen WN, Lemmens JA, et al. Mayer-Rokitansky-Kuster-Hauser
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43. Ingram JM. The bicycle seat stool in the treatment of vaginal agenesis and
stenosis: a preliminary report. Am J Obstet Gynecol 1981;140:86773.
44. Roberts CP, Haber MJ, Rock JA. Vaginal creation for mullerian agenesis. Am
J Obstet Gynecol 2001;185:134952.
45. von Rokitansky KE. Ober die sogenannten Verdoppelungen des Uterus. Med Jb
Ost Staat 1938;26:39.
46. Evans TN, Poland ML, Boving RL. Vaginal malformations. Am J Obstet Gynecol
1981;141:91020.
47. Rotmensch J, Rosenshein N, Dillon M, et al. Carcinoma arising in the neovagina:
case report and review of the literature. Obstet Gynecol 1983;61:5346.
48. Simpson JL. Genetics of the female reproductive ducts. Am J Med Genet 1999;
89:22439.
49. Scanlan KA, Pozniak MA, Fagerholm M, et al. Value of transperineal sonography
in the assessment of vaginal atresia. AJR Am J Roentgenol 1990;154:5458.
50. Suidan FG, Azoury RS. The transverse vaginal septum: a clinicopathologic evaluation. Obstet Gynecol 1979;54:27883.
51. Cramer DW, Ravnikar VA, Craighill M, et al. Mullerian aplasia associated with
maternal deficiency of galactose-1-phosphate uridyl transferase. Fertil Steril
1987;47:9304.
52. Fedele L, Dorta M, Brioschi D, et al. Magnetic resonance imaging in Mayer-Rokitansky-Kuster-Hauser syndrome. Obstet Gynecol 1990;76:5936.
53. Hauser GA, Schreiner WE. [Mayer-Rokitansky-Kuester syndrome. Rudimentary
solid bipartite uterus with solid vagina]. Schweiz Med Wochenschr 1961;91:
3814 [In German].
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54. Nussbaum Blask AR, Sanders R, Rock JA. Obstructed uterovaginal anomalies:
demonstration with sonography. Part II: teenagers. Pediatr Radiol 1991;179:848.
55. McIndoe A. The treatment of congenital absence and obliterative conditions of
the vagina. Br J Plast Surg 1950;2:25467.
56. Klingele CJ, Gebhart JB, Croak AJ, et al. McIndoe procedure for vaginal agenesis: long-term outcome and effect on quality of life. Am J Obstet Gynecol
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57. Noguchi S, Nakatsuka M, Sugiyama Y, et al. Use of artificial dermis and recombinant basic fibroblast growth factor for creating a neovagina in a patient with
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58. Lin WC, Chang CY, Shen YY, et al. Use of autologous buccal mucosa for vaginoplasty: a study of eight cases. Humanit Rep 2003;18:6047.
59. Motoyama S, Laoag-Fernandez JB, Mochizuki S, et al. Vaginoplasty with Interceed absorbable adhesion barrier for complete squamous epithelialization in
vaginal agenesis. Am J Obstet Gynecol 2003;188:12604.
60. Ashworth MF, Morton KE, Dewhurst J, et al. Vaginoplasty using amnion. Obstet
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61. Nisolle M, Donnez J. Vaginoplasty using amniotic membranes in cases of vaginal
agenesis or after vaginectomy. J Gynecol Surg 1992;8:2530.
62. Ismail IS, Cutner AS, Creighton SM. Laparoscopic vaginoplasty: alternative techniques in vaginal reconstruction. BJOG 2006;113:3403.
63. Veronikis DK, McClure GB, Nichols DH. The Vecchietti operation for constructing
a neovagina: indications, instrumentation, and techniques. Obstet Gynecol 1997;
90:3014.
64. Langebrekke A, Istre O, Busund B, et al. Laparoscopic assisted colpoiesis according to Davydov. Acta Obstet Gynecol Scand 1998;77:10278.
65. Giannesi A, Marchiole P, Benchaib M, et al. Sexuality after laparoscopic Davydov
in patients affected by congenital complete vaginal agenesis associated with
uterine agenesis or hypoplasia. Humanit Rep 2005;20:29547.
66. Karateke A, Gurbuz A, Haliloglu B, et al. Intestinal vaginoplasty: is it optimal treatment of vaginal agenesis? A pilot study. Surgical method of sigmoid colon vaginoplasty in vaginal agenesis. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:
405.
67. OConnor JL, DeMarco RT, Pope JCT, et al. Bowel vaginoplasty in children:
a retrospective review. J Pediatr Surg 2004;39:12058.
68. Communal PH, Chevret-Measson M, Golfier F, et al. Sexuality after sigmoid colpopoiesis in patients with Mayer-Rokitansky-Kuster-Hauser Syndrome. Fertil Steril
2003;80:6006.
69. Ekinci S, Karnak I, Ciftci AO, et al. Sigmoid colon vaginoplasty in children. Eur
J Pediatr Surg 2006;16:1827.
70. Khen-Dunlop N, Lortat-Jacob S, Thibaud E, et al. Rokitansky syndrome: clinical
experience and results of sigmoid vaginoplasty in 23 young girls. J Urol 2007;
177:110711.
71. Parsons JK, Gearhart SL, Gearhart JP. Vaginal reconstruction utilizing sigmoid
colon: complications and long-term results. J Pediatr Surg 2002;37:62933.
72. Darai E, Toullalan O, Besse O, et al. Anatomic and functional results of laparoscopic-perineal neovagina construction by sigmoid colpoplasty in women with
Rokitanskys syndrome. Humanit Rep 2003;18:24549.
73. Hensle TW, Shabsigh A, Shabsigh R, et al. Sexual function following bowel vaginoplasty. J Urol 2006;175:22836.
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74. Williams EA. Congenital absence of the vagina: a simple operation for its relief.
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75. Chudacoff RM, Alexander J, Alvero R, et al. Tissue expansion vaginoplasty for
treatment of congenital vaginal agenesis. Obstet Gynecol 1996;87:8658.
76. Creatsas G, Deligeoroglou E. Expert opinion: vaginal aplasia: creation of a neovagina following the Creatsas vaginoplasty. Eur J Obstet Gynecol Reprod Biol 2007;
131:24852.
77. Creatsas G, Deligeoroglou E, Makrakis E, et al. Creation of a neovagina following
Williams vaginoplasty and the Creatsas modification in 111 patients with MayerRokitansky-Kuster-Hauser syndrome. Fertil Steril 2001;76:103640.
78. Purushothaman V. Horse shoe flap vaginoplastya new technique of vaginal
reconstruction with labia minora flaps for primary vaginal agenesis. Br J Plast
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79. Lodi A. [Clinical and statistical study on vaginal malformations at the Obstetrical
and Gynecological Clinic in Milano, 190650.] Ann Ostet Ginecol 1951;73:
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80. Bates GW, Wiser WL. A technique for uterine conservation in adolescents with
vaginal agenesis and a functional uterus. Obstet Gynecol 1985;66:2904.
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detecting pelvic structures in cases of vaginal agenesis. J Pediatr Adolesc Gynecol 2002;15:1014.
82. Willemsen WN. Combination of the Mayer-Rokitansky-Kuster and Klippel-Feil
syndromea case report and literature review. Eur J Obstet Gynecol Reprod
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83. Coney PJ. Effects of vaginal agenesis on the adolescent: prognosis for normal
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Urolo gic Issues

in the Pediatric
and Adolescent
Gyne colo gy Patient
Elizabeth B.Yerkes, MD
KEYWORDS
Urinary tract infection Incontinence Enuresis
Vulvovaginitis Constipation Dysuria
Interlabial mass Biofeedback
Based on the close proximity of the organ systems and difficulty in localizing symptoms, there is natural overlap between the fields of pediatric and adolescent urology
and gynecology. This article lends the urologists perspective on perineal pain, repetitive posturing or perineal compression, vulvovaginitis, vaginal discharge, and interlabial masses. The fine points of obtaining an elimination history are shared, and the
management of recurrent urinary tract infection (UTI) and UTI-type symptoms is discussed. The spectrum of daytime incontinence and elimination disorders is outlined
to guide initial management in these challenging patients. A somewhat surprising
role of constipation, or functional fecal retention, in genitourinary complaints recurs
throughout the article (Box 1). The benefits of learning pelvic floor relaxation, through
basic voiding modification or formal biofeedback therapy, for management of genitourinary complaints are addressed. Two review cases are included at the end of the
article to put the history and physical examination to work.
The reader should understand that evidence-based management of these
complaints continues to evolve, with new terminology and classification systems at
every turn.1,2 The term dysfunctional elimination syndrome replaced the term dysfunctional voiding as we gained an appreciation of the close relation between urinary
symptoms, constipation, recurrent UTIs, and vesicoureteral reflux.1 New terminology
was recently presented by the International Childrens Continence Society (ICCS),2
and further updates are likely forthcoming. This article is intended to provide a practical
guide for initial evaluation and management of the common issues. An effort is made
to include current (in italics) and some more familiar terminology to avoid confusion.
Regardless of the terminology, it is important to pinpoint the specific issues for any given
child so that the program may be tailored to her needs. Successful therapy is
Northwestern Universitys Feinberg School of Medicine, Division of Urology, Childrens

Memorial Hospital, 2300 Childrens Plaza #24, Chicago, IL 60614, USA
doi:10.1016/j.ogc.2008.12.006
70
Yerkes
Box 1
Constipation and the pediatric and adolescent gynecology patient
Recurrent UTI or UTI-type symptoms
Daytime incontinence
Repetitive posturing or perineal compression
Perineal pain
Vulvovaginitis, recurrent or persistent
Lichen sclerosus
time-intensive, in the office and by telephone, but clinical progress yields great dividends
in terms of the self-esteem and social adjustment of the child or teen with urinary issues.
NEUROPHYSIOLOGY OF THE GENITOURINARY TRACT
A limited review of pelvic neurophysiology and reflex mechanisms is a relevant prelude

to any discussion of genitourinary issues. Voluntary control of micturition requires
modulation of sacral reflex pathways by the brain stem. Storage and elimination
involve the sacral parasympathetic and somatic nerves. Urine is stored at low pressures, based on the viscoelastic properties of the bladder. During filling, there is
a normal increase in sphincter tone. The first step of voluntary micturition is relaxation
of the striated urinary sphincter. Without relaxation of the external sphincter, coordinated or synergic micturition cannot occur.3 This highlights the importance of pelvic
floor relaxation in the pediatric and adolescent gynecology (PAG) patient who has
urinary complaints. Nonrelaxation or overactivity of the pelvic floor can be learned in
response to a painful stimulus, stressful social circumstances, or psychologic disturbance.4 Active sphincter contraction during a bladder contraction (detrusor external
sphincter dyssynergia) is, however, highly suspicious for a neurologic process and
should be thoroughly evaluated.5
Sensory information from the external genitalia and rectum also travels along the
sacral nerve roots. This relation accounts for the common association of genitourinary
and fecal issues and explains some of the difficulties in localizing genitourinary symptoms. Sensation and function are impaired to varying degrees in children with abnormalities of the conus medullaris, distal spinal canal, or sacral nerve roots (ie, tethered
cord syndrome, sacral agenesis).
EVALUATION OF GENITOURINARY COMPLAINTS
A comprehensive elimination history should be obtained to establish a diagnosis and

direct management. Unfortunately, the child or teen is often embarrassed and affected
by comments from peers or family members. The emotionally charged situation is
further complicated by difficulty in localizing and articulating associated symptoms.
A supportive rapport is important, but straight talk for the child and parent is also
necessary to maintain a working relationship.
The history should include daytime voiding habits, nighttime continence, fluid intake
and diet, frequency and quality of bowel movements, and any posturing or holding
behaviors noted. The childs altered perception of time, combined with the parents
lack of specific knowledge of the childs independent toilet habits, also makes the
accuracy of the initial information suspect.
Completion of an intake and elimination diary is a useful tool for all parties to understand the situation. From a practical standpoint, this is best accomplished on
Urologic Issues in the PAG Patient
weekends, but elimination habits may differ at home and at school. The patient and
parent should be provided with a sample diary (Table 1) and a urine hat or other
measuring device. Timing and quality of bowel movements should be recorded. Fluid
intake is an important element, because bladder sensation is impaired by slow bladder
filling.
It is also useful to learn how incontinence episodes are being handled by the parent
and child. Is the child hiding underwear? Are absorptive pads or garments used? Have
others noticed an odor or made unhelpful comments? Have there been punishments?
Eliciting a history of developmental or behavioral conditions and diagnoses is important, because these conditions may affect the childs ability to achieve continence and
may limit the providers ability to obtain a clear history. It may have an impact on her
recognition of or response to bladder activity, as in attention-deficit/hyperactivity
disorder, sensory integration disorders, developmental delay, spastic quadriplegia,
and spinal dysraphism. Spastic quadriplegia may affect her ability to get to the bathroom in time. A history of sexual abuse, another major traumatic life event, or an
underlying behavioral or psychiatric diagnosis would indicate a need for early involvement of child psychology in the treatment program.68
Any concerns regarding the childs development or any changes in her coordination
or stamina may suggest a neurologic influence. Significantly delayed ambulation in an
otherwise developmentally normal incontinent child could suggest occult spinal dysraphism or tethered cord. Back, buttock, or posterior leg pain or changes in gait could
suggest a tethered cord. Acute vision changes or changes in sensation or coordination
could also suggest a neurologic condition.
After eliciting a full history and gaining the confidence of the child and parent,
a comprehensive examination is completed. Special attention is given to the abdomen,
genitalia, spine, and lower extremities. The abdominal examination may reveal a distended or painful bladder or palpable stool in the lower abdomen. Examination of the
genitalia would detect any congenital anomaly, inflammation, mass, evidence of trauma
or abuse, or urine pooled within the vaginal vault. The anus is inspected for lesions and for
general tone and anal wink, but a formal digital examination is not typically warranted.
The entire spine is screened for neurocutaneous abnormalities, such as a dimple, hairy
tuft, vascular malformation, lipoma, skin appendage, or short or asymmetric gluteal cleft
Fig. 1. Assessment of the lower extremities includes general coordination and sensation,
symmetric tone, deep tendon reflexes, development of the calf muscles, and contour of
the pedal arch, again looking for suggestion of a neurologic process.
A clean-catch urine specimen should be obtained on all voiding patients. A urinalysis with microscopy screens for glucose and protein, and it allows quantification of
hematuria, pyuria, and epithelial cells. A culture is obtained if infection is suspected
based on symptoms or history. Consider repeating the specimen before treatment if
Table 1
Elimination diary
Date Time Food intake Fluid intake
Amount of Bowel
Other
(eg, 1 slice
(eg, 8 oz of
urine
movement
(Dry, damp,
of pizza, 1
milk, 12 oz of
voided
(Large and
wet, soaked;
apple)
cola)
(oz)
hard, small
urgency; pain;
hard pebbles,
bowel
hot dog)
accident;
potty dance
or other
posturing
71
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Yerkes
Fig.1. Neurocutaneous abnormality of the lumbosacral spine. Arrow demonstrates hairy tuft
overlying vascular patch.
the urinalysis and culture results are inconsistent, particularly if the urinalysis seems
benign but the culture is positive.
Although not necessarily warranted during initial management of genitourinary
complaints, there are several radiologic studies that may be elected. Adequacy of
bladder emptying can be assessed by ultrasound (Fig. 2). Imaging of the kidneys by
ultrasound or a voiding cystourethrogram would be indicated only in the setting of
febrile or recurrent urinary infection or high suspicion for an anatomic or neurologic
abnormality.
A plain film of the abdomen is useful in assessing the fecal load and its role in the
patients complaints, although there is no universally accepted classification and there
is some variability in correlation with symptoms.9,10 Attention to the rectal impaction
and the amount of formed stool throughout the colon is important (Fig. 3). The abdominal radiograph may also reveal a gross bony abnormality in occult spinal dysraphism
or sacral agenesis (Fig. 4). Use of a visual aid, such as the Bristol Stool Scale, to help
the child describe the stool,11 in combination with a thorough elimination diary, is
usually adequate. The parent, however, may require firm radiographic proof of constipation to comply with medical therapy.
Transabdominal ultrasound for measurement of the rectal diameter is gaining attention as a tool for diagnosing constipation and monitoring therapeutic progress.12,13
Fig. 2. Longitudinal ultrasound view of modest postvoid residual volume (B) and large rectal
fecal load (R).
Fig. 3. Abdominal radiograph to assess fecal load. Note extensive stool in the rectum and
throughout the colon.
The diameter is measured in the transverse view when at least 3 hours have passed
since the last bowel movement and if there is no acute urge to defecate. A mean diameter of 4.9 cm in constipated children versus 2.1 cm in controls has been demonstrated, although there is some crossover in diameter between clinically constipated
children and normal children.12 Office ultrasound and digital rectal examination are
equally efficacious in diagnosing fecal impaction, limiting the indication for digital
examination. Ultrasound could eliminate further radiographs or unpleasant examinations as the childs progress is monitored, and it could provide visual proof of constipation for the skeptical parent.13
Fig. 4. Abdominal radiograph to assess fecal load demonstrates sacral agenesis.
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Yerkes
COMMON ISSUES IN THE PEDIATRIC AND ADOLESCENT GYNECOLOGY PATIENT:

THE UROLOGISTS PERSPECTIVE
The following complaints are seen in the urology office and the PAG office. Note that
constipation figures prominently for each complaint. Suggestions for management of
constipation are discussed elsewhere in this article.
Perineal Pain
Evaluation of perineal pain should begin by determining if the pain is related to urination (dysuria) or if it is seemingly random. If dysuria is present, attempt to determine
whether there is primarily pain as the urine hits the perineum (external dysuria) or
whether there is suprapubic discomfort or urethral burning (internal dysuria). This
distinction is difficult for younger patients to understand. Once infection is ruled out,
application of a bland ointment, such as vitamin A and D containing petrolatum-based
ointment, provides a barrier to moisture and protects the tissues. Hydration to reduce
irritation from concentrated urine may also be helpful.
It is important to determine whether some element of constipation is present.
Habitual withholding of defecation with increased pelvic floor tone can result in perineal discomfort and dysuria. Constipation can lead to an overactive bladder or
a large-capacity bladder with poor sensation and poor emptying.14 Bladder spasms
associated with the overactive bladder may be experienced as pain at the urethral
meatus. Provide a visual aid, such as the Bristol Stool Scale, to help the patient
describe her stools.11 If no such aid is readily available, food analogies, such as
grapes, Baby Ruth, or hot dog, are easily understood. Large soft stools daily
or large soft stools more than once daily could also indicate a significant fecal load.
Query regarding potential injury, including prior severe dermatitis or vaginitis, traumatic radiologic testing, anal fissure, and sexual abuse. Examination for vaginal
discharge and for evidence of trauma or abuse is performed. While examining the perineum, ask the child to put one finger on the painful area. Intense pain or hypersensitivity with otherwise normal-appearing tissue may suggest a pain syndrome or
neuropathy.
Repetitive Posturing or Perineal Compression
Posturing is typically a response to uninhibited bladder contractions associated with

an overactive bladder or with postponement of urination. The parent may have
observed the posturing or repetitive behavior for years but never connected it to postponement of urination. Vincents curtsy is the classic maneuver in which the child
suddenly squats, pressing a heel into the perineum. The child may fidget, dance,
hold the genitalia, or freeze with the legs pressed together or crossed. The posturing
may occur in a standing, seated, or squatting position. Each of these maneuvers
directly compresses the perineum or contracts the pelvic floor to abort the bladder
contraction reflexively and prevent loss of urine. Although aware that an urgent event
has occurred, the child may subsequently deny the need to visit the toilet.
Vulvovaginitis and Vaginal Discharge
Evaluation and management of constipation should be part of the management of

vulvovaginitis as well. Constipation is commonly present in children who have bacterial and nonspecific vulvovaginitis and anogenital dermatologic conditions.15,16 If the
vaginitis is chronic and painful, the child may learn to withhold bowel movements
for fear of pain, further aggravating the constipation and perineal colonization with
coliform bacteria.
If the constipation is not addressed, the child may be refractory to conventional

treatments. Adherence to a consistent bowel program results in remission of bacterial
vaginitis.16
Lichen sclerosus of the anogenital region most commonly presents with pruritus,
but constipation is present in more than 60% of these cases.15 Failure to recognize
and treat the constipation may further aggravate this chronic dermatologic condition.
An ectopic ureter to the distal urethra, perineum, or vagina should be included in the
differential diagnosis for an infant with episodic thick vaginal discharge. The typical
presentation of constant dampness from an ectopic ureter is not discernable in children before toilet training.
Interlabial Masses of Urethral Origin
A variety of interlabial masses present during early childhood, most of which are benign
lesions. Attention to presenting features and local landmarks typically allows the diagnosis without radiographic evaluation. Several of these lesions are related to the vagina,
but several are urethral in origin. These lesions are briefly discussed in this section.
Paraurethral cysts or Skenes cysts typically present in infancy as a smooth whitish
painless paraurethral mass with fine overlying vessels. The lesions result from obstruction of the paraurethral gland ducts. The eccentric position of the cyst may cause deviation or splaying of the urinary stream or may deform the anterior vaginal wall. Most
lesions rupture spontaneously or resolve within the first several months. If the cyst
persists or is symptomatic, simple incision or needle aspiration results in full resolution
as well.17
A rather large purplish congested mass fills much of the vestibule in cases of
prolapsed ureterocele. The ureterocele has an eccentric position that may make it
difficult to visualize the urethral meatus, but labial retraction reveals a normal hymen.
The prolapse can result in bladder outlet obstruction or urosepsis if bacteriuria is
present. Ectopic ureteroceles are typically associated with the upper pole of a duplicated system and naturally distort the bladder outlet. If the diagnosis is in question,
renal and bladder ultrasound can guide initial management.17 Before onset of congestion, the acute prolapse can reduce spontaneously. Urgent urologic consultation is
indicated for any prolapsed ureterocele.
Urethral prolapse most commonly presents with bloody spotting in the underwear,
although dysuria, urinary retention, and perineal discomfort occur in some girls. The
prolapse may be circumferential or partial; in circumferential prolapse, the tissue
resembles a congested donut surrounding the urethral meatus. Focal ischemia may
be present Fig. 5. Four- to 5-year-old African-American girls are the most commonly
affected. The shearing of mucosa is not well understood but may be attributable to the
prepubertal hypoestrogenic state or straining. A recent history of coughing or constipation is often elicited. Conservative therapy consists of sitz baths, management of
constipation, and application of a short course of conjugated estrogen cream or emollients to help the tissue recess. Surgical excision is indicated in the event of necrosis,
refractory inflammation, or persistent symptoms after conservative therapy.17
URINARY TRACT INFECTION AND URINARY TRACT INFECTION TYPE SYMPTOMS
UTIs are one of the most common medical issues addressed by pediatric urologists.
The first step in management is to ascertain whether there is truly infection or whether
there are only UTI-type symptoms, such as external dysuria, urinary frequency, urinary
urgency, and urge incontinence. The behavioral modifications used to treat UTIs and
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Fig. 5. Urethral prolapse.
UTI-type symptoms are essentially the same, but antibiotic therapy (treatment or
prophylactic) or radiographic evaluation would be reserved for true infections.
As previously discussed, abnormal voiding habits, constipation, and UTIs are
closely related.1,9,10,18 Infections and abnormal elimination occur in a vicious cycle.
As a result of painful urination during an infection, the child may learn to postpone
urination. Postponement may increase the risk for recurrent infection, but the pelvic
floor contraction used to postpone urination may result in incomplete and high-pressure voiding and inefficient defecation (Fig. 6). Constipation further impairs the
efficiency of urination14 and may increase perineal colonization, thereby increasing
the risk for infection and so on. Constipation could be the entry point for this cycle
as well. Constipation can result in unstable bladder contractions (overactive bladder),
involuntary loss of urine, poor coordination of micturition, and a large-capacity bladder
Fig. 6. Spinning top urethra on voiding cystourethrogram suggests incomplete relaxation

of pelvic floor during urination.
with inefficient emptying (underactive bladder). Invagination of the posterior bladder

wall, mechanical obstruction of the bladder outlet, irritation of the trigone, and
impaired bladder contractility by shared neural pathways are potential means by
which rectal distention from constipation can affect bladder function (Fig. 7).14,19
Vesicoureteral reflux is also commonly present in children who have a UTI. In most
cases, the reflux is identified during radiographic evaluation of a first UTI. In general,
infection does not cause vesicoureteral reflux, and reflux does not cause a UTI. The
presence of reflux, however, complicates UTIs by allowing the bacteria access to
the upper urinary tract. In cases of high-grade (high volume) reflux, urinary stasis
occurs as refluxed urine returns to the bladder again after voiding. Bacteriuria may
be more difficult to clear when urinary stasis is present. Abnormal elimination habits
decrease the likelihood of spontaneous resolution of vesicoureteral reflux and also
increase the likelihood of UTIs.1,14
Common causes of UTIs in girls include poor fluid intake, infrequent or inefficient
urination, and constipation. Close proximity of the urethra to the vagina and rectum,
the short female urethra, and inherited bacterial adherence factors increase the risk
for infection. These factors cannot be changed, making efficient elimination of urine
and stool more important in girls.
Fluid intake is important for several reasons. Intake drives urine production, which,
in turn, results in more timely urination and clearance of bacteria from the lower urinary
tract. Water intake is one cornerstone of the management of constipation.
Infrequent urination may not be easily remedied in the child who has progressed
from postponement of urination to a large underactive bladder, but the more rapid
bladder filling with increased fluid intake helps to restore the sensation of bladder filling
necessary to initiate urination. Timed trips to the restroom (timed voiding) at least every
2 hours during the day is one early intervention for children and teens with UTIs and
other urinary complaints.
Fig. 7. (A) Stool in rectum deforms the bladder base and bladder outlet on voiding cystourethrogram. (B) Profound rectal distention (R) noted on MRI to rule out tethered cord. Rectal
distention can impair bladder contractility by shared neural pathways.
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Inefficient urination may be attributable to incomplete sphincter relaxation or poor

bladder contractility. Repositioning on the toilet to optimize relaxation of the external
sphincter and pelvic floor is taught at the first visit and reinforced at return visits
(Fig. 8). One must appreciate that this position may be difficult or embarrassing to
assume at school, given the lack of foot support and the need to remove undergarments completely. It is important to sit on the toilet at school and to continue voiding
at timed intervals, however. A Valsalva maneuver to release urine is discouraged
because it tightens the pelvic floor.14 Other relaxation techniques, such as yoga
breathing, blowing bubbles, and counting slowly, may be helpful.
Biofeedback for pelvic floor retraining is effective for children whose elimination
habits are refractory to the previously discussed measures. This noninvasive therapy
involves electromyographic (EMG) monitoring of the external sphincter complex by
means of perineal patch electrodes. Uroflowmetry is used to assess the quality of
the urinary stream, and ultrasound is used to check postvoid residual volumes.
Multiple sessions are used to help the child identify the appropriate muscles and practice relaxation of the complex. The afferent EMG output can be linked to interactive
computer games, with the game controlled by contraction and relaxation of the appropriate muscle groups. Progress is measured by the game score.20
Anecdotally, children who have been particularly affected emotionally by their elimination issues seem to thrive during the one-on-one sessions with the provider and
take pride in their progress. Biofeedback therapy has been shown to improve daytime
incontinence, abnormal voiding patterns, constipation, and other urinary complaints.
Resolution or improvement of vesicoureteral reflux is also enhanced with this therapy.21
Management of constipation is much more art than science. Each child has a unique
constitution and response to medical intervention. Basic principles of adequate water
intake, increased dietary fiber, and timed toileting with support of the feet apply to all
children. Specific recommendations for dietary fiber intake (age 1 5 g for normal children and twice that for constipated children)14 may be difficult to achieve in picky
Fig. 8. Repositioning on the toilet for pelvic floor relaxation and for management of vaginal
reflux.
eaters or younger children, but tasteless fiber supplements are available over the
counter. Time should be set aside for toileting 30 minutes after a large meal to take
advantage of the gastrocolic reflex. This quiet time may help the child to become
more aware of descent of stool within the rectum. The feet should be positioned so
that the angle between the upper and lower leg is 90 to allow pelvic floor relaxation.
Valsalva maneuvers or straining to push the stool out is discouraged, because the anal
sphincter closes with this maneuver.14
There are several other options for bowel management, and the program should be
tailored to the childs needs and progress. Experience and preferences of the provider
and willingness of the family to accept elements of the program play a role in the
regimen as well. Adjustments in the program should be made every 2 to 3 weeks as
needed rather than on a daily reactive basis. Polyethylene glycol powder is used by
many pediatric urologists and is well tolerated by the patient. Cramping and diarrhea
are the most common side effects that complicate treatment in some children.22 A
gradual upward titration of the daily dose to achieve the optimal result may minimize
these side effects. In more severe cases, impacted stool in the rectosigmoid colon
may be addressed with enemas for 1 to 2 days before starting an oral bowel program.
Rectal suppositories, mineral oil, magnesium hydroxide solution (Milk of Magnesia),
and senna laxatives are also commonly used.14 Each child needs a unique program
and requires follow-up to keep the family on track. Referral to a pediatric gastroenterologist for troublesome cases is appropriate.
SORTING OUT DAYTIME INCONTINENCE
As with any condition, an accurate history is extremely important in the management

of daytime incontinence. Various nontechnical terms, such as wetness, accidents,
dampness, leakage, or dripping, may be better understood than incontinence.
Beyond establishing the interval of urination and adequacy of fluid intake from the
elimination diary, it is important to characterize the timing and severity of incontinence.
Children who have never achieved daytime continence may have an anatomic abnormality, such as an ectopic ureter or female epispadias with bladder neck incompetence Fig. 9. Neurologic impairment or developmental issues may also result in
primary incontinence. Secondary onset of incontinence after toilet learning should
also raise concern for a neurologic process, but behavioral issues or poor elimination
habits are a far more common cause of secondary incontinence.
It is useful to distinguish damp panties from accidents that soak through the undergarment and outer layer. Although many children are reluctant to give specific details,
it is important to know whether the child is bothered enough to change clothes or wear
a pad during the day or whether the child barely seems to notice wet clothing. A desire
to become dry is essential as the treatment program gets underway.
Timing of involuntary urine loss and potential associated activities should also be
noted. The following terminology is consistent with the most recent ICCS guidelines.2
Wetness that occurs while the child is busy playing or that occurs only at home or
only at school suggests voiding postponement, a behavioral issue that can result in
true bladder dysfunction. Stress incontinence is uncommon in children in the absence
of a neurologic or anatomic abnormality. Incontinence associated with laughing, crying,
coughing, or while playing sports may, however, be attributable to overflow of urine after
voiding postponement. Giggle incontinence describes centrally mediated complete
bladder emptying associated with laughing or another strong emotion. The condition
is believed to be related to cataplexy and may be attributable to an imbalance between
cholinergic and monoaminergic input. Methylphenidate has been used successfully to
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Fig. 9. (A) Ectopic ureteral meatus on thicked anterior rim of hymen. (B) Female epispadias.
Arrow indicates anteriorly-placed vagina. Note bifid clitoris and patulous urethra.
manage this challenging condition,23 but many families are not willing to consider this
medication. Others believe that strong bladder contractions can be precipitated by
laughter and that most giggle incontinence occurs in girls with other daytime symptoms. These researchers support use of anticholinergic medication for management
of giggle incontinence.24 Incontinence that occurs only within 10 minutes of finishing
on the toilet is mostly likely attributable to vaginal reflux of urine during urination.
Getting a true idea of the childs sensation and awareness of impending or recent
incontinence can be difficult because the child often seems uncertain how to answer
or may experience incontinence in more than one setting. The child may also fear
repercussions based on her answer. It is important to establish a supportive rapport
and make the child aware that her answers are important in correcting the situation.
The parent often perceives that the child does not feel anything, particularly if the child
failed to interrupt her activities or if she continued to wear wet garments. If the parent
witnesses posturing or holding behaviors, a strong urgency or a bladder contraction
has likely occurred.
If the child indicates that she is aware of the need to urinate at the last minute but
cannot make it to the restroom in time, the condition may be overactive bladder
(bladder instability) or voiding postponement. If she first feels something as the urine
is coming out, stress incontinence or overflow incontinence with an underactive
bladder is the more likely situation. If she reports that she feels nothing until the underwear is soiled, she may be experiencing vaginal reflux or overflow incontinence with an
underactive bladder. If she does not seem to feel anything or notice that she is wet,
there may be a neurologic basis for the impaired sensation. Developmental or behavioral concerns should be strongly considered as well. A differential diagnosis for
daytime incontinence is listed in Box 2.
Because of the close relation between elimination habits, UTIs, and daytime incontinence, the management of daytime incontinence is rather similar to the management
of UTIs. In addition to hydration and treatment of constipation, timed voiding is
a reasonable early recommendation for all patients with daytime incontinence.25
Repositioning on the toilet is important to improve pelvic floor relaxation and to minimize vaginal reflux of urine. Biofeedback is used for more difficult cases.
Box 2
Differential diagnosis of daytime incontinence
UTI
Overactive bladder
Voiding postponement
Vaginal reflux
Giggle incontinence
Sphincteric incompetence (anatomic or neurogenic)
Ectopic ureter
Behavioral or developmental
The use of anticholinergic medications to reduce bladder overactivity or alphablockade to improve outlet relaxation should be reserved as second-line therapy after
modification of elimination habits. Medications are now infrequently recommended as
empiric management of daytime incontinence.2,25 Radiographic evidence of adequate
bladder emptying is desirable before a trial of anticholinergic medication, and the child
must continue to adhere to the timed voiding program. Alpha-blocker therapy should
be considered as an alternative to biofeedback in the management of urinary retention
and voiding dysfunction.26 The medication is well tolerated, and the therapy is far less
time-consuming for the family. Combination therapy of alpha-blockade and biofeedback is useful in refractory cases.27
SPECIAL TESTING
Specialized testing is not required in most children with the complaints addressed in
this article. Children who fail to improve with behavioral management or in whom the
diagnosis is not clear may benefit from further testing.
An MRI scan may be ordered when there is a high suspicion for occult spinal cord
pathologic findings. Because of its ability to image fluid-filled structures without the
use of contrast, MRI is effective for detection of an ectopic ureter associated with
a poorly functioning renal unit.
Formal urodynamic testing is indicated for refractory daytime incontinence or in
complicated cases without an obvious etiology.28 This specialized test provides information regarding sensation, capacity, storage pressure, contractility, leak or voiding
pressure, residual volume, and sphincter activity. Several of these data points are
available with much less invasive testing, including the elimination diary, postvoid
ultrasound, and noninvasive uroflow. Formal urodynamic testing is located near the
end of the algorithm for patients with elimination concerns. Similarly, cystoscopy
has limited indications in children who have infections, incontinence, or other dysfunction of elimination.29
SUMMARY
There is significant overlap between urology and pediatric and adolescent gynecology. A detailed history is essential to establish a diagnosis and formulate an appropriate treatment plan. The emotional subtitles accompanying many of these
complaints are important to recognize. Tremendous support and compassion are
required for many of the girls and their parents. With more scientific data available
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each day, management of voiding issues and recurrent UTIs is becoming less art
and more science, but individualization of therapy is likely to remain important in
the management of this diverse group of girls.
REVIEW CASES
Review Case 1
An 8-year-old girl is brought to the office by her parents with the concern that she
grabs her vagina often in public. She has done this since she toilet trained with
some difficulty at the age of 2 years. When confronted by her parents, she says her
bottom hurts. She has daytime accidents at least twice per week, and she always
runs to the restroom at the last minute, especially when busy playing. The parents
have also noted that the child suddenly stops and stares or squats down when playing. After a few minutes, she resumes normal activities. She has had at least two UTIs
and often complains of pain with urination. The parents report that the bowel movements are normal.
Examination reveals normal prepubertal genitalia with the exception of deep
erythema of the vestibule without discharge. The anus is normal. Examination of the
spine and extremities is normal.
After your assessment is complete, which medication would most likely address the
childs situation?
A.
B.
C.
D.
E.
Oxybutynin (anticholinergic)
1% hydrocortisone to the vulva
Methylphenidate
Trimethoprim-sulfamethoxazole prophylaxis
Polyethylene glycol
Review Case 2
A 6-year-old girl presents with intermittent thick vaginal discharge without pruritus. As
a thorough elimination history is elicited, the mother notes that the child is toilet trained
but has always been a little damp during the day and is wet every night. She voids five
to six times daily. The girl is not certain why she is wet, because there is no warning.
The mother has not witnessed any posturing to suggest voiding postponement. There
is no loss of urine with coughing, laughing, or gymnastics. The bowel movements are
type 4 and 5.11
On examination, there is mild erythema consistent with nonspecific vulvovaginitis
but no frank discharge. The clitoris is normal. With outward retraction of the labia,
a small amount of fluid is noted in the vagina. There is no foreign body. There are
no abnormalities of the lumbosacral spine or lower extremities.
Which of the following pairs of diagnoses remain in your differential?
A.
B.
C.
D.
E.
Giggle incontinence and constipation

Occult spinal dysraphism and stress incontinence
Voiding postponement and epispadias
Vaginal reflux and ectopic ureter
Constipation and stress incontinence
ANSWERS TO REVIEW CASES

