NASPAG Annual Meeting 2011

CHICAGO – Less than 40% of female college students and just 20% of their male counterparts responded correctly when asked to label the vagina on an anatomical diagram.

This startling finding, taken from a brief survey conducted among 236 students at a Midwestern university, highlights the general lack of gynecologic knowledge among today’s college students, according to lead author Dr. Jill S. Huppert.

"Although they report a high level of sexual activity, they have a significant knowledge deficit," she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "Addressing this gap in knowledge might be an important strategy in improving the sexual and reproductive health of many young women and men."

The 40-item survey was distributed to six health, physical education, and recreation classes; it was completed by 138 women and 98 men. A knowledge score was generated by totaling correct responses to nine items on menstruation, Pap smear, sexually transmitted diseases (STDs), and pregnancy, and using a word bank to correctly label 11 spots on a diagram of the female anatomy. The anatomy score ranged from 0 to 11, and the total knowledge score ranged from 0 to 20, and included the nine knowledge items plus the anatomy score.

The median age of the respondents was 20 years (range, 18-36 years), and 84% reported prior vaginal intercourse, Dr. Huppert noted. Men were significantly more likely to report having more than one lifetime sexual partner (61% vs. 39%), and less likely to have prior STD testing (30% vs. 43%). Notably, 10% of respondents had a parent who was a physician, and one-third of those were ob.gyns.

In general, women did better at identifying their own anatomy than men. The mean anatomy knowledge score was 7.2 for women vs. 4.5 for men, which was significantly different, said Dr. Huppert of Cincinnati Children’s Hospital Medical Center. The ovary was correctly identified by both sexes the most frequently and the vagina the least often. Just about 70% of women and less than 60% of men could find the clitoris. Scores were low overall, with only 53% of women and 29% of men correctly identifying more than 80% of the anatomical structures on the diagram.

With regard to general knowledge, half of the men and women knew that a Pap smear detects cancer, 60% knew that menarche usually occurs at age 12 years, and 73% understood that 25% of women aged 18-24 years were infected with an STD, she said. A majority, or 94%, of both sexes knew that pregnancy delays periods, while 68% knew that depot medroxyprogesterone acetate (Depo-Provera) can do likewise.

There were significant differences between the sexes, with 24% of men recognizing that the risk of pregnancy with unprotected sex for a year is at least 75%, compared with just 13% of women, Dr. Huppert said. Women, however, were significantly more likely than men to know that menstrual periods can be delayed by stress (94% vs. 76%), losing weight/anorexia (91% vs. 66%), or high levels of exercise (80% vs. 46%).

The mean total knowledge score was significantly lower at 10 for men vs. 13.4 for women. In regression analysis, scores were not influenced by sexual experience or STD testing, Dr. Huppert said.

When the researchers looked at the influence of parents, there was a trend for higher anatomy scores among both sexes if a parent was an ob.gyn. Total knowledge scores also trended higher among women if a parent was an ob.gyn., and were significantly higher among men if their mother or father was an ob.gyn. at 15.7, vs. 9.9 if a parent was not an ob.gyn., she said.

Dr. Huppert and her associates reported no relevant financial disclosures.

CHICAGO – Less than 40% of female college students and just 20% of their male counterparts responded correctly when asked to label the vagina on an anatomical diagram.

This startling finding, taken from a brief survey conducted among 236 students at a Midwestern university, highlights the general lack of gynecologic knowledge among today’s college students, according to lead author Dr. Jill S. Huppert.

"Although they report a high level of sexual activity, they have a significant knowledge deficit," she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "Addressing this gap in knowledge might be an important strategy in improving the sexual and reproductive health of many young women and men."

The 40-item survey was distributed to six health, physical education, and recreation classes; it was completed by 138 women and 98 men. A knowledge score was generated by totaling correct responses to nine items on menstruation, Pap smear, sexually transmitted diseases (STDs), and pregnancy, and using a word bank to correctly label 11 spots on a diagram of the female anatomy. The anatomy score ranged from 0 to 11, and the total knowledge score ranged from 0 to 20, and included the nine knowledge items plus the anatomy score.

The median age of the respondents was 20 years (range, 18-36 years), and 84% reported prior vaginal intercourse, Dr. Huppert noted. Men were significantly more likely to report having more than one lifetime sexual partner (61% vs. 39%), and less likely to have prior STD testing (30% vs. 43%). Notably, 10% of respondents had a parent who was a physician, and one-third of those were ob.gyns.

In general, women did better at identifying their own anatomy than men. The mean anatomy knowledge score was 7.2 for women vs. 4.5 for men, which was significantly different, said Dr. Huppert of Cincinnati Children’s Hospital Medical Center. The ovary was correctly identified by both sexes the most frequently and the vagina the least often. Just about 70% of women and less than 60% of men could find the clitoris. Scores were low overall, with only 53% of women and 29% of men correctly identifying more than 80% of the anatomical structures on the diagram.

With regard to general knowledge, half of the men and women knew that a Pap smear detects cancer, 60% knew that menarche usually occurs at age 12 years, and 73% understood that 25% of women aged 18-24 years were infected with an STD, she said. A majority, or 94%, of both sexes knew that pregnancy delays periods, while 68% knew that depot medroxyprogesterone acetate (Depo-Provera) can do likewise.

There were significant differences between the sexes, with 24% of men recognizing that the risk of pregnancy with unprotected sex for a year is at least 75%, compared with just 13% of women, Dr. Huppert said. Women, however, were significantly more likely than men to know that menstrual periods can be delayed by stress (94% vs. 76%), losing weight/anorexia (91% vs. 66%), or high levels of exercise (80% vs. 46%).

The mean total knowledge score was significantly lower at 10 for men vs. 13.4 for women. In regression analysis, scores were not influenced by sexual experience or STD testing, Dr. Huppert said.

When the researchers looked at the influence of parents, there was a trend for higher anatomy scores among both sexes if a parent was an ob.gyn. Total knowledge scores also trended higher among women if a parent was an ob.gyn., and were significantly higher among men if their mother or father was an ob.gyn. at 15.7, vs. 9.9 if a parent was not an ob.gyn., she said.

Dr. Huppert and her associates reported no relevant financial disclosures.

CHICAGO – Less than 40% of female college students and just 20% of their male counterparts responded correctly when asked to label the vagina on an anatomical diagram.

This startling finding, taken from a brief survey conducted among 236 students at a Midwestern university, highlights the general lack of gynecologic knowledge among today’s college students, according to lead author Dr. Jill S. Huppert.

"Although they report a high level of sexual activity, they have a significant knowledge deficit," she said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology. "Addressing this gap in knowledge might be an important strategy in improving the sexual and reproductive health of many young women and men."

The 40-item survey was distributed to six health, physical education, and recreation classes; it was completed by 138 women and 98 men. A knowledge score was generated by totaling correct responses to nine items on menstruation, Pap smear, sexually transmitted diseases (STDs), and pregnancy, and using a word bank to correctly label 11 spots on a diagram of the female anatomy. The anatomy score ranged from 0 to 11, and the total knowledge score ranged from 0 to 20, and included the nine knowledge items plus the anatomy score.

The median age of the respondents was 20 years (range, 18-36 years), and 84% reported prior vaginal intercourse, Dr. Huppert noted. Men were significantly more likely to report having more than one lifetime sexual partner (61% vs. 39%), and less likely to have prior STD testing (30% vs. 43%). Notably, 10% of respondents had a parent who was a physician, and one-third of those were ob.gyns.

In general, women did better at identifying their own anatomy than men. The mean anatomy knowledge score was 7.2 for women vs. 4.5 for men, which was significantly different, said Dr. Huppert of Cincinnati Children’s Hospital Medical Center. The ovary was correctly identified by both sexes the most frequently and the vagina the least often. Just about 70% of women and less than 60% of men could find the clitoris. Scores were low overall, with only 53% of women and 29% of men correctly identifying more than 80% of the anatomical structures on the diagram.

With regard to general knowledge, half of the men and women knew that a Pap smear detects cancer, 60% knew that menarche usually occurs at age 12 years, and 73% understood that 25% of women aged 18-24 years were infected with an STD, she said. A majority, or 94%, of both sexes knew that pregnancy delays periods, while 68% knew that depot medroxyprogesterone acetate (Depo-Provera) can do likewise.

There were significant differences between the sexes, with 24% of men recognizing that the risk of pregnancy with unprotected sex for a year is at least 75%, compared with just 13% of women, Dr. Huppert said. Women, however, were significantly more likely than men to know that menstrual periods can be delayed by stress (94% vs. 76%), losing weight/anorexia (91% vs. 66%), or high levels of exercise (80% vs. 46%).

The mean total knowledge score was significantly lower at 10 for men vs. 13.4 for women. In regression analysis, scores were not influenced by sexual experience or STD testing, Dr. Huppert said.

When the researchers looked at the influence of parents, there was a trend for higher anatomy scores among both sexes if a parent was an ob.gyn. Total knowledge scores also trended higher among women if a parent was an ob.gyn., and were significantly higher among men if their mother or father was an ob.gyn. at 15.7, vs. 9.9 if a parent was not an ob.gyn., she said.

Dr. Huppert and her associates reported no relevant financial disclosures.

CHICAGO – Etiology remains elusive in many patients with disorders of sexual development, according to data from one of the largest cohorts reported to date.

The analysis found that most patients with an XX disorder of sexual development (DSD) have an etiologic diagnosis, but that more than two-thirds of those with an XY disorder have only an anatomical diagnosis.

"We as clinicians should be aiming for an etiological diagnosis rather than an anatomical diagnosis in such patients to provide better care," Dr. Karamdeep Bhullar said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Recent consensus guidelines stress the importance of early diagnosis and coined the term DSD to describe any congenital condition in which the development of chromosomal, gonadal, or anatomical sex is atypical (Arch. Dis. Child. 2006;91:554-63). Although most cases of DSD are identified in infancy, individuals with normal male or female genitalia and discordant internal anatomy are often not identified until adulthood. A girl might present with primary amenorrhea in the case of vaginal agenesis or present with inguinal hernia that is actually testes in cases of complete androgen insensitivity syndrome, said Dr. Bhullar of the department of pediatrics at the University of Melbourne.

She presented an analysis of 199 patients, born between 1999 and 2008 and managed at the Royal Children’s Hospital in Melbourne, one of the world leaders in DSD research. In all, 107 (54%) presented with XY DSD, 64 (32%) with XX DSD, and 28 (14%) as sex chromosome aneuploidy DSD. A definitive diagnosis was made in only 57% of the cohort, Dr. Bhullar said.