Review Case 1
The answer is E. Several of the reported behaviors suggest that the child is having
uninhibited bladder contractions or spasms. She aborts the bladder contraction by
squatting or freezing in position and squeezing the pelvic floor. The parents describe
a form of Vincents curtsy, one of several postures used by these girls to postpone
urination. Empiric treatment with anticholinergic medication covers up the underlying
problems and is not indicated at this point. Although the parents report normal bowel
function, only the child is in a position to describe the stools and can do so when
provided with a visual aid11 or other familiar terms. This child most likely has constipation or functional fecal retention contributing to the bladder contractions, UTIs, and
vaginitis. If an adequate history cannot be obtained, a plain film of the abdomen should
identify constipation. Polyethylene glycol is one option for initial management of constipation, but fluid and fiber are essential as well. Although topical agents soothe and
treat the vaginitis, bland ointment is likely a better choice than topical corticosteroids
in this case.
In addition to management of constipation and timed voiding, biofeedback is likely
to be beneficial for this child to learn appropriate pelvic floor relaxation.
Review Case 2
The answer is D. The history and examination largely ruled out at least one of the diagnoses in each pair. This child most likely has vaginal reflux or ectopic ureter, although
occult dysraphism remains possible, even with a normal examination.
Vaginal reflux typically manifests with dampness shortly after a trip to the restroom.
The next step would be instruction in repositioning on the toilet (see Fig. 6).
An ectopic ureter that inserts into the distal urethra, perineum, or vagina results in
constant dampness despite otherwise normal voiding habits. The degree of
wetness depends on the function remaining in the renal unit. Intermittent discharge
(from a dilated ureter with stasis) is also a common complaint. The next step would
be evaluation with renal and bladder ultrasound, looking for a dilated distal ureter or
evidence of a suspicious renal anomaly. MRI of the abdomen and pelvis with delayed
contrast views is useful if suspicion remains high after a normal ultrasound.
REFERENCES
1. Koff SA, Wagner TT, Jayanthi VR. The relationship among dysfunctional elimination syndromes, primary vesicoureteral reflux and urinary tract infections in children. J Urol 1998;160:101922.
2. Neveus T, von Gontard A, Hoebeke P, et al. The standardization of terminology of
lower urinary tract function in children and adolescents: report from the Standardization Committee of the International Childrens Continence Society. J Urol 2006;
176:31424.
3. Normal micturition. In: Blaivas J, Chancellor M, Weiss J, et al, editors. Atlas of
urodynamics. 2nd edition. Malden (MA): Blackwell Publishing Inc.; 2007. p. 11.
4. Hinman F, Baumann FW. Vesical and ureteral damage from voiding dysfunction in
boys without neurologic or obstructive disease. J Urol 2002;167:106973 (reprinted from 1973).
5. Videourodynamics. In: Blaivas J, Chancellor M, Weiss J, et al, editors. Atlas of
urodynamics. 2nd edition. Malden (MA): Blackwell Publishing Inc.; 2007. p. 64.
6. Ellsworth PI, Merguerian PA, Copening ME. Sexual abuse: another causative
factor in dysfunctional voiding. J Urol 1995;153:7736.
7. Davila GW, Bernier F, Franco J, et al. Bladder dysfunction in sexual abuse survivors. J Urol 2003;170:4769.
8. Von Gontard A, Hollmann E. Comorbidity of functional urinary incontinence and
encopresis: somatic and behavioral associations. J Urol 2004;171:26447.
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9. Blethyn AJ, Jenkins HR, Roberts R, et al. Radiological evidence of constipation in

urinary tract infection. Arch Dis Child 1995;73:5345.
10. Giramonti KM, Kogan BA, Agboola OO, et al. The association of constipation with
childhood urinary tract infections. J Pediatr Urol 2005;1:2738.
11. Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time.
Scand J Gastroenterol 1997;32(9):9204.
12. Klijn AJ, Asselman M, Vijverberg MAW, et al. The diameter of the rectum on ultrasonography as a diagnostic tool for constipation in children with dysfunctional
voiding. J Urol 2004;172:19868.
13. Joensson IM, Siggaard C, Rittig S, et al. Transabdominal ultrasound of rectum as
a diagnostic tool in childhood constipation. J Urol 2008;179:19972002.
14. Chase JW, Homsy Y, Siggaard C, et al. Functional constipation in children. J Urol
2004;171:26413.
15. Maronn ML, Esterly NB. Constipation as a feature of anogenital lichen sclerosus
in children. Pediatrics 2005;115(2):e2302.
16. Van Neer PAFA, Korver CRW. Constipation presenting as recurrent vulvovaginitis
in prepubertal children. J Am Acad Dermatol 2000;43(4):7189.
17. Rink RC, Yerkes EB. Surgical management of female genital anomalies, intersex
(urogenital sinus) disorders and cloacal anomalies. In: Gearhart JP, Rink RC,
Mouriquand PDE, editors. Pediatric urology. Philadelphia: W.B. Saunders; 2001.
18. Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics 1997;100:
22832.
19. Miyazato M, Sugaya K, Nishijima S, et al. Rectal distention inhibits bladder
activity via glycinergic and GABAergic mechanisms in rats. J Urol 2004;171:
13536.
20. Herndon CDA, Decambre M, McKenna PH. Interactive computer games for treatment of pelvic floor dysfunction. J Urol 2001;166:18938.
21. Kibar Y, Ors O, Demir E, et al. Results of biofeedback treatment on reflux resolution rates in children with dysfunctional voiding and vesicoureteral reflux. Urology
2007;70:5636.
22. Erickson BA, Austin JC, Cooper CS, et al. Polyethylene glycol 3350 for constipation in children with dysfunctional elimination. J Urol 2003;170:181820.
23. Sher PK, Reinberg Y. Successful treatment of giggle incontinence with methylphenidate. J Urol 1996;156:6568.
24. Chandra M, Saharia R, Shi Q, et al. Giggle incontinence in children: a manifestation of detrusor instability. J Urol 2002;168:21847.
25. Allen HA, Austin JC, Boyt MA, et al. Initial trial of timed voiding is warranted for all
children with daytime incontinence. Urology 2007;69:9625.
26. Austin PF, Homsy YL, Masel JL, et al. a-Adrenergic blockade in children with
neuropathic and nonneuropathic voiding dysfunction. J Urol 1999;162:10647.
27. Yucel S, Akkaya E, Guntekin E, et al. Can alpha-blocker therapy be an alternative
to biofeedback for dysfunctional voiding and urinary retention? A prospective
study. J Urol 2005;174:16125.
28. Kaufman MR, DeMarco RT, Pope JC IV, et al. High yield of urodynamics
performed for refractory nonneurogenic dysfunctional voiding in the pediatric
population. J Urol 2006;176:18357.
29. Parekh DJ, Pope JC IV, Adams MC, et al. The use of radiography, urodynamics
studies and cystoscopy in the evaluation of voiding dysfunction. J Urol 2001;
165:2158.
Genital Tra uma

in the Pediatric
and Adolescent Female
Diane F. Merritt, MDa,b,c,d,*
KEYWORDS
Genital trauma Accidental genital injuries
Straddle injuries Female genital cutting or mutilation
Sexual abuse Sexual assault
Genital injuries in female children and adolescents may occur in the context of multiple
injuries (as in a motor vehicle accident) or as an isolated injury to the genitals (as in
a straddle injury). Some children are victims of an isolated assault or repeated abuses,
and some incidents are accidents that are unlikely to ever occur again. A thoughtful
approach is necessary to be supportive to the child or teen, who may be bleeding,
in pain, and frightened, and to the patients parents or guardians who have concerns
about the assessment and repair of an acute injury and the long-term significance for
future reproduction. The clinician has an obligation to assess whether the history
provided is compatible with the injuries found on genital examination. Inconsistencies
between the history and physical examination should arouse suspicion of sexual
assault or abuse.
The approach to the injured child follows the traditional assessment of vital signs,
airway, breathing, circulation, and evaluation of the sites and sources of trauma. In
the case of genital trauma, the severity of the injury and the amount of bleeding determine where and how the examination should take place. If the injury is not severe, the
child may be examined in a doctors office or emergency department without sedation. Force or restraint should not be used for a genital examination. When the child
or adolescent is unable or unwilling to allow an adequate examination to be accomplished, light conscious sedation for the assessment of genital injuries has been suggested but may be of limited use. General anesthesia may allow a better examination,
assessment, and repair.1
Department of Obstetrics and Gynecology, Pediatric and Adolescent Gynecology, Washington

University School of Medicine, 660 S. Euclid Avenue, Saint Louis, MO 63110, USA
b
Barnes Jewish Hospital, One Barnes-Jewish Hospital Plaza, Saint Louis, MO 63110, USA
c
Saint Louis Childrens Hospital, One Childrens Place, Saint Louis, MO 63110, USA
d
Missouri Baptist Medical Center, 3015 North Ballas Road, Saint Louis, MO 63131, USA
* Department of Obstetrics and Gynecology, Campus Box 8064, 660 S. Euclid, Saint Louis, MO
63110.
doi:10.1016/j.ogc.2009.01.003
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Merritt
HOW TO PERFORM AN EXAMINATION IN A CHILD OR ADOLESCENT
Evaluation of the external genitalia in the pediatric and adolescent population requires
a different technique and approach than used in the examination of an adult. An understanding of variations in normal anogenital anatomy is essential, as is an understanding of the physical findings that can mimic signs of trauma or sexual abuse.
There are several techniques to facilitate the examination of a young patient. After
the clinician obtains parental permission to perform the genital examination, the child
can be held in the parents lap, or the child can lie supine on the examination table. By
placing the child in either a frogleg or kneechest position, the examiner will be able to
assess for normal genital anatomy.2 Use of labial separation frequently fails to provide
the examiner with a complete view of the girls vestibule. The application of lateral
traction to the labia majora does provide a much better view of the girls vestibule
and the vaginal canal. If the posterior hymen is redundant, the folds may obscure
an injury. The prone kneechest position allows the hymen to unfold and drop
down, and the vaginal canal also may drop open, resulting in a better view of both
the hymen and the contents of vaginal canal.3,4 Concerns have been raised regarding
an examination method that places a girl or child in a face-down position.5
A study comparing the effectiveness of examination methods in helping the clinician
detect acute and nonacute injuries in pubertal and prepubertal girls assessed the three
different examination methods: supine labial separation, supine labial traction, and the
prone kneechest position. Each method had advantages, but the examiner had
a greater chance of identifying additional signs of trauma by combining the methods
than by using any single technique alone.6
If an injury such as a vulvar hematoma, a laceration, or vaginal bleeding is present,
the full extent of injury may be difficult to determine, especially if the child is unwilling or
unable to cooperate for an adequate examination. In such situations, examination with
sedation or under general anesthesia may be necessary. Standard vaginal speculums
should not be used to examine a prepubertal child, because they are designed for
adults. Vaginoscopy is an important tool used by the pediatric gynecologist; depending on the age and level of cooperation of the child, this procedure may be done with or
without anesthesia. Placement of a pediatric cystoscope into the vagina with gentle
opposition of the labia provides fluid distension to allow adequate visualization of
the vaginal vault in children. In this manner, injuries to the vagina can be assessed,
and foreign objects may be found (Fig. 1). When the vagina of an adolescent is examined, the speculum selected for use should be the proper size for the patient. A Graves
speculum can be used to evaluate an adult, but a narrower Pederson speculum is
easier to place in a young woman or virginal teen (Fig. 2).
ETIOLOGY AND MANAGEMENT OF ACCIDENTAL GENITAL INJURIES

Straddle Injury
Straddle injuries occur when the soft tissues of the vulva are compressed between an
object and the underlying bones of the pelvis. This trauma may result in ecchymoses
(bruises), abrasions, and lacerations. Extravasation of blood into the loose areolar
tissue in the labia, along the vagina, the mons, or clitoral area may cause a hematoma
to form. Examples of commonplace accidental straddle injuries include falling onto the
frame of a bicycle, playground equipment, or piece of furniture. Nonpenetrating
injuries usually involve the mons, clitoris, and labia and result in linear lacerations,
ecchymoses, and abrasions. Lacerations may require repair under local or general
anesthesia.
Genital Trauma in Pediatric and Adolescent Female
Fig. 1. Image of vaginoscopy in a 4-year-old child with a 3-week history of vaginal spotting
and bleeding. A foreign body is seen next to the cervix in the left vaginal fornix. The object
was removed, and the bleeding stopped. The foreign body grossly contained cotton fibers,
and the culture was positive for beta-hemolytic Streptococcus and Bacteroides species.
(Courtesy of Diane F. Merritt, MD, Saint Louis, Missouri.)
Vulvar Hematomas
Vulvar hematomas (often sustained as a result of a straddle injury) can be very painful
and may prevent a child or adolescent from urinating because of pain and swelling. If
the hematoma is not large, and the perineal anatomy is not distorted, and if the patient
Fig. 2. The vaginal speculum comes is a standard length of 4 inches. The Graves speculum
(left) is 1.5 inches wide, and the Pederson speculum (middle) is 1.0 inches wide. The narrow
Pederson speculum (right) is 0.75 in wide and is ideal for placement in a young adolescent to
view the vagina and cervix. (Courtesy of Diane F. Merritt, MD, Saint Louis, Missouri.)
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has no difficulty emptying her bladder, she can be managed conservatively with immediate application of ice packs and bed rest. As the hematoma resolves, the blood will
track along the fascial planes. The ecchymotic discoloration may take weeks to
resolve. If the patient has a larger vulvar hematoma and is unable to void, one should
place an indwelling urinary catheter and continue bladder drainage until the swelling
resolves. Very large vulvar hematomas may dissect into the loose areolar tissue along
the vaginal wall and along the fascial planes overlying the symphysis pubis and lower
abdominal wall. Pressure from an expanding hematoma may cause necrosis of the
skin overlying the hematoma. Evacuating the hematoma will reduce pain, hasten
recovery, and prevent necrosis, tissue loss, and secondary infection. When incising
large vulvar hematomas, one should incise along the medial mucosal surface near
the vaginal orifice. Because the periclitoral area has a rich blood supply, hematomas
in this area require careful isolation of the bleeding vessels. If adequate hemostasis is
not attained, the patient will be at risk for bleeding and reaccumulation of the hematoma. When the bed of the hematoma has been debrided of clot and devascularized
tissue, and hemostasis has been attained, one should place a closed system drain (ie,
Jackson-Pratt) to prevent reaccumulation of blood, to reduce pain, and to reduce the
risk of bacterial growth. The drain should exit the skin in a dependent position, and the
skin should be closed primarily. The drain can be removed in 24 hours in most cases.1
Accidental Penetrating Injuries
Penetrating injuries occur if the victim falls on a sharp or pointed object, and impales
herself. Many common household objects are the agent of impalement, including
in-lawn sprinkling systems, pipes, fence posts, trailer hitches, and furniture (chair
tops, bedposts, legs of stools). The vagina, urethra and bladder, anus, rectum, and
peritoneal cavity can be pierced by sharp or pointed objects. The physical findings
may appear to be quite minimal, but the patient may have a more serious underlying
injury. In a report of 34 perineal impalements, several patterns emerged. Most injuries
occurred in the home. Many children either slipped or fell in the bathroom on bathtub
toys, soap dispensers, or the shower diverter valves or fell onto objects when climbing
out of the tub or when running out of the bathroom after bathing. Slippery surfaces and
the lack of protective clothing were stated to be the common contributing factors.
Bedroom accidents occurred when children were jumping from one bed to another,
a common play activity with obvious risk. Infants and children should be supervised
in the bathtub, because they may be at risk for drowning and scalding injuries if the
bath water is too hot. They are also at risk for trauma from falls onto objects, but
even the presence of supervising adults did not completely prevent these accidents.7
Accidental penetrating injuries may closely mimic the injuries associated with sexual
assault. For this reason the medical history is essential. Corroboration of the events by
an eyewitness is very informative. The family can be asked to bring the object for
assessment by the trauma team, or the authorities may investigate the scene of the
injury. Because the internal trauma may be more severe than externally apparent,
these patients may require an examination under anesthesia to assess fully the extent
of the penetrating injury (Fig. 3). If the rectum or peritoneal cavities are entered, an
exploratory laparotomy or laparoscopy are should be preformed to determine the
full extent of injuries and to initiate repairs.1
There is some controversy in the trauma literature regarding the role of routine fecal
diversion in the management of anorectal injuries, and there are reports on primary
repair of anorectal injuries without proximal colostomy. The financial, psychologic,
and social disadvantages of a colostomy should be considered also. Onen and
colleagues8 recommend a colostomy to improve the outcome for unstable patients
Fig. 3. This girl jumped over a metal pole and landed on it. The injury noted in the fourchette appears minor, but under general anesthesia the anal sphincter was found to be
completely transected and required repair. (Courtesy of Diane F. Merritt, MD, Saint Louis,
Missouri.)
who have a genital injury score of V, severe contamination, and prolonged delay
before medical attention is received (Table 1).1
Accidental vaginal insufflation injuries
Vaginal insufflation injuries occur when females fall off jet skis and water skis, slide
down water chutes, or come in direct contact with pool or spa jets. As pressurized
water enters the vagina, the walls may overdistend and tear. Significant blood loss
can occur. Such injuries may produce no sign of external genital trauma, and only
careful vaginal examination (often under anesthesia) will reveal the source of bleeding
and true extent of injury. Children and women who participate in water sports can
decrease their risk for vaginal insufflation injuries by using protective clothing such
as neoprene wetsuits or cut-off jeans while water or jet skiing. On waterslides,
Table 1
Classification for genital injuries in female children
Genital Injury Score
Extent of Injury
Isolated genital injury distal to hymen
II
Isolated genital injury including hymen
III
Isolated genital injury including vagina
IV
Hymeneal or vaginal injury plus partial tear of anorectum
Vaginal injury plus complete tear of anorectum
Data from Onen A, Ozturk H, Yayla M, et al. Genital trauma in children: classification and management. Urology 2005;65(5):987.
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head-first entries usually are forbidden to prevent head and neck injury, but also it is
wise for girls to cross their ankles or to keep their feet together when entering water
from a waterslide to prevent genital trauma.911
Crush or Shear Injuries
Crush injuries may result from motor vehicle accidents, falls, or during collapse of
a building caused by structural problems, natural catastrophes (earthquakes), bombings, or warfare. Any time a pelvic fracture occurs, genital injuries may arise when fragments of a pelvic bone penetrate the vagina and lower urinary tract. This penetration
may lead to lacerations of the bladder, urethra, or vagina. Shear forces can lead to
lacerations when a fall is associated with rapid abduction of the lower extremities or
when a patient is run over by a motor vehicle. As reported by Boos and colleagues,12
two children had perianal lacerations and two had hymenal lacerations when the
wheel of the vehicle passed longitudinally over the childs torso.
Animal and Human Bites
Animal bites are rare but may be a cause of genital trauma. Animal bites usually are
caused by dogs that are family pets or are known to the victim. Most canine bites
involve the extremities, but in children may involve the face, neck, and buttocks.
Human bites tend to occur in children as a result of playing or fighting, whereas in
adults they usually are the result of aggressive behavior, participation in sports, or
sexual activity. Mammalian bites may cause significant damage to delicate tissue of
the genitalia. Microorganisms contained in saliva may cause infections resulting in
local cellulitis or facilitate inoculation and transmission of communicable diseases.
Both syphilis and HIV may be transmissible via a bite wound.13,14 Human bites should
be treated promptly by immediate irrigation with a bactericidal and virucidal solution
(1% povidine-iodine) using an 18- to 19-gauge needle and debridement of the wound.
The prophylactic use of antibiotics is controversial because of the lack of adequate
clinical studies. Simple scrapes and abrasions are unlikely to benefit from antibiotic
treatment. Antibiotics may be given if there is deep puncture or crushing, if the victim
has underlying diabetes mellitus or an immunodeficiency, or if the wound is obviously
infected. Genital bites are at high risk for infection because the loose subcutaneous
tissue may facilitate bacterial spread.15 Management of the bite wound involves irrigation, debridement, and antibiotic prophylaxis. Tetanus vaccination should be administered as part of wound care of mammalian bites, but no studies have assessed
the benefit of this strategy. Vaccination need not be performed if there is a record
of a tetanus shot being given in the previous 5 years. The need for rabies immunization
should be assessed on an individual basis, as should primary versus secondary
wound closure.16,17
Accidental and Inflicted Burns
Scalds are the leading cause of burn-related hospitalizations and emergency department
visits for young children. Most of the older pediatric burn literature focused on tap-water
scalding as a preventable cause of pediatric burns, but several recent publications point
out that the bulk of scald injuries are not tap waterrelated and instead are associated with
mealtime preparation of food. The most common behaviors include children pulling a hot
substance from the stove, microwave, or countertop or having liquid spilled on them while
the caregiver is cooking or is carrying the child and a hot liquid.18 Prevention of scald
injuries requires raised awareness of these common household events in addition to
reducing the temperature in domestic hot-water tanks and testing the water temperature
before placing an infant or child in the bath.19,20 Accidental immersion burns, in which
a child falls into a container of hot liquid, typically have irregular borders and non-uniform
depth as the victim struggles to escape the hot liquid. This thrashing also causes splash
marks, which, although they sometimes may be found in forced immersion, are more
characteristic of accidental immersion. Accidental burns are rarely full-thickness burns,
because they typically involve shorter contact time. In accidental splash and spill burns,
the head, neck, and trunk are commonly involved when the hot liquid is pulled or knocked
over from a higher surface and spilled over by the child. Accidental contact burns often
are patchy and superficial, because the child quickly withdraws from the hot object or
the falling object brushes across the skin. They may or may not show a clear imprint.
The child abuse literature recognizes that inflicted burns may occur. Scalds are the
most frequent form of burn abuse.21 Tide marks (ie, clear lines of demarcation) characterize nonaccidental bath scalds. These scalds also tend to have uniform burn
depth and commonly involve the buttocks, perineum, and lower extremities. Stocking
and glove burns occur when a childs hands and/or feet are immersed forcibly in hot
water, resulting in symmetric, circumferential, and well-demarcated burns. Zebra
stripes result from sparing of the flexural creases secondary to the bodys flexed position in the hot liquid. Donut-hole sparing occurs when the childs buttocks are pressed
against the bathtub, which is relatively cooler than the water in it. Simultaneous scald
burns to buttocks, feet, and perineum are highly suspicious for physical abuse and
warrant a thorough investigation, as do well-demarcated burns around the buttocks
or bilateral symmetric glove and stocking burns.
Inflicted contact burns are deeper, may be multiple, and have well-demarcated
margins. They commonly are caused by hot irons, radiators, hair dryers, curling irons,
and stoves. Contact burns with uniform depth and well-demarcated margins located
on typically protected areas of the body suggest abuse. Cigarette burns are a common
form of burn abuse. Inflicted cigarette burns appear as 7- to 10-mm round, well-demarcated burns that have a deep central crater. They heal with scarring because they extend
well into the dermis. Cigarette burns commonly appear grouped on the face, hands, and
feet. When accidental, they tend to be oval or eccentric and more superficial, because the
child usually brushes against the cigarette. The location of a burn, although not pathognomonic, can be helpful when ruling out abuse. Face, hands, legs, feet, perineum, and
buttocks tend to be predominant sites in abuse. The perineum and buttocks, in particular,
are infrequently involved in accidental burns, and burns in this area often are inflicted as
punishment for toilet training accidents.21 Batteries placed in the vagina may result in
chemical burns and have been described in the literature.22 Genital burns can occur
from the use of medications intended to treat genital warts (eg, imiquimod, podophyllin,
or trichloroacetic acid). Such chemical burns should be treated immediately by irrigation
to neutralize the chemicals and prevent further damage. The management of genital and
perineal burns includes cooling the burn for 20 minutes with cold tap water within 3 hours
of the injury to reduce pain and wound edema. It is unknown how effective topical application of antimicrobials and dressings are for the treatment of minor burns. A mixture of
a topical antibiotic ointment and estrogen cream has been helpful for minimizing scarring
from mucosal burns of the female genital tract. Silver sulphadiazine cream has been used
historically in the management of burn wounds to minimize the risk wound infection, but
no randomized trials or controlled clinical trials have evaluated its clinical effectiveness.
There is no current consensus about the optimal dressing for burns in the genital area.
Coitally Related Vaginal Injuries
Whenever an adolescent presents with vaginal trauma, consensual intercourse or

sexual assault should be considered in the differential diagnosis. The patient may
be too embarrassed or distressed to explain her injuries, and she may not give an
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accurate account of how the injury occurred. The diagnosis may be incorrectly attributed to a hymenal tear or menstrual bleeding, and the diagnosis of a more serious
injury may be overlooked or delayed unless a proper pelvic examination is done to
evaluate vaginal bleeding. Minor lacerations of the introitus and lower vagina can
occur with initial coitus. Adolescents who sustain deep vaginal lacerations from coitus
may present with intense vaginal pain, profuse or prolonged vaginal bleeding, and
shock. Predisposing factors for coital injury include initial or hurried intercourse;
incompatibility of sexual organ sizes (especially during a first sexual experience);
intoxication or substance use by either or both partners; extreme and vigorous sexual
penetration with coital positioning of the female in dorsal decubitus with hyperflexion
of the thighs or in sitting positions; clumsiness; pregnancy; vaginal spasm; retroversion of the uterus; insertion of foreign bodies; and sexual assault. Vaginal lacerations
and perforation may arise because of lack of physiologic preparation of the genitalia
from sexual arousal, as may happen when sexual intercourse occurs when the participants fear discovery. Patients who have vaginal agenesis may sustain deep lacerations from failed attempts at penetration. Urethral intercourse may occur in patients
who have vaginal agenesis.1,2325
GUIDELINES FOR THE MEDICAL CARE OF SEXUALLY ABUSED CHILDREN AND ADOLESCENTS
Guidelines for the care of the child or adolescent who has experienced sexual abuse
are best found in the literature dedicated to this topic. The American Academy of
Pediatrics recently published guidelines, and there are comprehensive reviews that
address the current knowledge base in this field.2628
Sexual abuse includes coerced or forced vaginal, anal, intercrural, and oralgenital
fondling or penetration. Victims of sexual assault might sustain extragenital physical
injury that occurs during resistance or is inflicted deliberately by the assailant. Sexual
violence entails a number of negative effects that may the affect victims health: pregnancy, spread of sexually transmissible diseases, exposure to HIV/AIDS, increased
risk for adoption of undesirable sexual behavior (eg, early initiation of sexual activity,
multiple sexual partners), and negative effects on mental health.29 It is unwise for families or professionals to assume that, because there are no symptoms, sexual abuse
has not taken place or that, if it has taken place, it has not involved penetration. No
child or adolescent alleging sexual abuse should be denied a medical examination
purely because they have no symptoms. In a study by Kelly and colleagues,30 most
of the children who had diagnostic findings consistent with sexual assault had no
physical symptoms. In a published study of 2384 children referred for possible sexual
abuse, 96.3% of all children had a normal examination. In this series, the incidence of
abnormal medical findings was only 5.5%, even in children who had a history of anal or
vaginal penetration.31
Female Genital Mutilation/Female Circumcision
The United Nations World Health Organization defines female genital mutilation (FGM),
often referred to as female circumcision, as the partial or total removal of the
female external genitalia or other injury to the female genital organs for cultural and
other non-therapeutic reasons. It is estimated that 100 to 140 million girls and women
in the world have undergone some form of FGM, and 3 million girls are at risk from the
practice each year (Box 1).32 Type I and 2 FGM account for 80% of the cases worldwide. Type 3 is the most extreme and accounts for 15% of the cases but is the practice
of choice in several African countries. Girls may undergo this procedure between the
age of 4 and 14 years, but it can take place in infancy, late adolescence, before
Box 1
Categories of female genital mutilation
Type 1: Excision of the precipice (the fold of skin surrounding the clitoris), with or without
excision of part of the entire clitoris
Type 2: Excision of the clitoris with partial or total removal of the labia minora (the smaller
inner folds of the vulva)
Type 3: Excision of part or all of the external genitalia and stitching or narrowing of the vaginal
opening
Type 4: Unclassified, which includes pricking, piercing, or incising of the clitoris and/or labia;
stretching of the clitoris and/or labia; cauterization by burning of the clitoris and surrounding
tissue; scraping of tissue surrounding the opening of the vagina (angurya cuts) or cutting of the
vagina (gishiri cuts); introduction of corrosive substances or herbs into the vagina to cause
bleeding or to tighten or narrow the vagina; and any other procedure that can be included in
the definition of female genital mutilation
Data from UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCHR, UNHCR, UNICEF, UNIFEM, WHO.
Eliminating female genital mutilation: an interagency statement. Geneva (Switzerland): World
Health Organization Press; 2008.
marriage, or at the time of the first pregnancy. Because of the immigration of women
from areas where FGM is practiced to other countries, medical care providers all over
the world now are caring for these women. The World Health Organization, the International Council of Nurses, the International Confederation of Midwives, and the International Federation of Gynecologists and Obstetricians have openly condemned this
practice of willful damage to healthy organs for nontherapeutic reasons. FGM is
considered a form of violence against girls and women. The immediate health consequences of FGM include severe pain, shock, hemorrhage, and sepsis. Victims may
suffer from urinary retention, menstrual retention, ulceration of the genital region,
and injury to adjacent tissue. Long-term complications include cysts and abscesses,
keloid scar formation, damage to the urethra resulting in urinary incontinence, dyspareunia, sexual dysfunction, and difficulties with childbirth. During vaginal deliveries, the
infibulated woman must be opened to allow passage of the baby. If this opening is not
done, she is at risk for formation of vesicovaginal and rectovaginal fistulas, as well as
undue suffering, including increased risk of stillbirth and maternal death. The practice
of FGM poses a serious challenge for the medical community. Obstetricians confronted by circumcised women must determine the safest way of monitoring pregnancy, given the constraints. Another ethical dilemma arises when women request
reinfibulation after giving birth. In the past, physicians have resewn the genitals in
an attempt to be culturally appropriate. Most recently, various medical communities
have issued guidelines stating that no woman should be recircumcised after giving
birth. The conflict between patient wishes and medical guidelines can create professional and ethical dilemmas for the health care worker.33
SPECIAL CONSIDERATIONS
Effect of Hormones
The influence of estrogen on tissues is well known. Newborns of both genders often
have breast buds because of exposure to maternal hormones. The impact of estrogen
on the external genital structures of a newborn is labial swelling, prominence of the
clitoris, edema of the hymen, a mucous vaginal discharge, and even occasional withdrawal bleeding or spotting from endometrial sloughing. By 6 to 8 months of age,
these changes gradually subside, and the infants breast buds usually are no longer
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palpable.34 Lack of endogenous estrogen production in childhood is associated with

flattening of the labia, decrease in the size of the clitoris, and thinning of the hymen.
The introital mucosa appears shiny and reddened, and trauma or infections may result
in bleeding. Vulvar infections in children most commonly are related to poor hygiene,
because the introital tissues are vulnerable to exposure to fecal pathogens. Traumatic
distention of the prepubertal hymen or vagina may result in tearing, because the
tissues do not allow for stretching, but minor injuries may heal rapidly. At puberty,
changes related to estrogen include breast development, enlargement of the labia minora, edematous and pink changes in the hymenal tissues, and a watery mucus
vaginal discharge (physiologic leukorrhea). Once exposed to estrogen, the postpubertal vagina and hymen are more distensible and less likely to tear with gentle distention
(tampon use). Blunt forceful penetrating trauma may result in lacerations, but even an
astute clinician cannot tell if a postpubertal woman has had genital penetration based
on the physical examination.35,36
Healing Times for Injuries
In a multicenter, retrospective study, photographs were used to document the healing

process and outcome of hymenal and nonhymenal genital injuries in prepubertal and
pubertal girls whose ages ranged from 4 months to 18 years. An interesting difference
was found. In prepubertal girls 88% of hymenal lacerations were in the posterior location, whereas in adolescents 60% were posterior and 23% were lateral at either the
3 oclock or 9 oclock location. The documented rapid resolution of these injuries
(Table 2) makes it imperative that a child or an adolescent be examined as soon as
possible when there is a suspicion of a possible sexual assault.37,38
DIAGNOSES THAT CAN BE CONFUSED WITH SEXUAL ABUSE OR INJURY
Normal variations in genital anatomy often are misinterpreted as evidence of old

trauma or past injuries. The pediatric hymen may have bumps associated with intravaginal ridges or septae or polyps. Labial adhesions, lichen sclerosus, and urethral
prolapse are common conditions that require a degree of clinical experience to diagnose and manage (Fig. 4). Molluscum contagiosum, viral-associated ulcerations,
vertically transmitted warts, vaginal foreign bodies, and vulvo-vaginitis (either nonspecific or with identified pathogens) caused by poor genital hygiene may be misleading.
It is valuable for families, health professionals, and legal authorities to have early
Table 2
Time required for nonhymenal genital injuries to heal or resolve
Type of Injury
Time of Resolution
Abrasions
23 days
Edema
5 days
Ecchymoses (bruising)
218 days
Labial hematoma
2 weeks to 4 weeks; may require surgical drainage
Petechia
24 hours
Blood blisters
30 days in prepubertal girl, 24 days in pubertal girl
Superficial lacerations
2 days with new vessel formation in the prepubertal girls, scar tissue
formation in pubertal girls
Deeper lacerations
May require surgical repair
Data from McCann J, Miyamoto S, Boyle C, et al. Healing of nonhymenal genital injuries in prepubertal and adolescent girls: a descriptive study. Pediatrics 2007;120(5):100011.
access to expert opinion that may prevent an unnecessary investigation for sexual
abuse. Any prepubertal child who has physical symptoms and in whom there is
a concern about sexual abuse should be seen urgently by a trained examiner, so
that the child can receive appropriate diagnosis and treatment. Some of these children
will, in fact, have been sexually abused, but when the concern is based largely on their
symptoms, many will not.30 The role of the clinician in these situations is to provide
expertise or to refer the patient and her family to someone who has expertise in the
normal variants of genital anatomy and abnormal genital findings.30
ADVOCACY
Research is ongoing to determine which children and adolescents are at greatest risk
for traumatic stress disorders (either immediate or delayed) because of victimization of
a sexual or nonsexual nature. It is thought that accidental trauma or an isolated sexual
assault at the hands of a stranger may be less provocative of psychopathology
because the family exists as an intact supportive unit. Various protective factors for
children in adverse circumstances include intelligence, parental attachment, external
interests, coping skills, peer relations, and temperament. Unfortunately, there is
a powerful relationship between adverse childhood experiences and the risk of
substance and illicit drug abuse, depressed affect, and attempted suicide.39
Poly-victimization refers to children who have experienced a pattern of on-going
or multiple victimizations instead of a single traumatizing event.40 Previously victimized children, especially those who experienced child maltreatment or family violence
or bullying, seem to be at greater risk for subsequent victimizations and are at greater
risk for anxiety and depression. These children may blame themselves and be less
Fig. 4. Untreated lichen sclerosus in a prepubertal child. (Courtesy of Diane F. Merritt, MD,
Saint Louis, Missouri.)
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resilient. Conversely, if the child lives in a cultural setting in which the victim sees other
children also being victimized, the child may be able to discount his or her personal
culpability and become less vulnerable. More research needs to be done on determining whether cumulative events take a greater toll than isolated events.
Advocacy for children and adolescent victims of violent genital injuries has reached
an international level. The United Nations Secretary Generals Study on Violence
against Children41 paints a detailed picture of the nature, extent, and causes of
violence against children and proposes recommendations on how to prevent and
respond to it. The World Health Organization held a global launch of the World Report
on Child Injury and Prevention in December 2008. More information on this program
can be found at http://www.who.int/violence_injury_prevention/child/injury/world_
report/en/.
Individual health care providers play an important role in the identification, support,
and referral of children and adolescents who suffer from violence as well as in the
management of its consequences.42,43
SUMMARY
Genital injuries in children and adolescents may occur accidentally or as the result of
an act of violence. This article discusses the etiologies and management of genital
trauma. Awareness needs to be heightened among individual providers of medical
care, as well as in the international community, to protect young girls from becoming
victims of violence and to provide avenues for recovery.
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of Arizona burn center pediatric patients and a proposal for prevention in the
Hispanic community. J Burn Care Res 2008;29(4):595605.
21. Kos L, Shwayder T. Cutaneous manifestations of child abuse. Pediatr Dermatol
2006;23(4):31120.
22. Yanoh K, Yonemura Y. Severe vaginal ulcerations secondary to insertion of an
alkaline battery. J Trauma 2005;58(2):4102.
23. Bechtel K, Santucci K, Walsh S. Hematoma of the labia majora in an adolescent
girl. Pediatr Emerg Care 2007;23(6):4078.
24. Jeng CJ, Wang LR. Vaginal laceration and hemorrhagic shock during consensual
sexual intercourse. J Sex Marital Ther 2007;33(3):24953.
25. Sloan MM, Karimian M, Ilbeigi P. Nonobstetric lacerations of the vagina.
J Am Osteopath Assoc 2006;106(5):2713.
26. Kellogg N. American Academy of Pediatrics Committee on Child Abuse and
Neglect. The evaluation of sexual abuse in children. Pediatrics 2005;116(2):
50612.
27. Adams JA, Kaplan RA, Starling SP, et al. Guidelines for medical care of children
who may have been sexually abused. J Pediatr Adolesc Gynecol 2007;20(3):
16372.
28. Adams JA. Guidelines for the medical care of children evaluated for suspected
sexual abuse: an update for 2008. Curr Opin Obstet Gynecol 2008;20(5):43541.
29. Alempijevic D, Saiv S, Pavlekic S, et al. Severity of injuries among sexual assault
victims. J Forensic Leg Med 2007;14(5):2669.
30. Kelly P, Koh J, Thompson JM. Diagnostic findings in alleged sexual abuse: symptoms have no predictive value. J Paediatr Child Health 2006;42(3):1127.
31. Heger A, Ticson L, Velasquez O, et al. Children referred for possible sexual
abuse: medical findings in 2384 children. Child Abuse Negl 2002;26(67):
64559.
32. UNAIDS, UNDP, UNECA, UNESCO, UNFPA, UNHCHR, UNHCR, UNICEF, UNIFEM, WHO. Eliminating female genital mutilation: an interagency statement.
Geneva (Switzerland): World Health Organization Press; 2008.
33. Baron EM, Denmark FL. An exploration of female genital mutilation. Ann N Y Acad
Sci 2006;1087:33955.
34. Abnormal puberty and growth problems. In: Speroff L, Fritz MA, editors. Clinical
endocrinology and infertility. 7th edition. Philadelphia: Lippincott Williams and
Wilkins; 2005. p. 362.
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35. Underhill RA, Dewhurst J. The doctor cannot always tell. Medical examination of
the intact hymen. Lancet 1978;1(8060):3756.
36. Kellogg ND, Menard SW, Santos A. Genital anatomy in pregnant adolescents:
normal does not mean nothing happened. Pediatrics 2004;113(1 Pt 1):e679.
37. McCann J, Miyamoto S, Boyle C, et al. Healing of nonhymenal genital injuries in
prepubertal and adolescent girls: a descriptive study. Pediatrics 2007;120(5):
100011.
38. McCann J, Miyamoto S, Boyle C, et al. Healing of hymenal injuries in prepubertal
and adolescent girls: a descriptive study. Pediatrics 2007;119(5):e1094106.
39. Dube SR, Anda RF, Felitti VJ, et al. Childhood abuse, household dysfunction, and
the risk of attempted suicide throughout the life span: findings from the Adverse
Childhood Experiences Study. JAMA 2001;286(24):308996.
40. Finkelhor D, Ormrod RK, Turner HA. Poly-victimization: a neglected component in
child victimization. Child Abuse Negl 2007;31(1):726.
41. The United Nations Secretary Generals study on violence against children. Sponsored by OHCHR, UNICEF, WHO. 2005. Available at: http://www.violencestudy.
org/r25. Accessed November 2, 2008.
42. Gender and Womens Health, Family and Community Health, Injuries and Violence
Prevention, Noncommunicable Diseases and Mental Health. Guidelines for
medico-legal care of victims of sexual violence. World Health Organization.
Geneva (Switzerland): World Health Organization Press; 2003.
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injuries and disability biennial report, 20062007. Geneva (Switzerland): World
Health Organization Press; 2008.
The Adolescent
Sexual Health Visit
Taraneh Shafii, MD, MPHa,*, Gale R. Burstein, MD, MPHb,c
KEYWORDS
Adolescent Sexually transmitted disease
Sexually transmitted infection Sexual history Risk behavior
Adolescents are a challenging population to reach. Yet, despite their stereotypical