An etiologic diagnosis was made in 87.5% of patients with XX DSD, but only 29% of those with XY DSD.

Of the XY children, 92% were raised as males and 8% as females, while only one (2%) XX DSD child was raised as a male. Of the chromosome aneuploidy DSD children, 68%were assigned female sex and 32%, male sex.

The consensus guidelines stress that all children with DSD should receive a sex assignment, and that evaluation and long-term management should be carried out at a center with an experienced multidisciplinary team. Senior author Dr. Garry Warne, director of Royal Children’s Hospital International, Melbourne, said that early assignment of sex is thought to be the best way to prevent psychosocial harm to the child. In addition, there is a significant risk of gonadal malignancy in 46, XY DSD and sex chromosome aneuploidy DSD when there is a Y chromosome. In two conditions – partial androgen insensitivity syndrome and Y chromosome–positive gonadal dysgenesis – the risk of cancer is around 50% if the gonad is intraabdominal.

"If the decision is made to retain a gonad in such circumstances, it is essential that a risk-management strategy be prepared and clearly communicated to the patient," Dr. Warne said in an interview. "This is done to prevent physical harm to the patient."

In the current analysis, the spectrum of diagnoses among children raised as males included cloacal and bladder exstrophy (17%), partial/mixed gonadal dysgenesis (6%), Klinefelter syndrome and its variants (4%), ovotesticular DSD (2%), testicular regression syndrome (2%), and partial androgen insensitivity syndrome (1%). An anatomical diagnosis without a definitive etiology was made in 68% of these patients, Dr. Bhullar said.

The most common diagnosis among children raised as females was congenital adrenal hyperplasia (CAH) (47%), followed by Turner syndrome and its variants (18%), cloacal and bladder exstrophy (12%), and ovotesticular DSD (6%). Other less common diagnoses included complete androgen insensitivity (CAIS) (4%), complete gonadal dysgenesis (1%), and partial/mixed gonadal dysgenesis (1%). About 11% of those raised as females had an anatomical diagnosis without any etiology established, she said.

Except for certain conditions such as CAH and CAIS, a female sex rearing is strongly preferred based on long-term outcomes, Dr. Warne said. For most other conditions, there are either insufficient long-term outcomes data or the diagnosis is so uncertain that it is impossible to be sure how things will turn out.

During a discussion of the analysis, an audience member said the data provide a good starting point for research aimed at better classifying these disorders, but pointed out that contention still exists regarding the consensus guidelines and the inclusion of isolated hypospadias with palpable gonads and the placement of coital entropies in the labial adhesion category.

Dr. Warne said it is important for guidelines to be evidence based as far as possible, and acknowledged that mistakes have been made in the past, resulting in postoperative gender dysphoria that is extremely difficult to treat and leaves many patients, understandably, feeling deeply aggrieved.

"There are movements dedicated to opposing what is perceived to be current medical practice," he said. "Having said that, the medical profession accepts that practices need to change, and is trying very hard to develop protocols that better protect the best interests of patients."

The researchers published a set of ethical principles for the management of infants with DSD (Horm. Res. Paediatr. 2010;74:412-8) that were endorsed by the Fifth World Congress on Family Law and Children’s Rights, and are looking to test the principles in Australia and other cultural settings. They also are studying new methods of molecular diagnosis using next-generation DNA sequencing and gene chip technology that may provide swift and accurate diagnoses, he said.

The authors said they had no relevant financial disclosures.

CHICAGO – Etiology remains elusive in many patients with disorders of sexual development, according to data from one of the largest cohorts reported to date.

The analysis found that most patients with an XX disorder of sexual development (DSD) have an etiologic diagnosis, but that more than two-thirds of those with an XY disorder have only an anatomical diagnosis.

"We as clinicians should be aiming for an etiological diagnosis rather than an anatomical diagnosis in such patients to provide better care," Dr. Karamdeep Bhullar said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Recent consensus guidelines stress the importance of early diagnosis and coined the term DSD to describe any congenital condition in which the development of chromosomal, gonadal, or anatomical sex is atypical (Arch. Dis. Child. 2006;91:554-63). Although most cases of DSD are identified in infancy, individuals with normal male or female genitalia and discordant internal anatomy are often not identified until adulthood. A girl might present with primary amenorrhea in the case of vaginal agenesis or present with inguinal hernia that is actually testes in cases of complete androgen insensitivity syndrome, said Dr. Bhullar of the department of pediatrics at the University of Melbourne.

She presented an analysis of 199 patients, born between 1999 and 2008 and managed at the Royal Children’s Hospital in Melbourne, one of the world leaders in DSD research. In all, 107 (54%) presented with XY DSD, 64 (32%) with XX DSD, and 28 (14%) as sex chromosome aneuploidy DSD. A definitive diagnosis was made in only 57% of the cohort, Dr. Bhullar said.

An etiologic diagnosis was made in 87.5% of patients with XX DSD, but only 29% of those with XY DSD.

Of the XY children, 92% were raised as males and 8% as females, while only one (2%) XX DSD child was raised as a male. Of the chromosome aneuploidy DSD children, 68%were assigned female sex and 32%, male sex.

The consensus guidelines stress that all children with DSD should receive a sex assignment, and that evaluation and long-term management should be carried out at a center with an experienced multidisciplinary team. Senior author Dr. Garry Warne, director of Royal Children’s Hospital International, Melbourne, said that early assignment of sex is thought to be the best way to prevent psychosocial harm to the child. In addition, there is a significant risk of gonadal malignancy in 46, XY DSD and sex chromosome aneuploidy DSD when there is a Y chromosome. In two conditions – partial androgen insensitivity syndrome and Y chromosome–positive gonadal dysgenesis – the risk of cancer is around 50% if the gonad is intraabdominal.

"If the decision is made to retain a gonad in such circumstances, it is essential that a risk-management strategy be prepared and clearly communicated to the patient," Dr. Warne said in an interview. "This is done to prevent physical harm to the patient."

In the current analysis, the spectrum of diagnoses among children raised as males included cloacal and bladder exstrophy (17%), partial/mixed gonadal dysgenesis (6%), Klinefelter syndrome and its variants (4%), ovotesticular DSD (2%), testicular regression syndrome (2%), and partial androgen insensitivity syndrome (1%). An anatomical diagnosis without a definitive etiology was made in 68% of these patients, Dr. Bhullar said.

The most common diagnosis among children raised as females was congenital adrenal hyperplasia (CAH) (47%), followed by Turner syndrome and its variants (18%), cloacal and bladder exstrophy (12%), and ovotesticular DSD (6%). Other less common diagnoses included complete androgen insensitivity (CAIS) (4%), complete gonadal dysgenesis (1%), and partial/mixed gonadal dysgenesis (1%). About 11% of those raised as females had an anatomical diagnosis without any etiology established, she said.

Except for certain conditions such as CAH and CAIS, a female sex rearing is strongly preferred based on long-term outcomes, Dr. Warne said. For most other conditions, there are either insufficient long-term outcomes data or the diagnosis is so uncertain that it is impossible to be sure how things will turn out.

During a discussion of the analysis, an audience member said the data provide a good starting point for research aimed at better classifying these disorders, but pointed out that contention still exists regarding the consensus guidelines and the inclusion of isolated hypospadias with palpable gonads and the placement of coital entropies in the labial adhesion category.

Dr. Warne said it is important for guidelines to be evidence based as far as possible, and acknowledged that mistakes have been made in the past, resulting in postoperative gender dysphoria that is extremely difficult to treat and leaves many patients, understandably, feeling deeply aggrieved.

"There are movements dedicated to opposing what is perceived to be current medical practice," he said. "Having said that, the medical profession accepts that practices need to change, and is trying very hard to develop protocols that better protect the best interests of patients."

The researchers published a set of ethical principles for the management of infants with DSD (Horm. Res. Paediatr. 2010;74:412-8) that were endorsed by the Fifth World Congress on Family Law and Children’s Rights, and are looking to test the principles in Australia and other cultural settings. They also are studying new methods of molecular diagnosis using next-generation DNA sequencing and gene chip technology that may provide swift and accurate diagnoses, he said.

The authors said they had no relevant financial disclosures.

CHICAGO – Etiology remains elusive in many patients with disorders of sexual development, according to data from one of the largest cohorts reported to date.

The analysis found that most patients with an XX disorder of sexual development (DSD) have an etiologic diagnosis, but that more than two-thirds of those with an XY disorder have only an anatomical diagnosis.

"We as clinicians should be aiming for an etiological diagnosis rather than an anatomical diagnosis in such patients to provide better care," Dr. Karamdeep Bhullar said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Recent consensus guidelines stress the importance of early diagnosis and coined the term DSD to describe any congenital condition in which the development of chromosomal, gonadal, or anatomical sex is atypical (Arch. Dis. Child. 2006;91:554-63). Although most cases of DSD are identified in infancy, individuals with normal male or female genitalia and discordant internal anatomy are often not identified until adulthood. A girl might present with primary amenorrhea in the case of vaginal agenesis or present with inguinal hernia that is actually testes in cases of complete androgen insensitivity syndrome, said Dr. Bhullar of the department of pediatrics at the University of Melbourne.

She presented an analysis of 199 patients, born between 1999 and 2008 and managed at the Royal Children’s Hospital in Melbourne, one of the world leaders in DSD research. In all, 107 (54%) presented with XY DSD, 64 (32%) with XX DSD, and 28 (14%) as sex chromosome aneuploidy DSD. A definitive diagnosis was made in only 57% of the cohort, Dr. Bhullar said.

An etiologic diagnosis was made in 87.5% of patients with XX DSD, but only 29% of those with XY DSD.

Of the XY children, 92% were raised as males and 8% as females, while only one (2%) XX DSD child was raised as a male. Of the chromosome aneuploidy DSD children, 68%were assigned female sex and 32%, male sex.

The consensus guidelines stress that all children with DSD should receive a sex assignment, and that evaluation and long-term management should be carried out at a center with an experienced multidisciplinary team. Senior author Dr. Garry Warne, director of Royal Children’s Hospital International, Melbourne, said that early assignment of sex is thought to be the best way to prevent psychosocial harm to the child. In addition, there is a significant risk of gonadal malignancy in 46, XY DSD and sex chromosome aneuploidy DSD when there is a Y chromosome. In two conditions – partial androgen insensitivity syndrome and Y chromosome–positive gonadal dysgenesis – the risk of cancer is around 50% if the gonad is intraabdominal.