outward appearance of shunning and ignoring authority figures, when medical
providers are able to create a safe, confidential, nonjudgmental, and empowering
atmosphere, adolescents are surprisingly open and candid about themselves, their
health, and their behavior, including sexuality. The caveat being that providers must
ask the sensitive health questions, as adolescents are often reticent to initiate questions about sex or concerns of sexually transmitted infection (STI) symptoms.
Addressing sexual health, screening, and counseling to prevent sequelae of risky
sexual behavior are essential components of the adolescent visit to the gynecologist.
Discussing sexuality and taking a sexual history may cause feelings of discomfort for
the provider and adolescent patient alike. Taking the time to build rapport and trust
and the guarantee of confidentiality are key to engaging adolescent patients to
discuss their personal health concerns with their provider, thereby permitting him or
her to provide optimal care.
This article offers recommendations to facilitate dialog with the adolescent patient,
addresses special considerations for the adolescent examination, discusses the use
of some of the newly available tests for STIs, and suggests the recommended
approach to management of STIs in adolescents.
WHY IS IT IMPORTANT TO DISCUSS SEXUALITY WITH ADOLESCENT PATIENTS?
Adolescence is a period of significant physical, cognitive, and psychosocial growth

and development. For most, adolescence is a time of relative good health, requiring
few visits to health care providers. Most health morbidity and mortality that plague
a
Section of Adolescent Medicine, Department of Pediatrics, University of Washington School

of Medicine, Harborview Medical Center, 325 9th Avenue, Box #359777, Seattle, WA 98104,
USA
b
Department of Pediatrics, SUNY at Buffalo School of Medicine and Biomedical Sciences, 95
Franklin Street, Room 984, Buffalo, NY 14202, USA
c
Epidemiology and Surveillance, Erie County Department of Health; 219 Bryant Street,
Buffalo, NY 14222, USA
E-mail address: [email protected] (T. Shafii).
doi:10.1016/j.ogc.2009.01.001
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Shafii & Burstein
adolescent health are from consequences of high-risk behaviors, exemplified in

adolescent sexual behavior.
ADOLESCENTS AND SEXUALLY TRANSMITTED INFECTIONS
In the United States, 65% of high school 12th grade students have had vaginal intercourse, and more than one third of all high school students have had sex in the past 3
months, with 15% having had four or more lifetime partners.1 The adverse health
consequences of adolescent high-risk sexual behaviors are demonstrated in the
astronomic rates of STIs.
Adolescents and young adults have the highest STI rates compared with other age
groups, with half of the almost 19 million STI cases in the United States diagnosed
annually occurring in 15- to 24-year-olds.2 Among females, the highest reported
gonorrhea and chlamydia rates are among 15- to 19-year-olds followed by 20- to
24-year-olds with the next highest. Among males, the highest reported rates are
among young adults age 20 to 24 years, with 15- to 19-year-old males following in
close second.3 In the United States, HIV/AIDS is now the seventh leading cause of
mortality in young adults younger than 25 years, and it accounts for 13% of all cases
diagnosed annually. HIV Infection diagnosed in those younger than 25 years old is
acquired predominantly through heterosexual contact.
WHY ARE ADOLESCENTS AT HIGH RISK FOR ACQUIRING SEXUALLY
TRANSMITTED INFECTIONS?
Factors that increase adolescents risk for STIs can be categorized as (1) biologic
susceptibility, (2) psychosocial development, (3) health care use and compliance,
and (4) concern for confidentiality, ethical, and legal issues. These four factors
contribute to adolescent health risk and influence high-risk behavior in the environment of evolving sexuality and sexual behavior as youth progress through puberty
(Fig. 1).
Biologic Factors
Because of developing physiologic characteristics, adolescent females are more

vulnerable to STIs than adult females. The immature and incompletely estrogenized
cervix is characterized by persistence of columnar epithelium extending to the ectocervix, referred to as cervical ectopy (Fig. 2). Columnar epithelium is more susceptible
to invasion by pathogens, such as Neisseria gonorrhoeae and Chlamydia trachomatis
Early Adolescence
11-13 years
Puberty and
Physical
Development
Middle Adolescence
14-16 years
Biologic
Susceptibility
Healthcare
Utilization
Concern for
confidentiality
Psychosocial
Development
Compliance
to care
Late Adolescence
17-21 years
Risk
Behaviors
Ethical and
Legal Issues
Sexuality
Fig. 1. Schematic of adolescent risk for sexually transmitted infections.
Sexually
Transmitted
Infection
The Adolescent Sexual Health Visit
Fig. 2. Cervical ectopy. (From Seattle STD/HIV Prevention Training Center at the University of
Washington/Claire E. Stevens; with permission.)
than squamous epithelium, which covers the vagina and the mature adult female
cervix. Adolescent females tend to have thinner cervical mucus than adult females,
thereby presenting a weaker barrier to pathogens infecting the cervix and upper reproductive tract.
Lower estrogen levels present in early adolescence result in thinner genital tissue. In
addition, insufficient sexual arousal results in inadequate vaginal lubrication before
penetration. This combination places adolescent females at increased risk for trauma
or irritation to the female genital tissue, creating potential portals of entry for
pathogens.
Psychosocial Development
To guide their approach to the patient, before initiating an interview with an adolescent, it is helpful for providers to be sensitive to adolescent psychosocial development. Adolescence spans approximately a 10-year period consisting of three
phases: early adolescence, age 11 to 13 years, or middle school age; middle adolescence, age 14 to 16 years, or high school age; and late adolescence, age 17 to 21
years, or late high school and college (Table 1). Many of the developmental issues
of older adolescents, however, are also operative in the young adult (eg, early 20s).
EARLY ADOLESCENCE (11 TO 13 YEARS)
Early adolescence is marked by the onset of puberty and physical changes that are
often rapid, dramatic, and may occur asynchronously and at different rates from their
peers. The underlying question of this age group, Am I normal?4 continuously is being
assessed in the classroom, in the locker room, and at sleepovers. During the physical
examination, especially the breast and genital examination, it is of utmost importance
that the provider reassures the adolescent that everything looks healthy and normal
for her developmental stage.
Early adolescence marks the conscious awakening of sexual feelings and usually
manifests as sexual fantasies and masturbation, all of which may be confusing and
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Table 1
Physical, psychosocial, and sexual development in adolescents
EarlyAdolescence
Middle Adolescence
Physical
growth
Onset of puberty;
rapid changes at
different timing
and rate from
peers
Full physical maturation Full adult physical

obtained by females
development
with menarche; more
obtained by all
variable in males with
continued growth
Late Adolescence
Body image
Am I normal?
Concern about body
and pubertal changes
Start acceptance
of body changes;
preoccupied with
making body
more attractive
Accepting and
comfortable with
pubertal changes
and body
Cognition
Concrete, unable to
think abstractedly
or plan ahead;
poor impulse
control
Able to conceptualize
and think abstractly;
may revert to
concrete thinking in
times of stress;
propensity for
risk-taking behavior
Abstract thought
and ability to
anticipate future
and plan
accordingly;
increased
self-efficacy
Independence/
peers
Increased interest in
friends with a
decreased focus
on family activities;
same-sex friendships
predominate
Height of conformity to
peer values,
appearance and
behavior; family
conflict; dating in
couples or groups
common
Establishment of
personal values and
goals; reacceptance
of family; conformity
to and influence
of peer group fades
Sexuality
Sexual myths,
fantasies,
masturbation;
usually no
sexual contact
with partner
Sexual contact ranges

from hand-holding
to intercourse; often
exploratory; serial
monogamy common
Sexual intercourse
achieved by most;
focus on intense
relationship with
one partner; serial
monogamy may
persist
Data from Radzik M, Sherer S, Neinstein LS. Psychosocial development in normal adolescents. In:
Neinstein LS, Gordon CM, Katzman DK, et al, editors. Adolescent health care: a practical guide.
5th edition. Philadelphia: Wolters Kluwer/Lippincott Williams and Wilkins; 2007.
guilt-producing to the youth. Sexual myths are common (eg, you cant get pregnant
the first time you have sex), as are dirty jokes amongst peers (eg, think back to the
antics of middle school boys). Sexual activity at this stage is usually nonphysical
and manifests as phone calls and passing of notes and text messages. Clinicians
must recognize that in some populations, however, adolescents are initiating sexual
intimacy at this age, including oral sex and anal and vaginal intercourse. In fact, 7%
of youth in the United States report first vaginal intercourse before 13 years of age.1
Early adolescent cognitive abilities are concrete, and young adolescents are unable
to think abstractly, conceptualize, or develop a plan for the future. For example, when
asked if she is sexually active, the concrete adolescent may think the provider is
asking if she is active during sex, or she may think the provider is asking if she is having
sex that day, instead of asking whether she has ever had sex. The cognitive abilities at
this developmental stage explain why many young adolescents do not plan ahead or
anticipate the need for condoms when sexually active.
Using a condom presents an additional challenge for these youth. In the setting of
heightened arousal and emotion, their manual dexterity is limited and they may have
difficulty with complex tasks requiring multiple steps like opening a condom package
and putting the condom on the penis. These limitations are supported in the findings
that younger adolescents are less likely to use condoms or other forms of contraception, and if used, are more likely to have difficulty.58
MIDDLE ADOLESCENCE (14 TO 16 YEARS)
Full physical maturation is attained by most in middle adolescence, with menarche

being the hallmark in females. Sexuality is heightened during this stage, involves
more physical contact and is often exploratory and experiential9 rather than an expression of emotional attachment. Sexual activity at this stage progresses to dating in
groups or as couples, hand-holding, touching, kissing, and mutual masturbation. As
the average age of sexual debut in the United States is 16.5 years, providers must
assume that their middle adolescent patient (1) already may be engaging in oral,
anal, or vaginal intercourse; (2) is, therefore, at risk of acquiring STIs; and (3) should
be screened by sexual history and laboratory testing. Many adolescents do not
seek health care until well after first intercourse.1014
Adolescents in this stage develop capabilities for abstract thinking and conceptualization, yet their ability to carry out such behavior may be limited. In addition, adolescents may revert back to concrete thinking during times of stress, which adds to their
susceptibility to high-risk behaviors in intense, hormonally or emotionally driven situations (eg, sexual activity).
This new abstract thinking skill leads to a belief in their own personal fable. They
presume that nothing bad will happen to me. those things only happen to other
people. Although most adolescents in this age group understand that driving while
intoxicated or engaging in unprotected sex can lead to harmful consequences, their
perceived omnipotence and immortality provide them with a false sense of security.4
Although these assumptions seem reckless to adults, they may point to the adolescents level of brain and cognitive development and their limited judgment to identify
and acknowledge potentially deleterious situations. Also, adolescents seemingly
cavalier attitude in part, may reflect the paucity of life experience. Adolescents may
have to validate for themselves the possibility of an adverse outcome to high-risk
behavior (eg, becoming infected with chlamydia from unprotected sex). Regardless,
the concern for these middle-adolescents is their propensity for engaging in highrisk behaviors that may be fueled further by peer, alcohol, or drug use influences
that compromise inhibitions and result in unexpected, yet adverse, health
consequences.
LATE ADOLESCENCE (17 TO 21 YEARS)
By the end of late adolescence, full adult physical maturation has been attained.
Sexual orientation is established, and intimacy and commitment with a single individual are the basis of sexual relationships.4 Abstract thought is established more
firmly for most. Late adolescents are able to plan for and effectively use condoms.
Interestingly, older adolescents condom use decreases as their use of hormonal
contraception increases, providing an opportunity for STI transmission.
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SERIAL MONOGAMY
An interesting societal trend contributing to adolescent sexual risk is the adolescent

relationships pattern, described as serial monogamy. Adolescents have relationships
of relatively short duration (eg, 2 weeks or 2 months) with one partner, but change
partners more frequently. So although they may be monogamous, which may be interpreted as a lower risk relationship, as they accrue an increased number of partners
over time, they are in fact still at significant risk for STI exposure. Each new partner
brings a renewed need for the potential challenge of negotiating safe sex once
more. To assess true STI exposure risk and obtain a more valid assessment of sexual
risk behaviors, providers should enquire about the number of partners in the past 3, 6,
and 12 months.
TREND FOR EARLIER PUBERTY, EARLIER SEXUAL DEBUT, AND DELAYED MARRIAGE
In the United States, the median age of menarche is approximately 12.4 years (12.1
years in black females); the median age of first sexual intercourse is 16.5 years,4
and the average age of marriage is the late 20s (an increase in approximately 5 to 8
years from the 1950s). Therefore, the average number of years when females are
fertile, hormonally primed for sexual activity, and not married has increased significantly over the past 50 years, resulting in the potential for a higher number of sexual
partners and increased likelihood for STI contact and acquisition.
SAME-SEX SEXUAL ACTIVITY AND HOMOSEXUALITY
Same-sex sexual activity is not uncommon in adolescence; it is often exploratory and

does not necessarily predict future homosexuality. In the 2002 National Survey of
Family Growth, 11% of 15- to 19-year-old girls and 14% of 20- to 24-year-old women
reported ever having any same-sex contact.15
Adolescence is the period when sexual orientation is discovered and established.
Although there have been societal trends in openness and acceptance of homosexuality in the past decade, the recognition of feeling different from ones peers, being attracted to the same sex, experiencing sexuality contrary to the messages of
mainstream society, and fearing rejection and abandonment by ones family and
friends may be catastrophic for the young person. Gay, lesbian, bisexual, transgender,
and questioning youth are at an increased risk for substance abuse, school failure,
homelessness, sexual activity, victimization, body image and eating disorders,
depression, and suicide.9
Sensitivity and awareness of these possible issues are important when interviewing
and obtaining a sexual history from an adolescent. Take for example a 15-year-old
girl who comes to the office for her first gynecology visit, and the provider asks,
So do you have a boyfriend? If the young woman in this scenario is struggling
with her sexuality, this approach may be detrimental; the health care provider, as
a health authority, is modeling that heterosexuality is the only acceptable orientation.
As the adolescent may feel embarrassed and ashamed by her doubts, the provider
may have alienated the youth, when instead, he or she could have offered a safe venue
for discussion of sexual feelings and important sexual health information and
resources of support.
Survey data suggest that anywhere from 3% to 10% of adults in the United States
report being lesbian or gay. Adolescents are in the process of understanding and accepting their sexuality as evident in the lower proportion (1% to 4%) of adolescents
who report being gay, lesbian, or bisexual and the greater proportion (1% to 11%) who
report being unsure about their sexual orientation.4,15
An alternative example of initiating a conversation about sex would be:
You are at the age when you start figuring out if you are interested in or attracted
to guys, girls or both . have you thought about that yet? Have you ever had sex
with a guy, girl or both?
Health care providers are in the unique position to normalize sexuality to youth of all
orientations by the words and objectivity used to discuss the topic. By acknowledging
different sexual orientations, providers send the message that individual attractions
are within the range of normal sexual behavior. This allows the struggling gay or transgender youth to begin to accept herself and provides a medical resource for support
and information to field questions and concerns. For the heterosexual youth, providers
are modeling a position of acceptance and tolerance for sexual minorities.
AGE DIFFERENTIAL IN SEXUAL PARTNERS AND REPORTING LAWS
A significant number of adolescent females engage in sexual relationships with older

males, increasing their likelihood of STI exposure and decreasing their power and
capacity to negotiate condom use. Adolescent females with partners who are at least
2 years older are at increased risk for STIs.5,6,8 Reporting laws for statutory rape and
sexual misconduct vary by state. Providers need to be aware of the laws in their state.
ESTABLISHING RAPPORT
Building rapport is the most important skill a provider needs in taking care of adolescents. Most adolescent adverse health consequences are the direct results of risktaking behaviors. To create an environment where the patient feels safe disclosing
sexual behaviors and health concerns, providers need to establish a good rapport
with their adolescent patients. A few simple techniques may help reassure the adolescent that her provider is trustworthy (Box 1).
Box 1
Techniques for establishing rapport with adolescents
Introduce yourself to the adolescent first, look her in the eye, shake her hand and sit down
during the interview
Acknowledge the adolescent as your primary patient by directing your questions primarily to
her rather than her parents.
Use conversation icebreakers to allow time for the adolescent to become more comfortable
and get a sense of who you are.
Allow the adolescent to remain dressed during the interview and sit in a chair rather than on
the examination table.
Interview the adolescent without her family present for sensitive questions.
Ensure confidentiality and provide a safe environment for her to be honest.
Practice reflective listening and take time to listen to what the adolescent is saying and not
saying.
Facilitate a comfortable experience for the adolescent by providing adolescent-friendly and
easy-to-access office and staff.
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Acknowledge the Adolescent as the Primary Patient
Although it may be common for mothers to initiate and accompany their daughters on
their first visit to the gynecologist, the adolescent is the primary patient; the parents/
guardians are secondary. To communicate this at the visit, upon entering the room,
look at the adolescent first, make eye contact, address her and shake her hand, before
acknowledging the accompanying caregiver. Remember to sit down! Whether in the
room for 5 minutes or 20 minutes, sitting down reaffirms to the adolescent that she is
important; the provider is not in a hurry, and she has the providers undivided attention.
Just as in introductions, speak directly to the adolescent when initiating the interview. What brings you in today? Younger adolescents may look at the parent/
guardian instead of answering the question. That is the cue to first interview the
accompanying adult; yet the provider should take every opportunity to return the interview to the adolescent, Do you agree? Is that how it feels? You tell me how it
feels. For older adolescents, start the interview of nonsensitive questions with the
patient and end by asking the parents/guardians if they have anything to add and to
state their specific concerns (as this may differ significantly from the adolescents).
Parents/guardians are valuable in providing past medical history and family history
for any age adolescent who may not know the details of her health history.
Interview the Adolescent without Accompanying Adults Present
Despite mothers accompanying their daughters to the office visit, providers should
assume that mothers do not know the extent of their daughters sexual activity. After
the parents/guardians have provided necessary health information and voiced their
concerns, ask the parent/guardian to leave the examination room to obtain private
time with the adolescent patient. Separating the parents/guardians and the adolescent is imperative and serves several purposes:
Being interviewed alone empowers the adolescent to be responsible for her own
health.
The time together helps to create a therapeutic alliance between the provider and
patient.
Time alone with the patient allows providers the opportunity to obtain a confidential
sexual history and screen for behavioral risks.
Never ask an adolescent about sexual activity in front of a parent/guardian; the
answer will most likely be, no. Most adults honor the request to step out briefly,
especially when the practitioner explains that they will be informed of any serious
health concerns and are allowed to return to the examination room for the conclusion
of the visit.
A useful technique to ensure parents/guardians will be comfortable leaving their
adolescent alone with the provider is to normalize the process during the initial interview. You are at the age where it is time to start taking on some of the responsibility
for your health yourself; therefore, I would like to spend some time with you alone
without your parents present. It is my practice with all patients your age to spend
some time talking to you without your parents present. It is our clinic policy
regarding adolescents to do a portion of the visit separate from the parents. Inviting
parents/guardians back into the room for the end of the visit to hear the assessment
and management plan, (that is, with your patients approval), (1) prevents them from
feeling alienated, (2) allows them to continue to be engaged in their adolescents
health at some level, and (3) assists with reinforcement of the care plan, as adolescents often have difficulty following through with medical directions.
Other simple steps providers can take to initiate the rapport and comfort-building
process before they even see their patient include providing an adolescent-friendly
space in the waiting room, and placing age-appropriate magazines, brochures and
posters or even a computerized health education module for teens available in the
waiting and examination rooms. Hiring staff members who enjoy adolescents and
are skilled in communicating with them on the telephone and in the office helps to alleviate the adolescents anxiety for the office visit and increases the likelihood that they
will return for ongoing care. Allowing the adolescent to remain dressed during the
interview and covered as much as possible during the examination contributes to feelings of safety and a sense of being in control of their bodies and their environment.
THE INTERVIEW
Effective communication with adolescents requires a sensitive, flexible, and developmentally oriented approach. Because diagnosis and treatment are the emphasis of
medical training, most providers have not received formal training in interviewing techniques or the opportunity to practice these skills with adolescent patients. In a busy
gynecologic practice, taking the time necessary to establish rapport and interview
the adolescent may not be feasible; alternatives are to have a nurse or midlevel
provider (eg, nurse practitioner, physician assistant) dedicated to this purpose, as it
must be done to provide optimal care.
Adolescents can be particularly challenging to interview. Their ability to reason lies
somewhere between the continuum of concrete operations of childhood and formal
operations of adulthood. Asking questions about sexuality also can be a particularly
difficult subject to approach. Most adolescents (and adults) prefer to avoid initiating
a conversation about sex. Providers must be comfortable with the subject of sexuality
to be able to make the adolescent feel comfortable discussing this sensitive and
private issue. It is worthwhile for providers to reflect on their own personal experiences
of puberty, adolescence, and sexuality to better understand and identify with their
patients. Health care providers must set personal views aside and provide patients
with comprehensive reproductive health care. If providers feel uncomfortable discussing sexuality and sexual behaviors with their adolescent patients, it is their obligation
to refer these patients to colleagues who are able to provide appropriate care. What
follows are useful strategies for interviewing adolescent patients, with special
emphasis on obtaining information most helpful in assessing sexual risk behaviors
and risk for STIs.
OUTLINE THE OFFICE VISIT
Outlining what is going to take place during the office visit helps to decrease the
adolescents anxiety. First, I am going to talk to you and your mom; then I would
like to talk to you by yourself for a bit. Then I will examine you, and if we need to do
any tests, I may need to get a blood or urine sample from you. An adolescent will
feel much more comfortable if she knows what to expect. Because genital examinations are a source of great anxiety and embarrassment for youth, if a genital examination will take place, the provider should inform the adolescent patient. If a pelvic
examination will be performed, a full explanation is imperative, especially if this is
the patients first examination. Showing the adolescent the speculum, and even letting
her handle it, usually diminishes rather than escalates anxiety. Diagrams or plastic
genitalia models and mirrors during the examination are useful to educate youth, as
most young females are unaware of their anatomy and do not know the proper terms.
Many young women never have seen their own anatomy.
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ENSURE CONFIDENTIALITY
At the opening of the interview, the provider must define his or her confidentiality
policy and under what circumstances confidentiality will be breached (eg, suicidal/
homicidal thoughts, physical/sexual abuse). What you and I talk about is confidential
from your family, which means I am not going to tell them what we talk about, unless I
am worried that you are hurting yourself, hurting someone else, or someone is hurting
you. An adolescent must understand that the provider is her health care provider, not
the parents. Most adolescents will not admit to engaging in any risk behaviors if she
believes parents/guardians will be informed.
Health insurance presents another challenge for providing confidential care to
adolescents. Most commercial health plans itemize services so the bill that is sent
to the adolescents family may divulge the type of care provided. So before guaranteeing confidential care to their adolescent patients, providers must be savvy to
whether the STI test they ordered will show up on the parents bill. Providers who
care for commercially insured sexually active adolescents can use as ICD-9 codes
symptoms (eg, dysmenorrhea, irregular menses) and general clinical findings (ie,
vaginal discharge, pyuria, urinary complaints or symptoms of vulvitis) rather than
specific STI diagnoses, such as trichomonas or chlamydia. Tools to enhance confidentiality and coding are available on the North American Society for Pediatric and
Adolescent Gynecology at: www.naspag.org/Professionals/clinicalResources.cfm.
ASK NONTHREATENING QUESTIONS FIRST
Begin the interview with nonthreatening questions, with subsequent progression to

more sensitive questions. Small talk (eg, ask casually about school, upcoming or
past vacations, sports) can be quite useful, because:
It is an icebreaker and gives the patient time to feel out the provider and adjust to
her surroundings.
It gives the provider a sense of how the rest of the interview will flow; is the patient
shy or relaxed.
If the parent/guardian is present, it gives the provider insight into the parentchild
dynamic.
Next ask the adolescent about her health concerns. It is important to have and
display genuine interest and concern throughout the interview; nothing is more effective in establishing rapport. An adolescents perception of disinterest will result in loss
of trust.
USE WRITTEN QUESTIONNAIRES FOR SENSITIVE QUESTIONS
Some adolescents find it easier to admit to risk behaviors on paper rather than out
loud to an adult provider. It may be useful to use paper questionnaires in a busy office
practice that does not allow time for lengthy get-to-know-you and rapport-building
visits (see Appendix for list of free, online, adolescent risk-behavior screening tools).
These forms can be completed while the patient is waiting to be seen and then quickly
reviewed by the provider to identify areas on which to focus during the patient interview. Remember to provide a parent-free space for the adolescent to complete the
questionnaire in privacy without fear of disclosure. The utility may be limited in patients
who have limited literacy skills or in populations where there are language barriers.
INTERVIEWING TECHNIQUES
Obtaining pertinent information from an adolescent and engaging her in a comfortable

conversation at the same time is an art. The following are several interview techniques
that can aid the provider in leading an informative dialog with the adolescent patient.4
Open-Ended Questions
An adolescent, especially one with concrete thought, will be quick to answer yes or
no in response to a specifically directed question. Avoid questions that yield yes or
no responses. One might phrase the question, How often do you use condoms?
rather than, Do you use condoms all the time?
Reflection Responses
Reflection responses mirror the adolescents feelings and can help stimulate further
conversation on a topic. So, you feel it is difficult to get your partner to use condoms?
Tell me about that.
Clarification Questions
Asking the adolescent to explain anything the practitioner does not understand is not
insulting, and is in fact empowering to the adolescent, as now she is the expert
teaching the practitioner, What do you mean when you say...?
Restatement and Summation Responses
Restating and summarizing the relevant issues can clarify the question and encourage
more dialog. It seems like you want to tell your partner that you have chlamydia, but
you are afraid he will blame you and get angry. Is that right?
Reassuring Statements and Generalization
Reassuring statements validate the adolescents feelings, reestablish the practitioners role as an advocate, and can stimulate more dialog. Many young women
your age decide to wait to have sex until they are older, out of high school, or even
married. Deciding what is right for you does not mean there is anything wrong with
you, even if it is different than what your friends are doing.
Support and Empathy
A supportive and empathetic response during the conversation acknowledging the

adolescents difficult experience can stimulate more dialog and impart further trust.
It sounds like this has been difficult for you. I see this happen to a lot of my patients ..
The Quiet Adolescent
For the noncommunicative adolescent, return to icebreakers; the goal is to get these
patients to talk about anything. Ask her to discuss something that interests her, such
as school, sports, or friends, to help her relax and feel comfortable.
Adolescent Sexuality, Culture, and Religion
In the next decade, the ethnic make up of adolescents in the United States will
lange of cultural and religious traditions.
continue to diversify, bringing with it a me
Health care providers must be savvy to the varying cultural and religious beliefs of their
patient population and demonstrate cultural sensitivity to different practices. For
example, youth may be resistant to discussing the topic of sex regardless of their level
of sexual experience, because sexual activity before marriage is shunned by many
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cultures and religions. Therefore, framing information about sexuality in the context of
helping their peers and friends who may be or become sexually active is a nonthreatening and effective method to provide sexual education to all patients.
Caveats to Asking the Sex QuestionsWhat Practitioners Need to Know About
their Patients Sexuality and How to do the Examination
The hidden agendaif practitioners ask, patients will tell; if practitioners
do not they will not
The hidden agenda is the phenomena of adolescents seeking care for a sensitive
health issue (eg, STI symptoms) and assuming their provider will know what is wrong
with them without actually verbalizing the problem. For example, an adolescent female
presents with complaints of a belly ache; the provider works up the abdominal pain,
but does not screen for sexual behaviors and treats the patient for presumed gastritis.
The patient leaves the office reassured that she is not infected with an STI, because
she believes the provider is omniscient and would have known if she were infected.
To know whether an adolescent patient is having sex, providers must ask the patient;
the adolescent will not always volunteer her true health concerns but is surprisingly
candid when asked directly.
What Kind of Sex?
Oral, anal, and vaginal sex and whether condoms are used and used correctly result in
varying levels of STI risk. As adolescents present in varying stages of cognitive development, sexual knowledge, and sexual experience, the general question of, Are you
sexually active? will be interpreted differently by individual adolescents. Providers
need to ask very direct and specific questions to yield the information needed to
make an accurate risk assessment and determine the extent of STI screening
required. Have you had sex with guys, girls, or both? Have you ever had oral sex?
Anal sex? Vaginal or regular sex? If in doubt of a youths understanding of the definitions of oral, anal, or vaginal sex, the provider should pose the questions to ensure
they are discussing the same behavior. Tell me what having sex means to you.
Most likely the adolescent will squirm, be embarrassed, and have difficulty answering
the question. The provider then has the opportunity to provide the definitions. For
example, I want to make sure we are talking about the same thing: so oral sex means
your partner kisses or puts his/her mouth on your vagina/penis; some people call it
going down on each other; have you ever done that? (Box 2).
The Physical Examination
Foremost, the provider always should make the adolescent feel like she is in control.
Providers should let the adolescent know what part of the examination will be performed next and that the physical examination will stop at any time if she is uncomfortable. Providers should explain that they are doing the examination to best take care of
their patients health and want to make sure that they are indeed healthy. Offer as
many options as possible during the examination to empower the patient and make
her feel as safe and comfortable as possible. For example, ask the adolescent if
she would be more comfortable completely undressing and changing into a gown
before the examination or would prefer to undress only the part of the body being
examined at the time, so that she remains partially dressed throughout the examination. Younger adolescents may prefer the latter option, because they may feel insecure about their bodies. Another strategy for females who are resistant to
undressing and only require an external genital examination is to allow them to
Box 2
Key topics to cover and sample questions for the sexual interview with adolescents
Introduce the topic and establish confidentiality
I need to ask you some personal questions that I ask all of my patients so that I can best take
care of your health. What we talk about is confidential from your family, which means I am not
going to tell them what we talk about, unless I am worried that somebody is hurting you, you
are hurting yourself, or you are hurting somebody else. You do not have to answer any
question that you dont want to answer.
Sexual orientation
You are at the age when people start to figure out who they like, are interested in or attracted
to. Have you thought about that? Do you like guys, girls, or both?
Sexual activity
Have you ever been so close to a guy/girl that you held hands or kissed? What about touching
your private areas, on top of or under your clothes? Have you ever had sex? By that I mean,
have you had sex where a guy puts his penis inside a girls vagina? What about oral sex where
your partner puts his or her mouth on your vagina? What about anal sex, where a guy puts his
penis inside your anus or bottom?
Sexual abuse
Have you ever had sex when you didnt really want to? Has anyone ever touched you in your
private areas in a way that made you feel uncomfortable?
Partners and concurrency
How many people have you had sex with in the past 2 months? Past year? Your whole life?
Do you think your partner is having sex with anyone else? Are you?
Sexually transmitted infections
Has a doctor ever told you that you had a sexually transmitted infection like chlamydia?
gonorrhea? trichomonas? herpes? genital warts? syphilis? HIV/AIDS? Have any of your partners
ever had one?
Pregnancy
Have you ever been pregnant? What happened with that pregnancy? Are you trying to get
pregnant right now?
Condoms
What do you do to keep yourself and your partner from getting a sexually transmitted
disease? Do you use condoms? Did you use a condom the last time you had sex? How often do
you think you use condoms? Have you ever had trouble using condoms? Did they ever break or
slip off during sex?
Hormonal contraception
What do you do to keep yourself from getting pregnant? Are you on any hormonal
contraception like the birth control pill? The shot? The patch? The ring? How is that going? Is it
hard to remember to take your pills?
continue wearing their underwear during the genital examination. For the examination,
the provider can shift the underwear to one side, allowing full visibility of the genitalia.
The stage of secondary sexual characteristic development should be documented
in any adolescent examination involving the genitalia. Tanner16 classified the level of
pubertal maturation into five levels based on breast and pubic hair development in
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Shafii & Burstein
females, and it is used as a measure of pubertal development. Figs. 3 and 4 describe

Tanners classification of stages of pubertal development.
With new urine-based STI testing and revised Papanicolaous test guidelines (recommending first adolescent test performed within 3 years after coitarche or by age
21 years), many asymptomatic adolescent females do not require a pelvic examination. Females presenting with genital symptoms and adolescents requiring their first
Papanicolaous test do need to have a pelvic examination performed. A first pelvic
examination can be an anxiety-provoking experience. A reassuring and confident
provider sets the tone for the examination. Providers should discuss what is going
to occur and answer all questions before initiating the examination. Pelvic models
or diagrams may be helpful to describe the procedure. Allowing a support person in
the room, such as a friend, relative, or nurse, can ease the tension for the patient.
As examination rooms are often cold, ensure that adolescent remains warm and as
Fig. 3. Female public hair development. Stage 1: prepubertal (can see velus hair similar to
abdominal wall). Stage 2: sparse growth of long, slightly pigmented hair, straight or curled,
along labia. Stage 3: darker, coarser, and more curled hair, spreading sparsely over junction
of pubes. Stage 4: hair adult in type, but covering smaller area than in adult; no spread to
medial surface of thighs. Stage 5: adult in type and quantity, with horizontal distribution.
(From Daniel WA, Paulshock BZ. A physicians guide to sexual maturity rating. Patient
Care 1979:13;122.)
Fig. 4. Female breast development. Stage 1: prepubertal. Stage 2: breast bud stage with
elevation of breast and papilla; enlargement of areola. Stage 3: further enlargement of
breast and areola; no separation of their contour. Stage 4: areola and papilla form
a secondary mound above level of breast. Stage 5: mature stage with projection of papilla
only, related to recession of areola. (From Daniel WA, Paulshock BZ. A physicians guide to
sexual maturity rating. Patient Care 1979:13;122.)
comfortable as possible with additional sheets or blankets. Visual imagery can help
the adolescent relax during the examination and is performed easily by encouraging
the adolescent to concentrate on imaging herself doing her favorite sport or activity
in her favorite location. Visual imagery and focused breathing are helpful techniques
to decrease anxiety and muscular tension, thereby facilitating the successful performance of the pelvic examination and a more positive experience for the adolescent.
Some providers also place an interesting and hopefully distracting poster on the
examination room ceiling for the patients to view during the examination.
Adolescent females may feel embarrassed and uncomfortable with male providers.
If the adolescent demonstrates discomfort, every effort should be taken, if at all
possible, to offer a choice in the provider gender. When there is discordant gender
in the provider and patient, chaperones should be used (eg, nurse, medical assistant,
or parent/guardian) as a measure of safety and comfort for the patient and to protect
the provider against false impropriety claims.
Laboratory Tests
Sexually active adolescents are at high risk for acquiring STIs, such as gonorrhea and
chlamydia. Current guidelines for delivery of adolescent primary care services recommend yearly STI screening for all sexually active adolescents.17 Tests for chlamydia,
gonorrhea, and trichomonas should be obtained routinely. Many experts recommend
chlamydia screening every 6 months for sexually active adolescent females. The Centers
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Shafii & Burstein
for Disease Control and Prevention (CDC) recommend using a nucleic acid amplification
test (NAAT), if resources permit, for diagnosing genital chlamydia and gonorrhea infections. NAATs are the most sensitive chlamydia tests available. In addition to testing endocervical and urethral specimens, NAATs allow for noninvasive STI testing by means of
urine and self-collected vaginal swabs, thereby avoiding invasive pelvic examinations as
a major obstacle to many adolescents seeking care. Studies demonstrate that gonorrhea and chlamydia NAATs also perform well on rectal and oropharyngeal specimens,
but are not US Food and Drug Administration (FDA)-approved. More information on chlamydia NAATs is available at www.igh.org/castd/downloadable/chlamydia_testing_
tables.pdf. Currently, CDC17 recommends HIV screening all Americans 13 to 64 years
at least once and more often as indicated by sexual risk behaviors.
TREATMENT
In all 50 states, adolescents may consent for reproductive health care without parental
consent. States vary, however, in regards to the age minimum required to consent for
health care related to STIs. Providers should check their state for age-specific guidelines. CDC-recommended adolescent STI management does not vary from that of
adults, except with the caveat of ensuring completed treatment. Because adolescents
are notorious for poor compliance with treatment and follow-up recommendations,
single-dose therapy is recommended when available, and directly observed therapy
is ideal.
Providers should verify that all sexual partners have been tested and treated.
Ensuring partner treatment can be an arduous task but is imperative for public health.
One strategy to increase partner treatment and decrease reinfection rates is expedited
partner therapy (EPT); treating a partner of an STI-infected individual without requiring
a prior clinical examination. EPT usually is practiced by patient-delivered partner
therapy (PDPT). With PDPT, the provider gives the index patient medications or
a prescription for medications to deliver to her partner(s). The medication usually is
accompanied by a brochure describing the infection, the medication, and the need
to see a clinician for a complete STI evaluation. As of February 2009, EPT is legal in
15 states as an option for providers when caring for heterosexual individuals infected
with gonorrhea or chlamydia. For more information on EPT, including legal status, go
to: www.dcd.gov/std/ept.
Follow-up
The no-show rate tends to be high for adolescent patients and is a perpetual challenge
for providers. Phone calls the night before and even day of the appointment are advisable. Documenting which telephone number is acceptable to maintain confidentiality
is important. For many adolescents, calling or texting them on their own cell phones is
feasible. Having a dedicated nurse who the adolescent can access easily when she
needs to promotes the usability of the practice and facilitates their return to care.
Monthly follow-up is ideal when taking care of any high-risk adolescent.
There are many reasons why adolescents do not keep appointments, so alerting
them to other options for care is useful: provide patients with a list of teen-friendly
clinics and pharmacies where they can be tested and obtain condoms and contraception and may be able to access after hours and on weekends.
SUMMARY
Adolescence is an exciting yet challenging time of life. Among adolescents, rate of

physical development surpasses their rate of cognitive development. Adolescents
are physically able to engage in behaviors that place them at risk for STIs, but they
have not yet fully developed the capabilities to judge when and how to protect themselves. Gynecologists are in the unique position and are a potentially valuable
resource to educate adolescents about their health and their bodies in a private and
safe environment where they can offer individualized information and strategies to
guide adolescents and young adults toward physical and emotional health. As
providers of health care for adolescents, it is the gynecologists job to support patients
to remain in good sexual health, despite their developmental dichotomy between
judgment and action.
APPENDIX
THE FOLLOWING IS A LIST OF WEB SITES FOR PROVIDERS:
The Adolescent Health Working Group: http://ahwg.net/