"If the decision is made to retain a gonad in such circumstances, it is essential that a risk-management strategy be prepared and clearly communicated to the patient," Dr. Warne said in an interview. "This is done to prevent physical harm to the patient."

In the current analysis, the spectrum of diagnoses among children raised as males included cloacal and bladder exstrophy (17%), partial/mixed gonadal dysgenesis (6%), Klinefelter syndrome and its variants (4%), ovotesticular DSD (2%), testicular regression syndrome (2%), and partial androgen insensitivity syndrome (1%). An anatomical diagnosis without a definitive etiology was made in 68% of these patients, Dr. Bhullar said.

The most common diagnosis among children raised as females was congenital adrenal hyperplasia (CAH) (47%), followed by Turner syndrome and its variants (18%), cloacal and bladder exstrophy (12%), and ovotesticular DSD (6%). Other less common diagnoses included complete androgen insensitivity (CAIS) (4%), complete gonadal dysgenesis (1%), and partial/mixed gonadal dysgenesis (1%). About 11% of those raised as females had an anatomical diagnosis without any etiology established, she said.

Except for certain conditions such as CAH and CAIS, a female sex rearing is strongly preferred based on long-term outcomes, Dr. Warne said. For most other conditions, there are either insufficient long-term outcomes data or the diagnosis is so uncertain that it is impossible to be sure how things will turn out.

During a discussion of the analysis, an audience member said the data provide a good starting point for research aimed at better classifying these disorders, but pointed out that contention still exists regarding the consensus guidelines and the inclusion of isolated hypospadias with palpable gonads and the placement of coital entropies in the labial adhesion category.

Dr. Warne said it is important for guidelines to be evidence based as far as possible, and acknowledged that mistakes have been made in the past, resulting in postoperative gender dysphoria that is extremely difficult to treat and leaves many patients, understandably, feeling deeply aggrieved.

"There are movements dedicated to opposing what is perceived to be current medical practice," he said. "Having said that, the medical profession accepts that practices need to change, and is trying very hard to develop protocols that better protect the best interests of patients."

The researchers published a set of ethical principles for the management of infants with DSD (Horm. Res. Paediatr. 2010;74:412-8) that were endorsed by the Fifth World Congress on Family Law and Children’s Rights, and are looking to test the principles in Australia and other cultural settings. They also are studying new methods of molecular diagnosis using next-generation DNA sequencing and gene chip technology that may provide swift and accurate diagnoses, he said.

The authors said they had no relevant financial disclosures.

CHICAGO – Women with recurrent pelvic inflammatory disease are significantly more likely to report infertility and chronic pelvic pain long-term than are those without recurrent PID, according to a secondary analysis of the PEACH study.

Rates of pregnancy (odds ratio, 1.0) and live births (OR, 0.7) were similar at 84 months after adjustment for age, race, parity, prior history of PID, and gonorrhea and chlamydia infection among 831 women with mild to moderate PID enrolled in the PID Evaluation and Clinical Health (PEACH) study.

Women with recurrent PID, however, were 1.8 times more likely to report infertility and 4.2 times more likely to report chronic pelvic pain than were those without recurrent episodes of PID, lead author Dr. Maria Trent said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Women with a subsequent sexually transmitted infection (STI) of the lower genital tract were 2.3 times more likely to have chronic pelvic pain than were those without an STI, but not more likely to have infertility.

"Our data and analysis substantiate the relationship between recurrent PID and adverse outcomes in the context of modern microbiology and outpatient and inpatient care approaches," said Dr. Trent, director of interdisciplinary education at the Johns Hopkins Children’s Center in Baltimore.

She explained that much of the current knowledge of the longitudinal outcomes of women with PID has been driven by research on a Scandinavian cohort of PID inpatients enrolled between 1960 and 1984. Since that time, however, there has been a shift in biological organisms causing PID and in clinical management to the outpatient setting. Previously, 60% of patients with PID had noncoccal or chlamydial disease, whereas newer data demonstrate that as few as 30% of PID patients have noncoccal or chlamydial disease and that newer organisms such as Mycoplasma genitalium are emerging, Dr. Trent said.

In the main PEACH study analysis, there was no difference in outcomes among the 831 women, aged 14-38 years, randomized to inpatient treatment initially using intravenous cefoxitin and doxycycline, or outpatient treatment with a single intramuscular injection of cefoxitin and oral doxycycline (Obstet. Gynecol. 2005;106:573-80). Participants were primarily African American (74.5%) and low income, and had regular access to care (65%).

When the women were interviewed at 84 months, 61% of them reported they were using some form of contraception. A prior history of PID was present in only 37% of women and 25% of adolescents (19 years or younger). Nine percent of all women and 12% of adolescents reported a new sexual partner.

At 84 months, 21% of women reported recurrent PID, 19% were categorized as infertile, 43% reported chronic pelvic pain, 57% became pregnant, and 42% had a live birth, Dr. Trent said.

Among the 209 adolescents, 71% had a pregnancy, 51% had a live birth, 18% were characterized as infertile, and 39% had chronic pelvic pain.

In an adjusted subanalysis of the adolescents, there were no significant differences in rates of pregnancy, live birth, and infertility based on PID status, but those with recurrent episodes of PID were five times more likely to report chronic pelvic pain than were adolescents without recurrent PID (OR, 5.0), Dr. Trent said.

"For PID, we often talk to adolescent girls about the difficulty of getting pregnant in the future, but we don’t necessarily talk to them about the possibility of chronic pelvic pain, which this study highlights is a significant issue," she said.

Based on the findings, the authors also advocate targeting public health interventions to young women and adolescents with PID.

"Acute PID should prompt linkage of affected patients to tailored STI risk-reduction services to prevent the adverse outcomes associated with PID," Dr. Trent said.

Dr. Maria Trent and her associates said they had no relevant financial disclosures.

CHICAGO – Women with recurrent pelvic inflammatory disease are significantly more likely to report infertility and chronic pelvic pain long-term than are those without recurrent PID, according to a secondary analysis of the PEACH study.

Rates of pregnancy (odds ratio, 1.0) and live births (OR, 0.7) were similar at 84 months after adjustment for age, race, parity, prior history of PID, and gonorrhea and chlamydia infection among 831 women with mild to moderate PID enrolled in the PID Evaluation and Clinical Health (PEACH) study.

Women with recurrent PID, however, were 1.8 times more likely to report infertility and 4.2 times more likely to report chronic pelvic pain than were those without recurrent episodes of PID, lead author Dr. Maria Trent said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Women with a subsequent sexually transmitted infection (STI) of the lower genital tract were 2.3 times more likely to have chronic pelvic pain than were those without an STI, but not more likely to have infertility.

"Our data and analysis substantiate the relationship between recurrent PID and adverse outcomes in the context of modern microbiology and outpatient and inpatient care approaches," said Dr. Trent, director of interdisciplinary education at the Johns Hopkins Children’s Center in Baltimore.

She explained that much of the current knowledge of the longitudinal outcomes of women with PID has been driven by research on a Scandinavian cohort of PID inpatients enrolled between 1960 and 1984. Since that time, however, there has been a shift in biological organisms causing PID and in clinical management to the outpatient setting. Previously, 60% of patients with PID had noncoccal or chlamydial disease, whereas newer data demonstrate that as few as 30% of PID patients have noncoccal or chlamydial disease and that newer organisms such as Mycoplasma genitalium are emerging, Dr. Trent said.

In the main PEACH study analysis, there was no difference in outcomes among the 831 women, aged 14-38 years, randomized to inpatient treatment initially using intravenous cefoxitin and doxycycline, or outpatient treatment with a single intramuscular injection of cefoxitin and oral doxycycline (Obstet. Gynecol. 2005;106:573-80). Participants were primarily African American (74.5%) and low income, and had regular access to care (65%).

When the women were interviewed at 84 months, 61% of them reported they were using some form of contraception. A prior history of PID was present in only 37% of women and 25% of adolescents (19 years or younger). Nine percent of all women and 12% of adolescents reported a new sexual partner.

At 84 months, 21% of women reported recurrent PID, 19% were categorized as infertile, 43% reported chronic pelvic pain, 57% became pregnant, and 42% had a live birth, Dr. Trent said.

Among the 209 adolescents, 71% had a pregnancy, 51% had a live birth, 18% were characterized as infertile, and 39% had chronic pelvic pain.

In an adjusted subanalysis of the adolescents, there were no significant differences in rates of pregnancy, live birth, and infertility based on PID status, but those with recurrent episodes of PID were five times more likely to report chronic pelvic pain than were adolescents without recurrent PID (OR, 5.0), Dr. Trent said.

"For PID, we often talk to adolescent girls about the difficulty of getting pregnant in the future, but we don’t necessarily talk to them about the possibility of chronic pelvic pain, which this study highlights is a significant issue," she said.

Based on the findings, the authors also advocate targeting public health interventions to young women and adolescents with PID.

"Acute PID should prompt linkage of affected patients to tailored STI risk-reduction services to prevent the adverse outcomes associated with PID," Dr. Trent said.

Dr. Maria Trent and her associates said they had no relevant financial disclosures.

CHICAGO – Women with recurrent pelvic inflammatory disease are significantly more likely to report infertility and chronic pelvic pain long-term than are those without recurrent PID, according to a secondary analysis of the PEACH study.

Rates of pregnancy (odds ratio, 1.0) and live births (OR, 0.7) were similar at 84 months after adjustment for age, race, parity, prior history of PID, and gonorrhea and chlamydia infection among 831 women with mild to moderate PID enrolled in the PID Evaluation and Clinical Health (PEACH) study.

Women with recurrent PID, however, were 1.8 times more likely to report infertility and 4.2 times more likely to report chronic pelvic pain than were those without recurrent episodes of PID, lead author Dr. Maria Trent said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Women with a subsequent sexually transmitted infection (STI) of the lower genital tract were 2.3 times more likely to have chronic pelvic pain than were those without an STI, but not more likely to have infertility.

"Our data and analysis substantiate the relationship between recurrent PID and adverse outcomes in the context of modern microbiology and outpatient and inpatient care approaches," said Dr. Trent, director of interdisciplinary education at the Johns Hopkins Children’s Center in Baltimore.

She explained that much of the current knowledge of the longitudinal outcomes of women with PID has been driven by research on a Scandinavian cohort of PID inpatients enrolled between 1960 and 1984. Since that time, however, there has been a shift in biological organisms causing PID and in clinical management to the outpatient setting. Previously, 60% of patients with PID had noncoccal or chlamydial disease, whereas newer data demonstrate that as few as 30% of PID patients have noncoccal or chlamydial disease and that newer organisms such as Mycoplasma genitalium are emerging, Dr. Trent said.

In the main PEACH study analysis, there was no difference in outcomes among the 831 women, aged 14-38 years, randomized to inpatient treatment initially using intravenous cefoxitin and doxycycline, or outpatient treatment with a single intramuscular injection of cefoxitin and oral doxycycline (Obstet. Gynecol. 2005;106:573-80). Participants were primarily African American (74.5%) and low income, and had regular access to care (65%).

When the women were interviewed at 84 months, 61% of them reported they were using some form of contraception. A prior history of PID was present in only 37% of women and 25% of adolescents (19 years or younger). Nine percent of all women and 12% of adolescents reported a new sexual partner.

At 84 months, 21% of women reported recurrent PID, 19% were categorized as infertile, 43% reported chronic pelvic pain, 57% became pregnant, and 42% had a live birth, Dr. Trent said.

Among the 209 adolescents, 71% had a pregnancy, 51% had a live birth, 18% were characterized as infertile, and 39% had chronic pelvic pain.

In an adjusted subanalysis of the adolescents, there were no significant differences in rates of pregnancy, live birth, and infertility based on PID status, but those with recurrent episodes of PID were five times more likely to report chronic pelvic pain than were adolescents without recurrent PID (OR, 5.0), Dr. Trent said.

"For PID, we often talk to adolescent girls about the difficulty of getting pregnant in the future, but we don’t necessarily talk to them about the possibility of chronic pelvic pain, which this study highlights is a significant issue," she said.

Based on the findings, the authors also advocate targeting public health interventions to young women and adolescents with PID.

"Acute PID should prompt linkage of affected patients to tailored STI risk-reduction services to prevent the adverse outcomes associated with PID," Dr. Trent said.

Dr. Maria Trent and her associates said they had no relevant financial disclosures.

CHICAGO – Women with recurrent pelvic inflammatory disease are significantly more likely to report infertility and chronic pelvic pain long-term than are those without recurrent PID, according to a secondary analysis of the PEACH study.

Rates of pregnancy (odds ratio, 1.0) and live births (OR, 0.7) were similar at 84 months after adjustment for age, race, parity, prior history of PID, and gonorrhea and chlamydia infection among 831 women with mild to moderate PID enrolled in the PID Evaluation and Clinical Health (PEACH) study.

Women with recurrent PID, however, were 1.8 times more likely to report infertility and 4.2 times more likely to report chronic pelvic pain than were those without recurrent episodes of PID, lead author Dr. Maria Trent said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Women with a subsequent sexually transmitted infection (STI) of the lower genital tract were 2.3 times more likely to have chronic pelvic pain than were those without an STI, but not more likely to have infertility.

"Our data and analysis substantiate the relationship between recurrent PID and adverse outcomes in the context of modern microbiology and outpatient and inpatient care approaches," said Dr. Trent, director of interdisciplinary education at the Johns Hopkins Children’s Center in Baltimore.

She explained that much of the current knowledge of the longitudinal outcomes of women with PID has been driven by research on a Scandinavian cohort of PID inpatients enrolled between 1960 and 1984. Since that time, however, there has been a shift in biological organisms causing PID and in clinical management to the outpatient setting. Previously, 60% of patients with PID had noncoccal or chlamydial disease, whereas newer data demonstrate that as few as 30% of PID patients have noncoccal or chlamydial disease and that newer organisms such as Mycoplasma genitalium are emerging, Dr. Trent said.

In the main PEACH study analysis, there was no difference in outcomes among the 831 women, aged 14-38 years, randomized to inpatient treatment initially using intravenous cefoxitin and doxycycline, or outpatient treatment with a single intramuscular injection of cefoxitin and oral doxycycline (Obstet. Gynecol. 2005;106:573-80). Participants were primarily African American (74.5%) and low income, and had regular access to care (65%).

When the women were interviewed at 84 months, 61% of them reported they were using some form of contraception. A prior history of PID was present in only 37% of women and 25% of adolescents (19 years or younger). Nine percent of all women and 12% of adolescents reported a new sexual partner.

At 84 months, 21% of women reported recurrent PID, 19% were categorized as infertile, 43% reported chronic pelvic pain, 57% became pregnant, and 42% had a live birth, Dr. Trent said.

Among the 209 adolescents, 71% had a pregnancy, 51% had a live birth, 18% were characterized as infertile, and 39% had chronic pelvic pain.

In an adjusted subanalysis of the adolescents, there were no significant differences in rates of pregnancy, live birth, and infertility based on PID status, but those with recurrent episodes of PID were five times more likely to report chronic pelvic pain than were adolescents without recurrent PID (OR, 5.0), Dr. Trent said.

"For PID, we often talk to adolescent girls about the difficulty of getting pregnant in the future, but we don’t necessarily talk to them about the possibility of chronic pelvic pain, which this study highlights is a significant issue," she said.

Based on the findings, the authors also advocate targeting public health interventions to young women and adolescents with PID.

"Acute PID should prompt linkage of affected patients to tailored STI risk-reduction services to prevent the adverse outcomes associated with PID," Dr. Trent said.

Dr. Maria Trent and her associates said they had no relevant financial disclosures.

CHICAGO – Women with recurrent pelvic inflammatory disease are significantly more likely to report infertility and chronic pelvic pain long-term than are those without recurrent PID, according to a secondary analysis of the PEACH study.

Rates of pregnancy (odds ratio, 1.0) and live births (OR, 0.7) were similar at 84 months after adjustment for age, race, parity, prior history of PID, and gonorrhea and chlamydia infection among 831 women with mild to moderate PID enrolled in the PID Evaluation and Clinical Health (PEACH) study.

Women with recurrent PID, however, were 1.8 times more likely to report infertility and 4.2 times more likely to report chronic pelvic pain than were those without recurrent episodes of PID, lead author Dr. Maria Trent said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Women with a subsequent sexually transmitted infection (STI) of the lower genital tract were 2.3 times more likely to have chronic pelvic pain than were those without an STI, but not more likely to have infertility.

"Our data and analysis substantiate the relationship between recurrent PID and adverse outcomes in the context of modern microbiology and outpatient and inpatient care approaches," said Dr. Trent, director of interdisciplinary education at the Johns Hopkins Children’s Center in Baltimore.

She explained that much of the current knowledge of the longitudinal outcomes of women with PID has been driven by research on a Scandinavian cohort of PID inpatients enrolled between 1960 and 1984. Since that time, however, there has been a shift in biological organisms causing PID and in clinical management to the outpatient setting. Previously, 60% of patients with PID had noncoccal or chlamydial disease, whereas newer data demonstrate that as few as 30% of PID patients have noncoccal or chlamydial disease and that newer organisms such as Mycoplasma genitalium are emerging, Dr. Trent said.

In the main PEACH study analysis, there was no difference in outcomes among the 831 women, aged 14-38 years, randomized to inpatient treatment initially using intravenous cefoxitin and doxycycline, or outpatient treatment with a single intramuscular injection of cefoxitin and oral doxycycline (Obstet. Gynecol. 2005;106:573-80). Participants were primarily African American (74.5%) and low income, and had regular access to care (65%).

When the women were interviewed at 84 months, 61% of them reported they were using some form of contraception. A prior history of PID was present in only 37% of women and 25% of adolescents (19 years or younger). Nine percent of all women and 12% of adolescents reported a new sexual partner.

At 84 months, 21% of women reported recurrent PID, 19% were categorized as infertile, 43% reported chronic pelvic pain, 57% became pregnant, and 42% had a live birth, Dr. Trent said.

Among the 209 adolescents, 71% had a pregnancy, 51% had a live birth, 18% were characterized as infertile, and 39% had chronic pelvic pain.

In an adjusted subanalysis of the adolescents, there were no significant differences in rates of pregnancy, live birth, and infertility based on PID status, but those with recurrent episodes of PID were five times more likely to report chronic pelvic pain than were adolescents without recurrent PID (OR, 5.0), Dr. Trent said.

"For PID, we often talk to adolescent girls about the difficulty of getting pregnant in the future, but we don’t necessarily talk to them about the possibility of chronic pelvic pain, which this study highlights is a significant issue," she said.

Based on the findings, the authors also advocate targeting public health interventions to young women and adolescents with PID.

"Acute PID should prompt linkage of affected patients to tailored STI risk-reduction services to prevent the adverse outcomes associated with PID," Dr. Trent said.

Dr. Maria Trent and her associates said they had no relevant financial disclosures.

CHICAGO – Women with recurrent pelvic inflammatory disease are significantly more likely to report infertility and chronic pelvic pain long-term than are those without recurrent PID, according to a secondary analysis of the PEACH study.

Rates of pregnancy (odds ratio, 1.0) and live births (OR, 0.7) were similar at 84 months after adjustment for age, race, parity, prior history of PID, and gonorrhea and chlamydia infection among 831 women with mild to moderate PID enrolled in the PID Evaluation and Clinical Health (PEACH) study.

Women with recurrent PID, however, were 1.8 times more likely to report infertility and 4.2 times more likely to report chronic pelvic pain than were those without recurrent episodes of PID, lead author Dr. Maria Trent said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

Women with a subsequent sexually transmitted infection (STI) of the lower genital tract were 2.3 times more likely to have chronic pelvic pain than were those without an STI, but not more likely to have infertility.

"Our data and analysis substantiate the relationship between recurrent PID and adverse outcomes in the context of modern microbiology and outpatient and inpatient care approaches," said Dr. Trent, director of interdisciplinary education at the Johns Hopkins Children’s Center in Baltimore.

She explained that much of the current knowledge of the longitudinal outcomes of women with PID has been driven by research on a Scandinavian cohort of PID inpatients enrolled between 1960 and 1984. Since that time, however, there has been a shift in biological organisms causing PID and in clinical management to the outpatient setting. Previously, 60% of patients with PID had noncoccal or chlamydial disease, whereas newer data demonstrate that as few as 30% of PID patients have noncoccal or chlamydial disease and that newer organisms such as Mycoplasma genitalium are emerging, Dr. Trent said.

In the main PEACH study analysis, there was no difference in outcomes among the 831 women, aged 14-38 years, randomized to inpatient treatment initially using intravenous cefoxitin and doxycycline, or outpatient treatment with a single intramuscular injection of cefoxitin and oral doxycycline (Obstet. Gynecol. 2005;106:573-80). Participants were primarily African American (74.5%) and low income, and had regular access to care (65%).