The Adolescent Wellness through Access to Resources to Education (AWARE)
Foundation: http://www.awarefoundation.org/
Advocates for Youth: http://www.advocatesforyouth.org/
American College of Preventive Medicine Adolescent Health Initiative: http://www.
acpm.org/ah/default.htm
American College of Obstetrics and Gynecology Adolescent Health Care: http://
www.acog.org/departments/dept_web.cfm?recno 5 7
American Social Health Association (ASHA): www.ashastd.org
The California STD/HIV Prevention Training Center: www.stdhivtraining.org/educ/
training_module/tools.html
Centers for Disease Control and Prevention: www.cdc.gov/std/treatment
The Center for Young Womens Health (CYWH): http://www.youngwomenshealth.
org/
ETR Associates (patient brochures): www.etr.org
Gay and Lesbian Medical Association (GLMA): http://www.glma.org
The Guttmacher Institute: http://www.guttmacher.org/
Kaiser Family Foundation: http://www.kff.org/
The Massachusetts STD/HIV Prevention Training Center: http://www.mass.gov/
dph/cdc/std/guidelines/chlamydia_toolkit.pdf
The National Campaign to Prevent Teen Pregnancy: http://www.teenpregnancy.
org/
The North American Society for Pediatric and Adolescent Gynecology: http://www.
naspag.org/
Pediatric Health Care Alliance Teen Growth: http://www.teengrowth.com/
Planned Parenthood Federation of America: http://www.plannedparenthood.org/
index.htm
Rutgers, the State University of New Jersey, teen sexual health information Web
site for parents and professionals at: http://sexetc.org/page/parents_
professionals/
Society of Obstetricians and Gynecologists of Canada: www.sexualityandu.ca
ADOLESCENT RISK-SCREENING TOOLS FOR PROVIDERS INCLUDE:
American College of Obstetrics and Gynecology Tool Kit for Teen Care: http://
www.acog.org/bookstore/Tool_Kit_for_Teen_Care_P348.cfm
Adolescent Health Working Group: http://ahwg.net/
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Shafii & Burstein
American Medical Association Guidelines for Adolescent Preventive Services

(GAPS): http://www.ama-assn.org/ama/pub/category/1980.html
New York State Department of Health Office of Managed Care Screener/Trigger
questionnaire: http://www.urmc.rochester.edu/gchas/div/adol/leah/resources.
HTM
THE LIST OF WEB SITES FOR ADOLESCENT PATIENTS INCLUDES:
Advocates for Youth Youth Lounge information: http://www.advocatesforyouth.

org/youth/index.htm
Advocates for Youth Web site for gay, lesbian, bisexual, transgender, and questioning (GLBTQ): http://www.youthresource.com/
The American Social Health Association adolescent sexual health information:
http://www.iwannaknow.org
Atlantic Health System: http://www.teenhealthfx.com
Campaign for Our Children: http://www.cfoc.org/
Canadian Association for Adolescent Health: www.youngandhealthy.ca
The Center for Young Womens Health (CYWH): http://www.youngwomenshealth.
org/
Columbia Universitys Health Promotion Program Go Ask Alice Web site for
adolescents and young adults: http://www.goaskalice.columbia.edu/
DIPEx Web site (UK) at: http://www.youthhealthtalk.org/
MTV collaboration with Kaiser Family Foundation: http://www.itsyoursexlife.com/
The Nemours Foundations Center for Childrens Health Media: http://www.
kidshealth.org/teen/sexual_health/
Palo Alto Medical Foundation (PAMF): http://www.pamf.org/teen/
Pediatric Health Care Alliance Teen Growth: www.TeenGrowth.com
Planned Parenthood Teens: http://www.teenwire.com/
Rutgers, the State University of New Jersey, teen sexual health: http://www.sexetc.
org/
Teenage Health Websites Ltd Web site at (UK): http://www.doctorann.org/
Youth Embassy Web site at: http://www.youthembassy.com/
THE LIST OF WEB SITES FOR PARENTS OR GUARDIANS OF ADOLESCENTS INCLUDES:

Advocates for Youth: http://www.advocatesforyouth.org/
Advocates for Youth Parents Sex Ed Center: http://www.advocatesforyouth.
org/parents/index.htm
The American Social Health Association adolescent sexual health: http://www.
iwannaknow.org
Campaign for Our Children: http://www.cfoc.org/
Children Now: http://www.talkingwithkids.org/
Palo Alto Medical Foundation (PAMF) Web site for parents at: http://www.pamf.
org/teen/parents/
Rutgers, the State University of New Jersey, teen sexual health information for
parents and professionals: http://www.sexetc.org/page/parents_professionals/
Youth Embassy (for parents): http://www.youthembassy.com/parents.asp
REFERENCES
1. Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillanceUnited

States, 2007. MMWR Surveill Summ 2008;57(4):1131.
2. Weinstock H, Berman S, Cates W Jr. Sexually transmitted diseases among American youth: incidence and prevalence estimates, 2000. Perspect Sex Reprod
Health 2004;36(1):610.
3. CDC. Youth risk behavior surveillanceUnited States. MMWR Morb Mortal Wkly
Rep 2003;53:129.
4. Neinstein L. Adolescent healthcare: a practical guide. New York: Lippincott
Williams & Wilkins; 2002.
5. Ford K, Lepkowski JM. Characteristics of sexual partners and STD infection
among American adolescents. Int J STD AIDS 2004;15(4):2605.
6. Kirby D. Antecedents of adolescent initiation of sex, contraceptive use, and pregnancy. Am J Health Behav 2002;26(6):47385.
7. Shafii T, Stovel K, Davis R, et al. Is condom use habit-forming? condom use at
sexual debut and subsequent condom use. Sex Transm Dis 2004;31(6):36672.
8. Upchurch DM, Mason WM, Kusunoki Y, et al. Social and behavioral determinants
of self-reported STD among adolescents. Perspect Sex Reprod Health 2004;
36(6):27687.
9. Strassburger V, Brown RT, Braverman PK, et al. Adolescent medicine: a handbook
of primary care. New York: Lippincott Williams & Wilkins; 2006.
10. Bar-Cohen A, Lia-Hoagberg B, Edwards L. First family planning visit in schoolbased clinics. J Sch Health 1990;60(8):41822.
11. Finer LB, Zabin LS. Does the timing of the first family planning visit still matter?
Fam Plann Perspect 1998;30(1):303 42.
12. McKee MD, Karasz A, Weber CM. Health care seeking among urban minority
adolescent girls: the crisis at sexual debut. Ann Fam Med 2004;2(6):54954.
13. Stone N, Ingham R. When and why do young people in the United Kingdom first
use sexual health services? Perspect Sex Reprod Health 2003;35(3):11420.
14. Zabin LS, Stark HA, Emerson MR. Reasons for delay in contraceptive clinic utilization. Adolescent clinic and nonclinic populations compared. J Adolesc Health
1991;12(3):22532.
15. Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures:
men and women 15-44 years of age, United States, 2002. Advanced data from
vital health statistics; no 362. Hyattsville, MD: National Center for Health Statistics:
p. 156.
16. Tanner J. Growth at adolescence. 2nd edition. Springfield (IL): Charles
C Thomas; 1962.
17. Centers for Disease Control and Prevention Sexually transmitted diseases treatment guidelines, 2006. MMWR 2006;55(No.RR-11):195.
117
Update in Adolescent
Contraception
Eduardo Lara-Torre, MD, FACOG
KEYWORDS
Adolescent Contraception Long term methods
Despite a recent decrease in the pregnancy rate in the United States, the pregnancy
rates in Europe and Canada remain close to 50% lower than that in the United States.1
The use of appropriate contraception is especially important in adolescents. As this
age group matures and becomes capable of reproduction, visits to a practitioner
should include counseling on adequate methods of birth control to target adolescents
needs and ability to improve their compliance. Unfortunately, it is not uncommon to
see adolescents months after their initiation of sexual activity, with some patients
seeking contraception up to 12 months or later. The misconception that pregnancy
cannot occur during your first time or during certain times of the month increases
the risk for unintended pregnancy and provides false reassurance to teens. The
2007 Youth Risk Behavior Surveillance System, which tracks different health risk
behaviors among high-school students, including sexual behaviors that contribute
to unintended pregnancies, surveyed more than 14,000 high-school students from
every state and the District of Columbia.2 Important findings of this survey included
the following:
47.8% of students reported ever having had sexual intercourse (46.8% in 2005)
7.1% of students reported having had sex before the age of 13 years (6.2% in
2005)
14.9% of students reported having had sex with four or more sexual partners
(14.3% in 2005)
35.0% of students reported being currently sexually active, defined as having
had sexual intercourse in the 3 months before the survey (33.9% in 2005)
61.5% of sexually active students reported that they or their partner had used
a condom during last sex (62.8% in 2005)
These findings reinforce the importance of addressing contraception during an
adolescents initial health care evaluation.
Preventive visits are a great venue for discussing contraception even before the initiation of sexual activity provided that this information does not result in an increased
rate of sexual activity, earlier age at first intercourse, or greater number of sexual
Department of Obstetrics and Gynecology, Carilion Clinic, Virginia Tech-Carilion School of
Medicine, 102 Highland Avenue, Suite 303, Roanoke, VA 24013, USA
doi:10.1016/j.ogc.2008.12.003
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Lara-Torre
partners. On the contrary, if the adolescent perceives that there is an obstacle to obtaining contraception, he or she is more likely to experience negative outcomes
related to sexual activity.3 The American College of Obstetricians and Gynecologists
(ACOG) has recently published recommendations for the first preventive visit with
a gynecologist to be between the ages of 13 and 15 years.4 The time spent with their
provider allows adolescents the opportunity to identify risk factors and challenges that
can be overcome before the initiation of hormonal or nonhormonal contraception, in
addition to encouraging abstinence.
Many teens also perceive the pelvic examination to be a barrier for accessing
contraceptive services; therefore, the physical examination may be deferred until after
initiation of contraceptives if requested by the patient and judged appropriate by the
clinician. One significant reason why adolescents hesitate or delay in obtaining family
planning services or contraception is concern about confidentiality. Health care
providers need to be familiar with current local statutes on the rights of minors to
consent to health care services that affect confidentiality. For more information and
up to-date reproductive health reproductive rights of adolescents, visit the
Guttmacher Institute Web site.5
The purpose of this review is to provide some new developments of commonly used
contraceptive methods as they apply to adolescents and some new information to the
reader for use in his or her daily practice. A table from the World Health Organization
(WHO) is provided, with updates on the changes for patients who have specific
medical conditions for which certain contraceptive methods may be contraindicated
(Table 1). New absolute contraindications for contraception are limited to only two
conditions: thromboembolic mutations and the use of estrogen-containing methods
and current pelvic inflammatory disease or mucopurulent cervicitis and initial placement of an intrauterine device (IUD).
ABSTINENCE
Although abstinence is the most effective means of birth control, the lack of other
contraception education has caused controversy and disagreement with the efforts
of specialty societies. During the first part of the decade, the US administration placed
an emphasis on abstinence-only education for pregnancy prevention. Unfortunately,
recent data suggest that abstinence-only programs are not as effective as those in
which other contraceptive options are offered at the same time.6 The choice to remain
or return to abstinence may be a difficult one for some adolescents, and adequate
resources, such as support and chat rooms for counseling, may be required. Those
who choose abstinence should be encouraged and reminded of the advantages of
decreased risk for pregnancy and sexually transmitted infections (STIs).
BARRIER METHODS
Barrier methods include such devices as male condoms, female condoms, cervical
caps, diaphragms, and spermicidal and contraceptive film and ovules. Although effective, the use of these devices by adolescents is not consistent, even when chosen by
them as their method to protect against STIs.7 The need for application before each
sexual encounter decreases the use of the method by decreasing the spontaneity
of the act, as some teens explain.
The male condom is the most commonly used barrier method by adolescents. The
efficacy in preventing STIs and the HIV epidemic increased their use during the 1990s.
Despite their widespread availability, however, the use of condoms is still not
Adolescent Contraception
widespread. Many limitations, such as cost, personal beliefs, and the inability of
adolescents to be good planners, allows for inconsistency of use.
Female barrier methods, such as the female condom, have not received great popularity within the adolescent population. Discontinuation rates are as high as 55%, and
when used,8 it is common to have accidents secondary to the inappropriate use of
the method. Practitioners should encourage the use of barrier methods, even when
the teen is on another form of contraception.
COMBINED ORAL CONTRACEPTIVE PILLS
The combined oral contraceptive pill (OCP) is the most commonly used method of
contraception in the adolescent group, with the rate of use approaching 50%.9 A wide
range of estrogen dosing and progestin products makes the choice of the best pill difficult. The contraceptive and noncontraceptive benefits (eg, light, predictable, regular
pain-free menses) of the different combinations are about the same, and the brand
should be chosen based on the side effect profile and practitioners preference. In the
quest for the best contraceptive method, adolescents look for safety, convenience,
privacy, and efficacy as the most important factors in choosing a contraceptive method.
Because the incidence and severity of side effects increase with age and smoking, the
overall safety provided by OCPs in adolescents without thromboembolic disease risk
factors may assist the practitioner in reassuring teens about the use of this method.10
Other indications of use may also influence the selection of this method in adolescents. In particular, the prevalence of acne and premenstrual dysphoric disorder
(PMDD) may play an important role in selecting this method as the one of choice for
many of our patients. Newer indications, such as PMDD with a low-dose (ethinyl estradiol, 20 mg) formulation containing drospirenone (3 mg), which has antiandrogenic and
antimineralocorticoid properties, in a 24/4 regimen (24 days of active drug/4 days of
placebo), have proved to be efficacious in reducing symptoms of PMDD.11 By the
same token, this formulation has been proved efficacious in the treatment of
acne.12 Information on the efficacy of some other formulations in reducing acne,
including cyproterone, levonorgestrel, or desogestrel, may also favor the use of
some combinations and allow the patient to obtain multiple benefits with one drug.13
Unfortunately, despite the wide use of the OCP, adolescent users have failure rates
as high as 15% in the first year of use because of missed pills, with 28% of 15- to
17-year-old patients reporting that they have missed two or more pills in their most
recent cycle (compared with 13% of those aged 18 years and older).9,14 To prevent
some of the noncompliance in adolescents, initiation of the pill on the same day (Quick
Start) versus the traditional start initiation on a Sunday seems to improve compliance
and still maintains an acceptable side effect profile without any teratogenic effects,
even if the patient is pregnant. This innovative method may be yet another way to
encourage adolescent patients to take their method of birth control even before
they leave the office, with the hope of improving their compliance.15
Extended regimens, such as the available 84/7-day package (ethinyl estradiol
[30 mg]/levonorgestrel [150 mg]), have shown similar efficacy and compliance, with
only a mild increase in breakthrough bleeding in the adult population, and may be
a good option for patients who desire less frequent menses, such as athletes and military personal, although studies in adolescents are lacking.7
OTHER COMBINED HORMONAL METHODS
The contraceptive transdermal patch uses the technology of a medicated adhesive

that allows the skin to absorb and maintain a constant hormonal level without the
121
122
Condition
COC
CIC
POP
DMPA NET-EN
LNG/ETG
Cu-IUD
LNG-IUD
Personal characteristics andreproductive history

Obesity
R30 kg/m2 BMI
Cardiovascular disease
Known thrombogenic mutations (eg, factor V Leiden; prothrombin
mutation; protein S, protein C, and antithrombin deficiencies)
Depressive disorders
Depressive disorders
Reproductive tract infections and disorders
Uterine fibroids
(a) Without distortion of the uterine cavity
(b) With distortion of the uterinecavity
PID
(a) Past PID (assuming no current risk factors for STIs)
(i) With subsequent pregnancy
(ii) Without subsequent pregnancy
(b) PID: current

STIs
(a) Current purulent cervicitis or chlamydial infection or gonorrhoea
(b) Other STIs (excluding HIV and hepatitis)
(c) Vaginitis (including trichomonas vaginalis and bacterial vaginosis)
(d) Increased risk for STIs
2/3
2/3
HIV/AIDS
High risk for HIV
Lara-Torre
Table 1
WHO categories of safety for use of contraceptive methods: changes since 2002
HIV-infected
AIDS
Clinically well on antiretroviral therapy
See antiretroviral therapy
Drug interactions
Drugs which affect liver enzymes
(a) Rifampicin
(b) Certain anticonvulsants (phenytoin, carbamazepine, barbiturates,

primidone, topiramate, oxcarbazepine)
(a) Griseofulvin
(b) Other antibiotics
Antibiotics (excluding rifampicin)
Antiretroviral therapy
I
2/3
1
C
2
I
2/3
C
2
Conditions for which there was a classification change for one or more methods or a major modification to the condition description. Changed classifications are in
bold.
Abbreviations: BMI, body mass index; C, continuation; CICs, combined injectable contraceptives; COCs, low-dose combined oral contraceptives; Cu-IUDs, copper
intrauterine devices; DMPA, depot-medroxyprogesterone acetate; ETG, etonogestrel; I, initiation; LNG, levonorgestrel; LNG-IUDs, levonorgestrel-releasing IUDs;
NET-EN, norethisterone enantate; PID, pelvic inflammatory disease; POPs, progestogen-only pills.
1. A condition for which there is no restriction for the use of the contraceptive method.
2. A condition where the advantages of using the method generally outweigh the theoretic or proved risks.
3. A condition where the theoretic or proved risks usually outweigh the advantages of using the method.
4. A condition which represents an unacceptable health risk if the contraceptive method is used.
Also,
1. Use method in any circumstances
2. Generally use the method
3. Use of method not usually recommended unless other more appropriate methods are not available or not acceptable
4. Method not to be used
From World Health Organization. Categories of safety for use of contraceptive methods. Changes since 2002. In: Medical eligibility criteria for contraceptive use.
3rd edition. Geneva (Switzerland): Reproductive Health Research, World Health Organization; 2004; with permission. Available at: www.who.org. Accessed
August 1, 2008.
123
124
Lara-Torre
fluctuations seen with orally absorbed forms. In the adult population, failure rates and
side effect profiles are similar to those of OCPs. In adolescents, 21% experienced
a patch coming off completely and 32% experienced a patch peeling partially in the
corner.16 Given the weekly dosing, many adolescents find this method appealing.
Good acceptance, cycle control, and adherence rates have been shown and are
greater than those observed with the OCP.1619 Most adolescents were extremely
or somewhat satisfied with the patch, and 93% would recommend it to a friend.15
Recent safety data released by the manufacturer warn of an increased exposure to
estrogen compared with the average-dose OCP, which may increase the risk for
cardiovascular events.20 Adolescents should be cautioned about these risks and
counseled about the potential side effects before prescribing the method, remembering that the risk for thromboembolic or cardiovascular events associated with pregnancy is greater in an adolescent than that associated with the transdermal patch. For
those noncompliant with the pill, the patch may be a good alternative.
The vaginal contraceptive ring (ethinyl estradiol [15 mg]/etonogestrel [120 mg]) is
another approved method of birth control. This method requires motivation from the
patient to insert and remove the contraceptive device from the vagina once a month
and has not been well studied in adolescents. Adequate trials on adolescents are still
underway and should provide additional information regarding other applications,
such as extended regimens. Preliminary results indicate favorable acceptability
when compared with the OCP.21
The transdermal patch and intravaginal ring methods have been used in a continuous fashion. They have shown promising results without affecting safety or
effectiveness.22,23
The monthly injectable combination contraceptive that combines medroxyprogesterone acetate (25 mg) and estradiol cypionate (5 mg) has been recalled by the
manufacturer and is not available for use in the United States. Previous studies of
this product did show good efficacy, and the future release of a revised version of
this method is predicted. The once-monthly dosing of the regimen may provide teens
with another alternative to improve their compliance.
PROGESTIN-ONLY METHODS
The progestin-only contraceptive pill has been shown to have similar efficacy to the
OCP. Unfortunately, given its short half-life, failure rates may be increased because
of patient noncompliance with the proper timing of the pill, which requires taking it
around the same time of day (within 3 hours) each day.24 Extensive education
regarding the irregular bleeding occurring in the first 3 months and need for compliance with pill dosing at a similar time each day is required to enhance adolescent
compliance. Certain contraindications to these hormonal methods may include sensitivity to the agents, osteoporosis, undiagnosed vaginal bleeding, pregnancy, or severe
liver disease.
Depot medroxyprogesterone acetate (DMPA) is a common contraceptive used by
the adolescent population because of the minimal intervention on the part of the
patient required to achieve compliance. This method is the choice for adolescents
who are breastfeeding and those with contraindications to the use of estrogen,
such as thrombophilias and certain medical conditions. The application of one intramuscular dose of 150 mg every 3 months increases convenience but still requires
compliance to continue the method. Although its efficacy has been shown to be better
than that of the OCP, most of its effect is probably related to compliance and ease of
use. Weight gain and irregular bleeding are common and unpleasant side effects for
adolescents. The product insert indicates an average weight gain of 2.5 kg after the
first year of use, 3.7 kg after the second year of use, and 6.3 kg after the fourth year
of use.25 Conversely, amenorrhea occurs in 55% to 60% of DMPA users at 12 months
and in up to 68% of users at greater then 1 year.26 Many teenagers perceive this as an
appealing feature of the medication, which may contribute to their compliance and
request for this method.
A recent concern has been the effect of the hypoestrogenic state created by longterm use of DMPA on bone density in adolescents. The use of DMPA has been shown
to decrease the bone mineral density of adolescent users when compared with the
bone mineral density of normal menstrual controls and oral contraceptive users;
however, the potential effect on future bone health is unknown.27 The lack of longterm prospective trials on the bone health of adults who used DMPA as adolescents,
in addition to the potential bone loss associated with pregnancy in the absence of
contraception, makes DMPA a valid and reliable method to prevent pregnancy until
further data are obtained. Those patients who are smokers and sedentary should
be counseled on the detrimental implication regarding bone health and encouraged
to quit smoking and get involved in exercise. Appropriate calcium intake (1200
1500 mg/d) and monitoring of bone density should be encouraged in those adolescents who use the method for more than 2 years, especially those who continue to
be amenorrheic and have any of the other risk factors mentioned previously. The
WHO suggests that the advantages of using DMPA generally outweigh the theoretic
safety concerns regarding fracture risk in the adolescent population (younger than
18 years of age).28
Recent reports have shown the recovery of bone mineral density in those DMPA
users who stop the method when compared with nonusers and should encourage
its continuing use.29 The addition of estrogen (oral or injectable) may be considered
in these patients and may provide protection against bone mineral density loss.30
Progestin subdermal implants in the form of six levonorgestrel rods were previously
commonly used in the adolescent population because of the long-term contraception
provided (5 years) and a 12-month continuation rate of 91%.13 The difficulty in
removing the six rods, in addition to the voluntary recall of certain lots by the manufacturer during 1999, limited the use of this method, however.
In 1998, the introduction of a single etonogestrel implant, with a 3-year contraceptive duration and easy insertion and removal, has reopened subdermal implants as an
alternative for adolescents looking for long-term contraception.31 Unfortunately,
menstrual irregularities are common and may deter teens from using this method or
result in a request for removal after insertion.
EMERGENCY CONTRACEPTION
Emergency contraception (ECP), the use of nonabortifacient hormonal medications

within 72 to 120 hours after unprotected or underprotected coitus for the prevention
of unintended pregnancy, is an important part of contraception counseling in adolescents. Misconceptions regarding the effectiveness, availability, and mechanism of
action make this method less used than its counterparts. Even when providers are
trained in adolescent care, only 80% of them provide the method to their patients
and believe that its efficacy is reserved to 48 hours.13
The use of ECP decreases the risk for pregnancy from 8% to 1% to 2% after a single
episode of unprotected coitus.32 The most efficient method consists of levonorgestrel,
1.5 mg, divided in two doses taken 12 hours apart. A recent Cochrane review showed
that taking a single dose of levonorgestrel, 1.5 mg, may be as efficacious as when it is
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Lara-Torre
taken in divided doses, possibly increasing compliance.33 Timing is of importance, but

recent studies have shown that even if more than 72 hours have passed, either
regimen is efficacious and should be offered, with the understanding that there may
be a reduction in its efficacy the later it is taken. Advanced prescription of ECP has
been shown to increase the likelihood of the use of ECP by young women and teens
when needed and yet not to increase sexual or contraceptive risk-taking behavior
when compared with those receiving only education about ECP.34
INTRAUTERINE DEVICES AND SYSTEMS
The experience with IUDs and intrauterine systems (IUSs) in adolescents is limited.
Traditionally, use of an IUD or IUS has been avoided in adolescents, because this population has the highest rates for STIs. Age alone is not an absolute contraindication to
the use of these devices. In fact, the WHO categorizes this forms of contraception as
class 2 for individuals less than or equal to the age of 20 years. With proper counseling
and condom use, an IUD or IUS may be a viable option for some teens, regardless of
their gravidity and parity status, and should be considered as part of the available
armamentarium for contraception.35
In recent studies, there has not been an increase in infertility or STI incidence with
the use of these devices.6 Most of the ascending infections are probably related to
contracting the infection from lack of condom use rather than to the presence of the
device facilitating it. The risk for ascending infection is probably related to the presence of an STI at the time of insertion, and screening patients before insertion should
be encouraged. The use of STI prophylaxis at the time of insertion is currently not
required but may be of value in those patients in whom the STI incidence is higher
than 5% and there are no adequate screening tests.36 In 2007, the Adolescent Healthcare Committee of the ACOG advocated for the increased use of an IUD or IUS in this
population and has undertaken a full review on the topic.37
SUMMARY
The future of adolescent contraception requires the collaboration between providers,

patients, and, sometimes, their parents. New contraceptive methods allow teens to
choose from a variety of convenient, safe, reliable, and confidential options. Teen
pregnancy prevention in the United States is a priority because of the implications
for the patient and society as a whole. The ability to provide nondiscriminatory, confidential, accessible care and our role in the education and guidance of our patients are
likely to determine the future of this generation of teens.
Long-term contraceptives, such as injectables and implantable devices or IUDs, are
safe for use in young patients. As providers of adolescent health care, encouraging
patients and other providers to use these methods should be part of our efforts to
improve the health care of this population. Limiting access to comprehensive care,
which includes abstinence and all contraceptive methods, and requiring pelvic examinations before the provision of services would be detrimental to the success of our
prevention programs and should be discouraged.
REFERENCES
1. Darroch JE, Singh S, Frost JJ. Differences in teenage pregnancy rates among five
developed countries: the roles of sexual activity and contraceptive use. Fam
Plann Perspect 2001;33:24450.
2. Centers for Disease Control and Prevention. Youth risk behavior surveillance
United States 2007. MMWR Surveill Summ 2008;57(4):1131.
3. Smith CA. Factors associated with early sexual activity among urban adolescents. Soc Work 1997;42:33446.
4. American College of Obstetricians and Gynecologists. The initial reproductive
health visit. ACOG Committee Opinion No. 335. Obstet Gynecol 2006;107:7457.
5. Available at: www.guthmacher.org. Accessed August 1, 2008.
6. Kohler PK, Manhart LE, Lafferty WE. Abstinence-only and comprehensive sex
education and the initiation of sexual activity and teen pregnancy. J Adolesc
Health 2008;42:34451.
7. Stuart GS, Castano PM. Sexually transmitted infections and contraceptives:
selective issues. Obstet Gynecol Clin North Am 2003;30:795808.
8. Anderson FD, Hait H. A multicenter, randomized study of an extended cycle oral
contraceptive. Contraception 2003;68:8996.
9. Hewitt G, Cromer B. Update on adolescent contraception. Obstet Gynecol Clin
North Am 2000;27:14362.
10. Rimsza ME. Counseling the adolescent about contraception. Pediatr Rev 2003;
24:16270.
11. Yonkers KA, Brown C, Pearlstein TB, et al. Efficacy of a new low-dose oral contraceptive with drospirenone in premenstrual dysphoric disorder. Obstet Gynecol
2005;106:492501.
12. Batukan C, Muderris II, Ozcelik B, et al. Comparison of two oral contraceptives
containing either drospirenone or cyproterone acetate in the treatment of
hirsutism. Gynecol Endocrinol 2007;23:3844.
13. Arowojolu AO, Gallo MF, Lopez LM, et al. Combined oral contraceptive pills for
treatment of acne. Cochrane Database Syst Rev 2007:CD004425.
14. Polaneczky M. Adolescent contraception. Curr Opin Obstet Gynecol 1998;10:2139.
15. Lara-Torre E, Schroeder B. Adolescent compliance and side effects with Quick
Start initiation of oral contraceptive pills. Contraception 2002;66:815.
16. Harel Z, Riggs S, Vaz R, et al. Adolescents experience with the combined
estrogen and progestin transdermal contraceptive method Ortho Evra. J Pediatr
17. Gupta N. Advances in hormonal contraception. Adolesc Med Clin 2006;17:
65371 [abstract xi].
18. Burkman RT. The transdermal contraceptive system. Am J Obstet Gynecol 2004;
190(4 Suppl):S4953.
19. Archer DF, Bigrigg A, Smallwood GH, et al. Assessment of compliance with
a weekly contraceptive patch (Ortho Evra/Evra) among North American women.
Fertil Steril 2002;77(2 Suppl 2):S2731.
20. FDA warning on the contraceptive patch. Available at: http://www.fda.gov/bbs/
topics/news/2005/NEW01262.html. Accessed August 1, 2008.
21. Stewart FH, Brown BA, Raine TR, et al. Adolescent and young womens experience with the vaginal ring and oral contraceptive pills. J Pediatr Adolesc Gynecol
2007;20:34551.
22. Stewart FH, Kaunitz AM, Laguardia KD, et al. Extended use of transdermal norelgestromin/ethinyl estradiol: a randomized trial. Obstet Gynecol 2005;105:
138996.
23. Miller L, Verhoeven CH, Hout J. Extended regimens of the contraceptive vaginal
ring: a randomized trial. Obstet Gynecol 2005;106:47382.
24. Graham S, Fraser IS. The progestogen-only mini-pill. Contraception 1982;26:
37388.
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25. Black A, Francoeur D, Rowe T, et al. Canadian contraception consensus.

J Obstet Gynaecol Can 2004;26:34787, 389436.
26. Menstrual bleeding patterns in untreated women and with long-acting methods of
contraception. Task Force on Long-Acting Systemic Agents for Fertility Regulation. Adv Contracept 1991;7:25770.
27. Lara-Torre E, Edwards CP, Perlman SE, et al. Prospective study evaluating bone
mineral density in adolescent females using Depo-Provera. J Pediatr Adolesc
Gynecol 2004;17:1721.
28. World Health Organization. WHO statement on hormonal contraception and bone
health. Wkly Epidemiol Rec 2005;80:3024.
29. Scholes D, LaCroix AZ, Ichikawa LE, et al. Change in bone mineral density
among adolescent women using and discontinuing depot medroxyprogesterone
acetate contraception. Arch Pediatr Adolesc Med 2005;159:13944.
30. Cromer BA, Lazebnik R, Rome E, et al. Double-blinded randomized controlled
trial of estrogen supplementation in adolescent girls who receive depot medroxyprogesterone acetate for contraception. Am J Obstet Gynecol 2005;192:427.
31. Le J, Tsourounis C. Implanon: a critical review. Ann Pharmacother 2001;35:
32936.
32. Randomized controlled trial of levonorgestrel versus the Yuzpe regimen of
combined oral contraceptives for emergency contraception. Task Force on
Postovulatory Methods of Fertility Regulation. Lancet 1998;352:42833.
33. Cheng L, Gulmezoglu AM, Oel CJ, et al. Interventions for emergency contraception. Cochrane Database Syst Rev 2004;(3):CD001324.
34. Belzer M, Uoshida E, Tejirian R, et al. Advanced supply of emergency contraception for adolescent mothers increased utilization without reducing condom or
primary contraception use. J Adolesc Health 2003;32:1223.
35. World Health Organization. Improving access to quality care in family planning:
medical eligibility criteria for contraceptive use. 2nd edition. Geneva: WHO;
2001.
36. Grimes DA, Schulz KF. Prophylactic antibiotics for intrauterine device insertion:
a metaanalysis of the randomized controlled trials. Contraception 1999;60:5763.
37. American College of Obstetricians and Gynecologists. Intrauterine device and
adolescents. ACOG Committee Opinion No. 392. Obstet Gynecol 2007;110:
14935.
Polyc ystic Ovar y

Syndrome in the
Adolescent
Samantha M. Pfeifer, MDa,*, Sari Kives, MDb
KEYWORDS
Polycystic ovarian syndrome Hirsutism Insulin resistance
Adolescent Obesity Acne
Polycystic ovary syndrome (PCOS), traditionally thought of as a triad of oligomenorrhea, hirsutism, and obesity, is now recognized as a heterogeneous disorder that
results in overproduction of androgens, primarily from the ovary, and is associated
with insulin resistance. The disorder is characterized by oligo- or amenorrhea and
signs of hyperandrogenism. Because many women who have PCOS have the onset
of symptoms during adolescence, it is important to be able to recognize and understand this disorder so as to facilitate treatment and prevention of long-term sequelae.
PATHOPHYSIOLOGY
The prevalence of PCOS in the general population has been estimated to be 5% to

10% of women of reproductive age.1,2 Screening of an unselected population in the
southwestern United States showed an incidence of 4%.3 Studies in first-degree relatives of patients who have PCOS have shown that 24% of mothers and 32% of sisters
are affected, suggesting a major genetic association.4 Although candidate genes have
been proposed, the gene or genes responsible for the syndrome have not been
identified.
The cause of PCOS remains unknown, and this is an area of active investigation.
Theories focus on the impact of luteinizing hormone (LH) stimulation and the role of
insulin in the production of ovarian hyperandrogenism. Increased LH pulse amplitude
and frequency have been demonstrated in women and adolescents who have PCOS,
suggesting an aberrant pattern of hypothalamic gonadotropin-releasing hormone
(GnRH) secretion as a causative factor.58 This increase in LH leads to increased
production of androgens from the theca cell of the ovary. Preferential LH secretion
from GnRH pulsatility may be explained by observations in rats showing that variations
of GnRH pulse frequencies result in differential expression of subunit genes.9 A rapid
a
University of Pennsylvania Medical Center, 3701 Market Street, Suite 800, Philadelphia, PA
19104, USA
b
Hospital for Sick Children, Toronto, ON, Canada
E-mail address: [email protected] (S.M. Pfeifer).
doi:10.1016/j.ogc.2008.12.004
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Pfeifer & Kives
frequency of GnRH leads to an increase in a and LHb mRNA expression, thereby

favoring LH secretion. Some nonobese patients who have PCOS have an elevated
LH/follicle-stimulating hormone (FSH) ratio (>2).10
Insulin resistance has been implicated in the pathophysiology of PCOS because of
the evidence that insulin stimulates androgen production from the ovary in hyperandrogenic women. Ovarian stroma obtained from hyperandrogenic women has been
shown to produce high levels of androgens when exposed to insulin. Insulin had no
effect on androgen production from ovarian stroma from nonhyperandrogenic
women, however.11 An observational study in five obese women who had PCOS
demonstrated that administration of diazoxide, which decreases insulin secretion, resulted in a significant decrease in androgen levels after administration for 10 days.12 In
a case report of an adolescent female patient who had severe type II diabetes and hyperandrogenism, intravenous administration of insulin to control blood glucose was
shown to increase serum androgen levels significantly. These androgen levels returned to baseline when the insulin infusion was stopped.13
Women who have PCOS have decreased sensitivity to insulin in muscle and
adipose tissue, leading to a compensatory increase in insulin levels. Decreased
insulin sensitivity has been demonstrated in lean and obese women, suggesting
that the defect is intrinsic to PCOS.14 Insulin resistance has been described in
20% to 60% of women who have PCOS.15 It has also been proposed that all women
who have PCOS have insulin resistance; however, because of differences in populations studied and the sensitivity and specificity of the methods used to measure
insulin resistance, not all women who have PCOS manifest insulin resistance.16
In PCOS, insulin resistance is selective: insulin action on glucose transport and
metabolic pathways is affected, whereas insulins action on ovarian steroidogenesis
is preserved. There are several theories to explain this apparent paradox. Insulin
resistance in PCOS seems to be attributable to a postbinding defect in insulin
receptor signaling.17 Binding to the insulin receptor results in tyrosine phosphorylation before stimulating insulin action. If, however, serine phosphorylation occurs,
insulin action is inhibited by decreasing its kinase activity.1 In the ovary, serine phosphorylation stimulates 17,20 lyase activity, the enzyme responsible for converting
17-hydroxy progesterone to androstenedione, which results in increased production
of androgens from the ovary.18 Therefore, serine phosphorylation inhibits insulin
action in the metabolic pathways and stimulates insulin action to produce androgens
in the ovary.
There are several theories to explain how insulin stimulates release of androgens.
Insulin stimulates ovarian androgen production by direct and indirect mechanisms.1
Insulin has been shown to decrease secretion of sex hormone-binding globulin
(SHBG), which, in turn, increases available and active androgens. Insulin directly
increases production of LH and androgens by activating its own receptor on the
ovary, adrenal, and pituitary. Insulin also binds to the insulin-like growth factor I
(IGF-I) receptor on the ovary, thereby directly stimulating androgen production.
Insulin indirectly stimulates the production of androgens by up-regulating
IGF-I receptor number and decreasing insulin-like growth factor binding protein-1
(IGFBP-1), which, in turn leads, to an increase in IGF-I.
In summary, insulin postreceptor binding defects in PCOS explain how insulin
can stimulate and suppress actions in metabolic pathways and in the ovary. Insulin
binding to the pituitary results in release of LH hormones. Insulin-stimulated release
of LH, in combination with direct and indirect stimulation to adrenal and ovary,
results in release of androgens from the ovary and adrenal glands. The result is
hyperandrogenism.
Polycystic Ovary Syndrome in the Adolescent
HEALTH CONSEQUENCES OF POLYCYSTIC OVARY SYNDROME
Health consequences of PCOS relate to insulin resistance and hyperandrogenism.