When the women were interviewed at 84 months, 61% of them reported they were using some form of contraception. A prior history of PID was present in only 37% of women and 25% of adolescents (19 years or younger). Nine percent of all women and 12% of adolescents reported a new sexual partner.

At 84 months, 21% of women reported recurrent PID, 19% were categorized as infertile, 43% reported chronic pelvic pain, 57% became pregnant, and 42% had a live birth, Dr. Trent said.

Among the 209 adolescents, 71% had a pregnancy, 51% had a live birth, 18% were characterized as infertile, and 39% had chronic pelvic pain.

In an adjusted subanalysis of the adolescents, there were no significant differences in rates of pregnancy, live birth, and infertility based on PID status, but those with recurrent episodes of PID were five times more likely to report chronic pelvic pain than were adolescents without recurrent PID (OR, 5.0), Dr. Trent said.

"For PID, we often talk to adolescent girls about the difficulty of getting pregnant in the future, but we don’t necessarily talk to them about the possibility of chronic pelvic pain, which this study highlights is a significant issue," she said.

Based on the findings, the authors also advocate targeting public health interventions to young women and adolescents with PID.

"Acute PID should prompt linkage of affected patients to tailored STI risk-reduction services to prevent the adverse outcomes associated with PID," Dr. Trent said.

Dr. Maria Trent and her associates said they had no relevant financial disclosures.

CHICAGO – Norethindrone acetate is a well-tolerated, effective option to decrease both endometriosis-related pain and bleeding among adolescents.

The synthetic progestin was effective for all stages of endometriosis in a retrospective analysis, and 67% of patients reported no side effects, Dr. Daniel Kaser said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We conclude that progestin-only oral therapy should be considered a valuable tool in adolescents with endometriosis, regardless of stage of disease," he said.

Norethindrone acetate is used in clinical practice in combination with other hormones for contraception and for hormonal suppression of endometriosis-associated pain. To date, there have been no reported studies on the efficacy of oral progestins in adolescents with endometriosis, said Dr. Kaser, a gynecologist with Children’s Hospital Boston.

Dr. Kaser and his colleague, Dr. Mark Laufer, chief of gynecology at Children’s, reported on 129 adolescents with surgically diagnosed endometriosis treated with norethindrone acetate from 1992 to 2010 by one gynecologist at a single children’s hospital. From a starting dose of 5 mg, patients were asked to self-titrate by increasing doses of 2.5-mg increments over the course of 2 weeks until they induced amenorrhea and had decreased pain. In the analysis, 68% achieved the maximum approved dose of 15 mg.

Consistent with clinical experience and other reports, most of the patients had early-stage disease (100 patients had stage 1, 25 had stage 2, none had stage 3, and 4 had stage 4). Their mean age was 16.4 years (range, 12-21 years) and mean body mass index was 23.9 kg/m² (range 12-37 kg/m²).

The most common indication for progestin-only therapy was failure of combined oral contraceptives (53.5%), followed by migraine headaches with aura (25%), he said.

When all stages of endometriosis were pooled, norethindrone acetate significantly reduced the self-reported mean pain score from 5.6 to 2.6 and mean bleeding score from 7.2 to 3.4, Dr. Kaser said. When stratified by disease severity, norethindrone acetate still significantly reduced pain and bleeding scores in all stages of endometriosis.

Mean pain scores decreased for patients with stage-1 disease from 7.2 at baseline to 3.4 at the most recent clinic visit or upon discontinuation, from 5.6 to 2.8 for stage 2, and from 7 to 1.3 for stage 4. Mean bleeding scores decreased from 2.1 to 0.5 (stage 1), from 1.6 to 0.2 (stage 2), and from 1.5 to 0 (stage 4).

"Due to the fact that all of these patients have surgically confirmed endometriosis, we feel the study population is homogenous and the results should be externally valid to adolescents with endometriosis," he said.

The average duration of therapy was 11.3 months (range, 1-36 months), with 69% of patients still using norethindrone acetate at their most recent visit. Among those who stopped therapy, 70% did so because of persistent pain or bleeding. Interestingly, 15.5% of patients actually down-titrated their dose because of the persistence of pain, and of those who did, 60% had success on the lower dose, he said.

The most common side effects, reported by 14% of patients each, were weight gain and mood swings. Acne was reported by 10%, hot flushes by 8%, headache by 4%, and nausea by 3%.

The most common prescription upon discontinuation was GnRH-agonists plus add-back therapy with norethindrone acetate (52.5%), followed by continuous estrogen/progesterone (32.5%), Dr. Kaser said.

Dr. Kaser and Dr. Laufer reports no conflicts of interest.

CHICAGO – Norethindrone acetate is a well-tolerated, effective option to decrease both endometriosis-related pain and bleeding among adolescents.

The synthetic progestin was effective for all stages of endometriosis in a retrospective analysis, and 67% of patients reported no side effects, Dr. Daniel Kaser said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We conclude that progestin-only oral therapy should be considered a valuable tool in adolescents with endometriosis, regardless of stage of disease," he said.

Norethindrone acetate is used in clinical practice in combination with other hormones for contraception and for hormonal suppression of endometriosis-associated pain. To date, there have been no reported studies on the efficacy of oral progestins in adolescents with endometriosis, said Dr. Kaser, a gynecologist with Children’s Hospital Boston.

Dr. Kaser and his colleague, Dr. Mark Laufer, chief of gynecology at Children’s, reported on 129 adolescents with surgically diagnosed endometriosis treated with norethindrone acetate from 1992 to 2010 by one gynecologist at a single children’s hospital. From a starting dose of 5 mg, patients were asked to self-titrate by increasing doses of 2.5-mg increments over the course of 2 weeks until they induced amenorrhea and had decreased pain. In the analysis, 68% achieved the maximum approved dose of 15 mg.

Consistent with clinical experience and other reports, most of the patients had early-stage disease (100 patients had stage 1, 25 had stage 2, none had stage 3, and 4 had stage 4). Their mean age was 16.4 years (range, 12-21 years) and mean body mass index was 23.9 kg/m² (range 12-37 kg/m²).

The most common indication for progestin-only therapy was failure of combined oral contraceptives (53.5%), followed by migraine headaches with aura (25%), he said.

When all stages of endometriosis were pooled, norethindrone acetate significantly reduced the self-reported mean pain score from 5.6 to 2.6 and mean bleeding score from 7.2 to 3.4, Dr. Kaser said. When stratified by disease severity, norethindrone acetate still significantly reduced pain and bleeding scores in all stages of endometriosis.

Mean pain scores decreased for patients with stage-1 disease from 7.2 at baseline to 3.4 at the most recent clinic visit or upon discontinuation, from 5.6 to 2.8 for stage 2, and from 7 to 1.3 for stage 4. Mean bleeding scores decreased from 2.1 to 0.5 (stage 1), from 1.6 to 0.2 (stage 2), and from 1.5 to 0 (stage 4).

"Due to the fact that all of these patients have surgically confirmed endometriosis, we feel the study population is homogenous and the results should be externally valid to adolescents with endometriosis," he said.

The average duration of therapy was 11.3 months (range, 1-36 months), with 69% of patients still using norethindrone acetate at their most recent visit. Among those who stopped therapy, 70% did so because of persistent pain or bleeding. Interestingly, 15.5% of patients actually down-titrated their dose because of the persistence of pain, and of those who did, 60% had success on the lower dose, he said.

The most common side effects, reported by 14% of patients each, were weight gain and mood swings. Acne was reported by 10%, hot flushes by 8%, headache by 4%, and nausea by 3%.

The most common prescription upon discontinuation was GnRH-agonists plus add-back therapy with norethindrone acetate (52.5%), followed by continuous estrogen/progesterone (32.5%), Dr. Kaser said.

Dr. Kaser and Dr. Laufer reports no conflicts of interest.

CHICAGO – Norethindrone acetate is a well-tolerated, effective option to decrease both endometriosis-related pain and bleeding among adolescents.

The synthetic progestin was effective for all stages of endometriosis in a retrospective analysis, and 67% of patients reported no side effects, Dr. Daniel Kaser said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We conclude that progestin-only oral therapy should be considered a valuable tool in adolescents with endometriosis, regardless of stage of disease," he said.

Norethindrone acetate is used in clinical practice in combination with other hormones for contraception and for hormonal suppression of endometriosis-associated pain. To date, there have been no reported studies on the efficacy of oral progestins in adolescents with endometriosis, said Dr. Kaser, a gynecologist with Children’s Hospital Boston.

Dr. Kaser and his colleague, Dr. Mark Laufer, chief of gynecology at Children’s, reported on 129 adolescents with surgically diagnosed endometriosis treated with norethindrone acetate from 1992 to 2010 by one gynecologist at a single children’s hospital. From a starting dose of 5 mg, patients were asked to self-titrate by increasing doses of 2.5-mg increments over the course of 2 weeks until they induced amenorrhea and had decreased pain. In the analysis, 68% achieved the maximum approved dose of 15 mg.

Consistent with clinical experience and other reports, most of the patients had early-stage disease (100 patients had stage 1, 25 had stage 2, none had stage 3, and 4 had stage 4). Their mean age was 16.4 years (range, 12-21 years) and mean body mass index was 23.9 kg/m² (range 12-37 kg/m²).

The most common indication for progestin-only therapy was failure of combined oral contraceptives (53.5%), followed by migraine headaches with aura (25%), he said.

When all stages of endometriosis were pooled, norethindrone acetate significantly reduced the self-reported mean pain score from 5.6 to 2.6 and mean bleeding score from 7.2 to 3.4, Dr. Kaser said. When stratified by disease severity, norethindrone acetate still significantly reduced pain and bleeding scores in all stages of endometriosis.

Mean pain scores decreased for patients with stage-1 disease from 7.2 at baseline to 3.4 at the most recent clinic visit or upon discontinuation, from 5.6 to 2.8 for stage 2, and from 7 to 1.3 for stage 4. Mean bleeding scores decreased from 2.1 to 0.5 (stage 1), from 1.6 to 0.2 (stage 2), and from 1.5 to 0 (stage 4).

"Due to the fact that all of these patients have surgically confirmed endometriosis, we feel the study population is homogenous and the results should be externally valid to adolescents with endometriosis," he said.

The average duration of therapy was 11.3 months (range, 1-36 months), with 69% of patients still using norethindrone acetate at their most recent visit. Among those who stopped therapy, 70% did so because of persistent pain or bleeding. Interestingly, 15.5% of patients actually down-titrated their dose because of the persistence of pain, and of those who did, 60% had success on the lower dose, he said.

The most common side effects, reported by 14% of patients each, were weight gain and mood swings. Acne was reported by 10%, hot flushes by 8%, headache by 4%, and nausea by 3%.

The most common prescription upon discontinuation was GnRH-agonists plus add-back therapy with norethindrone acetate (52.5%), followed by continuous estrogen/progesterone (32.5%), Dr. Kaser said.

Dr. Kaser and Dr. Laufer reports no conflicts of interest.

CHICAGO – Norethindrone acetate is a well-tolerated, effective option to decrease both endometriosis-related pain and bleeding among adolescents.

The synthetic progestin was effective for all stages of endometriosis in a retrospective analysis, and 67% of patients reported no side effects, Dr. Daniel Kaser said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We conclude that progestin-only oral therapy should be considered a valuable tool in adolescents with endometriosis, regardless of stage of disease," he said.

Norethindrone acetate is used in clinical practice in combination with other hormones for contraception and for hormonal suppression of endometriosis-associated pain. To date, there have been no reported studies on the efficacy of oral progestins in adolescents with endometriosis, said Dr. Kaser, a gynecologist with Children’s Hospital Boston.

Dr. Kaser and his colleague, Dr. Mark Laufer, chief of gynecology at Children’s, reported on 129 adolescents with surgically diagnosed endometriosis treated with norethindrone acetate from 1992 to 2010 by one gynecologist at a single children’s hospital. From a starting dose of 5 mg, patients were asked to self-titrate by increasing doses of 2.5-mg increments over the course of 2 weeks until they induced amenorrhea and had decreased pain. In the analysis, 68% achieved the maximum approved dose of 15 mg.

Consistent with clinical experience and other reports, most of the patients had early-stage disease (100 patients had stage 1, 25 had stage 2, none had stage 3, and 4 had stage 4). Their mean age was 16.4 years (range, 12-21 years) and mean body mass index was 23.9 kg/m² (range 12-37 kg/m²).

The most common indication for progestin-only therapy was failure of combined oral contraceptives (53.5%), followed by migraine headaches with aura (25%), he said.

When all stages of endometriosis were pooled, norethindrone acetate significantly reduced the self-reported mean pain score from 5.6 to 2.6 and mean bleeding score from 7.2 to 3.4, Dr. Kaser said. When stratified by disease severity, norethindrone acetate still significantly reduced pain and bleeding scores in all stages of endometriosis.

Mean pain scores decreased for patients with stage-1 disease from 7.2 at baseline to 3.4 at the most recent clinic visit or upon discontinuation, from 5.6 to 2.8 for stage 2, and from 7 to 1.3 for stage 4. Mean bleeding scores decreased from 2.1 to 0.5 (stage 1), from 1.6 to 0.2 (stage 2), and from 1.5 to 0 (stage 4).

"Due to the fact that all of these patients have surgically confirmed endometriosis, we feel the study population is homogenous and the results should be externally valid to adolescents with endometriosis," he said.

The average duration of therapy was 11.3 months (range, 1-36 months), with 69% of patients still using norethindrone acetate at their most recent visit. Among those who stopped therapy, 70% did so because of persistent pain or bleeding. Interestingly, 15.5% of patients actually down-titrated their dose because of the persistence of pain, and of those who did, 60% had success on the lower dose, he said.

The most common side effects, reported by 14% of patients each, were weight gain and mood swings. Acne was reported by 10%, hot flushes by 8%, headache by 4%, and nausea by 3%.

The most common prescription upon discontinuation was GnRH-agonists plus add-back therapy with norethindrone acetate (52.5%), followed by continuous estrogen/progesterone (32.5%), Dr. Kaser said.

Dr. Kaser and Dr. Laufer reports no conflicts of interest.

CHICAGO – Norethindrone acetate is a well-tolerated, effective option to decrease both endometriosis-related pain and bleeding among adolescents.

The synthetic progestin was effective for all stages of endometriosis in a retrospective analysis, and 67% of patients reported no side effects, Dr. Daniel Kaser said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We conclude that progestin-only oral therapy should be considered a valuable tool in adolescents with endometriosis, regardless of stage of disease," he said.

Norethindrone acetate is used in clinical practice in combination with other hormones for contraception and for hormonal suppression of endometriosis-associated pain. To date, there have been no reported studies on the efficacy of oral progestins in adolescents with endometriosis, said Dr. Kaser, a gynecologist with Children’s Hospital Boston.

Dr. Kaser and his colleague, Dr. Mark Laufer, chief of gynecology at Children’s, reported on 129 adolescents with surgically diagnosed endometriosis treated with norethindrone acetate from 1992 to 2010 by one gynecologist at a single children’s hospital. From a starting dose of 5 mg, patients were asked to self-titrate by increasing doses of 2.5-mg increments over the course of 2 weeks until they induced amenorrhea and had decreased pain. In the analysis, 68% achieved the maximum approved dose of 15 mg.

Consistent with clinical experience and other reports, most of the patients had early-stage disease (100 patients had stage 1, 25 had stage 2, none had stage 3, and 4 had stage 4). Their mean age was 16.4 years (range, 12-21 years) and mean body mass index was 23.9 kg/m² (range 12-37 kg/m²).

The most common indication for progestin-only therapy was failure of combined oral contraceptives (53.5%), followed by migraine headaches with aura (25%), he said.

When all stages of endometriosis were pooled, norethindrone acetate significantly reduced the self-reported mean pain score from 5.6 to 2.6 and mean bleeding score from 7.2 to 3.4, Dr. Kaser said. When stratified by disease severity, norethindrone acetate still significantly reduced pain and bleeding scores in all stages of endometriosis.

Mean pain scores decreased for patients with stage-1 disease from 7.2 at baseline to 3.4 at the most recent clinic visit or upon discontinuation, from 5.6 to 2.8 for stage 2, and from 7 to 1.3 for stage 4. Mean bleeding scores decreased from 2.1 to 0.5 (stage 1), from 1.6 to 0.2 (stage 2), and from 1.5 to 0 (stage 4).

"Due to the fact that all of these patients have surgically confirmed endometriosis, we feel the study population is homogenous and the results should be externally valid to adolescents with endometriosis," he said.

The average duration of therapy was 11.3 months (range, 1-36 months), with 69% of patients still using norethindrone acetate at their most recent visit. Among those who stopped therapy, 70% did so because of persistent pain or bleeding. Interestingly, 15.5% of patients actually down-titrated their dose because of the persistence of pain, and of those who did, 60% had success on the lower dose, he said.

The most common side effects, reported by 14% of patients each, were weight gain and mood swings. Acne was reported by 10%, hot flushes by 8%, headache by 4%, and nausea by 3%.

The most common prescription upon discontinuation was GnRH-agonists plus add-back therapy with norethindrone acetate (52.5%), followed by continuous estrogen/progesterone (32.5%), Dr. Kaser said.

Dr. Kaser and Dr. Laufer reports no conflicts of interest.

CHICAGO – Norethindrone acetate is a well-tolerated, effective option to decrease both endometriosis-related pain and bleeding among adolescents.

The synthetic progestin was effective for all stages of endometriosis in a retrospective analysis, and 67% of patients reported no side effects, Dr. Daniel Kaser said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We conclude that progestin-only oral therapy should be considered a valuable tool in adolescents with endometriosis, regardless of stage of disease," he said.

Norethindrone acetate is used in clinical practice in combination with other hormones for contraception and for hormonal suppression of endometriosis-associated pain. To date, there have been no reported studies on the efficacy of oral progestins in adolescents with endometriosis, said Dr. Kaser, a gynecologist with Children’s Hospital Boston.

Dr. Kaser and his colleague, Dr. Mark Laufer, chief of gynecology at Children’s, reported on 129 adolescents with surgically diagnosed endometriosis treated with norethindrone acetate from 1992 to 2010 by one gynecologist at a single children’s hospital. From a starting dose of 5 mg, patients were asked to self-titrate by increasing doses of 2.5-mg increments over the course of 2 weeks until they induced amenorrhea and had decreased pain. In the analysis, 68% achieved the maximum approved dose of 15 mg.

Consistent with clinical experience and other reports, most of the patients had early-stage disease (100 patients had stage 1, 25 had stage 2, none had stage 3, and 4 had stage 4). Their mean age was 16.4 years (range, 12-21 years) and mean body mass index was 23.9 kg/m² (range 12-37 kg/m²).

The most common indication for progestin-only therapy was failure of combined oral contraceptives (53.5%), followed by migraine headaches with aura (25%), he said.

When all stages of endometriosis were pooled, norethindrone acetate significantly reduced the self-reported mean pain score from 5.6 to 2.6 and mean bleeding score from 7.2 to 3.4, Dr. Kaser said. When stratified by disease severity, norethindrone acetate still significantly reduced pain and bleeding scores in all stages of endometriosis.

Mean pain scores decreased for patients with stage-1 disease from 7.2 at baseline to 3.4 at the most recent clinic visit or upon discontinuation, from 5.6 to 2.8 for stage 2, and from 7 to 1.3 for stage 4. Mean bleeding scores decreased from 2.1 to 0.5 (stage 1), from 1.6 to 0.2 (stage 2), and from 1.5 to 0 (stage 4).

"Due to the fact that all of these patients have surgically confirmed endometriosis, we feel the study population is homogenous and the results should be externally valid to adolescents with endometriosis," he said.

The average duration of therapy was 11.3 months (range, 1-36 months), with 69% of patients still using norethindrone acetate at their most recent visit. Among those who stopped therapy, 70% did so because of persistent pain or bleeding. Interestingly, 15.5% of patients actually down-titrated their dose because of the persistence of pain, and of those who did, 60% had success on the lower dose, he said.

The most common side effects, reported by 14% of patients each, were weight gain and mood swings. Acne was reported by 10%, hot flushes by 8%, headache by 4%, and nausea by 3%.

The most common prescription upon discontinuation was GnRH-agonists plus add-back therapy with norethindrone acetate (52.5%), followed by continuous estrogen/progesterone (32.5%), Dr. Kaser said.

Dr. Kaser and Dr. Laufer reports no conflicts of interest.

CHICAGO – Norethindrone acetate is a well-tolerated, effective option to decrease both endometriosis-related pain and bleeding among adolescents.