They include diabetes, obesity, metabolic syndrome (MS), endometrial hyperplasia,
anovulatory infertility, and depression.
Diabetes
The risk for diabetes has been shown to be higher in women and adolescents who
have PCOS. Studies have shown that in women who have PCOS, 7.5% to 10% had
type II diabetes and approximately 30% to 35% had impaired glucose tolerance.19,20
The incidence of type II diabetes and impaired glucose tolerance in the control
population was significantly lower at 0% and 14%, respectively.19 Impaired glucose
tolerance is known to be a significant risk factor for developing diabetes, as was
shown in the Diabetes Prevention Trial.21 In this study, more than 3000 people with
impaired glucose tolerance were randomized to treatment or placebo. In the placebo
group, 11% went on to develop diabetes, with a mean follow-up of 2.8 years. Detecting impaired glucose tolerance in women and adolescents who have PCOS is important so that treatment can be initiated to decrease the risk for developing type II
diabetes. The most sensitive way to detect impaired glucose tolerance in women
who have PCOS is the 2-hour glucose tolerance test. This test involves drawing serum
glucose at baseline (fasting) and then again at 1 and 2 hours after a 75-g oral glucose
load. In adults and adolescents, the 2-hour glucose tolerance test is more sensitive
than the fasting glucose measurement. In adults and adolescents, the incidence of
abnormal fasting glucose was 5% and 8%, respectively. The incidence of an abnormal
2-hour glucose tolerance test result was higher at 31% and 33%, respectively, reflecting the better sensitivity of the 2-hour glucose tolerance test.19,22
Obesity
Obesity is another significant health consequence of PCOS. Obesity is determined by

a body mass index (BMI) greater than 30 kg/m2. In women who have PCOS, the incidence of obesity is in the range of 50% to 75%. The weight accumulation is predominantly in the abdominal area and is reflected in an increased waist-to-hip ratio. In
addition to health consequences of obesity later in life, obesity in adolescents is correlated inversely with obstructive sleep apnea, orthopedic disorders, fatty liver, and
decreased quality of life.23
Metabolic Syndrome
MS is a constellation of cardiovascular disease risk factors associated with insulin

resistance, including glucose intolerance, dyslipidemia, hypertension, and central
obesity. The prevalence of MS in obese women who have PCOS has been shown
to be significantly higher (33%40%) compared with nonobese controls
(10%13%).24 Adolescent girls who have PCOS have also been shown to have
a higher incidence of MS compared with the general population. In one study, 49
adolescents who had PCOS were compared with 165 girls from the Third National
Health and Nutrition Examination Survey (NHANES III).25 Thirty-seven percent of girls
who had PCOS had MS compared with 5% of girls from the NHANES III (P<.0001). MS
in the girls who had PCOS was also associated with BMI. The incidence of MS in
normal BMI, overweight, and obese PCOS girls was 0%, 11%, and 63%, respectively.
In this study, hyperandrogenism was also found to be a risk factor for MS independent
of obesity and insulin resistance. In contrast, a cross-sectional study of overweight
and obese adolescents who had PCOS compared with BMI-matched controls
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Pfeifer & Kives
showed that the incidence of MS was no different in the PCOS group compared with
controls.26 The investigators concluded that PCOS did not increase the risk for MS
more than the risk associated with obesity alone. The group that had PCOS did
demonstrate higher levels of total testosterone and free androgen index, increased
incidence of glucose intolerance, and higher plasminogen activator inhibitor-1
(PAI-1). Further studies are needed to evaluate the association with MS and the
diverse phenotypes of PCOS.
Cardiovascular Disease
PCOS is associated with many signs and symptoms that correlate with increased risk
for cardiovascular disease. These include obesity, dyslipidemia, diabetes and insulin
resistance, and hyperandrogenemia. PCOS has also been shown to be associated
with increased carotid intima-media thickness and increased PAI-I, both of which
are risk factors for cardiovascular disease. Although these risk factors are present
in women who have PCOS, an increase in cardiovascular events has not been
observed in this population.2729 Additional studies are needed to clarify the relation
between observed risk factors and prevalence of cardiovascular disease.
Endometrial Hyperplasia
Endometrial hyperplasia is a potential consequence of the effect of unopposed

estrogen stimulation on the endometrium. Endometrial hyperplasia is seen most
frequently in perimenopausal women and historically in postmenopausal women
treated with unopposed estrogen. Adolescents and reproductive-aged women who
have PCOS are also at risk because of the chronic anovulation associated with this
disorder, however. Endometrial hyperplasia, if left untreated, can progress to adenocarcinoma. The risk is lowest for simple hyperplasia without atypia (1%) and highest
for complex hyperplasia with atypia (29%).30 The incidence of endometrial hyperplasia
in a study of 56 women who had PCOS and anovulatory infertility (age range: 2141
years) was found to be 36%.31 Of the women who had endometrial hyperplasia,
25% were found to have cytologic atypia, which increases the risk for developing
endometrial adenocarcinoma. The risk for having endometrial hyperplasia was significantly correlated with an intermenstrual interval of longer than 3 months and an
endometrial thickness, measured by transvaginal ultrasound, of greater than 7 mm.
The risk for endometrial hyperplasia in the adolescent population that had PCOS
has not been determined, but it is probably quite low.
Infertility
Infertility in women who have PCOS seems to be caused by oligo- or anovulation. This
condition is treatable. It is important to reassure the adolescent that pregnancy is
possible with current treatments available, because many are left with the impression
that they are never going to be able to conceive. Treatment options include weight
reduction for obese individuals, because pregnancy rates are poorer in morbidly
obese women.32 In addition, pregnancy complications, such as gestational diabetes,
pre-eclampsia, large-for-gestation infants, and neonatal death, are significantly
increased in obese and morbidly obese individuals.33,34 Clomiphene citrate is the
first-line drug for treatment of anovulation. Approximately 75% to 80% of women
ovulate in response to clomiphene citrate.35 Cumulative pregnancy rates have been
reported as 40% to 50% for 6 or fewer months and 70% to 75% for 6 to 9
months.3638 Conception rates per cycle with clomiphene citrate have been reported
to be 22%, which is comparable to normal cycle fecundity.35 Metformin is not recommended as a first-line therapy for anovulatory infertility, because success rates are not
as good as with clomiphene citrate.39,40 The use of metformin as an adjunct to other

therapies in subsets of women who have PCOS with infertility has yet to be determined. Gonadotropin therapy and in vitro fertilization are also valuable techniques
to treat anovulatory infertility in women who have failed to ovulate or conceive with
clomiphene citrate. The pregnancy rate with gonadotropin therapy is approximately
22% per cycle, but there is a risk for high-order multiple gestations because of multifollicular development.35 Clinical pregnancy rates with in vitro fertilization and embryo
transfer are similar for women with PCOS compared with women who do not have
PCOS.35
Impaired Quality of Life
Depression and decreased quality of life have been reported in women who have
PCOS more frequently than in controls. It seems that increased weight is the largest
contributor to poor quality of life in women who have PCOS.41 Quality-of-life scores
in adolescents and women who have PCOS have also been shown to be inversely
correlated to BMI.42,43 In a study of 104 women diagnosed with PCOS, the relative
risk for depressive disorder compared with control women was 4.23 (95% confidence
interval [CI]: 1.4911.98) and was independent of obesity and infertility.44
DIAGNOSTIC CONSIDERATIONS
PCOS is the most common cause of androgen excess, with a suspected incidence of
3% in the adolescent population.45 There are no good estimates of the prevalence of
the disorder in this age group, however. The classic presentation of PCOS is a heterogeneous syndrome characterized by features of anovulation amenorrhea, oligomenorrhea, or irregular cycles in combination with signs of androgen excess acne, hirsutism,
or alopecia.46 Some researchers think that PCOS is a maladaptation of the evolutionary phenomenon that is adrenarche. During pubertal development, adolescents
typically have relative androgenemia, insulin resistance, cystic ovaries, and anovulatory cycles, which transition into an estrogenic state later in puberty. Failure to
make this transition may result in PCOS secondary to abnormal pubertal development.47 The path to PCOS remains unknown, however. Persistent menstrual irregularity seems to be a better predictor compared with biochemical parameters in
predicting PCOS.48
The American Society for Reproductive Medicine and the European Society of
Human Reproduction and Embryology have developed a consensus called the 2003
Rotterdam criteria to diagnose PCOS.49 The diagnosis depends on the presence of
two of the three following features: chronic anovulation characterized by persistent
menstrual irregularities for more than 6 months, ultrasonographic appearance of the
polycystic ovary (of at least one ovary greater than 10 cm3 [10 mL] or polycystic
ovarian morphology with 12 or more peripheral follicles 29 mm in diameter), and
androgen excess (clinical or laboratory), with the exclusion of other etiologies.49
There has been some debate about the Rotterdam criteria because they include
women with polycystic ovaries and anovulation but no clinical or biochemical
evidence of hyperandrogenism. The general practice is to include all subgroups within
the spectrum of PCOS. Some investigators have found that the different subgroups
arising from the Rotterdam criteria have varying significance with respect to developing metabolic disturbances and the long-term consequences, such as type 2
diabetes mellitus, which occurs in women who have PCOS.5052 The nonhyperandrogenic phenotype may represent a form of PCOS associated with a milder metabolic
profile.53
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Some researchers have proposed an alternative method for diagnosis of PCOS in

the adolescent, which includes four of the following five criteria: (1) oligo- or amenorrhea 2 years after menarche, (2) clinical hyperandrogenism, (3) biologic hyperandrogenism (eg, elevated plasma testosterone, LH/FSH ratio >2), (4) insulin resistance or
hyperinsulinemia (eg, acanthosis nigricans, abdominal obesity, glucose intolerance),
and (5) polycystic ovaries.54 This set of diagnostic criteria is suggested as a way to
avoid mislabeling an adolescent with transitional functional hyperandrogenism and
menstrual disorders as having PCOS. Some researchers think that the Rotterdam
criteria may overestimate the diagnosis in the adolescent; however, currently, the
definition of PCOS is the same for adolescents and adults.
Using menstrual irregularity to diagnosis PCOS in the adolescent population is difficult, because a history of menstrual irregularity is considered normal in the first few
years after menarche secondary to anovulation.50 Persistent irregularity of cycles for
longer than 2 years after menarche is a strong predictor of continued irregularity and
PCOS, because most adolescent have regular cycles 2 years after menarche.5557
Furthermore, adolescents with irregular cycles within the first 3 years of menarche
and no evidence of clinical hyperandrogenism may, in fact, have biochemical evidence
of hyperandrogenism similar to that found in PCOS.58 Hyperandrogenism can occasionally be found in the postmenarchal years without significant sequelae in adolescents with anovulatory regular cycles.59
Rarely, an adolescent who has PCOS presents with primary amenorrhea as the first
manifestation. Depending on the literature, primary amenorrhea as the initial feature
occurs in 1.4% to 14% of all adolescents.6062 This group of adolescents exhibits
more features of the MS and has higher androstenedione levels, which may represent
a more severe spectrum of this common condition.63 In addition, this group of adolescents may be less likely to respond to a progesterone challenge because of a persistently decidualized endometrium in response to the high levels of androgens.63
PCOS may also present before menarche in the form of androgen excess. Premature pubarche and adrenarche are manifestations of androgen excess and may
predispose adolescents to PCOS.57,64 The correlation found between androgen levels
at the time of presentation of premature pubarche and the development of PCOS in
adolescence is thought to be compatible with an inborn dysregulation of steroidogenesis in the ovary and the adrenal gland.57
In addition to menstrual irregularity, adolescents have a physiologic increase in
insulin resistance and androgen levels in response to growth hormone (GH).65,66
The GH may lead to an increase in insulin levels and a decrease in circulating
SHBG.65,66 Both of these features are cardinal to the diagnosis of PCOS but may
also represent a normal variation in many adolescents. Hirsutism, hyperandrogenism,
and ultrasonographic evidence of polycystic ovaries are often not evident in the
adolescent who has PCOS.
Recent literature has identified a specific biochemical marker (adiopentin), which is
significantly lower in concentration in the daughters of women who have PCOS before
the onset of hyperandrogenism and may be an early marker of metabolic derangement
in adolescent girls.67
PHYSICAL FINDINGS
Hirsutism
Hirsutism tends to be less marked in adolescents, because the duration of exposure to

excess androgens is much shorter than in their adult counterparts. Adolescents may
also hide their excess hair by shaving or laser treatment, and therefore should be
specifically asked about excess hair on their upper lip, chin, neck, or abdomen. In
addition, ethnicity, sensitivity of the hair follicles, and levels of androgens can all cause
variations in the extent of the hirsutism.68 The Ferriman-Gallwey score may not be as
useful in the adolescent who may only exhibit upper lip hair. Furthermore, this grading
system was standardized in white women older than 24 years of age.69
Acne
Acne affects fewer adolescents who have PCOS and has been correlated with an
increase in dehydroepiandrosterone sulfate (DHEAS) rather than free testosterone.56
It is often the first sign of hyperandrogenism in the adolescent.70
Obesity
Although obesity is common in women who have PCOS, it is not necessary to make
the diagnosis. In fact, the prevalence of obesity varies, and many patients who have
PCOS have a normal BMI. The presence of obesity does, however, amplify the
severity of PCOS and increase the risk for metabolic dysfunction.46 For most patients,
there is an increased upper body adiposity or central distribution that gives rise to an
increased waist-to-hip ratio.56 In addition, insulin resistance is worsened by obesity.
Acanthosis nigricans, a marker of insulin resistance, is more common in the obese
adolescent who has PCOS. Common areas involve the dorsal surface of the neck
and intertriginous areas, such as the upper thigh and axilla. More children today are
overweight, which puts more adolescents who have PCOS at risk for an increase in
the severity of their symptoms. In fact, with the rising tide of childhood obesity,
children who may have never displayed symptoms of PCOS, with the exception of
irregular cycles, may now experience symptoms of anovulation and androgen
excess.46 Obesity exacerbates the PCOS phenotype in previously asymptomatic individuals.71 Weight reduction in adults has been shown to improve free androgen levels,
insulin sensitivity, and ovulatory function.72
DIAGNOSIS
As with adults, the Rotterdam criteria should be used to make the diagnosis of PCOS
in adolescents. A history of persistent oligomenorrhea or secondary amenorrhea
should be evaluated, and other conditions that could cause these symptoms should
be excluded. Blood tests for FSH, estradiol, thyroid-stimulating hormone, and
prolactin should be performed to rule out premature ovarian failure, thyroid disease,
and hyperprolactinemia. The adolescent should be examined for signs and symptoms
of hyperandrogenism, and blood tests for total and free testosterone, and possibly for
androstenedione, should be obtained. An ultrasound scan is indicated to evaluate for
polycystic ovarian morphology. Height and weight should be obtained, and the
adolescent should be examined for signs of insulin resistance (acanthosis nigricans),
virilization, and other endocrinopathies (eg, Cushings syndrome).
Role of Luteinizing Hormone/Follicle-Stimulating Hormone Ratio
It is important to check FSH and estradiol levels when evaluating for PCOS to exclude
the diagnosis of premature ovarian failure. Obtaining the LH/FSH ratio is not
necessary. Multiple studies support the finding that an elevation of the plasma LH
concentration, or an LH/FSH ratio greater than 2, is not required for the diagnosis of
hyperandrogenism.7375 In one recent study, only 11 of the 24 patients who had female
hyperandrogenism had elevated baseline LH levels, suggesting a primary hypothalamic-pituitary abnormality.74 The remaining 13 had ovarian hyperandrogenism
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independent of an elevation in LH, suggesting abnormal modulation of ovarian

androgen responsiveness to normal levels of LH. Similar to adults who have PCOS,
however, some adolescents have an increased LH concentration and elevated LH/
FSH ratio.76
Testosterone, Dehydroepiandrosterone Sulfate,
and Androstenedione Measurements
Androgen levels are traditionally ordered to exclude more serious causes of androgen
excess, such as an ovarian or adrenal tumor. Total testosterone greater than
200 ng/dL and DHEAS greater than 6000 ng/mL are suggestive of ovarian and adrenal
tumors and require further evaluation. Rapid onset and progression of hyperandrogenic symptoms also suggest tumor or drug exposure rather than PCOS and should
be investigated. In PCOS, total testosterone can be normal or slightly elevated, but
free testosterone is thought to be a more sensitive test for androgen excess. Free
testosterone has been reported to be elevated in 60% to 80% of adult women who
have PCOS (>10 pg/mL), whereas DHEAS is elevated in only 25% of patients.77 The
difficulty often encountered with androgen measurements is in interpreting the results,
because there is a tendency for significant variation among laboratories.68 Furthermore, in adolescents, the range of normal testosterone levels is generally lower than
that observed in adults. Free testosterone is the most specific because it has been
demonstrated to reach adult levels by midpuberty in normal girls.78
Ultrasound
The Rotterdam criteria include polycystic ovaries demonstrated by ultrasound as one

of the key features of the syndrome.49 The ultrasound definition of polycystic ovarian
morphology is the presence of 12 or more follicles with a 2- to 9-mm diameter on the
ovary. An increased ovarian volume of greater than 10 mL is also suggestive. Only one
ovary consistent with polycystic ovarian morphology is sufficient for the diagnosis.
Transvaginal ultrasound is the preferred technique over the transabdominal approach
to detect polycystic morphology, but in a virginal adolescent, it is not reasonable to
perform transvaginal ultrasound. In addition, transabdominal ultrasound may underestimate the presence of PCOS.68 Although the ultrasound appearance of ovaries is
included in the diagnosis of PCOS, recent studies in hyperandrogenic women do
not confirm the consistency of transvaginal ultrasound accuracy in detecting all
patients who have female hyperandrogenism.73 In one study of 42 adolescents, pelvic
ultrasound failed to detect 46% of patients who had female ovarian hyperandrogenism.45 The role of ultrasound in the adolescent population is further complicated by
the mere fact that many controls have polycystic ovaries that are not pathologic. In
one study, 48% of controls with no evidence of PCOS (regular cycles, no hirsutism,
normal oral glucose tolerance) had polycystic ovaries.49 Similarly, ultrasound imaging
has shown that 25% of healthy adolescent volunteers develop multifollicular ovaries,
defined as 6 to 10 follicles 4 to 10 mm in diameter without increased stroma.77,79 The
prevalence of polycystic ovaries seems to occur at a rate of 10% in regular menstruating adolescents.71 The presence of polycystic ovaries in asymptomatic adolescents
may represent a subclinical PCOS type of ovarian dysfunction.80 In women who have
PCOS, polycystic ovaries occur as frequently as 95% of the time, suggesting that
these ultrasound findings are usually abnormal.81
The typical ovarian findings of polycystic morphology or ovarian volume are related
to increased stroma. The volume of the ovary is much less specific than the
morphology of the ovary in detecting individuals who have PCOS. In one series,
neither the morphology nor the size of the ovaries was helpful in identifying distinctive
metabolic or reproductive abnormalities in women who had PCOS.81 In another series,

however, adolescents who had PCOS or irregular cycles for longer than 3 years more
frequently had an increased ovarian volume as compared with multiple cysts.58
At present, the role of ultrasound in women with a history of anovulation and hyperandrogenism is uncertain when a diagnosis of PCOS is already made.45,82 Ultrasound
may help to screen for anatomic abnormalities (ie, polyps), but in the adolescent,
routine ultrasound may be unnecessary. In addition, in the adolescent population,
pelvic ultrasound is usually performed transabdominally rather than transvaginally,
which can make counting follicles more problematic and underestimates the prevalence of polycystic ovaries.68 MRI has been used in this setting to confirm PCOS
morphology, particularly in an obese girl with hirsutism and oligomenorrhea.83 Alternatively, three-dimensional transrectal ultrasound may improve the precision of the diagnosis of PCOS in the adolescent.84
Role of 17-OH Progesterone
17-OH progesterone (17-OHP) is a good screening test for the detection of nonclassic
adrenal hyperplasia (NCAH). Blood samples should be drawn in the early morning,
when adrenal secretion of hormones is highest, and in the follicular phase of the
menstrual cycle in cycling women to avoid confusion with ovarian production of
17-OHP in the luteal phase. A follicular phase/morning 17-OHP level of 2 ng/mL or
less is normal, suggesting that NCAH is not present with a specificity of 100%.85 If
the 17-OHP level is greater than 2 ng/mL, the diagnosis of NCAH should be confirmed
by a corticotropin stimulation test.
Many patients who have PCOS exhibit exaggerated 17-OHP responses to adrenal
stimulation but not high enough to be consistent with NCAH.74 Previous researchers
have suggested that this elevation in 17-OHP may, in fact, be a mild homozygous or
heterozygous form of nonclassic congenital adrenal hyperplasia, whereas others
suggest that it is simply generalized overactivity to corticotropin stimulation by the
adrenal gland, and the carrier status for 21-OH deficiency may be an incidental
finding.86
Oral Glucose Screen
Adolescents who are obese and have a diagnosis of PCOS should undergo a 2-hour
75-g oral glucose tolerance test (OGTT).46 This is a more sensitive test than a fasting
glucose test to detect diabetes and impaired glucose tolerance, a significant risk
factor for diabetes.22 Adolescent girls with premature pubarche during childhood
who develop functional ovarian hyperandrogenism show increased mean serum
insulin in response to an OGTT, which correlates with evidence of ovarian hyperandrogenism.87 The significance of hyperinsulinemia diagnosed at such at early age is
unknown, but it may act as a marker for the development of functional ovarian
hyperandrogenism.87
Insulin Testing
There is no accurate way to measure insulin resistance. Fasting insulin levels are not
reliable, because 25% of normal patients have insulin values that overlap with those of
patients with insulin resistance.1 The most accurate tests for insulin resistance are the
euglycemic clamp technique and the frequently sampled intravenous glucose
tolerance test. Both of these require inpatient hospitalization, however, and are not
practical for screening. A fasting glucose/insulin ratio has been proposed as a rapid
and easy screening alternative. In obese adult women, a fasting glucose/insulin ratio
less than 4.5 suggests insulin resistance, whereas in the adolescent, a ratio less than 7
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is suggestive.88,89 The clinical recognition of insulin resistance is based on the associated physical features of acanthosis nigricans and obesity.56 Evidence of insulin
resistance in the adolescent with menstrual irregularities may be consistent with
a diagnosis of PCOS.
Stimulation Tests
The leuprolide acetate stimulation test may be a reliable tool for identification of the
ovary as the cause of ovarian excess. In one study of 42 adolescents, more than
half (58%) of hyperandrogenic adolescents had an abnormal response to leuprolide
acetate testing suggestive of functional ovarian hyperandrogenism.45 The rapid
GnRH pulse frequency favors the pituitary synthesis and secretion of LH over FSH,
resulting in the abnormal LH/FSH ratios seen in these individuals. This test is not
frequently performed.
Metabolic Syndrome
The incidence of MS is increasing in the obese adolescent and occurs frequently in the
adolescent who has PCOS. The incidence of MS has been shown to be increased
significantly in adolescents with increasing BMI, insulin resistance, and hyperandrogenemia as compared with adolescents in the general population.25 Adolescent phenotypes with hyperandrogenemia are also at increased risk for elevated triglycerides and
low-density lipoprotein cholesterol.90 Any adolescent with androgen excess should be
monitored for evidence of hypertension and hypertriglyceridemia (MS) regardless of
body weight, because the risk for MS in women who have PCOS seems to be
independent of BMI.25 Obesity is thought to be a stronger predictor of MS than is
PCOS, however.26
TREATMENT
Treatment options for PCOS in the adolescent include weight loss for obese
individuals, symptom-directed therapy to address the main symptoms noted by the
adolescent, and metabolic correction of the underlying insulin resistance using
insulin-sensitizing medications. For the adolescent, the goal should be addressing
the most distressing symptoms while stressing a healthy lifestyle with reduction of
risks for long-term sequelae of PCOS.
Weight Loss
Weight loss should be the first-line treatment, or at least an important component of

treatment, for all adolescents who are overweight or obese. Weight loss of approximately 5% to 10% has been shown to result in reduction in testosterone, increase
in SHBG, resumption of menses, and improved reproductive outcome in women
who have PCOS.9197 Other advantages of weight loss include low cost, few negative
side effects, and avoidance of use of long-term medications. Weight loss in women
who have PCOS is difficult, however.
Lifestyle Modification
The emphasis of weight loss should be lifestyle modification, with a program

encompassing calorie restriction and an increase in formal exercise. Regular physical
exercise is essential for weight loss and long-term weight management. A minimum
of 30 minutes of moderately intense exercise at least 3 days per week is
recommended.98 Women participating in structured weight loss programs that include
a behavioral modification component do better than women attempting weight loss on
their own.99 One study evaluated patients who had PCOS and were enrolled in
a calorie restriction and exercise program over 6 months.95 The mean weight loss
was 2% to 5%. Decreased abdominal fat and improved insulin sensitivity were
observed. Nine of the 15 anovulatory patients became ovulatory. Another study evaluated a structured weight loss program, including calorie restriction and exercise, of
6 months duration in anovulatory infertile women.92,94 The average weight loss was
15 lb. The spontaneous ovulation rate was 92%, and there was a 33% to 45% spontaneous pregnancy rate.
Dietary interventions should focus on restricting calories and increasing energy
expenditure. A low-calorie diet is considered to be 1000 to 1200 kcal/d, which should
reduce total body weight by average loss of 10% over 6 months.100 A 500- to 1000kcal/d reduction from usual intake should result in weight loss of 1 to 2 lb/wk. Calorie
restriction is the most important factor for weight loss. It does not seem to matter what
the dietary composition is. Theoretically, low-fat high-carbohydrate diets should not
be beneficial in women who have PCOS, because carbohydrates induce insulin secretion. In obese women who have PCOS, however, low-carbohydrate low-fat diets result
in a similar decrease in weight and abdominal fat in addition to improvements in insulin
sensitivity.97 In obese individuals, a low-carbohydrate diet causes greater weight loss
at 6 months when compared with a low-fat diet; however, at 12 months, both diets
result in the same weight loss.101 Comparison of the Atkins, Ornish, Weight Watchers,
and Zone diets over a 1-year period show that all result in similar weight reduction.102
Greater weight loss was associated with dietary adherence. Decreases in insulin, total
cholesterol, and C-reactive protein were associated with weight loss and did not differ
among diets. The difficulty is finding a diet that the individual can maintain and
making a change in lifestyle.
Unfortunately, like all chronic conditions, lifestyle changes must be continued or
women regain weight. This is particularly difficult for the adolescent, who may not
be offered healthy food choices at home and who also may have difficulty in dealing
with peers. Diet and behavioral therapies have been shown to fail within 3 years of
follow-up, with weight regain of 60% to 86 % at 3.5 years and 75% to 121% at 5 years
reported.103
Bariatric Surgery
For those who are unable to lose weight despite multiple attempts, bariatric surgery
may offer the only hope for significant weight loss. Bariatric surgery is being used
with increasing frequency to treat morbid obesity. From 1990 to 2000, there was
a sixfold increase in the national annual rate of bariatric surgery performed, from 2.4
to 14.1 per 100,000 adults (P 5 .001).104 Bariatric surgical procedures currently in
use can be classified as restrictive procedures or combined restrictive/malabsorptive
procedures. Restrictive procedures, such as vertical banded gastroplasty, adjustable
gastric banding, and intragastric balloon, involve the creation of a small gastric pouch,
which fills rapidly, leading to early satiety. Restrictive/malabsorptive procedures, such
as the Roux-en-Y bypass, involve reducing the size of the gastric pouch in addition to
bypassing a large section of the small bowel, thereby reducing the surface area for
absorption. The introduction of high osmolar material into the jejunum leads to
a dumping syndrome and avoidance of food. Currently, gastric bypass (Roux-en-Y
gastric bypass) procedures are performed most commonly, with more than half
performed laparoscopically.
The 1991, a National Institutes of Health Consensus Development Panel recommended that surgical treatment be considered for any adult patient with a BMI of
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40 kg/m2 or greater or for those with a BMI of 35 kg/m2 or greater who have serious
coexisting medical problems worsened by obesity.105 Additional selection criteria
for bariatric surgery include failed dietary therapy, psychologic stability, knowledge
about the operation and sequelae, highly motivated patient, and medical problems
that do not preclude likely survival from the operation.
Improvement of obesity-related medical problems is the primary goal of bariatric
surgery. Two large meta-analyses have shown that in patients who have a BMI of
40 kg/m2 or greater, surgery results in a mean weight loss of 20 to 40 kg over 2 years,
which was maintained for up to 10 years.106,107 Overall mortality from all procedures is
less than 1%.106 In addition to weight loss, significant improvement in diabetes, hypertension, dyslipidemia, and sleep apnea has been observed.106,107 Bariatric surgery
also results in improved menstrual regularity and fertility in women.108
Despite much information about bariatric surgery in obese adults, there is a lack of
studies on bariatric surgery in adolescents, much less adolescent girls who have
PCOS.23,109,110 What is the impact on adolescent growth and development? Should
the recommendations for performing bariatric surgery in adolescents be the same
as for adults? There are few long-term data evaluating the effect of bariatric surgery
on the adolescent decades later in adulthood. Further research is needed before
this procedure is widely used in this population.
When considering bariatric surgery in a young adolescent female patient,
consequences for future pregnancy must be considered. One large population-based
study found that previous bariatric surgery was not associated with an adverse perinatal outcome.111 Additional studies of pregnancies after bariatric surgery have found
that the pregnancies were uncomplicated and well tolerated by the mothers.112,113
Although there is a higher incidence of anemia and nutritional deficiencies, weight
loss from bariatric surgery decreases the risk of pregnancy complications compared
with these risks in the obese pregnant population.
Symptom-Directed Therapy for Polycystic Ovary Syndrome

Hirsutism or acne
Hirsutism is a significant issue for the adolescent. Abnormal hair growth attributable to
excess androgens is progressive; therefore, the sooner it is treated, the better is the
success. The approach to treating hirsutism involves suppression and removal of
current hair in addition to prevention of new hair growth. This is best accomplished
by using many methods simultaneously: hair removal techniques should be combined
with medical suppression of current and new hair growth. It is advisable to institute
therapy in a young adolescent with minimal hirsutism, because early intervention
can prevent significant accumulation of excess hair. Because of the growth cycle of
hair, it is important to allow 6 months of therapy before judging the efficacy of
treatment.
Hair removal techniques
The first-line treatment for addressing excess body or facial hair is hair removal techniques. These include waxing, plucking, shaving, depilation, electrolysis, and laser hair
removal techniques. Contrary to popular belief, shaving does not make hair grow back
faster and it avoids the folliculitis seen with waxing and plucking. Electrolysis results in
permanent hair removal, but it is time-consuming and costly and results depend on the
ability of the individual performing the electrolysis. Laser techniques are best suited to
individuals with pale skin and dark hair, limiting this technique in treating dark-skinned
individuals.
Combined hormonal contraceptive
The most common treatment offered for PCOS is the combined hormonal
contraceptive because it effectively controls symptoms of PCOS. This refers to medication containing estrogen and progestin. The most common form is the combined
oral contraceptive, but transdermal and vaginal ring systems are also now available.
The advantages of the combined hormonal contraceptive include regulation of
menstruation, prevention of endometrial hyperplasia, and control of hirsutism or
acne. The mechanism of action is primarily decreased production of androgens
from the ovary and increased production of SHBG from the liver. The result is
a decrease in free, or active, androgens. A study in women who had PCOS compared
with controls demonstrated that use of a combined oral contraceptive resulted in
significant decreases in androgens and gonadotropins in the women who had
PCOS and in controls.114 In the women who had PCOS, however, there was a significant decrease in LH, total testosterone, and androstenedione, whereas FSH levels did
not change. In a similar fashion, it has been demonstrated that SHBG serum levels
increased significantly after administration of combined oral contraceptives containing ethinyl estradiol and desogestrel or norethindrone.115 Combined oral contraceptives have also been shown to increase insulin resistance;116 however, this effect is
not thought to be clinically significant when compared with the therapeutic benefits
derived from their use.
The progestin component of the older combined hormonal contraceptives is
a testosterone derivative and has some androgenic activity in vitro. There is no difference in clinical efficacy in suppression of androgenic symptoms between the available
hormonal contraceptives containing the more androgenic progestins (norethindrone
or levonorgestrel) and the newer less androgenic progestins (desogestrel, norgestimate, or drospirenone), however.117 Low-dose oral contraceptives containing ethinyl
estradiol, 20 mg, have also been shown to be effective in the management of acne.118
Therefore, in deciding on a combined hormonal contraceptive, it is best to use the one
that has the fewest side effects, best efficacy, and best compliance for that individual.
Antiandrogens
These medications work at the level of the hair follicle to block androgen binding to the
androgen receptor or inhibit 5a-reductase, the enzyme that converts testosterone to
the active androgen dihydrotestosterone (DHT). Several antiandrogen medications
are available in the United States. The most commonly used antiandrogen is spironolactone. Its mechanism of action is primarily competitive binding at the level of the
androgen receptor. It also has some inhibitory effect on 5a-reductase and decreases
testosterone production. The recommended dosage is 100 to 200 mg/d usually given
in divided doses. Side effects include urinary frequency and postural hypotension.
Because it is a potassium-sparing diuretic, use of this medication can result in hyperkalemia; thus, potassium levels should be checked after initiation of therapy. Flutamide is commonly used in adolescents in Europe. It is an androgen receptor
blocker that inhibits DHT binding. It also decreases adrenal 17,20 lyase activity, resulting in decreased androgen production. The recommended dosage is 250 to 500 mg/d.
Hepatic failure is a rare complication of this medication. Finasteride is a 5a-reductase
inhibitor. It is rarely used for treatment of hirsutism in women. The recommended
dosage is 5 mg/d.
Spironolactone, flutamide, and finasteride are all equally effective in the treatment of
hirsutism. A randomized placebo-controlled trial over 6 months in hirsute women
showed equivalent and significant decreases in Ferriman-Gallwey hirsutism scores
for all three medications compared with placebo.119 Flutamide has been studied in
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adolescents in Europe for the treatment of hirsutism. In an observational study in

a group of 18 adolescent female subjects aged 14 to 18 years of age, 18-month
treatment with flutamide resulted in a significant decrease in Ferriman-Gallwey scores
and free androgen index.120 In the United States, spironolactone is the most widely
used antiandrogen because of its effectiveness, lower cost, and side-effect profile.
None of these medications are approved by the US Food and Drug Administration
for the treatment of hirsutism. In addition, these medications are potential teratogens
and should be used with caution in women of reproductive age, especially teenagers,
who may not be forthcoming about their sexual activity and need for contraception.
Antiandrogens are frequently used in combination with combined hormonal contraceptives because their mechanism of action is different and their combined effect is
additive.121,122
Gonadotropin-releasing hormone agonists
GnRH agonists represent a modification of the natural GnRH decapeptide, which