The synthetic progestin was effective for all stages of endometriosis in a retrospective analysis, and 67% of patients reported no side effects, Dr. Daniel Kaser said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We conclude that progestin-only oral therapy should be considered a valuable tool in adolescents with endometriosis, regardless of stage of disease," he said.

Norethindrone acetate is used in clinical practice in combination with other hormones for contraception and for hormonal suppression of endometriosis-associated pain. To date, there have been no reported studies on the efficacy of oral progestins in adolescents with endometriosis, said Dr. Kaser, a gynecologist with Children’s Hospital Boston.

Dr. Kaser and his colleague, Dr. Mark Laufer, chief of gynecology at Children’s, reported on 129 adolescents with surgically diagnosed endometriosis treated with norethindrone acetate from 1992 to 2010 by one gynecologist at a single children’s hospital. From a starting dose of 5 mg, patients were asked to self-titrate by increasing doses of 2.5-mg increments over the course of 2 weeks until they induced amenorrhea and had decreased pain. In the analysis, 68% achieved the maximum approved dose of 15 mg.

Consistent with clinical experience and other reports, most of the patients had early-stage disease (100 patients had stage 1, 25 had stage 2, none had stage 3, and 4 had stage 4). Their mean age was 16.4 years (range, 12-21 years) and mean body mass index was 23.9 kg/m² (range 12-37 kg/m²).

The most common indication for progestin-only therapy was failure of combined oral contraceptives (53.5%), followed by migraine headaches with aura (25%), he said.

When all stages of endometriosis were pooled, norethindrone acetate significantly reduced the self-reported mean pain score from 5.6 to 2.6 and mean bleeding score from 7.2 to 3.4, Dr. Kaser said. When stratified by disease severity, norethindrone acetate still significantly reduced pain and bleeding scores in all stages of endometriosis.

Mean pain scores decreased for patients with stage-1 disease from 7.2 at baseline to 3.4 at the most recent clinic visit or upon discontinuation, from 5.6 to 2.8 for stage 2, and from 7 to 1.3 for stage 4. Mean bleeding scores decreased from 2.1 to 0.5 (stage 1), from 1.6 to 0.2 (stage 2), and from 1.5 to 0 (stage 4).

"Due to the fact that all of these patients have surgically confirmed endometriosis, we feel the study population is homogenous and the results should be externally valid to adolescents with endometriosis," he said.

The average duration of therapy was 11.3 months (range, 1-36 months), with 69% of patients still using norethindrone acetate at their most recent visit. Among those who stopped therapy, 70% did so because of persistent pain or bleeding. Interestingly, 15.5% of patients actually down-titrated their dose because of the persistence of pain, and of those who did, 60% had success on the lower dose, he said.

The most common side effects, reported by 14% of patients each, were weight gain and mood swings. Acne was reported by 10%, hot flushes by 8%, headache by 4%, and nausea by 3%.

The most common prescription upon discontinuation was GnRH-agonists plus add-back therapy with norethindrone acetate (52.5%), followed by continuous estrogen/progesterone (32.5%), Dr. Kaser said.

Dr. Kaser and Dr. Laufer reports no conflicts of interest.

CHICAGO – Norethindrone acetate is a well-tolerated, effective option to decrease both endometriosis-related pain and bleeding among adolescents.

The synthetic progestin was effective for all stages of endometriosis in a retrospective analysis, and 67% of patients reported no side effects, Dr. Daniel Kaser said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We conclude that progestin-only oral therapy should be considered a valuable tool in adolescents with endometriosis, regardless of stage of disease," he said.

Norethindrone acetate is used in clinical practice in combination with other hormones for contraception and for hormonal suppression of endometriosis-associated pain. To date, there have been no reported studies on the efficacy of oral progestins in adolescents with endometriosis, said Dr. Kaser, a gynecologist with Children’s Hospital Boston.

Dr. Kaser and his colleague, Dr. Mark Laufer, chief of gynecology at Children’s, reported on 129 adolescents with surgically diagnosed endometriosis treated with norethindrone acetate from 1992 to 2010 by one gynecologist at a single children’s hospital. From a starting dose of 5 mg, patients were asked to self-titrate by increasing doses of 2.5-mg increments over the course of 2 weeks until they induced amenorrhea and had decreased pain. In the analysis, 68% achieved the maximum approved dose of 15 mg.

Consistent with clinical experience and other reports, most of the patients had early-stage disease (100 patients had stage 1, 25 had stage 2, none had stage 3, and 4 had stage 4). Their mean age was 16.4 years (range, 12-21 years) and mean body mass index was 23.9 kg/m² (range 12-37 kg/m²).

The most common indication for progestin-only therapy was failure of combined oral contraceptives (53.5%), followed by migraine headaches with aura (25%), he said.

When all stages of endometriosis were pooled, norethindrone acetate significantly reduced the self-reported mean pain score from 5.6 to 2.6 and mean bleeding score from 7.2 to 3.4, Dr. Kaser said. When stratified by disease severity, norethindrone acetate still significantly reduced pain and bleeding scores in all stages of endometriosis.

Mean pain scores decreased for patients with stage-1 disease from 7.2 at baseline to 3.4 at the most recent clinic visit or upon discontinuation, from 5.6 to 2.8 for stage 2, and from 7 to 1.3 for stage 4. Mean bleeding scores decreased from 2.1 to 0.5 (stage 1), from 1.6 to 0.2 (stage 2), and from 1.5 to 0 (stage 4).

"Due to the fact that all of these patients have surgically confirmed endometriosis, we feel the study population is homogenous and the results should be externally valid to adolescents with endometriosis," he said.

The average duration of therapy was 11.3 months (range, 1-36 months), with 69% of patients still using norethindrone acetate at their most recent visit. Among those who stopped therapy, 70% did so because of persistent pain or bleeding. Interestingly, 15.5% of patients actually down-titrated their dose because of the persistence of pain, and of those who did, 60% had success on the lower dose, he said.

The most common side effects, reported by 14% of patients each, were weight gain and mood swings. Acne was reported by 10%, hot flushes by 8%, headache by 4%, and nausea by 3%.

The most common prescription upon discontinuation was GnRH-agonists plus add-back therapy with norethindrone acetate (52.5%), followed by continuous estrogen/progesterone (32.5%), Dr. Kaser said.

Dr. Kaser and Dr. Laufer reports no conflicts of interest.

CHICAGO – Norethindrone acetate is a well-tolerated, effective option to decrease both endometriosis-related pain and bleeding among adolescents.

The synthetic progestin was effective for all stages of endometriosis in a retrospective analysis, and 67% of patients reported no side effects, Dr. Daniel Kaser said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"We conclude that progestin-only oral therapy should be considered a valuable tool in adolescents with endometriosis, regardless of stage of disease," he said.

Norethindrone acetate is used in clinical practice in combination with other hormones for contraception and for hormonal suppression of endometriosis-associated pain. To date, there have been no reported studies on the efficacy of oral progestins in adolescents with endometriosis, said Dr. Kaser, a gynecologist with Children’s Hospital Boston.

Dr. Kaser and his colleague, Dr. Mark Laufer, chief of gynecology at Children’s, reported on 129 adolescents with surgically diagnosed endometriosis treated with norethindrone acetate from 1992 to 2010 by one gynecologist at a single children’s hospital. From a starting dose of 5 mg, patients were asked to self-titrate by increasing doses of 2.5-mg increments over the course of 2 weeks until they induced amenorrhea and had decreased pain. In the analysis, 68% achieved the maximum approved dose of 15 mg.

Consistent with clinical experience and other reports, most of the patients had early-stage disease (100 patients had stage 1, 25 had stage 2, none had stage 3, and 4 had stage 4). Their mean age was 16.4 years (range, 12-21 years) and mean body mass index was 23.9 kg/m² (range 12-37 kg/m²).

The most common indication for progestin-only therapy was failure of combined oral contraceptives (53.5%), followed by migraine headaches with aura (25%), he said.

When all stages of endometriosis were pooled, norethindrone acetate significantly reduced the self-reported mean pain score from 5.6 to 2.6 and mean bleeding score from 7.2 to 3.4, Dr. Kaser said. When stratified by disease severity, norethindrone acetate still significantly reduced pain and bleeding scores in all stages of endometriosis.

Mean pain scores decreased for patients with stage-1 disease from 7.2 at baseline to 3.4 at the most recent clinic visit or upon discontinuation, from 5.6 to 2.8 for stage 2, and from 7 to 1.3 for stage 4. Mean bleeding scores decreased from 2.1 to 0.5 (stage 1), from 1.6 to 0.2 (stage 2), and from 1.5 to 0 (stage 4).

"Due to the fact that all of these patients have surgically confirmed endometriosis, we feel the study population is homogenous and the results should be externally valid to adolescents with endometriosis," he said.

The average duration of therapy was 11.3 months (range, 1-36 months), with 69% of patients still using norethindrone acetate at their most recent visit. Among those who stopped therapy, 70% did so because of persistent pain or bleeding. Interestingly, 15.5% of patients actually down-titrated their dose because of the persistence of pain, and of those who did, 60% had success on the lower dose, he said.

The most common side effects, reported by 14% of patients each, were weight gain and mood swings. Acne was reported by 10%, hot flushes by 8%, headache by 4%, and nausea by 3%.

The most common prescription upon discontinuation was GnRH-agonists plus add-back therapy with norethindrone acetate (52.5%), followed by continuous estrogen/progesterone (32.5%), Dr. Kaser said.

Dr. Kaser and Dr. Laufer reports no conflicts of interest.

CHICAGO – Standard platelet aggregation studies were not sufficiently sensitive in detecting platelet function disorders in 40% of 35 adolescents with menorrhagia, a study has shown.

All 14 teens were subsequently diagnosed with dense granule platelet storage pool deficiency by electron microscopy, Dr. Lawrence Amesse said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Normal platelet aggregation testing in this subset does not exclude additional studies, particularly if there’s a high clinical suspicion and a family history of bleeding tendencies," he said. "Further studies to consider are electron microscopy or lumi-aggregometry, if available, to identify or exclude storage pool deficiencies."

He pointed out that electron microscopy is not feasible in all patients at roughly $500 vs. just $100 for standard platelet aggregation testing, which is increasingly being used to identify platelet function disorders (PFDs) as an etiology of menorrhagia.

Still, standard aggregation testing is difficult and time consuming to conduct, is subject to a wide range of variables, and lacks standardization. Testing with at least two agonists is associated with a significantly higher likelihood of detecting true PFDs, but also creates a clinical dilemma because it would exclude patients having impaired aggregation with only one agonist, explained Dr. Amesse, professor of obstetrics and gynecology and professor of pediatrics at Wright State University in Dayton, Ohio.