results in an increase in the half-life. GnRH agonists, when used continuously, result
in down-regulation of the pituitary with a resulting decrease in hormone production
from the ovary, including estrogen and androgens. When used alone, the resulting hypoestrogenism leads to significant bone loss that is believed to be reversible after
therapy for 6 months or less. A randomized placebo-controlled study in 64 patients
who had PCOS evaluated the GnRH agonist nafarelin alone or in combination with
the combined oral contraceptive pill for 6 months.123 Although total testosterone
and free testosterone were seen to decrease significantly with nafarelin and the
combined hormonal contraceptive, the combination of these two medications
resulted in a more significant decrease in total testosterone and increase in SHBG.
Although this medication has been shown to be effective in the short term, its longterm use in adolescent girls is not advisable because of a potential detrimental effect
on bone density and the availability of alternative medications with fewer side effects.
Abnormal bleeding
The goals of treating abnormal bleeding are to regulate menstrual cycle bleeding,
thereby preventing anemia, and menstrual bleeding accidents, which can be embarrassing for the adolescent, and also to prevent long-term risk for endometrial
hyperplasia. Standard treatments to regulate menses include combined hormonal
contraceptives as discussed previously. These medications afford excellent cycle
regulation and decreased menstrual flow. Another option to regulate bleeding is
the use of progestins. Progestins can be administered on a cyclic or continuous
schedule. Cyclic options include medroxyprogesterone acetate, 5 to 10 mg; norethindrone acetate, 5 mg; or oral micronized progesterone, 100 to 200 mg. These
medications should be given monthly for 10 to 14 days to achieve the greatest
reduction in development of endometrial hyperplasia.30 Some have suggested
that these medications can be given every 3 months to induce menses four times
a year, however.124 Another option is to use the progestin-only pill. This pill contains
norethindrone at a dose of 0.35 mg/d. The incidence of abnormal spotting is higher
with this pill compared with the combined hormonal contraceptive, although the
contraceptive benefit is similar. Depo-medroxy progesterone acetate can also be
used in women who have PCOS, although weight gain is a concern for overweight
and obese individuals. In addition, with Depo-Provera and any of the progestin-only
alternatives, the effect on hirsutism and acne is not as significant as with the
combined hormonal contraceptives, because progestin alone does not increase
SHBG and does not suppress ovarian function as well.
Metabolic Correction with Insulin-Sensitizing Agents
With emerging evidence that insulin resistance plays a significant role in the
pathophysiology of PCOS, insulin-sensitizing agents have been proposed as treatment
for this disorder. Metformin and thiazolidinediones are the two classes of insulin-sensitizing medications that have been studied. Thiazolidinediones have been associated
with liver failure and should not be used in the adolescent until their efficacy and safety
in this population have been studied. Metformin, the most widely studied of all the
insulin-sensitizing drugs, inhibits hepatic glucose production and increases peripheral
tissue sensitivity to insulin.125 At a dosage of 1500 to 2000 mg/d, metformin has been
shown to decrease androgens, decrease insulin, improve ovulatory rates, and resume
menstrual cyclicity.126128 A meta-analysis of the use of metformin versus placebo revealed that the odds ratio of ovulating on metformin compared with placebo for women
who have PCOS was 3.88 (95% CI: 2.256.69).129 Metformin alone does not reliably
lead to weight loss in patients who have PCOS.127,130,131 When metformin is combined
with a restricted calorie diet, however, significant weight loss is observed.132,133
Although the use of metformin seems promising, several issues remain. Most
published studies evaluating metformin in women who have PCOS involve a small
number of select patients, are observational in design, and are of short duration
(1226 weeks). There are few randomized controlled studies comparing metformin with
established therapies. The effect of metformin on hirsutism has not been adequately
studied, and results are conflicting.120,130 In addition, there are few studies evaluating
the use of metformin in adolescents.134 Metformin use in obese and nonobese
adolescent girls who have PCOS has shown resumption of menses in 91% to
100% of subjects133,135 and ovulation in 78% of subjects.136 In sexually active adolescents taking metformin, contraception is necessary, and there are no contraindications
to using hormonal contraception with this drug.
The use of metformin compared with other therapies has been evaluated in a few
studies. One prospective randomized trial in adolescents who had hyperinsulinemia
and PCOS compared metformin (750 mg given twice daily) with placebo in conjunction
with healthy lifestyle counseling over 12 weeks.137 The use of metformin was found to
be associated with a significant decrease in testosterone and an increased relative risk
for menses of 2.5 (95% CI: 1.125.58) when compared with placebo. There was no
significant change in BMI, total cholesterol, or insulin sensitivity.
A randomized placebo-controlled trial in 43 obese adolescent female subjects who
had PCOS evaluated the effect of four treatment arms over 6 months: placebo, metformin, oral contraceptive, or lifestyle management.138 In the oral contraceptive and lifestyle modification groups, SHBG was increased and total and free androgens were
decreased. Those who lost weight showed greater increases in SHBG. Metformin
was associated with increased menstrual frequency but not with a change in weight.
Another randomized placebo-controlled trial was performed in 36 obese adolescent
subjects who had PCOS and were placed on lifestyle modification and oral contraceptives and randomized to metformin, 1500 mg/d, or placebo over 6 months.138 BMI was
reduced in the placebo and metformin groups but did not differ between groups. Waist
circumference was reduced significantly in the metformin-only group. Free androgen
index was equally decreased in the placebo and metformin groups, but suppression of
total testosterone was greater in the metformin group. The investigators concluded
that there may be a beneficial impact of a lifestyle program in combination with oral
contraceptives. Metformin, when combined with lifestyle modification and oral contraceptives, may enhance reduction in central adiposity and androgen suppression.
Larger prospective randomized studies are needed.
143
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Surgical Therapy
Stein and Leventhal139 first described ovarian wedge resection as a treatment for
anovulation in seven amenorrheic women who had PCOS in 1935. This procedure
involved removal of one half to three fourths of each ovary at laparotomy. In a subsequent series of 108 women who had PCOS published in 1966, ovarian wedge
resection was shown to result in a resumption of menses in 95% and pregnancy in
86.7%.140 This technique is no longer used because of invasiveness, risk for significant periovarian adhesions leading to infertility, and ovarian failure. Laparoscopic
ovarian drilling was introduced as a less invasive alternative to wedge resection in
women with infertility. This procedure involves drilling holes into the ovary at laparoscopy using monopolar cautery, bipolar cautery, or laser. Three to five holes per ovary
are sufficient to achieve resumption of ovulation.141 A greater number of holes and
more energy may be associated with ovarian failure. Review of the literature reveals
this technique to result in decreased serum testosterone and LH and resumption of
spontaneous ovulation in 50% to 100% of patients.140 The mechanism of action is
not understood, but theories suggest that destruction of follicles results in decreased
local concentration of androgens. Laparoscopic ovarian drilling is a procedure to
correct anovulation and infertility and should not be used as a treatment for
adolescents who have PCOS.
Treatment Approach
Treatment of the adolescent should be instituted early. Early intervention has the
advantage of treating distressing symptoms in the adolescent, such as hirsutism,
acne, and weight gain, with the goal of improving self-esteem and quality of life.
This strategy may also prevent long-term sequelae of PCOS by controlling symptoms
at a younger age. A symptom-directed treatment strategy should be used. For the
obese or overweight adolescent, counseling or enrollment in programs for healthy
diet and exercise regimens should be instituted. Manual hair removal techniques,
including electrolysis or laser, should be considered for hirsutism, in addition to referral
to a dermatologist for treatment of acne. Hormonal contraceptives should be considered as first-line medical treatment. This therapy offers the advantage of regulating
menses and treating hirsutism and acne while preventing new hair growth. Hormonal
contraceptives do not lead to earlier sexual activity in the adolescent, which is often
a concern of the parent. Antiandrogen therapy, usually with spironolactone, can be
added to hormonal contraceptives for treatment of hirsutism or acne. Metformin
should be reserved for those adolescents with insulin resistance or who are not
responding or do not tolerate other therapies. Metformin is not a weight loss drug.
Some patients have less hunger on metformin, however, and are better able to sustain
a healthy diet. Adolescents should be reassured about their ability to have children in
the future using medical therapy or assisted reproductive technologies if necessary.
SUMMARY
PCOS is a heterogeneous endocrinologic disorder that is characterized by oligo- or

amenorrhea and signs of hyperandrogenism. The cause of PCOS is unknown, but
the syndrome is associated with insulin resistance, which, in turn, leads to hyperandrogenism. Long-term health consequences of PCOS are significant and include
obesity, diabetes, MS, and anovulatory infertility. The symptoms of PCOS can be
disturbing to an adolescent girl. Early diagnosis and intervention are important to treat
these symptoms and prevent long-term sequelae. The Rotterdam criteria for PCOS
should be used for diagnosis in the adolescent. Current treatment regimens target
the specific symptoms of PCOS. These include weight management and reduction
programs for obese adolescents and hormonal contraceptives and antiandrogens
for menstrual irregularity, hirsutism, and acne. Insulin-sensitizing agents are promising
in the treatment of this disorder, especially in those with insulin resistance, but
randomized controlled trials are needed to determine the long-term risks and benefits
in addition to efficacy over traditional therapies before using them as first-line therapy.
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111. Sheiner E, et al. Pregnancy after bariatric surgery is not associated with adverse
perinatal outcome. Am J Obstet Gynecol 2004;190:133540.
112. Printen KJ, Scott D, et al. Pregnancy following gastric bypass for the treatment
of morbid obesity. Am Surg 1982;48:3635.
113. Marceau P, Kaufman D, Biron S, et al. Outcome of pregnancies after biliopancreatic diversion. Obes Surg 2004;14:31824.
114. Korytkowski MT, Mokan M, Horwitz MJ, et al. Metabolic effects of oral contraceptives in women with polycystic ovary syndrome. J Clin Endocrinol Metab
1995;80:332734.
115. Jung-Hoffmann C, Kuhl H. Divergent effects of two low-dose oral contraceptives
on sex hormone-binding globulin and free testosterone. Am J Obstet Gynecol
1987;156:199203.
116. Mastorakos G, Koliopoulos C, Deligeoroglou E, et al. Effects of two forms of
combined oral contraceptives on carbohydrate metabolism in adolescents
with polycystic ovary syndrome. Fertil Steril 2006;85:4207.
117. Burkman RT. The role of oral contraceptives in the treatment of hyperandrogenic
disorders. Am J Med 1995;98(1A):130S6S.
118. Thorneycroft IH, Stanczyk FZ, Bradshaw KD, et al. Effect of low-dose oral contraceptives on androgenic markers and acne. Contraception 1999;60:25562.
119. Moghetti P, Tosi F, Tosti A, et al. Comparison of spironolactone, flutamide, and
finasteride efficacy in the treatment of hirsutism: a randomized double blind,
placebo-controlled trial. J Clin Endocrinol Metab 2000;85:8994.
120. Ibanez L, Potau N, Marcos MV, et al. Treatment of hirsutism, hyperandrogenism,
oligomenorrhea, dyslipidemia, and hyperinsulinism in nonobese, adolescent
girls: effect of flutamide. J Clin Endocrinol Metab 2000;85(9):32515.
121. Cusan L, Dupont A, Gomex J, et al. Comparison of flutamide and spironolactone n
the treatment of hirsutism: a randomized controlled trial. Fertil Steril 1994;61:2817.
122. Tartagni M, Schonauer LM, De Salvia MA, et al. Comparison of Diane 35 and Diane
35 plus finasteride in the treatment of hirsutism. Fertil Steril 2000;73:71823.
123. Heiner JS, Greendale GA, Kawakami AK, et al. Comparison of a gonadotropinreleasing hormone agonist and a low dose oral contraceptive given alone or
together in the treatment of hirsutism. J Clin Endocrinol Metab 1995;80:
34128.
124. Ettinger B, Selby J, Citron JT, et al. Cyclic hormone replacement therapy using
quarterly progestin. Obstet Gynecol 1994;83:693700.
125. Inzucchi SE, Maggs DG, Spollett GR, et al. Efficacy and metabolic effects of
metformin and troglitazone in type II diabetes mellitus. N Engl J Med 1998;
338(13):86772.
126. Sattar N, Hopkinson ZE, Greer IA. Insulin-sensitizing agents in polycystic ovary
syndrome. Lancet 1998;351:3057.
127. Moghetti P, Castello R, Negri C, et al. Metformin effects on clinical features,
endocrine and metabolic profiles, and insulin sensitivity in polycystic ovary
syndrome: a randomized, double-blind, placebo-controlled 6-month trial, followed by open, long-term clinical evaluation. J Clin Endocrinol Metab 2000;
85:13946.
128. Fleming R, Hopkinson ZE, Wallace AM, et al. Ovarian function and metabolic
factors in women with oligomenorrhea treated with metformin in a randomized
double blind placebo controlled trial. J Clin Endocrinol Metab 2002;87:56974.
129. Lord JM, Flight IH, Norman RJ. Metformin in polycystic ovary syndrome: systematic review and meta-analysis. BMJ 2003;327:9513.
130. Diamanti-Kandarakis E, Kouli C, Tsianateli T, et al. Therapeutic effects of metformin on insulin resistance and hyperandrogenism in polycystic ovary syndrome.
Eur J Endocrinol 1998;138(3):26974.
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131. Morin-Papunen LC, Koivunen RM, Roukonen A, et al. Metformin therapy

improves the menstrual pattern with minimal endocrine and metabolic effects
in women with polycystic ovary syndrome. Fertil Steril 1998;69:6916.
132. Pasquali R, Gambineri A, Biscotti D, et al. Effect of long-term treatment with metformin added to hypocaloric diet on body composition, fat distribution and
androgen and insulin levels in abdominally obese women with and without the
polycystic ovary syndrome. J Clin Endocrinol Metab 2000;85(8):276774.
133. Glueck CJ, Wang P, Fontaine R, et al. Metformin to restore normal menses in
oligo-amenorrheic teenage girls with polycystic ovary syndrome (PCOS). J Adolesc Health 2001;29:1609.
134. Costello MF, Eden JA. A systematic review of the reproductive system effects of
metformin in patients with polycystic ovary syndrome. Fertil Steril 2003;79:113.
135. Ibanez L, Valls C, Potau N, et al. Sensitization to insulin in adolescent girls to
normalize hirsutism, hyperandrogenism, oligomenorrhea, dyslipidemia, and
hyperinsulinism after precocious pubarche. J Clin Endocrinol Metab 2000;85:
352630.
136. Ibanez L, Valls C, Ferrer A, et al. Sensitization to insulin induces ovulation in nonobese adolescents with anovulatory hyperandrogenism. J Clin Endocrinol
Metab 2001;86:35958.
137. Bridger T, MacDonald S, Baltzer F, et al. Randomized placebo-controlled trial of
metformin for adolescents with polycystic ovary syndrome. Arch Pediatr
Adolesc Med 2006;160:2416.
138. Hoeger K, Davidson K, Kochman L, et al. The impact of metformin, oral contraceptives and lifestyle modification on polycystic ovary syndrome in obese
adolescent women in two randomized, placebo-controlled clinical trials. J Clin
Endocrinol Metab 2008;93:4299306 [Epub 2008 Aug 26].
139. Stein IF, Leventhal ML. Amenorrhea associated with bilateral polycystic ovaries.
Am J Obstet Gynecol 1935;29:18191.
140. Seow K, Juan C, Hwang J, et al. Laparoscopic surgery in polycystic ovary
syndrome: reproductive and metabolic effects. Semin Reprod Med 2008;26:
10110.
141. Armar NA, McGarrigle HH, Honour J, et al. Laparoscopic ovarian diathermy in
the management of anovulatory infertility in women with polycystic ovaries:
endocrine changes and clinical outcome. Fertil Steril 1990;53:459.
Ble e ding Disorders

in Adolescents
Andra H. James, MD, MPH
KEYWORDS
Menorrhagia Adolescent Bleeding disorder
Von Willebrand disease Hemorrhagic ovarian cyst
Normal hemostasis requires a normal number of platelets, normal platelet function,

normal collagen in the subendothelium, and normal levels of clotting factors. Abnormal
bleeding can result from thrombocytopenia; disorders of platelet function; abnormal
collagen (eg, Ehlers-Danlos syndrome); and clotting factor deficiencies, including deficiency of von Willebrand factor (VWF), which is required to adhere platelets to
exposed subendothelium and protect factor VIII from proteolysis in the circulation.
Bleeding disorders may be inherited or acquired. Disorders of platelet function are
probably more common than von Willebrand disease (VWD), but VWD is the most
common inherited bleeding disorder. VWD results from a deficiency of VWF (type 1),
abnormal VWF (type 2), or absence of VWF (type 3). Based on studies of individuals
with bleeding symptoms, a family history of bleeding, and low levels of VWF, VWD
affects as many as 1 in 100 individuals.1 Based on the numbers of individuals enrolled
at hemophilia treatment centers, however, VWD affects only 1 in 10,000 individuals.1
Nonetheless, there are probably many people who have mild type 1 VWD and other
mild bleeding disorders who have never been diagnosed. In general, mild bleeding
disorders are common, and severe bleeding disorders (eg, type 3 VWD) are rare,
affecting as few as 1 in 10,000 to 1 in 1 million people.2
Signs and symptoms of VWD and other bleeding disorders include the following:

Prolonged bleeding from wounds

Heavy, prolonged, or recurrent bleeding after surgery
Bruising with minimal or no trauma, especially bruising resulting in a lump
Nosebleeds that last more than 10 minutes or require medical attention to stop
Heavy, prolonged, or recurrent bleeding after dental procedures or tooth
extraction
Unexplained bleeding from the gastrointestinal tract
Anemia requiring iron therapy or transfusion
Heavy menstrual bleeding or menorrhagia
Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Box 3967, Durham, NC 27710, USA
doi:10.1016/j.ogc.2008.12.002
154
James
MENORRHAGIA
Heavy menstrual bleeding, or menorrhagia, is the most common symptom that

women who have bleeding disorders experience. Most data about the prevalence
of menorrhagia in women who have bleeding disorders comes from reports of women
who have VWD. The prevalence of menorrhagia in these reports ranges from 32% to
100%.3 In a survey of 102 women who had VWD compared with controls conducted
by the US Centers for Disease Control and Prevention (CDC), 95% of the women who
had VWD reported a history of menorrhagia compared with 61% of controls.4 Sramek
and colleagues5 found that women who had VWD were five times more likely to experience menorrhagia than women who did not have the condition. With respect to the
prevalence of menorrhagia in women who have other bleeding disorders, the prevalence in women who have severe platelet dysfunction has been reported to be 51%
in women who have Bernard-Soulier syndrome6 and 98% in women who have Glanzmanns thrombasthenia;7 the prevalence in women who have factor XI deficiency, an
inherited bleeding disorder of varying severity, has been reported to be 59%;8 the
prevalence in hemophilia carriers, who have variably reduced levels of factor VIII or
factor IX, has been reported to be 10% to 57%;912 and the prevalence in women
with rare factor deficiencies has been reported to be 35% to 70%.1316
Not only is menorrhagia more prevalent among women who have bleeding disorders but bleeding disorders are more prevalent among women who have menorrhagia. Among women who have menorrhagia, the prevalence of VWD has been
reported to be 5% to 20%;17 the prevalence of platelet dysfunction, depending on
how it its defined, has been reported to be less than 1% to 47%;3 the prevalence of
factor XI deficiency has been reported to be less than 1% to 4%;3 the prevalence of
hemophilia carriage has been reported to be less than 1% to 4%;3 and the prevalence
of rare factor deficiencies has been reported to be less than 1%.3
There are limited data regarding the prevalence of bleeding disorders among
adolescents who have menorrhagia, but they are at least as likely to have an underlying bleeding disorder as adult women with heavy menstrual bleeding. Among
adolescents who have menorrhagia, the prevalence of VWD has been reported to
be 5% to 36%; the prevalence of platelet dysfunction, depending on how it is defined,
has been reported to be 2% to 44%; the prevalence of clotting factor deficiency has
been reported to be 8%;18 and the prevalence of thrombocytopenia has been reported to be 13% to 20% (Table 1).
Recently, the American College of Obstetrics and Gynecology19 Committee on
Adolescent Health Care and the American Academy of Pediatrics Committee on
Adolescence came to a consensus on what constitutes normal menstruation in girls
and adolescents. Their report was issued in the form of a committee opinion published
by the American College of Obstetricians and Gynecologists in November of 2006.
The title of the document was Menstruation in Girls and Adolescents: Using the
Menstrual Cycle as a Vital Sign. The committee agreed that normal menstruation
begins at 11 to 14 years of age, the normal cycle length is 21 to 45 days, the length
of the period is 7 days or less, and product use is no more than three to six pads or
tampons per day.
Menorrhagia is defined as heavy menstrual bleeding that lasts for more than 7
days20 or results in the loss of more than 80 mL of blood per menstrual cycle.20 The
clinical definition of 80 mL or more was formulated after a study by Hallberg and
colleagues21,22 found that the 95th percentile of blood loss per menstrual cycle among
183 normal women was 76 mL and that the prevalence of impaired iron status was
higher among women with blood loss of more than 60 mL. These investigators
concluded that that the upper limit of normal menstrual blood loss was between 60
Bleeding Disorders in Adolescents
Table 1
Bleeding disorders associated with menorrhagia in adolescents
N
Site
% Platelet % Low %
% VWD Dysfxn
Factor Low Platelets
Claessens and
Cowell, 198154
59
Inpatient
Smith et al, 199855
46
Inpatient
11
Oral et al, 200256
25
Inpatient
20
Bevan et al, 200157
71
ED, inpatient
13
Philipp et al, 200518
25
Outpatient
44
Jayasinghe et al,
200558
106 Inpatient, outpatient 5
Mikhail et al, 200759
61
HTC
36
Abbreviations: ED, Emergency department; HTC, Hemophilia treatment center; Plt Dysfxn, Platelet
dysfunction.
and 80 mL.21 Subsequently, the upper limit of 80 mL per cycle has been adopted as
the threshold for menorrhagia.23
Because measuring actual menstrual blood loss is unfeasible in clinical practice,
Higham and colleagues24 devised a pictorial blood assessment chart (PBAC) as an
alternative. In their original study, women compared the degree of saturation of their
pads and tampons with those depicted on a chart. Lightly stained pads or tampons
obtained a score of 1, moderately stained pads or tampons obtained a score of 5,
and soaked pads or tampons obtained a score of 20. The scores were summed,
and a total score of greater than 100 per cycle was associated with menstrual blood
loss of greater than 80 mL. A drawback of the use of the chart is that it must be
completed prospectively and results are not available at the time of an initial evaluation. Additionally, the validity of the chart remains uncertain.25,26
Therefore, the practitioner must rely on a menstrual history and clinical impression.
Warner and colleagues27 attempted to assess the volume of blood loss by means of
specific clinical features. In a logistic regression model, the variables that predicted
menstrual blood loss of more than 80 mL were clots greater than a 50-pence coin
in size (approximately 1 inch in diameter), low ferritin (according to the investigators
laboratory reference), or changing a pad or tampon more than hourly (flooding). The
presence of these features may help the practitioner to determine which adolescents
truly have heavy menstrual bleeding.
SCREENING FOR BLEEDING DISORDERS IN ADOLESCENTS WHO HAVE MENORRHAGIA
Philipp and colleagues28 studied strategies for screening women with menorrhagia for
an underlying bleeding disorder. A womans bleeding history (the screening tool)
was considered positive if (1) her duration of menses was greater than or equal to 7
days and she experienced flooding or impairment of daily activities with most periods;
(2) she had a history of treatment for anemia; (3) she had a family history of a diagnosed
bleeding disorder; or (4) she had a history of excessive bleeding with tooth extraction,
delivery, miscarriage, or surgery. A positive bleeding history alone had a sensitivity for
detecting any bleeding disorder (including VWD, platelet function defect, or clotting
factor deficiency) of 82%. The negative predictive value was 93% for VWD, 45% for
platelet function defect, and 38% for any bleeding disorder. Sensitivity increased to
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84% by the addition of the results of platelet function assessment, using an automated
platelet function analyzer, to 94% by the addition of a PBAC score of greater than 100,
and to 95% by the addition of both.
Based on these data, an evaluation for an underlying bleeding disorder should be
considered if an adolescent has a positive bleeding history as described by Philipp
and colleagues.28 Conversely, if an adolescent has a negative bleeding history as
described by Philipp and colleagues,28 VWD or a serious bleeding disorder is unlikely.
The patient who is suspected of having a bleeding disorder can be referred to a hemophilia treatment center or hematologist with expertise in bleeding disorders before or
after an initial laboratory evaluation. The initial laboratory evaluation should include
a complete blood cell count to assess the hemoglobin level and to exclude thrombocytopenia and a prothrombin time, activated partial thromboplastin time (aPTT), and
fibrinogen or thrombin clot time to exclude a clotting factor deficiency. Although these
tests are useful for excluding clotting factor deficiencies, the aPTT should be normal in
patients with platelet dysfunction and may be normal in patients who have VWD. The
next series of tests includes specific tests for VWD. If VWD is excluded, other categories of bleeding disorders that should be considered are platelet function defects;
abnormalities of fibrinolysis; and, rarely, collagen defects, such as Ehlers-Danlos
syndrome.
HEMORRHAGIC OVARIAN CYSTS
Although menorrhagia is the most common manifestation of reproductive tract

bleeding that women who have bleeding disorders experience, it is not the only manifestation. In the same survey of 102 women who had VWD compared with controls
conducted by the CDC, the next most common reproductive tract abnormality that
women who had VWD reported, after menorrhagia, was a history of ovarian cysts
(52% among cases compared with 22% among controls). Although ovulation is not
normally accompanied by any significant amount of bleeding, in women who have
VWD or other bleeding disorders, ovulation can result in bleeding into the follicular
sac, the peritoneum, the broad ligament, and the retroperitoneum. In a case series
of patients who had VWD, Silwer29 found the incidence of hemorrhagic ovarian cysts
in women to be 6.8%. Hemorrhagic ovarian cysts have also been reported in women
who have hemophilia carriage, afibrinogenemia, factor X deficiency, factor XIII deficiency, and platelet defects.3 Acutely, surgical therapy, tranexamic acid, and factor
replacement have been used to manage hemorrhagic ovarian cysts.11,30,31 Oral
contraceptives, which suppress ovulation and may increase clotting factors, have
been used to prevent recurrences.3133
ENDOMETRIOSIS
In the same CDC survey, 30% of women who had VWD reported a history of endometriosis compared with 13% of controls.4 There are several possible reasons why
women who have VWD and other bleeding disorders would be more likely to be diagnosed with endometriosis. Although there is disagreement regarding the etiology of
endometriosis, the prevailing theory is that it results from retrograde menstruation.34
Heavy menstrual bleeding is a risk factor for retrograde menstruation and endometriosis.35 Women who have bleeding disorders have heavier menstrual bleeding, more
retrograde menstruation, and, possibly, more endometriosis. Another possible explanation is that women who have bleeding disorders are more likely to experience symptomatic bleeding from extrauterine endometrial implants. A third possibility is that
women who have bleeding disorders are more likely to experience hemorrhagic
ovarian cysts or intraperitoneal bleeding that is misdiagnosed as endometriosis.
GYNECOLOGIC MANAGEMENT OF MENORRHAGIA IN ADOLESCENTS WHO
HAVE BLEEDING DISORDERS
There are data regarding the management of menorrhagia in women and adolescents
who have bleeding disorders. Oral contraceptives reduce menstrual blood loss36 in
women with VWD, and possibly increase VWF and factor VIII levels.3739 The levonorgestrel intrauterine device (IUD) is effective at reducing menstrual blood loss.40 Kingman and colleagues40 reported a significant decrease in PBAC scores and
a significant increase in hemoglobin concentration (g/dL) in 16 women who had
bleeding disorders after the insertion of the levonorgestrel IUD. There are unpublished
reports of the levonorgestrel IUD being used successfully in adolescents who have
bleeding disorders to reduce menstrual blood loss. Although there are no accumulated data in women who have bleeding disorders regarding the use of other hormonal
therapies, there is no reason to believe that other combined hormonal contraceptives,
such as patches and rings, would not also be useful.
The extended-use and continuous-use oral contraceptives offer an additional possibility of reducing menstrual blood loss. Edelman and colleagues randomized subjects
to receive levonorgestrel (100 mg)/ethinyl estradiol (20 mg), levonorgestrel (100 mg)/
ethinyl estradiol (30 mg), norethindrone acetate (1000 mg)/ethinyl estradiol (20 mg), or
norethindrone acetate (1000 mg)/ethinyl (30 mg) continuously for 180 days. Subjects
who received formulations with norethindrone, 1000 mg, experienced less bleeding
than subjects who received formulations with levonorgestrel, 100 mg. Additional
ethinyl estradiol (10 mg) did not improve bleeding patterns, suggesting that a formulation with norethindrone acetate (1000 mg)/ethinyl estradiol (20 mg) would be preferred
in a continuous regimen.41
Other progestin-only contraceptives, such as medroxyprogesterone acetate injections, progestin-only pills, and the progestin implant should also reduce endometrial
proliferation and reduce menstrual blood loss. Medroxyprogesterone acetate is now
available in a subcutaneous formulation, providing an alternative to the intramuscular
formulation that might result in intramuscular bleeding in a patient who has a severe
bleeding disorder. Insertion of the progestin implant could cause bleeding in a patient
who has a severe bleeding disorder and might require pretreatment with a hemostatic
agent.
HEMOSTATIC MANAGEMENT OF MENORRHAGIA IN ADOLESCENTS WHO
HAVE BLEEDING DISORDERS
Adolescents who have had a proper gynecologic evaluation and fail hormonal
management should be referred for consideration of hemostatic therapies, which
have been reported to be effective in controlling menorrhagia in women and adolescents with bleeding disorders. These hemostatic therapies include 1-desamino-8-Darginine vasopressin (DDAVP), antifibrinolytic medications (aminocaproic acid and
tranexamic acid), and clotting factor concentrates.
DDAVP is a synthetic vasopressin that stimulates the release of VWF from endothelial cells. DDAVP is useful in the treatment of type 1 VWD, some cases of type 2 VWD,
and some cases of platelet dysfunction and can be administered intranasally or intravenously. DDAVP causes some water retention and can reduce sodium levels. For this
reason, and also because DDAVP relies on the release of stored VWF, DDAVP use
should be limited to 48 hours. In a retrospective study, Amesse and colleagues42
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found that intranasal DDAVP was no more effective than oral contraceptives in
controlling menorrhagia but was associated with severe headaches and flushing.
Aminocaproic acid and tranexamic acid inhibit fibrinolysis. The use of aminocaproic
acid is limited by its gastrointestinal side effects. Tranexamic acid is better tolerated
but is not currently available in the United States, although it is expected to be reintroduced in the next few years.
A recent multisite, prospective, crossover study demonstrated that DDAVP and tranexamic acid reduce menstrual blood flow in women who have bleeding disorders.
Inclusion criteria were heavy menstrual bleeding and a PBAC score of greater than
100 with a negative gynecologic evaluation and abnormal laboratory hemostasis.
The investigators enrolled 117 women aged 18 to 50 years: 62% had platelet dysfunction, 15% had VWD, and 23% had some other coagulation defect. Subjects were
randomly assigned to DDAVP or tranexamic acid for two menstrual cycles, followed
by crossover to the second study drug for an additional two cycles. The PBAC score
and quality-of-life instruments were used to assess outcomes. With DDAVP, there was
a decrease in the PBAC score from a baseline of 66.0, and with tranexamic acid,
there was a decrease in the PBAC score from a baseline of 107.8. This difference
of 41.8 was statistically significant, although both treatments improved quality of life.43
Clotting factor concentrates may be required at the time of surgery, peripartum, at
the time of serious injury, and in episodes of severe acute bleeding (eg, severe acute
menorrhagia). VWD can be treated with VWF concentrates, hemophilia carriers can be
treated with recombinant factor VIII and factor IX products, and other factor deficiencies may be treated with fresh-frozen plasma or cryoprecipitate. Whenever
possible, clotting factor concentrates, which are purified and carry an extremely low
risk for viral transmission, should be administered as opposed to fresh-frozen plasma
or cryoprecipitate, neither of which is purified. In Europe, there are specific clotting
factor concentrates for fibrinogen, factor XI, and factor XIII deficiency, but these products are not available in the United States.
MANAGEMENT OF ACUTE SEVERE MENORRHAGIA
In the management of acute severe menorrhagia, every effort is made to preserve

future fertility. In addition to clotting factor concentrates and intravenous antifibrinolytic medication, recombinant factor VIIa can be tried and has been used successfully
in two cases of Bernard Soulier syndrome.44 Platelet transfusions have been used in
cases of severe thrombocytopenia.45 Additionally, a single intravenous 25-mg dose of
conjugated equine estrogen has been shown to be effective in the treatment of acute
menorrhagia.46 In women whose bleeding has not stopped within 3 hours, a second
dose may be administered.46 The duration of the effect of this treatment in healthy
women is unknown, but in patients with renal failure, the effect lasted 2 to 3 weeks.47
Although there have been no randomized trials, oral conjugated equine estrogen has
been used successfully.48 Treatment with conjugated equine estrogen is followed by
treatment with progestins or combined oral contraceptives. Leuprolide acetate has
been used to induce amenorrhea in patients at risk for severe acute menorrhagia
attributable to thrombocytopenia.49,50
Surgical therapies have also been used to treat acute severe menorrhagia. Dilation
and curettage (D & C), although occasionally necessary to diagnose intrauterine pathologic findings, is not particularly effective in controlling heavy menstrual bleeding in
women who have bleeding disorders. In two cases of women who had VWD reported
by Greer and colleagues11 and two cases reported by Kadir and colleagues,9 D & C
resulted in further blood loss. In the absence of significant endometrial proliferation,

D & C should be avoided.
Nonhormonal gynecologic therapies have been used successfully to control acute
severe menorrhagia in adolescents. Rouhani and colleagues51 reported using a Foley
balloon to tamponade the endometrial cavity of a 12-year-old female patient with plasminogen activator inhibitor during her second menstrual period; Bowkley and
colleagues52 reported using uterine artery embolization with plasminogen activator
inhibitor in a 12-year-old female patient during her first menstrual period; and Markovitch and collegues53 reported packing the uterus of a 14-year-old female patient who
had Glanzmanns thrombasthenia during her second menstrual period.
GENERAL ISSUES
Girls and adolescents with known bleeding disorders should be counseled before
menarche and have a plan in place for the possibility of acute severe menorrhagia,
which could occur with their first or any subsequent menstrual period. The plan should
be made by the patients gynecologist and hematologist in conjunction with the patients family. Because of the increased risk of transfusion, girls and adolescents
who have not already been immunized against hepatitis A and hepatitis B should be
immunized. If they have not already done so, adolescents who have inherited bleeding
disorders and their families should have the opportunity to speak with a knowledgeable genetic counselor.
SUMMARY
Adolescents who have bleeding disorders come to the attention of the gynecologist
when menarche is anticipated or they develop reproductive tract bleeding. Menorrhagia is the most common symptom that adolescents who have bleeding disorders
experience. Not only is menorrhagia more prevalent among adolescents who have
bleeding disorders but bleeding disorders are more prevalent among adolescents
who have menorrhagia. Adolescents who have bleeding disorders are probably also
at an increased risk for hemorrhagic ovarian cysts and endometriosis. The patient
who is suspected of having a bleeding disorder can be referred to a hemophilia treatment center or hematologist with expertise in bleeding disorders for evaluation.
Adolescents and their parents need to understand and accept that hormonal contraception is the first-line treatment for menorrhagia. Adolescents who have a bleeding
disorder, have had a proper gynecologic evaluation, and fail hormonal management
should be considered for possible hemostatic therapy. Successful management of
reproductive tract bleeding in adolescents requires the combined expertise of knowledgeable hematologists and gynecologists.
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17. James A, Matchar DB, Myers ER. Testing for von Willebrand disease in women
with menorrhagia: a systematic review. Obstet Gynecol 2004;104(2):3818.
18. Philipp CS, Faiz A, Dowling N, et al. Age and the prevalence of bleeding disorders in women with menorrhagia. Obstet Gynecol 2005;105(1):616.
19. ACOG. Menstruation in girls and adolescents: using the menstrual cycle as a vital
sign. Washington, DC: American College of Obstetricians and Gynecologists;
2006.
20. ACOG. Management of anovulatory bleeding. Washington, DC: American
College of Obstetricians and Gynecologists; 2000.
21. Hallberg L, Hogdahl AM, Nilsson L, et al. Menstrual blood lossa population
study. Variation at different ages and attempts to define normality. Acta Obstet
Gynecol Scand 1966;45(3):32051.
22. Hallberg L, Hogdahl AM, Nilsson L, et al. Menstrual blood loss and iron deficiency. Acta Med Scand 1966;180(5):63950.
23. Warner PE, Critchley HO, Lumsden MA, et al. Menorrhagia II: is the 80-mL blood
loss criterion useful in management of complaint of menorrhagia? Am J Obstet
Gynecol 2004;190(5):12249.
24. Higham JM, OBrien PM, Shaw RW. Assessment of menstrual blood loss using
a pictorial chart. Br J Obstet Gynaecol 1990;97(8):7349.
25. Janssen CA, Scholten PC, Heintz AP. A simple visual assessment technique to
discriminate between menorrhagia and normal menstrual blood loss. Obstet
Gynecol 1995;85(6):97782.
26. Reid PC, Coker A, Coltart R. Assessment of menstrual blood loss using a pictorial
chart: a validation study. BJOG 2000;107(3):3202.
27. Warner PE, Critchley HO, Lumsden MA, et al. Menorrhagia I: measured blood
loss, clinical features, and outcome in women with heavy periods: a survey
with follow-up data. Am J Obstet Gynecol 2004;190(5):121623.
28. Philipp CS, Faiz A, Dowling NF, et al. Development of a screening tool for identifying women with menorrhagia for hemostatic evaluation. Am J Obstet Gynecol
2008;198(2):163 e1618.
29. Silwer J. von Willebrands disease in Sweden. Acta Paediatr Scand Suppl 1973;
238:1159.
30. Gomez A, Lucia JF, Perella M, et al. Haemoperitoneum caused by haemorrhagic
corpus luteum in a patient with type 3 von Willebrands disease. Haemophilia
1998;4(1):602.
31. Jarvis RR, Olsen ME. Type I von Willebrands disease presenting as recurrent
corpus hemorrhagicum. Obstet Gynecol 2002;99(5 Pt 2):8878.
32. Ghosh K, Mohanty D, Pathare AV, et al. Recurrent haemoperitoneum in a female
patient with type III von Willebrands disease responded to administration of oral
contraceptive. Haemophilia 1998;4(5):7678.
33. Bottini E, Pareti FI, Mari D, et al. Prevention of hemoperitoneum during ovulation
by oral contraceptives in women with type III von Willebrand disease and afibrinogenemia. Case reports. Haematologica 1991;76(5):4313.
34. Lobo RA. Endometriosis: etiology, pathology, diagnosis, management. In: Katz V,
Lentz G, Lobo R, et al, editors. Katz: comprehensive gynecology. 5th edition. Philadelphia: Mosby; 2007. p. 47395.
35. Vercellini P, De Giorgi O, Aimi G, et al. Menstrual characteristics in women with
and without endometriosis. Obstet Gynecol 1997;90(2):2648.
36. Foster PA. The reproductive health of women with von Willebrand disease unresponsive to DDAVP: results of an international survey. On behalf of the Subcommittee on von Willebrand Factor of the Scientific and Standardization Committee
of the ISTH. Thromb Haemost 1995;74(2):78490.
37. Beller FK, Ebert C. Effects of oral contraceptives on blood coagulation. A review.
Obstet Gynecol Surv 1985;40(7):42536.
38. Kadir RA, Economides DL, Sabin CA, et al. Variations in coagulation factors in
women: effects of age, ethnicity, menstrual cycle and combined oral contraceptive. Thromb Haemost 1999;82(5):145661.
39. Middeldorp S, Meijers JC, van den Ende AE, et al. Effects on coagulation of levonorgestrel- and desogestrel-containing low dose oral contraceptives: a crossover study. Thromb Haemost 2000;84(1):48.
40. Kingman CE, Kadir RA, Lee CA, et al. The use of levonorgestrel-releasing intrauterine system for treatment of menorrhagia in women with inherited bleeding
disorders. BJOG 2004;111(12):14258.
41. Edelman AB, Koontz SL, Nichols MD, et al. Continuous oral contraceptives: are
bleeding patterns dependent on the hormones given? Obstet Gynecol 2006;
107(3):65765.
42. Amesse LS, Pfaff-Amesse T, Leonardi R, et al. Oral contraceptives and DDAVP
nasal spray: patterns of use in managing vWD-associated menorrhagia:
a single-institution study. J Pediatr Hematol Oncol 2005;27(7):35763.
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43. Kouides PA, Heit JA, Philipp CS, et al. A multi-site, prospective, cross-over study
of intranasal desmopressin and oral tranexamic acid in women with menorrhagia
and abnormal laboratory hemostasis. Blood 2007;110:711 [ASH Annual Meeting
Abstracts].
44. Ozelo MC, Svirin P, Larina L. Use of recombinant factor VIIa in the management of
severe bleeding episodes in patients with Bernard-Soulier syndrome. Ann Hematol 2005;84(12):81622.
45. Levens ED, Scheinberg P, DeCherney AH. Severe menorrhagia associated with
thrombocytopenia. Obstet Gynecol 2007;110(4):9137.
46. DeVore GR, Owens O, Kase N. Use of intravenous Premarin in the treatment of
dysfunctional uterine bleedinga double-blind randomized control study. Obstet
Gynecol 1982;59(3):28591.
47. Livio M, Mannucci PM, Vigano G, et al. Conjugated estrogens for the management of bleeding associated with renal failure. N Engl J Med 1986;315(12):7315.
48. Lobo RA. Abnormal uterine bleeding. In: Katz V, Lentz G, Lobo R, et al,
editors. Katz: comprehensive gynecology. 5th edition. Philadelphia: Mosby;
2007. p. 91529.
49. Laufer MR, Townsend NL, Parsons KE, et al. Inducing amenorrhea during bone
marrow transplantation. A pilot study of leuprolide acetate. J Reprod Med
1997;42(9):53741.
50. Amsterdam A, Jakubowski A, Castro-Malaspina H, et al. Treatment of menorrhagia in women undergoing hematopoietic stem cell transplantation. Bone
Marrow Transplant 2004;34(4):3636.
51. Rouhani G, Menon S, Burgis J, et al. An unusual method to manage a rare blood
dyscrasia. J Pediatr Adolesc Gynecol 2003;20(2):S1234.
52. Bowkley CW, Dubel GJ, Haas RA, et al. Uterine artery embolization for control of
life-threatening hemorrhage at menarche: brief report. J Vasc Interv Radiol 2007;
18(1 Pt 1):12731.
53. Markovitch O, Ellis M, Holzinger M, et al. Severe juvenile vaginal bleeding due to
Glanzmanns thrombasthenia: case report and review of the literature. Am J Hematol 1998;57(3):2257.
54. Claessens EA, Cowell CA. Acute adolescent menorrhagia. Am J Obstet Gynecol
1981;139(3):27780.
55. Smith YR, Quint EH, Hertzberg RB. Menorrhagia in adolescents requiring hospitalization. J Pediatr Adolesc Gynecol 1998;11(1):135.
56. Oral E, Cagdas A, Gezer A, et al. Hematological abnormalities in adolescent
menorrhagia. Arch Gynecol Obstet 2002;266(2):724.
57. Bevan JA, Maloney KW, Hillery CA, et al. Bleeding disorders: a common cause of
menorrhagia in adolescents. J Pediatr 2001;138(6):85661.
58. Jayasinghe Y, Moore P, Donath S, et al. Bleeding disorders in teenagers presenting with menorrhagia. Aust N Z J Obstet Gynaecol 2005;45(5):43943.
59. Mikhail S, Varadarajan R, Kouides P. The prevalence of disorders of haemostasis
in adolescents with menorrhagia referred to a haemophilia treatment centre. Haemophilia 2007;13(5):62732.
Thrombophilic
Conditions in the
Adolescent :
The Gynecologic Impact
Jennifer E. Dietrich, MD, MSca,b,*, Donald L.Yee, MD, MSb
KEYWORDS
Thrombophilia Combined hormonal contraception
Progesterone-only methods Thrombosis risk Adolescent
Adolescent girls frequently present to providers with gynecologic concerns, ranging

from routine health education about pubertal development and sexual activity to
more acute disorders, such as ovarian cysts, dysfunctional uterine bleeding, dysmenorrhea, and many other common problems. Adolescent girls are a main population
seeking benefit from contraceptive hormones,1 because contraceptives are a primary
treatment for many gynecologic problems and an effective means of birth control.
Nonetheless, contraceptive hormone use has been linked conclusively to an increased
risk for thrombosis. As conditions predisposing to thrombosis are being increasingly
recognized and thrombosis in teenagers is increasingly diagnosed, the practitioner
of adolescent gynecology must be knowledgeable about thrombophilic conditions
and their potential interaction with such important components of the therapeutic
armamentarium. This article provides a basic overview of the hemostatic system
and the main thrombophilic conditions currently recognized, in addition to a discussion
of the specific risks imposed by these conditions and a review of the primary
therapeutic options available for affected patients who have gynecologic problems.
THE HEMOSTATIC SYSTEM: AN OVERVIEW
A detailed comprehensive review of the hemostatic system2 is beyond the scope of

this article; however, the physiology underlying hemostasis and thrombosis can be
considered in terms of several constituent processes (Fig. 1). Primary hemostasis
refers to the initial sequence of events leading to the formation of a platelet plug at
Department of Obstetrics and Gynecology, Baylor College of Medicine, 6620 Main Street,
Suite 1450, Houston, TX 77030, USA
b
Department of Pediatrics, Baylor College of Medicine, 6621 Fannin Street, MC3-3320,
Houston, TX 77030, USA
E-mail address: [email protected] (J.E. Dietrich).
doi:10.1016/j.ogc.2008.12.001
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Fig.1. Components of hemostasis. (A) With vessel injury, circulating platelets adhere to sites
of injury. (B) With progressive adhesion, platelets undergo activation, culminating in formation of the platelet plug. (C) At the activated platelet surface, phosphatidylserine (a coagulation cofactor) is preferentially exposed at the outer membrane leaflet, thereby
potentiating the activation of factor X to factor Xa and factor II (prothrombin) to factor
IIa (thrombin). Thrombin is the critical enzyme that allows formation of the fibrin clot.
(From Yee DL. Platelets as modifiers of clinical phenotype in hemophilia. Scientific World
Journal 2006;6:6618; with permission.)
the site of vascular injury. Platelets and von Willebrand factor are the major contributors to this process. Although distinct from the prothrombotic risk factors that are the
focus of this review, loss-of-function abnormalities in primary hemostasis (eg,
thrombocytopenia, platelet hypofunction, von Willebrand factor deficiency) are of
special importance to obstetricians and gynecologists because they can manifest
as menorrhagia, menometrorrhagia, or postpartum hemorrhage. In contrast,
secondary hemostasis (ie, coagulation) is the series of catalytic reactions involving
plasma serine proteases and their cofactors that culminates in thrombin generation
and the formation of a stable fibrin clot at the site of the platelet plug. Elevated levels
of these circulating plasma proteins and mutated versions of them that resist inactivation (eg, factor V Leiden [FVL]) contribute to increased thrombotic risk. Natural anticoagulants (eg, protein C, protein S, antithrombin, tissue factor pathway inhibitor) serve
primarily as checks on key portions of the coagulation cascade. Deficiencies in these
natural anticoagulants have long been recognized as prothrombotic risk factors and
are discussed further elsewhere in this article. Circulating components of the fibrinolytic system include plasminogen, tissue type plasminogen activator, and plasminogen activator inhibitor-1. This system breaks down clots and is a key regulator of
the fine line between appropriate hemostasis and pathologic thrombosis. Each of
the systems and processes described here must be appropriately balanced to achieve
vascular homeostasis. When the delicate balance shifts toward hemostatic hyperfunction or inadequate fibrinolysis, thrombophilia can result.
THROMBOPHILIC CONDITIONS
The terms thrombophilia, hypercoagulable state, and prothrombotic state have each
been used to describe conditions of increased risk for thromboembolic events
(TEs). Many clinicians use these terms solely to signify laboratory-based findings
Thrombophilic Conditions in the Adolescent
that have been linked with increased thrombotic risk (Table 1). Many risk factors that
are not based on laboratory testing are extremely important to consider in any determination of an individual patients risk for thrombosis, however. Many of these clinical
risk factors even supersede laboratory-based factors in terms of their effect on risk
(see Table 1). Although much of this discussion pertains to patients with identified
laboratory-based prothrombotic risk factors, it should be emphasized that clinical
risk factors may be most important; indeed, a history of thrombosis is perhaps the
most significant risk factor to consider.3
Following is a brief review of several of the more widely recognized laboratory-based
prothrombotic risk factors and their relevant epidemiology. Most of these currently
recognized risk factors involve abnormalities of the natural anticoagulant system or
secondary hemostasis. Given the critical role of primary hemostasis and the fibrinolytic
system in forming and maintaining a thrombus, however, additional prothrombotic
abnormalities involving these systems are likely to be identified in the future.4,5
Activated protein C resistance and FVL: a mutation (G1691A) in the gene encoding factor V leads to the substitution of glutamine for arginine at position 506 of
the factor V molecule, accounting for FVL.6 Approximately 3% to 8% of white
individuals are heterozygotes for FVL, which renders the activated factor V molecule resistant to cleavage by the natural anticoagulant-activated protein C (APC),
leading to persistence of the activated procoagulant molecule. The condition
(which can involve a heterozygous or homozygous state) is the most common
cause for the laboratory finding of increased resistance to APC, which can also
be caused by oral contraceptive use, a lupus anticoagulant, and other less
common genetic variants of factor V.
The prothrombin G20210A mutation (G20210A) in the 30 untranslated region of
the prothrombin gene was described in 1996,7 and 2% to 3% of whites are
Table 1
Risk factors for thrombosis
Clinical
Laboratory Based
Personal or family history of thrombosis
FVL
Pregnancy and puerperium
Activated protein C resistance without FVL
Hormonal therapy
Prothrombin gene mutation
Obesity
Antithrombin deficiency
Intravascular access devices
Protein C deficiency
Immobility
Protein S deficiency
Infection
Tissue factor pathway inhibitor deficiency
Inflammation
Elevated factor VIII
Autoimmune disorders
Elevated factor IX
Dehydration
Elevated factor XI
Surgery or trauma
Elevated fibrinogen
Spinal cord injury
APS
Acute medical illness
Plasminogen deficiency
Cancer
Elevated homocysteine
Congenital heart disease
Elevated lipoprotein A
Prosthetic heart valves
Dysfibrinogenemia
Nephrotic syndrome
Myeloproliferative disorders
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heterozygotes. This mutation leads to increased levels of prothrombin (factor II)

and enhanced thrombin generation.
The lupus anticoagulant and antiphospholipid antibodies are distinct classes of
autoantibodies detected by a clot-based assay and ELISA-based assay, respectively. Each is a diagnostic criterion for antiphospholipid syndrome (APS),
a disorder characterized by recurrent thrombotic complications. Although most
of the thrombophilias are linked to recurrent fetal loss and other obstetric complications related to placental vascular insufficiency, such outcomes actually serve
as diagnostic criteria for APS.8 The mechanism underlying thrombosis in APS
remains an active area of study, but inhibition of the protein C pathway and
altered platelet/endothelial balance are primary considerations.9 Reliable population-based data on the prevalence of this acquired form of thrombophilia in
adolescents are not available, but the reported prevalence of the antibodies
among children who have thrombosis is as high as 24%.10
Congenital deficiencies of antithrombin, protein C, and protein S are less prevalent (w1 in 500)11,12 than the thrombophilias described previously, but because
of the critical role that these natural anticoagulants play in regulating activated
procoagulant moieties, even mild deficiencies (ie, heterozygous state leading
to levels approximating 50% or more of normal) lead to increased thrombotic
risk. Homozygous/compound heterozygous states are incompatible with life or
are associated with severe thrombotic disease early in life. Many conditions
(eg, liver disease, disseminated intravascular coagulation, acute thrombosis)
can lead to acquired deficiency of these proteins, complicating the diagnosis
of hereditary deficiency states. In particular, protein S levels decline significantly
with pregnancy and oral contraceptive use.
Elevated factor levels are associated with increased thrombotic risk, with high
levels of factors VIII, IX, and XI cited as risk factors for venous thrombosis.1315
Elevated homocysteine levels are a risk factor for venous and arterial thrombosis,
although recent prospective studies have failed to show that therapy that
successfully lowers these levels also reduces thrombotic risk.16,17 Testing for
the presence of a distinct polymorphism (at nucleotide 677) in the gene encoding
methylenetetrahydrofolate reductase is a common component of many hypercoagulation panels. The less common allele of this polymorphism renders the
enzyme thermolabile with an associated loss of enzyme activity and mild to
moderate homocystinemia in the presence of dietary folate depletion. The utility
of testing for this variant is likely low, however, especially when compared with
direct testing of homocysteine levels.
Additional prothrombotic risk factors are listed in Table 1. Any of these risk factors
may occur in combination with any of the others (including homozygosity or
compound heterozygosity for a single prothrombotic trait). The combination of such
plasma-based factors with each other and with other clinical risk factors comprises
the gene-gene and gene-environment interactions that dictate why an individual
develops a clot at a given point in time.18 Therefore, a careful individualized assessment of all such factors must occur to guide clinical decision making relevant to
a patients thrombotic risk.
HORMONAL THERAPY: AN IMPORTANT ACQUIRED RISK FACTOR FOR THROMBOSIS
One of the most significant prothrombotic risk factors to consider is hormonal therapy.
Hormones are some of the most commonly prescribed drugs in adolescent girls, and
combined oral contraceptives (COCs; estrogen and progestagen) are the most
common class of these. A variety of studies in adults show that COCs induce resistance to APC;19 increase levels of procoagulant proteins (factors II, VII, VIII, and fibrinogen);20 decrease levels of antithrombin, protein S, tissue factor pathway inhibitor,
and fibrinolytic proteins; and increase markers of coagulation and fibrinolysis
activation.21,22
The thrombotic risk associated with oral contraceptive use varies with the time
interval since starting treatment but is highest in the first year of use, especially in
women who have a prothrombotic defect.23,24 The dose of estrogen25 and the type
of progestagen used in the combination also influence thrombotic risk. Third-generation COCs containing the progestagen component gestodene or desogestrel have
been associated with a roughly doubled risk for venous thrombosis compared with
second-generation pills containing levonorgestrel.23,24 Recent studies have identified
differences in APC resistance, protein S, and tissue factor pathway inhibitor levels
among the various formulations that differ by the progestagen component, thus
providing a mechanistic rationale for the clinical observations.19,26
Although some have suggested that progestagens counteract the prothrombotic
effect of estrogens27 and raise protein S levels,28 data are relatively scarce regarding
the thrombotic risk associated with progesterone-only oral contraceptives. The
available evidence, however, does not suggest that there is increased risk.29,30
ABSOLUTE AND RELATIVE RISKS FOR THROMBOSIS
To provide a more meaningful context for this discussion, a consideration of the absolute risk for thrombosis in adolescents and the relative risks imposed by the described
risk factors is in order. Thrombosis risk increases with age (Table 2),31 such that this
risk is fairly minimal for adolescents compared with more senescent adults. Adolescents do constitute the second highest risk age group for thrombosis among pediatric
patients, however.32 Although specific population-based incidence data are not available for adolescents, a reasonable conservative estimate for the absolute thrombotic
risk for this age group would be between those rates reported for the pediatric age
group and young adults as listed in Table 2 (estimate italicized). Inherited and
acquired thrombophilic risk factors (eg, FVL, lupus anticoagulant) and prothrombotic
clinical risk factors (eg, oral contraceptive use, pregnancy, obesity) increase this risk
further (Table 3). The magnitude of these risks, how they may be modified, and their
interaction with other aspects of the clinical scenario must be carefully weighed when
making clinical decisions that have an impact on thrombotic risk. Often, decision
making may be enhanced through involvement of a hematologist or other consultant
experienced in dealing with disorders of hemostasis and thrombosis.
Table 2
Absolute thrombotic risk by age
Age Group
Incidence (Cases per 10,000 perYear)
All children and adolescents (age %18 years)
0.070.1432,68
Adolescents
Estimated 0.51
Young adults (age %40 years)
1269,70
All adults
102031,71
Elderly adults (age %85 years)
w10031
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Table 3
Risk for venous thrombosis associated with various prothrombotic conditions
Prothrombotic Condition
Relative Risk
Pregnancy
4127274
Postpartum state
202572
Low-dose COC
3474
High-dose COC
61074
FVL (heterozygous)
875
FVL (homozygous)
5010039
FVL and COC use
3575
Elevated factor VIII (>150 IU/dL)
476,a
Elevated factor VIII and COC use
1076,a
Defined control groups varied with the different studies but, in all cases, comprised girls or women
unexposed to the risk factor being assessed.
a
Reported as odds ratio.
It must be emphasized that thrombotic risk is further modified by the combination of

multiple risk factors, including the use of COCs in the setting of inherited or acquired
thrombophilic traits. For example, the combination of FVL (heterozygous state) with
COC use increases the apparent thrombotic risk far beyond that which would be
observed with either risk factor alone (see Table 3). Although such synergism seems
to be the rule, the magnitude of effect seems to vary with the prothrombotic risk factor
involved; a recent systematic review summarizes results for other thrombophilias.33
Finally, it should be mentioned that in addition to overt thrombosis, thrombophilic
conditions have been linked to a variety of adverse pregnancy outcomes, including
pre-eclampsia, intrauterine growth retardation, placental abruption, and recurrent
fetal loss.34,35
SHOULD SCREENING FOR THROMBOPHILIA BE PERFORMED?
Thrombophilia testing has become widely available, and the increased thrombotic risk
imposed by oral contraceptive pill (OCP) use raises the important question of whether
patients should be screened for thrombophilic traits before initiating such therapy.
Although OCP use is associated with an increased relative risk for thrombosis, the
absolute risk remains low and universal screening of patients before starting OCP
therapy is not indicated. A cost-effectiveness study published in 1999 reported that
more than 92,000 carriers of FVL would need to be identified and stopped from using
COCs to prevent a single death attributable to COC use and the coexistence of this
trait, at a charge exceeding $300 million.36 A more recent analysis reported that
screening for thrombophilic defects before initiating COC use would incur an additional 200,402 to prevent one additional case of venous thrombosis.37 This figure
dropped to 79,085 in the model in which screening was restricted to women who
had a personal or family history of thrombosis. Of several screening strategies
analyzed in this study, including screening with onset of pregnancy, before hormone
replacement therapy, and before orthopedic surgery, thrombophilia screening before
initiating COC use was the least cost-effective strategy evaluated.37 Based largely on
such cost-effectiveness data, the clear consensus is that screening before COC use in
adolescents should not be universal but that careful evaluation for a personal or family
history of thrombosis should be performed and directed screening should be
considered on an individualized basis.38,39 Box 1 lists specific questions that may be

helpful to the clinician in eliciting such histories.
INDICATIONS FOR HORMONAL THERAPY
Managing common gynecologic problems or recommending contraception can be

challenging in adolescents, especially in light of recent teen statistics.1 In the United
States, approximately 800,000 teen pregnancies occur annually, with nearly 80%
being unintended and one third ending in abortion. Sexual activity is not only seen
among older adolescents, but current statistics demonstrate that 7% of teens become
sexually active before the age of 12 years.1,40,41 Negative consequences from early
sexual activity abound, because 25% of all teens have had or currently have a sexually
transmitted infection, with high-risk behavior demonstrated across all socioeconomic
groups. Because adolescents are a sexually active group as a whole, there is clearly
a need for contraception and sex education.4143
Sexual activity and contraception are not the only reasons for prescribing hormonal
contraception in adolescents. Acute gynecologic concerns are common among this
population; therefore, many noncontraceptive benefits are gained from hormone pills.
For example, ovarian cysts are present in approximately 20% of teens 12 to 17 years
of age, and they are frequently benign in this age group.44 Such cysts may be functional, be hemorrhagic, have cystic or solid components, and may vary in size.
Menstrual cycle irregularity is also common in this age group, occurring in 75% of
adolescents within the first few years of menarche.44 Other reasons why an adolescent may present to a gynecologist include dysmenorrhea, premenstrual syndrome,
endometriosis, outflow tract obstruction, pelvic pain, hyperandrogenism, and acne.
Hormonal contraception may play a role in the treatment of each of these conditions.45
Adolescent girls who have coexisting conditions, such as systemic lupus erythematosus, APS, sickle cell disease, a history of TE, or other thrombophilic conditions
(see Table 1), have relative contraindications to combination hormonal contraceptive
methods, however, because these medications place them at higher risk for TE.4649
Therefore, decisions regarding contraception or noncontraceptive medical management for adolescents who have such coexisting conditions may be more
difficult.40,47,50,51
First-Line Hormonal Options for Contraception and Noncontraceptive
Medical Therapy
Presently, there are many options for teens with thrombophilic conditions, which allow
individuals to choose an alternative that fits their lifestyle.30,5254 Progesterone-only
Box 1
Screening questions for personal or family history of thrombosis
Have you or a close family member ever had blood clots in the legs or lungs?
Have you or a close family member ever been hospitalized for blood clots in the legs or lungs?
What were the circumstances in which the blood clot took place (eg, cancer, airline travel,
obesity, immobility, postpartum)?
Did you or your family member require blood thinning medication?
From Sass AE, Neufeld EJ. Risk factors for thromboembolism in teens: when should I test? Curr
Opin Pediatr 2002;14:3745; with permission.
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methods have become a primary choice because of their ease of use and apparent
lack of thromboembolic side effects.30 Contraceptive progestagens have two important effects. First, they thicken cervical mucus, leading to endometrial atrophy.
Numerous studies have demonstrated that failure rates for progesterone-only
methods are less than 1% when taken correctly. Second, progesterone methods
may lower TE risk by up-regulating free and total protein S, making this cofactor
to protein C more available for anticoagulant effect.55 The relative risk for a TE
while using a contraceptive progestin has been previously reported as no more
than 1.30,40,56
Pills
Contraceptive progestin pills are currently limited to norethindrone in the United

States. These pills are taken daily and are available at a dose of 0.35 mg. Because
this agent has a short half-life, follicular function can still persist. Pills are administered
daily without a placebo week. Progestin pills are well tolerated by teens but can result
in difficulties with compliance because of the need for daily administration54,57 and the
frequent side effect of breakthrough bleeding.
Injectables
There are two forms available for contraceptive administration. Depomedroxyprogesterone acetate (DMPA) is available for subcutaneous or intramuscular use. The intramuscular dose of 150 mg is administered once every 3 months. The subcutaneous
dose of 104 mg is also administered once every 3 months. Both are options for the
adolescent who may be less compliant with daily pills.58 Important side effects include
breakthrough bleeding, weight gain, loss of bone mineral density, and, rarely,
episodes of depression. For management of other gynecologic conditions, such as
endometriosis, or uncontrolled menorrhagia, gonadotropin-releasing hormone
analogues may be used without increased risk for thrombosis. There are several
different formulations available for use, but patients can choose to have administration
of this medication monthly or once every 3 months.52,58
Implantables
The etonogestrel implant is the most recent method of contraception approved by the
US Food and Drug Administration. Approximately 22% of patients achieve amenorrhea, and 33.6% report infrequent bleeding episodes. Bleeding irregularity was still
the most common reason for method discontinuation.53,59 Use of an implant with etonogestrel has also been associated with down-regulation of the coagulation cascade
and subsequent thrombin generation, suggesting that this method may reduce TE
risk.60
Intrauterine devices
Newer evidence suggests that intrauterine device (IUD) use in adolescents may be
appropriate in certain situations. The levonorgestrel IUD is reversible, lasts 5 years,
and induces amenorrhea in 20% of patients after 1 year of use. Irregular bleeding
remains a concern, however, and may occur for 3 to 6 months after insertion. Candidates for IUD insertion include individuals who cannot receive estrogens and those
who wish to use a long-acting progestin.6163
Emergency contraception
Adolescents who are sexually active may inquire about options for pregnancy prevention in the setting of recent exposure. Progesterone-only emergency contraception is
available and can be administered without increasing TE risk. Levonorgestrel in the
form of 0.75-mg tablets is available for administration in two divided doses, but even
when taken as one combined dose, efficacy rates are similar.64
Nonhormonal Options
There are several natural family planning methods available for adolescents who have
known thrombophilias. The natural methods can be effective in the compliant adolescent with regular menstrual cycles. Using menstrual calendars or cycle beads may be
helpful to remind adolescents when their most fertile period is and when to avoid
sexual contact for pregnancy prevention. Because many adolescents are anovulatory
and have irregular cycles, however, natural family planning cannot be used by
everyone. Failure rates for menstrual calendar and cycle bead methods approach
20%, which is similar to using the withdrawal method.45 Another option for pregnancy
prevention in sexually active adolescent girls who have thrombophilias is barrier
contraception. Barrier options include condoms, spermicides, sponges, cervical
caps, and diaphragms. These methods are effective if used correctly, but typical
failure rates range between 10% and 30%. Finally, a copper IUD is an effective
method for pregnancy prevention, with failure rates of less than 1%; however, this
may not be an option for an adolescent who has a history of pelvic inflammatory
disease at the time of insertion, who is not currently in a monogamous relationship,
or who desires a decrease in menstrual flow.45
ANTITHROMBOTIC TREATMENT AND PROPHYLAXIS IN ADOLESCENT GIRLS
For the adolescent who requires antithrombotic therapy or prophylaxis, several

options are available. These include unfractionated heparin, low molecular weight
heparin, and vitamin K antagonists (eg, warfarin). Although unfractionated heparin
and low molecular weight heparin do not cross the placenta, adolescents taking
warfarin must be warned about the potential for adverse fetal effects, and effective
contraception must be undertaken. In patients who require warfarin, concomitant
use of a low-dose COC or DMPA may be a reasonable choice to consider, given
the teratogenic risks, the risk for intraperitoneal bleeding associated with ovulation,
and the expected benefit of reduced menstrual flow.56,65 Other antithrombotic strategies include use of graduated compression stockings or sequential compression
devices after surgery or during other periods of risk (eg, prolonged immobilization).
For specific details regarding thrombosis treatment and prophylaxis, the American
College of Chest Physicians has published formal treatment guidelines for adolescents,66 but close consultation with a hematologist is strongly recommended.
Any anticoagulant therapy carries a risk for severe bleeding, including menorrhagia.
Appropriate management of acute and chronic menorrhagia requires knowledge of
current anticoagulation status and a clear understanding of the underlying thrombophilia. A gonadotropin-releasing hormone agonist may be a useful adjunct in
managing heavy menses in anticoagulated patients because it does not seem to
increase thrombotic risk.67 For acute management of severe menorrhagia or other
severe bleeding, it may be necessary to withhold, or even reverse, anticoagulation.
Such decisions should also involve close hematologic consultation, however.
SUMMARY
Thrombophilias, hereditary and acquired, encompass a wide-ranging array of conditions and traits that lead to increased thrombotic risk among those affected. It is of
particular importance for clinicians to assess for TE risk in individuals seeking
hormonal contraception or in those who are candidates for hormonal therapy for other
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indications. Universal laboratory screening of such patients for thrombophilia is not

recommended. A careful evaluation of each patients personal and family history is
critical for identifying individuals who may (1) be at increased risk for thrombosis,
(2) not be suitable for standard hormonal therapy, or (3) benefit from more directed
thrombophilic testing, however. Furthermore, consultation with a hematologist is
crucial for effective management of patients at increased risk for thrombosis. Finally,
adolescent girls identified with a thrombophilic condition should fully understand the
impact on their future gynecologic health.
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175
Adolescent
Endometriosis
Claire Templeman, MD
KEYWORDS
Adolescent Endometriosis Pelvic pain Management
The presence of endometrial glands and stroma outside the uterus, typically in the
pelvis, is known as endometriosis. An adolescent with this diagnosis usually presents
with chronic pelvic pain, and she and her family are anxious for an explanation of her
symptoms. Traditionally, endometriosis had been thought to occur only rarely in
adolescence, but with an increasing awareness of the disease among the medical
community, it is being diagnosed more frequently. An outline of the disease and the
issues surrounding its diagnosis and management in adolescents is the focus of
this article.
INCIDENCE AND PATHOPHYSIOLOGY
The prevalence of endometriosis varies depending on the population studied; therefore, it has been difficult to establish firm rates for adolescents. Indeed, studies reporting the presence of endometriosis in adolescents undergoing laparoscopy for pelvic
pain vary. Goldstein and colleagues1 reported a 47% incidence of disease in adolescent girls undergoing laparoscopy for chronic pelvic pain, whereas Laufer and
colleagues2 have reported a finding of endometriosis at the time of surgery in 67%
of adolescents who have pain refractory to simple medical treatments like nonsteroidal anti-inflammatory agents (NSAIDS) or oral contraceptive pills (OCPs).
In terms of economic burden, Gao and colleagues3 have produced some data highlighting the importance of endometriosis among adolescents. These researchers
assessed the economic burden of endometriosis and concluded that as endometriosis-related hospital length of stay steadily declined from 1993 to 2002, per-patient
cost increased 61%. In addition, these researchers found that adolescents (aged
1017 years) had endometriosis-related hospitalizations and female patients 23 years
of age or younger constituted greater than 20% of endometriosis-related outpatient
visits.3
Department of Obstetrics and Gynecology, Womens and Childrens Hospital, Keck School of
Medicine of the University of Southern California, 1240 North Mission Road, L919, Los Angeles,
CA 90033, USA
doi:10.1016/j.ogc.2008.12.005
178
Templeman
PATHOPHYSIOLOGY HIGHLIGHTS: GENETICS, EPIDEMIOLOGY, INFLAMMATORY
The pathogenesis of endometriosis remains an enigma, and, as a result, no single

theory can explain the development of endometriosis in all patients. Retrograde
menstruation with implantation in the peritoneal cavity was suggested as a possible
cause for endometriosis by Sampson4 some 60 years age and seems to be particularly
important in adolescents with obstructive Mullerian anomalies.5 Retrograde menstruation is found in most women at the time of menstruation; therefore, why some women
develop endometriosis and others do not is a focus of intense interest.
There are specific defects in the endometrium of women who have endometriosis
that include a decrease in endometrial cell apoptosis6 and sensitivity to progesterone,
resulting in increased matrix metalloproteinase activity.7 The effect of these defects is
an increase in the number of cells with invasive capacity that are refluxed through the
fallopian tubes and into the peritoneal cavity. In addition, neoangiogenesis, as the
result of cytokine and vascular endothelial growth factor secretion, may play an important role in the establishment of endometriosis.8 Another focus of research is in the
area of environmental toxins and oxidative stress. In particular, dioxin has been implicated in the pathophysiology of endometriosis.9
Investigation into the genetics of endometriosis is being undertaken at several
centers.10 This focus includes linkage analysis for sibling pairs in which first-degree
relatives of patients who have surgically confirmed endometriosis are evaluated.
These data have demonstrated a 6.9% relative risk for the disease in comparison
with controls.11 In addition, microarray12 and epigenetic evaluation of DNA13 are techniques aimed at determining important genes in pivotal molecular pathways that may
be associated with the development of endometriosis.
The finding of predominantly smooth muscle endometriotic lesions in the rectovaginal septum14 of some women has led to the theory of embryonic Mullerian rests15 as
an cause for endometriosis. This theory is also supported by the finding of endometriosis in the pelvis of premenarcheal girls.16 Still other patients develop endometriosis in
surgical site wounds, such as caesarean section wounds or episiotomy sites. Because
hematogenous and lymphatic spread to a single site is unlikely, this has led to the
unintentional surgical transplantation theory of endometriosis.
Endometriosis lesions themselves seem to have a developmental pathway.
Koninckx and colleagues17 have found that the typical lesions of endometriosis
black and white scarred areas, along with endometriomasseem to increase with
age. This is consistent with other researchers who have found that red flame-like
and atypical clear vesicular lesions are more prominent in younger aged patients.18
It is these findings that have led to the suggestion that endometriosis is a progressive
disease. Sutton and colleagues19 have produced some evidence about the natural
history of endometriosis. In their randomized placebo-controlled trial evaluating the
laparoscopic treatment of endometriosis, these investigators demonstrated that equal
numbers of placebo patients had disease that progressed, regressed, and remained
static at second-look laparoscopy.
Koninckx and colleagues17 also found that the only significant correlate with pain
symptoms was the depth of endometriosis invasion. This would suggest that the
more superficial red and atypical lesions present in adolescents should not be painful.
It has become clear, however, that there are alternative mechanisms for the production of pain in endometriosis and that red lesions, in particular, are extremely active in
the synthesis of prostaglandins,20 which are likely to be important in pain symptomatology. In addition, several other mechanisms may be important in the production
of pain in patients who have endometriosis, and these include cytokine production,
Adolescent Endometriosis
bleeding within the implant itself, and stimulation of neural tissue within the lesion21
and within the endometrium of patients who have endometriosis.22
PRESENTATION AND DIAGNOSIS
Dysmenorrhea in adolescents may be primary or secondary to endometriosis. The

true prevalence of primary dysmenorrhea is difficult to assess because many girls
do not seek medical attention, with one study revealing 98% of adolescents using
nonpharmacologic means to address their symptoms.23 Dysmenorrhea is reported
to have a significant impact on school absenteeism and quality of life in white adolescents, with recent reports confirming a similar pattern among African-American and
Hispanic girls.23
Endometriosis should be considered in girls who do not respond to simple NSAIDS
and OCPs, because two thirds of girls who are investigated with laparoscopy in this
clinical setting have been found to have endometriosis.2
Recent data from the Endometriosis Association suggest that patients who have
symptoms suggestive of endometriosis as an adolescent wait longer to be surgically
diagnosed than those women who are first symptomatic as adults.24 In addition, girls
who saw a physician other than a gynecologist have a longer time to definitive diagnosis.24 Some of this delay may be explained by the diversity of symptoms that
patients who have endometriosis experience, in addition to the fact that laparoscopy
is required for a definitive diagnosis.
A detailed history and physical examination are critical in the assessment of adolescents presenting with pain symptomatology. If appropriate, a pelvic examination for
signs of uterosacral nodularity and levator tenderness may point to the diagnosis of
endometriosis; however, in virginal patients, this examination is likely to be omitted.
External genital inspection with labial traction and rectoabdominal examination should
be considered if there is suspicion of an obstructive anomaly. Abdominal wall assessment for signs of muscle injury and trigger points is helpful because this indicates that
physical therapy is likely to be useful in the management of pain symptoms.25 Imaging
with pelvic ultrasound is useful to exclude the possibility of an endometrioma and to
confirm the presence of a uterine anomaly. Tumor markers, such as Ca125, are
unlikely to be helpful in adolescents because such patients have early-stage disease
and rarely have endometriomas.
MANAGEMENT STRATEGIES
The history and physical examination should help the treating physician develop a firm
idea about the likely cause of the pain symptomatology. Often, what began as pain
secondary to endometriosis has progressed to involve a component of musculoskeletal pain with associated depression and anxiety.26 Therefore, it is important to recognize that for treatment to be effective, the managing physician must seek and address
all these issues, if present.
The treatment algorithms used to manage adolescents are based on research performed in adults. Typically, medical management is used initially, although surgical
intervention may be required if a Mullerian anomaly is suspected or the endometriosis
is of advanced stage. If the adolescent has persistent pain despite intervention with
medical therapy, she should be offered laparoscopy for a definitive diagnosis. Empiric
gonadotropin-releasing hormone (GnRH) agonist therapy has been used in adults with
chronic pelvic pain and a suspected diagnosis of endometriosis. This approach may
be considered in adolescents, with special consideration given to patient age.
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Templeman
In the absence of a clinically useful marker, however, the challenge is in distinguishing which patients may have progressive disease and which patients have disease
that may remain the same or even regress. Clinically, however, the physician is often
confronted with an adolescent in chronic pain; therefore, intervention to relieve symptoms becomes a priority.
Medical Therapy
NSAIDs are often the first-line medication used to treat dysmenorrhea, and many
adolescents have used these at the time of presentation. The American College of
Obstetrics and Gynecology (ACOG) has issued a statement supporting the empiric
use of NSAIDS for dysmenorrhea.27
These drugs act through inhibition of the cyclooxygenase (COX) enzyme pathway,
which is responsible for the production of prostaglandins and leukotrienes. Some
drugs in this family may also act through promotion of prostaglandin E2, a vasodilator.
In placebo-controlled trials, NSAIDS have been found to decrease menstrual loss and
improve primary dysmenorrhea significantly.28 In endometriotic lesions, there is a positive feedback loop between prostaglandins and estrogen production through aromatase production. In addition, COX-2 inhibitors have been found in mouse
endometriosis models to decrease the size and microvessel density within endometriosis lesions.29
Other medical treatments for endometriosis are aimed at suppressing steroid
hormonal production from the hypothalamus or ovary. This results in atrophy of the
endometrial implants, at least while the patient is taking the medication. OCPs are
used empirically to treat primary dysmenorrhea and dysmenorrhea secondary to
endometriosis,30 and despite the paucity of randomized trials demonstrating effectiveness, the ACOG also supports the use of OCPs in this setting.27 Perhaps the major
reason why OCPs are so commonly used as first-line therapy in this age group is their
relatively low incidence of side effects and the ease with which they can be stopped
should the patient wish to change medications. In addition, a trial of OCPs after or
concurrent with NSAIDS is helpful in assessing the likelihood that the adolescent
has endometriosis. Laufer and colleagues2 demonstrated that 67% of adolescents
who had persistent cyclic or noncyclic pain despite OCP use were found to have
endometriosis at the time of laparoscopy.
Progestins have been shown to be effective in reducing pain symptoms in patients
who have endometriosis.31 Possible mechanisms for this include down-regulation of
estrogen receptors and a reduction in matrix metalloproteinases in endometriosis
tissue,32 with the added benefit of amenorrhea, particularly with the depot injections
and medicated intrauterine device (IUD) delivery systems.33 Depot medroxyprogesterone acetate is a monthly injection that has been used in adolescents who have endometriosis as a method of treating pain symptoms, with the added benefit of being an
effective contraceptive. Recently, a subcutaneous monthly formulation has been introduced that has comparable efficacy to the intramuscular injection but has less impact
on bone mineralization.34 Although the medicated IUD is not approved by the US Food
and Drug Administration for the treatment of endometriosis, a Cochrane review suggested that this system does reduce painful periods in women who have had surgery
for endometriosis; however, this review was based on one small study, and these
researchers also comment on the need for further well-designed randomized
controlled trials (RCTs) in this setting.35 Of note, the ACOG, in a technical bulletin,
supports the use of IUDs in the adolescent population.36 Newer drugs available in
experimental protocols in adults include aromatase inhibitors;37 however, there are
no data on the use of these medications in adolescents.
Fig. 1. Protocol for evaluation and treatment of adolescent pelvic pain and endometriosis.
(Modified from Bandera CA, Brown LR, Laufer MR. Adolescents and endometriosis. Clin
Consult Obstet Gynecol 1995;7:206; with permission.).
GnRH agonists have been shown to be effective in reducing pain associated with
endometriosis.38 They are effective by suppressing the hypothalamic pituitary axis,
which results in a hypoestrogenic environment and side effects like hot flushes and
mood changes. Empiric use of GnRH analogues has been advocated for adults with
chronic pain, but they should not be used in adolescents younger than 18 years of
age because of detrimental effects on bone density.27 They may be used in adolescents as young as 16 years of age who have known endometriosis and are refractory
181
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Templeman
to other medical therapies, with some special considerations. These include the use of
add-back therapy, typically norethisterone acetate (5 mg/d), vitamin D, and calcium,
along with appropriate monitoring of bone mineral density by means of age-matched
z scores at least every 2 years.27,39 These measures are aimed at maximizing the
effect of GnRH analogues and minimizing the side effects.
Laparoscopic surgery remains the gold standard for the diagnosis of endometriosis. This is typically performed in adolescents who have pain symptoms refractory to
medical treatment or if there is concern about a Mullerian anomaly. In looking for endometriosis in adolescents at the time of surgery, it is important to be aware that the
disease is most commonly located in the cul-de-sac and is atypical in appearance.40
Two RCTs in adults have established a relation between surgical intervention and
reduction of pain in patients who have endometriosis. Sutton and colleagues19
demonstrated a significant reduction in pain, lasting up to 6 months, in patients who
underwent resection of their disease when compared with those who had diagnostic
laparoscopy alone. Interestingly, these results were poorer for stage I disease than for
stage III disease. Abbott and colleagues41 confirmed these results and included
quality-of-life measures, which were also improved at 6 months of follow-up. Whether
such intervention changes the natural history of the disease or improves future reproductive potential in adolescents is unknown. In terms of long-term follow-up, Abbott
and colleagues42 have shown that the improvement in pain may last up to 5 years
but that the risk for further intervention is higher with younger age and less aggressive
surgical measures. Nerve ablation techniques, including presacral neurectomy and
uterine nerve ablation techniques, have not been studied in the adolescent population.
Pre- and postoperative hormonal suppression generally have not been shown to be
of benefit in terms of decreasing the number of patients with symptom recurrence over
time.43 There is a paucity of randomized trials in this area, however, and further
research is needed. Recently, there has been a report of a significant reduction in endometrioma recurrence at 36 months in patients who take the OCP after surgery
compared with those who do not.44 Further studies, particularly RCTs, are required
to confirm this finding, however. Fig. 1 presents a protocol developed by the ACOG
for the management of chronic pelvic pain and endometriosis in adolescents.27
Complimentary Management
In treating adolescents with endometriosis, it is important to realize than chronic pain

is often multifactorial. Behavioral modification techniques, such as relaxation and
biofeedback, in addition to cognitive therapy aimed at improving coping skills can
be helpful. Physical therapy may also be helpful in patients in whom musculoskeletal
conditions of the abdominal wall and pelvic floor are contributing to their symptoms.45
Wayne and colleagues46 have reported on a small RCT using Japanese acupuncture.
A total of 18 patients were enrolled, and 14 completed the study treatments over 8
weeks. Pain was reduced in the treatment group, but there was no statistically significant difference between the groups after 4 weeks. Larger trials in this area are
needed.
SUMMARY
The natural history of endometriosis remains largely unknown; therefore, it is difficult to

determine whether early intervention in adolescents enhances future fertility or
improves long-term disease outcome. The most immediate issue is a young woman
in pain and a physician who needs to make a diagnosis and manage the symptoms.
Laparoscopy remains the gold standard for establishing the diagnosis, and long-term
control of symptoms in adolescents requires medical management, often in combination with complimentary therapies. Current research focused on the pathophysiology of
endometriosis is likely to add to our understanding of the natural history of the disease,
allowing future studies to better assess therapeutic outcomes in adolescents.
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Health Care 1980;1(1):3741.
2. Laufer MR, Goitein L, Bush M, et al. Prevalence of endometriosis in adolescent
girls with chronic pelvic pain not responding to conventional therapy. J Pediatr
Adolesc Gynecol 1997;10(4):199202.
3. Gao X, Outley J, Botteman M, et al. Economic burden of endometriosis. Fertil
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4. Sampson J. The development of the implantation theory for the origin of peritoneal endometriosis. Am J Obstet Gynecol 1940;40:54957.
5. Sanfilippo JS, Wakim NG, Schikler KN, et al. Endometriosis in association with
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6. Harada T, Kaponis A, Iwabe T, et al. Apoptosis in human endometrium and
endometriosis. Hum Reprod Update 2004;10(1):2938.
7. Osteen KG, Yeaman GR, Bruner-Tran KL. Matrix metalloproteinases and endometriosis. Semin Reprod Med 2003;21(2):15564.
8. Di Carlo C, Bonifacio M, Tommaselli GA, et al. Metalloproteinases, vascular
endothelial growth factor, and angiopoietin 1 and 2 in eutopic and ectopic endometrium. Fertil Steril 2008 Jul 19.
9. Bruner-Tran KL, Yeaman GR, Crispens MA, et al. Dioxin may promote inflammation-related development of endometriosis. Fertil Steril 2008;89(5 Suppl):
128798.
10. Montgomery GW, Nyholt DR, Zhao ZZ, et al. The search for genes contributing to
endometriosis risk. Hum Reprod Update 2008;14(5):44757.
11. Simpson JL, Elias S, Malinak LR, et al. Heritable aspects of endometriosis.
I. Genetic studies. Am J Obstet Gynecol 1980;137(3):32731.
12. Mettler L, Salmassi A, Schollmeyer T, et al. Comparison of c-DNA microarray
analysis of gene expression between eutopic endometrium and ectopic endometrium (endometriosis). J Assist Reprod Genet 2007;24(6):24958.
13. Wu Y, Halverson G, Basir Z, et al. Aberrant methylation at HOXA10 may be
responsible for its aberrant expression in the endometrium of patients with
endometriosis. Am J Obstet Gynecol 2005;193(2):37180.
14. Nisolle M, Donnez J. Peritoneal endometriosis, ovarian endometriosis, and
adenomyotic nodules of the rectovaginal septum are three different entities. Fertil
Steril 1997;68(4):58596.
15. Batt RE, Smith RA. Embryologic theory of histogenesis of endometriosis in
peritoneal pockets. Obstet Gynecol Clin North Am 1989;16(1):1528.
16. Marsh EE, Laufer MR. Endometriosis in premenarcheal girls who do not have an
associated obstructive anomaly. Fertil Steril 2005;83(3):75860.
17. Koninckx PR, Meuleman C, Demeyere S, et al. Suggestive evidence that pelvic
endometriosis is a progressive disease, whereas deeply infiltrating endometriosis
is associated with pelvic pain. Fertil Steril 1991;55(4):75965.
18. Davis GD, Thillet E, Lindemann J. Clinical characteristics of adolescent
endometriosis. J Adolesc Health 1993;14(5):3628.
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19. Sutton CJ, Ewen SP, Whitelaw N, et al. Prospective, randomized, double-blind,
controlled trial of laser laparoscopy in the treatment of pelvic pain associated
with minimal, mild, and moderate endometriosis. Fertil Steril 1994;62(4):696700.
20. Wu MH, Shoji Y, Chuang PC, et al. Endometriosis: disease pathophysiology and
the role of prostaglandins. Expert Rev Mol Med 2007;9(2):120.
21. Tokushige N, Markham R, Russell P, et al. Nerve fibres in peritoneal endometriosis. Hum Reprod 2006;21(11):30017.
22. Tokushige N, Markham R, Russell P, et al. Different types of small nerve fibers in
eutopic endometrium and myometrium in women with endometriosis. Fertil Steril
2007;88(4):795803.
23. Harel Z. Dysmenorrhea in adolescents and young adults: etiology and management. J Pediatr Adolesc Gynecol 2006;19(6):36371.
24. Greene R, Stratton P, Cleary SD, et al. Diagnostic experience among 4,334
women reporting surgically diagnosed endometriosis. Fertil Steril 2008 Mar 24.
25. Schroeder B, Sanfilippo JS, Hertweck SP. Musculoskeletal pelvic pain in a pediatric and adolescent gynecology practice. J Pediatr Adolesc Gynecol 2000;
13(2):90.
26. Sinaii N, Cleary SD, Younes N, et al. Treatment utilization for endometriosis symptoms: a cross-sectional survey study of lifetime experience. Fertil Steril 2007;
87(6):127786.
27. ACOG Committee Opinion No. 310, April 2005. Endometriosis in adolescents.
Obstet Gynecol 2005;105(4):9217.
28. Roy SN, Bhattacharya S. Benefits and risks of pharmacological agents used for
the treatment of menorrhagia. Drug Saf 2004;27(2):7590.
29. Ozawa Y, Murakami T, Tamura M, et al. A selective cyclooxygenase-2 inhibitor
suppresses the growth of endometriosis xenografts via antiangiogenic activity in
severe combined immunodeficiency mice. Fertil Steril 2006;86(4 Suppl):114651.
30. Davis L, Kennedy SS, Moore J, et al. Modern combined oral contraceptives for
pain associated with endometriosis. Cochrane Database Syst Rev 2007;(3):
CD001019.
31. Prentice A, Deary AJ, Bland E. Progestagens and anti-progestagens for pain
associated with endometriosis. Cochrane Database Syst Rev 2000;(2):
CD002122.
32. Rodgers AK, Falcone T. Treatment strategies for endometriosis. Expert Opin
Pharmacother 2008;9(2):24355.
33. Vercellini P, Frontino G, De Giorgi O, et al. Comparison of a levonorgestrelreleasing intrauterine device versus expectant management after conservative
surgery for symptomatic endometriosis: a pilot study. Fertil Steril 2003;80(2):3059.
34. Schlaff WD, Carson SA, Luciano A, et al. Subcutaneous injection of depot
medroxyprogesterone acetate compared with leuprolide acetate in the treatment
of endometriosis-associated pain. Fertil Steril 2006;85(2):31425.
35. Abou-Setta AM, Al-Inany HG, Farquhar CM. Levonorgestrel-releasing intrauterine
device (LNG-IUD) for symptomatic endometriosis following surgery. Cochrane
Database Syst Rev 2006;(4):CD005072.
36. ACOG Committee Opinion No. 392, December 2007. Intrauterine device and
adolescents. Obstet Gynecol 2007;110(6):14935.
37. ACOG Committee Opinion. Aromatase inhibitors in gynecologic practice. Obstet
Gynecol 2008;112(2 Pt 1):4057.
38. Dlugi AM, Miller JD, Knittle J. Lupron depot (leuprolide acetate for depot suspension) in the treatment of endometriosis: a randomized, placebo-controlled,
double-blind study. Lupron Study Group. Fertil Steril 1990;54(3):41927.
39. Laufer MR. Current approaches to optimizing the treatment of endometriosis in

adolescents. Gynecol Obstet Invest 2008;66(Suppl 1):1927.
40. Laufer MR. Identification of clear vesicular lesions of atypical endometriosis:
a new technique. Fertil Steril 1997;68(4):73940.
41. Abbott J, Hawe J, Hunter D, et al. Laparoscopic excision of endometriosis:
a randomized, placebo-controlled trial. Fertil Steril 2004;82(4):87884.
42. Abbott JA, Hawe J, Clayton RD, et al. The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 25 year follow-up.
Hum Reprod 2003;18(9):19227.
43. Yap C, Furness S, Farquhar C. Pre and post operative medical therapy for
endometriosis surgery. Cochrane Database Syst Rev 2004;(3):CD003678.
44. Vercellini P, Somigliana E, Daguati R, et al. Postoperative oral contraceptive
exposure and risk of endometrioma recurrence. Am J Obstet Gynecol 2008;
198(5):504 e1e5.
45. Greco CD. Management of adolescent chronic pelvic pain from endometriosis:
a pain center perspective. J Pediatr Adolesc Gynecol 2003;16(3 Suppl):S179.
46. Wayne PM, Kerr CE, Schnyer RN, et al. Japanese-style acupuncture for endometriosis-related pelvic pain in adolescents and young women: results of a randomized sham-controlled trial. J Pediatr Adolesc Gynecol 2008;21(5):24757.
185
The Epidemiolo gy
of Anal Huma n
Papillomavirus a nd
Relate d Ne oplasia
Joel M. Palefsky, MDa,b,c,*, Mary Rubin, PhD, NPb,d
KEYWORDS
Anal cytology Human papillomavirus (HPV)
High resolution anoscopy (HRA) Geriatric Management
The relationship between cervical cancer and human papillomavirus (HPV) is well
known. Cervical cancer remains one of the most common cancers among women
worldwide, resulting in approximately 275,000 deaths per year globally.1 In developed
countries the incidence of cervical cancer has been reduced through screening for the
cervical cancer precursor, high-grade cervical intraepithelial neoplasia (CIN), and
removal of the lesion before it progresses to cancer. The advent of an effective vaccine
against HPV 16 and HPV 18, which together account for approximately 70% of
cervical cancers, offers another new approach to reducing the incidence of cervical
cancer.
In addition to cervical cancer, several other cancers are known to be associated
with HPV, and the HPV vaccine has focused new attention on the role that HPV vaccination may play in their prevention. These include cancers of the penis, oropharynx,
vulva, vagina, and anus.2 Among these, cancers of the oropharynx3 and anus stand
out for their increasing incidence.4 Both of these cancers occur among men and
women. Unlike oral cancer, anal cancer in the general population is more common
This work was supported by the National Cancer Institute (R01 CA 88739 and R01 CA 085178),
NIH/NCRR UCSF-CTSI Grant Number UL1 RR02413,1 and the American Cancer Society (Grant
SPRSG-03-242-01).
This article was originally planned to appear in the December 2008 issue of Obstetrics and
Gynecology Clinics of North America.
a
Division of Infectious Disease, Department of Medicine, University of California, Box 0126,
Room M1203, San Francisco, CA 94143, USA
b
Anal Neoplasia Clinic, University of California Helen Diller Family Comprehensive Cancer
Center, San Francisco, CA, USA
c
Clinical and Translational Research School of Medicine, CA, USA
d
School of Nursing, University of California, San Francisco, CA, USA
* Corresponding author. Division of Infectious disease, Department of Medicine, University of
California, Box 0126, Room M1203, San Francisco, CA 94143.
E-mail address: [email protected] (J. M. Palefsky).
doi:10.1016/j.ogc.2009.02.003
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Palefsky & Rubin
among women than among men. However, the epidemiology of anal cancer is particularly distinctive in that the risk is particularly high in certain risk groups, including
those with HIV-related and transplant-related immunosuppression. Like cervical
cancer, anal cancer is preceded by a series of precancerous changes, ie, anal intraepithelial neoplasia, raising the possibility that like cervical cancer, anal can be prevented. Further, given the known risk factors for anal cancer, prevention efforts
could be targeted to high-risk groups, providing a unique example of a screening
program targeted to high-risk individuals. This article describes the epidemiology of
anal HPV infection, anal intraepithelial neoplasia (AIN), and anal cancer among men
and women, as well as current efforts to prevent anal cancers.
EPIDEMIOLOGY OF ANAL CANCER
The incidence of anal cancer in the population continues to grow.4 In contrast, the incidence of cervical cancer has steadily declined over the past 40 years. According to
data from the American Cancer Society, an estimated 5070 new cases will occur in
2008, including 3050 women and 2020 men, and 690 persons will die of anal cancer.5
This is in comparison to 11,070 new cases of cervical cancer with 3870 deaths estimated to occur in 2008.
The incidence of anal cancer is relatively uncommon in the general population.
Between 1973 and 1979, rates of anal cancer were lower for men than for women
(1.06 per 100,000 compared with 1.39 per 100,000). However, between 1994 and
2000 rates were similar for men and women (2.04 per 100,000 and 2.06 per 100,000
respectively) and increased for both genders.6
Risk factors for anal cancer include a history of smoking, history of condyloma (reflecting exposure to HPV), and history of anal intercourse, reflecting acquisition of HPV
in the anal canal.7,8 Given these risk factors, it is not surprising that a history of having
sex with men is an important risk factor for anal cancer among men.7,9 Before the AIDS
epidemic in 1982, the incidence of anal cancer among men who have sex with men
(MSM) was estimated to be between 12.5 and 36.9 per 100,000, a figure that is nearly
as high as the incidence of cervical cancer in the general population of women before
the introduction of cervical cytology screening.
The onset of the HIV epidemic heralded two successive eras of increased risk of
anal cancer among MSM. The first corresponds to the years before the advent of
highly active antiretroviral (ART) therapy for HIV when HIV-positive men and women
were immunosuppressed and usually died of an HIV-related complication. Despite
their relatively short lifespan after onset of HIV-related immunosuppression, the incidence of anal cancer among HIV-positive MSM was estimated to be double that of
HIV-negative MSM.1012 One study matching cancer databases to AIDS databases,
the relative risk of developing anal cancer among HIV-positive men with a history of
homosexual contact was 59.5.13 In that same report, the relative risk for anal cancer
was 6.8 (2.714.0) in HIV-positive women compared with the general population of
women.
In the general population of San Francisco, the incidence of anal cancer increased in
men aged 40 to 64 from 3.7 in 1973 to 1978 to 20.6 per 100,000 in 1996 to 1999.14
These data likely reflecting the large proportion of MSM and the large number of
HIV-positive men living in San Francisco, because similar increases were not demonstrated in any other counties in California.
The second era corresponds to the widespread availability of ART, with increased
lifespan among HIV-positive men and women. Although one study did not show an
increase in the incidence of anal cancer in the post-ART era among HIV-positive
The Epidemiology of Anal Human Papillomavirus
MSM,15 three recent studies did show an increase, with an annual incidence rate of
75/100,000 137/100,000, and 78/100,00 respectively.13,16,17 These numbers may
reflect the presence of a longer lifespan among at-risk individuals, allowing anal
cancer precursors more time to progress to cancer in the absence of systematic
programs to screen and treat these lesions.
Other groups at increased risk include patients who are chronically immunosuppressed because of causes other than HIV, including taking medications to treat autoimmune disorders and other illnesses, as well as organ transplant recipients.1820
Women with a history of vulvar cancer, high-grade vulvar intraepithelial neoplasia,21
and cervical cancer22 are also at increased risk, presumably because of increased risk
of exposure to HPV in the anal region.
EPIDEMIOLOGY OF ANAL HUMAN PAPILLOMAVIRUS INFECTION
There is biologic similarity between the cervix and the anus with respect to the
preferred location of HPV infection; the transformation zone of the cervix is the target
area for HPV where there is transition between two types of epithelium. In the cervix
this is where the squamous epithelium on the exocervix meets the columnar epithelium on the endocervical canal. In the anus, this is where the squamous epithelium
of the anus meets the columnar epithelium of the rectum.
In contrast to the age-related prevalence of cervical HPV infection in women, which
declines after the age of 30 years,23 anal HPV in HIV-negative MSM remains high (50%
to 60%) and is constant throughout life.24 Although this may reflect differences
between the biology of the anal canal and the cervix, it more likely is a result of the
acquisition of new HPV types from a higher number of new sexual partners over
time among MSM compared with women. Among HIV-positive men, anal HPV infection is nearly universal.25,26 The primary risk factors for anal HPV infection are lower
CD41 level, and among HIV-negative men risk factors included history of receptive
anal intercourse and higher number of sexual partners.24
A somewhat surprising finding in recent years is that in some populations of women,
the prevalence of anal HPV is actually higher than the prevalence of cervical HPV infection. This was shown in the Womens Interagency HIV Study among HIV-positive women
and women at high risk of HIV infection, as well as other similar populations.2729
Anal HPV infection was also found to be as common as cervical HPV infection in a population of healthy Hawaiian women.30 Overall, the distribution of HPV types in the anal
canal is similar to that of the cervix, but individual women do not necessarily have
concurrent infection with same HPV types. Risk factors among women include HIV
positivity, lower CD41 level, cervical HPV infection, and younger age.28 Together
these data indicate that anal HPV infection is more common than has been appreciated in the past. The clinical consequences of anal HPV infection in women include
the development of anal cancer and potentially spread of HPV to the cervix. It is
also clear that the anus must be less biologically susceptible to cancer development
than the cervix since the incidence of anal cancer per anal HPV infection is likely lower
than that of cervical cancer per cervical HPV infection.
EPIDEMIOLOGY OF ANAL INTRAEPITHELIAL NEOPLASIA
The histopathologic classification of AIN 1, 2, and 3 corresponds to CIN 1, 2, and 3.

Well-understood cervical cytology and histology classifications are also used for
anal disease, although in the anus, squamous intraepithelial lesions (SIL) are often
called anal intraepithelial neoplasia (AIN) grades I, II, and III. Low-grade AIN includes
AIN 1 and condyloma whereas high-grade AIN includes AIN 2 and AIN 3. Although
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there are no large population-based studies showing direct progression of an AIN 23

lesion to anal cancer, several studies of smaller groups of patients demonstrate the
oncogenic potential of AIN 23.3133 Among HIV-negative MSM, the age-related prevalence of abnormal cytology mirrors that of anal HPV infection in that the age-related
prevalence is flat between the ages of 25 and 60 years. In one study, 18% to 23% of
MSM had AIN on anal cytology after the age of 20 with 5% to 10% having AIN 23.
These numbers underestimate the true prevalence of AIN because, like cervical
cytology, anal cytology is relatively insensitive.34
The prevalence of AIN is higher among HIV-positive MSM than among HIV-negative
MSM.35,36 In one study performed after the introduction of ART, the prevalence of
high-grade AIN was over 50% among HIV-positive MSM.35 Additionally, the incidence
of AIN 23 is higher among HIV-positive MSM compared with HIV-negative MSM.37,38
Data have now been accumulating regarding the effect of ART on the natural history
of AIN, and the evidence to date suggests that there is limited or no benefit for reduction of high-grade disease and cancer. In studies examining CIN, ART seems to have
little or no effect on regression of CIN 23.39 None of the studies show that HPV is
eradicated from the cervix; there is neither a regression nor a lower incidence of
high-grade AIN.23
There are relatively few data on the prevalence and incidence of AIN in women. In
one of the earliest studies, abnormal anal cytology was found in 26% of HIV-positive
women and 8% of high-risk HIV-negative women.26 Risk factors among HIV-positive
women included anal intercourse and abnormal cervical cytology, consistent with the
relationship between anal and cervical HPV infection. In a more recent, larger study,
AIN was found in 21% of HIV-positive women and 6% of high-risk HIV-negative
women.40 Among HIV-infected women, risk factors for AIN 1/condyloma were
younger age, history of receptive anal intercourse, anal HPV, and cervical HPV infection. In multivariable analyses among HIV-infected women, the only significant risk
factor for AIN 23 was anal HPV infection. The same HPV types associated with
high grade disease in the cervix are found in association with high-grade AIN, with
HPV 16 responsible for most high-grade AIN as well as anal cancer.41
SCREENING FOR ANAL INTRAEPITHELIAL NEOPLASIA AND ANAL CANCER
It is clear that patients who are HIV-positive and other immunosuppressed individuals
are at increased risk to develop anal cancer, as are MSM and HIV-negative women
with a history of anal intercourse and/or other HPV-related anogenital malignancies.
Given the high prevalence and incidence of anal HPV infection and high-grade AIN
in these populations, as well as the demonstrated potential of high-grade AIN (HGAIN) to progress to anal cancer, the authors and others have suggested that these
groups be considered for screening to identify and treat HG-AIN. United States Public
Health Service and Infectious Disease Society of America guidelines have not recommended routine screening because studies to demonstrate that treatment of highgrade AIN prevents cancer have not yet been done. Instead, they cite expert opinion
to indicate that some experts in the field believe that screening may be warranted.42
Other professional societies, such as the New York State Department of Public Health
recommend routine anal cytology screening for HIV-positive men and women (http://
www.hivguidelines.org/GuideLine.aspx?PageID5257&GuideLineID522#V.%20ANAL
%20DYSPLASIA%20AND%20CANCER).43
Before establishing an anal cytology screening program, the authors recommend
that each of the following components be in place: (1) clinicians trained to perform
anal cytology; (2) clinicians trained to perform high-resolution anoscopy (HRA) and
HRA-guided anal biopsy; (3) pathologists trained to interpret anal cytology and
pathology; (4) clinicians trained to treat AIN in the office; and (5) anal surgeons trained
to treat AIN in the operating room and complications of anal diagnostic and treatment
procedures. Anal cytology screening has been shown to be cost effective among both
HIV-positive and HIV-negative MSM; studies have not yet been done in women or
other risk groups.44,45
It is also important to understand the role of digital rectal examinations (DRE). DRE is
a test that clinicians, even those without any special training, should consider for all atrisk patients, at least annually. The purpose of DRE is to feel for masses consistent
with cancer, and DRE is thus considered to be an anal cancer screening test.
Conversely, anal cytology and HRA-guided biopsy are primarily aimed at detecting
AIN, and are thus focused instead on prevention of anal cancer; the latter should be
performed only by trained clinicians. The authors therefore recommend that people
at increased risk of anal cancer have regular and careful DRE, and, in settings where
the infrastructure described above is in place, anal cytology screening and HRA.
Patients with any symptoms or abnormalities suspicious for cancer, including otherwise unexplained anal pain or bleeding, rapid growth of a lesion, and inguinal adenopathy, should be referred to clinicians experienced in managing anorectal problems for
assessment and biopsy.
The anus is composed of squamous epithelium. The rectum or colon is columnar
epithelium. The anal canal is mucosa lined and the anal margin is epidermal. The proximal end of the anal canal begins at the junction of the levator ani muscle and external
anal sphincter and extends to the anal verge. It is 2 to 4 cm in length, and is shorter in
women compared with men. The dentate line is approximately equivalent to the original squamocolumnar junction (SCJ) in colposcopic terminology and is considered to
be a fixed anatomic zone, whereas the anal transformation zone (AnTZ) is dynamic
and undergoing squamous metaplasia. The AnTZ is the current SCJ. The anal margin
begins at the verge and represents the transition from mucosal to epidermal epithelium and extends to the perianal skin. By consensus, perianal skin is considered to
extend approximately 5 cm from the anal margin. Areas for screening include the
SCJ, AnTZ, anal canal, verge, margin, and perianal skin. Thorough evaluation with
HRA for warts and perianal intraepithelial neoplasia is also recommended.
Screening procedures used for the cervix, including cytology and colposcopy, have
been modified for screening of AIN. Sensitivity and specificity of anal cytology are
similar to cervical cytology and liquid-based cytology has been shown to improve
quality of samples.46 Colposcopy of the anal canal is called HRA. Colposcopy techniques, including use of Lugols solution, and terminology have been validated for
anal canal disease.47
ANAL SCREENING ALGORITHMS
Different screening algorithms may be used. The one used at the University of California San Francisco Anal Neoplasia Clinic is shown in Fig. 1. In settings where there is
a sufficient number of trained anoscopists, high-risk patients could be considered for
direct referral to HRA instead of undergoing anal cytology screening, given their very
high risk of AIN. Although there are still a limited number of centers with trained individuals who perform HRA, it is becoming more routine in many areas of the country for
those high-risk individuals with abnormal anal cytology to undergo HRA. Some
primary care clinicians who care for immunocompromised patients refer patients
with a history of genital warts, irrespective of abnormal cytology.
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Palefsky & Rubin
Anal cytology screening and triage
ASC-US
ASC-H
Normal
Repeat 6 months (HIV+)

Repeat 12 months (HIV-)
Repeat HRA for HSIL

Repeat HRA 4-6 months
for
LSIL/ASC-H
Repeat HRA 6 months for
ASCUS
LSIL
HSIL
Cancer
High resolution anoscopy
Normal
No lesions seen or
ASC-US
LGAIN
AIN I
Follow or
treat if
symptomatic
Surgical consult
HGAIN
AIN II or III
Cancer:
Suspicious/
Suggestive of
cancer
Treat
ASC-US, atypical squamous cells of undetermined significance

ASC-H, atypical squamous cells cannot rule out high-grade lesion
LSIL, low-grade squamous intraepithelial lesion
HSIL, high-grade squamous intraepithelial lesion
LGAIN, low-grade anal intraepithelial neoplasia
HGAIN, high-grade anal intraepithelial neoplasia
HRA, high resolution anoscopy
Fig. 1. Algorithm for anal cytology and high-resolution anoscopy.
The role of HPV testing is not yet clear; given the high prevalence of anal HPV infection in high-risk populations, it is unlikely that anal HPV testing will add significant positive predictive value when used alone or in conjunction with cervical cytology. It is
possible that anal HPV testing might provide negative predictive value if the HPV
test is negative, and in low-risk populations, it is possible that a positive anal HPV
test might provide useful positive predictive value. Further research is needed in
each of these areas.
PERFORMING ANAL CYTOLOGY
These features of the anal canal lend themselves well to securing an anal cytology
specimen. The steps to securing an adequate sample are as follows:
1. The anal cytology specimen should be performed before any other procedures to
provide the highest yield of cells.
2. There must be no lubrication before obtaining a cytology sample because the lubricant may interfere with the processing and interpretation of the sample.
3. Gently separate the buttocks; the patient can hold their right cheek to facilitate view.
4. Insert a moistened Dacron swab as far into the anus as possible, approximately 3 to
4 cm, to ensure sampling of cells from the AnTZ. The swab should be inserted until
it reaches the wall of the rectum. If initial resistance is encountered, change position
of swab and re-insert.
5. Remove swab in a circular motion to sample cells from all aspects of the anal canal.
Apply pressure so that the swab bends while slowly removing it. Count slowly to 10
as you remove it.
6. Preserve quickly on slides or in liquid medium. Fewer cells exfoliate from the anal
canal than the cervix and it is easier to get air-dried artifacts.
PERFORMING A HIGH-RESOLUTION ANOSCOPY
1. Obtain relevant history including current anal symptoms such as pruritis, bleeding,
and pain. Determine prior history of anal or perianal condyloma and whether treatments were surgical or office-based. Determine prior history of any anal abnormalities such as fissures, fistula, abscesses, or hemorrhoids requiring
intervention. Determine any prior treatments that may have caused scarring or
other alterations in the normal anal mucosa such as abscess lancing, fistula
repairs, or hemorrhoidectomies.
2. Consent patient with explanation of procedures to be performed.
3. Assist the patient into one of the following positions:
Left Lateral
Lithotomy can be used if also performing cervical examination but most women
prefer to switch to left lateral for the HRA
Prone (if overhead colposcope is available)
In the left lateral and prone positions, patients should be as close to the bottom
edge of the table as possible to facilitate focusing the colposcope.
4. Be clear and consistent in describing location of lesions and the position used.
The anal clock is different than the gynecologic clock. The coccyx is 12:00,
regardless of the position used to examine the patient. When referring patients
for follow-up to anal surgeons it is helpful to use anatomic descriptors (posterior,
anterior, left or right lateral) in place of or in addition to the clock positions.
5. Obtain cytology specimen if needed (new patients or those referred with abnormal
cytology specimens >3 months old).
6. Lubricate the anal canal with KY jelly mixed with 1% to 5% lidocaine.
7. Perform DRE: palpate for warts, masses, ulcerations, fissures, and focal areas of
discomfort or pain. The presence of hard and fixed lesions should increase the
index of suspicion for cancer because these are not the usual presentation of
hemorrhoids and warts.
8. Insert anoscope, remove obturator, and insert Q-tip wrapped in gauze, which has
been soaked in 3% acetic acid. Remove anoscope leaving the Q-tip wrapped
gauze pad inside. Soak for 1 to 2 minutes.
9. Remove gauze and re-insert anoscope.
10. Observe through colposcope while slowly removing the anoscope until the anal
transformation zone (AnTZ) comes into focus.
11. Continue to apply acetic acid with scopettes or Q-tips during the examination.
Using Q-tips to manipulate folds, hemorrhoids, or prolapsing mucosa as well as adjusting the anoscope will help to view all aspects of the AnTZ. In most cases, the
entire AnTZ should be seen and the examination will be considered satisfactory.
Continue withdrawing the anoscope until the entire canal has been observed.
12. Biopsies
Biopsies are directed at areas thought to represent the highest grade of
abnormality.
Anal biopsies should be smaller than those typically taken of the cervix using
forceps no larger than 2 to 3 mm.
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Fig. 2. Normal squamocolumnar junction (arrows A and B); columnar epithelium of the
colon (arrow C); squamous epithelium of the anus (arrow D); no lesions seen.
Internal biopsies do not require anesthesia. External biopsies require injecting

a small amount of 1% lidocaine with epinephrine buffered with sodium bicarbonate (2 mL NaHC03: 10 mL lidocaine) similar to biopsies of the vulva. The injection can be preceded by numbing topically with lidocaine gel or spray.
Monsels solution or silver nitrate is used for hemostasis, although the pressure of
the anal walls will generally stop bleeding for internal biopsies.
HRA can reveal the wide range of cellular and vascular changes associated with
cytologic abnormality. Figs. 2 to 10 demonstrate changes from normal to cancer.
TREATMENT MODALITIES
Once AIN has been diagnosed with HRA and biopsy, treatment planning begins. With
low-grade AIN the choices range from follow-up without treatment at 6-month intervals to chemical treatment of warts and flat lesions with bichloroacetic acid or trichloroacetic acid (TCA). This is effective for small lesions, typically limited in
number but requires multiple applications. External condyloma may also be treated
with imiquimod, podophyllotoxin, and 15% sinecatechins ointment (green tea extract).
Fig. 3. Low-grade AIN with acetowhite epithelium from 6 oclock to 9 oclock at the
squamocolumnar.
Fig. 4. LGAIN with areas of partial Lugols staining (arrow A) or no staining (arrows B and C);
Lugols staining consistent with normal anal tissue (arrow D).
Fig. 5. Focal warty lesions (arrows A and B) at the squamocolumnar junction.
Fig. 6. Warty lesions 360 degrees obscuring the squamocolumnar junction.
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Fig. 7. Large high-grade AIN lesion acetowhite epithelium (arrows A and B), punctation
(arrow C).
Fig. 8. Early invasion: nodular lesion with acetowhite epithelium background (arrow A),
coarse punctation (arrow B), and atypical vessels (arrow C).
Fig. 9. Peri-anal warts.
Fig. 10. Peri-anal high-grade anal intraepithelial neoplasia: partially denuded epithelium
(arrow A), acetowhite epithelium (arrow B), and hyperpigmented epithelium (arrow C).
None of these products are approved for intra-anal use. Cryotherapy is used primarily
for external disease and like TCA often requires more than one treatment.
Infrared coagulation (IRC) can be used for intra-anal or peri-anal low-grade AIN or
high-grade AIN. Symptoms and extent of the disease help to dictate which treatment
might be most appropriate and effective. Recent studies show that about two thirds of
HIV-positive patients with high-grade AIN can be successfully treated after 1 year of
follow-up.29,48 Electrocautery and laser therapy are also options for intra-anal disease.
Surgery is reserved for patients undergoing examination under anesthesia where
biopsies to rule out cancer are not possible in the office, and to treat extensive AIN.
Recent surgical data show improved outcomes compared with earlier surgical
experience.49
SUMMARY
With the advent of the HPV vaccine, increased attention is being paid to cancers associated with HPV in addition to cervical cancer. Because of its strong association with
HPV 16, the vaccines currently approved for use to prevent cervical cancer may well
prevent anal cancer as well; however, results from studies to determine their efficacy
to prevent anal HPV infection and AIN are not yet available. Further, if these vaccines
do work to prevent anal HPV infection and disease, it will be necessary to reexamine
vaccination strategies, because vaccination of boys will be necessary to prevent
spread of HPV among high-risk groups such as MSM.
Regardless of whether these vaccines prevent anal HPV infection and AIN, they are
designed to be preventative and will likely not help individuals who already have anal
HPV infection and AIN owing to HPV types in the vaccine. For these individuals,
screening and treatment of high-grade AIN may be the only way to prevent development of anal cancer, but studies to demonstrate the efficacy of this approach have not
yet been done. A critical question is how to best care for at-risk men and women until
all of the study results are available. The approach of the authors is to screen and treat
high-risk individuals with high-grade AIN until those results are available, based on the
assumption that the cervical model of prevention is valid. However, there is divergence of opinion on the best approach at this time and not all centers have the infrastructure to screen and treat appropriately; in these settings, at a minimum, clinicians
should be vigilant for anal cancer and perform routine visual inspection and DRE. This
is especially true for clinicians caring for men and women immunosuppressed
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because of HIV or other causes; men who have sex with men; and women with
a history of cervical or vulvar cancer.
ACKNOWLEDGMENTS
The authors gratefully acknowledge the support and contributions from Dr. J.
Michael Berry and Dr. Naomi Jay.
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Pediatric and Adolescent Gynecology

William F. Rayburn, MD, MBA

This issue pertaining to Pediatric and Adolescent Gynecology (PAG), edited by

Obstet Gynecol Clin N Am 36 (2009) xiiixiv

Committee on Adolescent Health Care. The risks of exposure to violence, substance

Pediatric and Adolescent Gynecology

Pediatric and adolescent gynecology (PAG) is a unique subspecialty of gynecology

Obstet Gynecol Clin N Am 36 (2009) xvxvi

Most cases of dysmenorrhea in adolescents represent primary dysmenorrhea; that is,

A 12-year-old complained of predominantly right-sided dysmenorrhea beginning with

A Photo Album of Pediatric, Adolescent Gynecology

Fig. 4. (Case 2) Evacuation of clotted hematocolpos from obstructed right-sided hemivagina.

Fig. 5. (Case 2) Septum (S) excision in progress.

A Photo Album of Pediatric, Adolescent Gynecology

Fig. 8. (Case 4) Open myomectomy in 15-year-old girl. L, leiomyoma; U, uterus.

Fig. 9. (Case 4) Leiomyoma after removal.

A Photo Album of Pediatric, Adolescent Gynecology

Fig. 10. Abdomen distended by ovarian dermoid in an adolescent.

Case 5: Benign Dermoid (Teratoma) (Figs. 1114)

Fig. 12. (Case 5) Ovarian cystectomy salvaging ovarian cortex in progress.

A Photo Album of Pediatric, Adolescent Gynecology

Case 6: Massive Ovarian Edema (Fig. 15)

A Photo Album of Pediatric, Adolescent Gynecology

Case 9: Psoriasis of the Vulva (Fig. 19)

A Photo Album of Pediatric, Adolescent Gynecology

In recent years a nonspecific, nonsexually transmitted condition referred to as vulvar

Case 11: Vulvar Varicella (Fig. 21)

Fig. 22. (Case 12) Crohns ulcer/fistula.

A Photo Album of Pediatric, Adolescent Gynecology

Case 13: Imperforate Hymen (Figs. 2325)

Unfortunately, an 16-year-old female who had factitious disorder and self-harm

A Photo Album of Pediatric, Adolescent Gynecology

a complete mid-vaginal colpoclesis similar to that performed in patients who have

A 16-year-old presented with primary amenorrhea. She gave no history to suggest an

Fig. 27. (Case 15) Full Tanner V breast development.

Blind pouch or absent

Gonads (gonadectomy) Testes Leydig cell replete

Egg retrieval with surrogate

A Photo Album of Pediatric, Adolescent Gynecology

A Photo Album of Pediatric, Adolescent Gynecology

A Photo Album of Pediatric, Adolescent Gynecology

72. Galani A, Kitsiou-Tzeli S, Sofokleous C, et al. Androgen insensitivity syndrome:

DISORDERS OF SEX DEVELOPMENT CLASSIFICATION AND ETIOLOGIES

Disorders of sex development may result from a heterogeneous group of etiologies.

Disorders of Sexual Development

Congenital adrenal hyperplasia

Pure gonadal dysgenesis (XY)

45XO Turner Syndrome

of genital ambiguity such as a reduction in penile size, absence of a phallus, scrotal

with ambiguous genitalia (ie, X-linked conditions such as androgen insensitivity

Disorders of Sexual Development

Rule out CAH (17 OH progesterone)

Fig. 2. Algorithm of investigations for disorders of sexual development.

Disorders of Sexual Development

Typical Gender Assignment

Female (advanced Prader stages, late diagnosis consideration

Disorders of Sexual Development

treatment to adolescence or adulthood is logical when decisions may be made by the

Disorders of Sexual Development

PAIS (with female gender assignment)