He reported on a retrospective analysis of 35 adolescents with PFDs and unexplained menorrhagia who underwent light transmission aggregometry studies using a PACKS-4 (Platelet Aggregation Chromogenic Kinetics System-4) aggregometer with five standard agonists. Aggregation was considered defective when the maximum percentage for platelet aggregation responsiveness was less than reference ranges with at least one agonist.

Interestingly, the girls had normal values of hematocrit, mean corpuscular volume, platelet counts and morphology, prothrombin time, and activated partial thromboplastin time, he said. They were negative for all von Willebrand factor assay studies and had an average pictorial blood loss assessment chart score of more than 100. Their average age was 14.5 years and they began menstruating at a mean age of 11.8 years. The majority (81%) were white and 84% had a family history of bleeding tendencies.

In all, 21 girls (60%) had abnormal aggregation responsiveness with at least one agonist, Dr. Amesse said. Nine girls (43%) had impaired responsiveness with one agonist, six girls (28.6%) with two agonists, and six girls (28.6%) with three or more agonists.

Epinephrine was the most common agonist to elicit reduced aggregation responsiveness (57%), followed by adenosine diphosphate, or ADP (48%), ristocetin (38%), arachidonic acid (24%), and collagen (9.5%).

Of the 14 girls who had impaired platelet aggregation responsiveness with epinephrine, 64% also had reduced aggregation responsiveness with other agonists. The same was true for 70% of the girls who had abnormal aggregation responsiveness with ADP, and for 100% with ristocetin, 80% with arachidonic acid, and 50% with collagen.

"Impaired agonist-induced aggregation patterns showed marked variability," he said.

Overall, 14 of the 35 teens (40%) had normal platelet aggregation responsiveness with all five agonists, and, as noted, were subsequently diagnosed with dense granule storage pool deficiency using electron microscopy. Dense granule deficiency is one of four major types of congenital platelet storage pool disorders that have been identified, and is thought to result in prolonged bleeding times because of reduced release of ADP by platelet-dense granules. Clinical features of storage pool disorders include nosebleeds, menorrhagia, easy bruising, recurrent anemia, and obstetric or surgical bleeding.

An audience member asked whether the girls had other bleeding symptoms and whether they started off with normal periods and developed menorrhagia later on. Dr. Amesse replied that two-thirds had other bleeding symptoms such as nosebleeds and easy bruising, and that most began menstruating normally. He pointed out that contrary to other studies in von Willebrand’s disease, all of the girls had normal hematocrit and hemoglobin levels, suggesting a chronic rather than an acute presentation.

When asked how the girls were treated, he said they were typically treated with oral contraceptives.

Dr. Amesse reported receiving a grant from the CSL Behring Foundation.

CHICAGO – Standard platelet aggregation studies were not sufficiently sensitive in detecting platelet function disorders in 40% of 35 adolescents with menorrhagia, a study has shown.

All 14 teens were subsequently diagnosed with dense granule platelet storage pool deficiency by electron microscopy, Dr. Lawrence Amesse said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Normal platelet aggregation testing in this subset does not exclude additional studies, particularly if there’s a high clinical suspicion and a family history of bleeding tendencies," he said. "Further studies to consider are electron microscopy or lumi-aggregometry, if available, to identify or exclude storage pool deficiencies."

He pointed out that electron microscopy is not feasible in all patients at roughly $500 vs. just $100 for standard platelet aggregation testing, which is increasingly being used to identify platelet function disorders (PFDs) as an etiology of menorrhagia.

Still, standard aggregation testing is difficult and time consuming to conduct, is subject to a wide range of variables, and lacks standardization. Testing with at least two agonists is associated with a significantly higher likelihood of detecting true PFDs, but also creates a clinical dilemma because it would exclude patients having impaired aggregation with only one agonist, explained Dr. Amesse, professor of obstetrics and gynecology and professor of pediatrics at Wright State University in Dayton, Ohio.

He reported on a retrospective analysis of 35 adolescents with PFDs and unexplained menorrhagia who underwent light transmission aggregometry studies using a PACKS-4 (Platelet Aggregation Chromogenic Kinetics System-4) aggregometer with five standard agonists. Aggregation was considered defective when the maximum percentage for platelet aggregation responsiveness was less than reference ranges with at least one agonist.

Interestingly, the girls had normal values of hematocrit, mean corpuscular volume, platelet counts and morphology, prothrombin time, and activated partial thromboplastin time, he said. They were negative for all von Willebrand factor assay studies and had an average pictorial blood loss assessment chart score of more than 100. Their average age was 14.5 years and they began menstruating at a mean age of 11.8 years. The majority (81%) were white and 84% had a family history of bleeding tendencies.

In all, 21 girls (60%) had abnormal aggregation responsiveness with at least one agonist, Dr. Amesse said. Nine girls (43%) had impaired responsiveness with one agonist, six girls (28.6%) with two agonists, and six girls (28.6%) with three or more agonists.

Epinephrine was the most common agonist to elicit reduced aggregation responsiveness (57%), followed by adenosine diphosphate, or ADP (48%), ristocetin (38%), arachidonic acid (24%), and collagen (9.5%).

Of the 14 girls who had impaired platelet aggregation responsiveness with epinephrine, 64% also had reduced aggregation responsiveness with other agonists. The same was true for 70% of the girls who had abnormal aggregation responsiveness with ADP, and for 100% with ristocetin, 80% with arachidonic acid, and 50% with collagen.

"Impaired agonist-induced aggregation patterns showed marked variability," he said.

Overall, 14 of the 35 teens (40%) had normal platelet aggregation responsiveness with all five agonists, and, as noted, were subsequently diagnosed with dense granule storage pool deficiency using electron microscopy. Dense granule deficiency is one of four major types of congenital platelet storage pool disorders that have been identified, and is thought to result in prolonged bleeding times because of reduced release of ADP by platelet-dense granules. Clinical features of storage pool disorders include nosebleeds, menorrhagia, easy bruising, recurrent anemia, and obstetric or surgical bleeding.

An audience member asked whether the girls had other bleeding symptoms and whether they started off with normal periods and developed menorrhagia later on. Dr. Amesse replied that two-thirds had other bleeding symptoms such as nosebleeds and easy bruising, and that most began menstruating normally. He pointed out that contrary to other studies in von Willebrand’s disease, all of the girls had normal hematocrit and hemoglobin levels, suggesting a chronic rather than an acute presentation.

When asked how the girls were treated, he said they were typically treated with oral contraceptives.

Dr. Amesse reported receiving a grant from the CSL Behring Foundation.

CHICAGO – Standard platelet aggregation studies were not sufficiently sensitive in detecting platelet function disorders in 40% of 35 adolescents with menorrhagia, a study has shown.

All 14 teens were subsequently diagnosed with dense granule platelet storage pool deficiency by electron microscopy, Dr. Lawrence Amesse said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Normal platelet aggregation testing in this subset does not exclude additional studies, particularly if there’s a high clinical suspicion and a family history of bleeding tendencies," he said. "Further studies to consider are electron microscopy or lumi-aggregometry, if available, to identify or exclude storage pool deficiencies."

He pointed out that electron microscopy is not feasible in all patients at roughly $500 vs. just $100 for standard platelet aggregation testing, which is increasingly being used to identify platelet function disorders (PFDs) as an etiology of menorrhagia.

Still, standard aggregation testing is difficult and time consuming to conduct, is subject to a wide range of variables, and lacks standardization. Testing with at least two agonists is associated with a significantly higher likelihood of detecting true PFDs, but also creates a clinical dilemma because it would exclude patients having impaired aggregation with only one agonist, explained Dr. Amesse, professor of obstetrics and gynecology and professor of pediatrics at Wright State University in Dayton, Ohio.

He reported on a retrospective analysis of 35 adolescents with PFDs and unexplained menorrhagia who underwent light transmission aggregometry studies using a PACKS-4 (Platelet Aggregation Chromogenic Kinetics System-4) aggregometer with five standard agonists. Aggregation was considered defective when the maximum percentage for platelet aggregation responsiveness was less than reference ranges with at least one agonist.

Interestingly, the girls had normal values of hematocrit, mean corpuscular volume, platelet counts and morphology, prothrombin time, and activated partial thromboplastin time, he said. They were negative for all von Willebrand factor assay studies and had an average pictorial blood loss assessment chart score of more than 100. Their average age was 14.5 years and they began menstruating at a mean age of 11.8 years. The majority (81%) were white and 84% had a family history of bleeding tendencies.

In all, 21 girls (60%) had abnormal aggregation responsiveness with at least one agonist, Dr. Amesse said. Nine girls (43%) had impaired responsiveness with one agonist, six girls (28.6%) with two agonists, and six girls (28.6%) with three or more agonists.

Epinephrine was the most common agonist to elicit reduced aggregation responsiveness (57%), followed by adenosine diphosphate, or ADP (48%), ristocetin (38%), arachidonic acid (24%), and collagen (9.5%).

Of the 14 girls who had impaired platelet aggregation responsiveness with epinephrine, 64% also had reduced aggregation responsiveness with other agonists. The same was true for 70% of the girls who had abnormal aggregation responsiveness with ADP, and for 100% with ristocetin, 80% with arachidonic acid, and 50% with collagen.

"Impaired agonist-induced aggregation patterns showed marked variability," he said.

Overall, 14 of the 35 teens (40%) had normal platelet aggregation responsiveness with all five agonists, and, as noted, were subsequently diagnosed with dense granule storage pool deficiency using electron microscopy. Dense granule deficiency is one of four major types of congenital platelet storage pool disorders that have been identified, and is thought to result in prolonged bleeding times because of reduced release of ADP by platelet-dense granules. Clinical features of storage pool disorders include nosebleeds, menorrhagia, easy bruising, recurrent anemia, and obstetric or surgical bleeding.

An audience member asked whether the girls had other bleeding symptoms and whether they started off with normal periods and developed menorrhagia later on. Dr. Amesse replied that two-thirds had other bleeding symptoms such as nosebleeds and easy bruising, and that most began menstruating normally. He pointed out that contrary to other studies in von Willebrand’s disease, all of the girls had normal hematocrit and hemoglobin levels, suggesting a chronic rather than an acute presentation.

When asked how the girls were treated, he said they were typically treated with oral contraceptives.

Dr. Amesse reported receiving a grant from the CSL Behring Foundation.

CHICAGO – Standard platelet aggregation studies were not sufficiently sensitive in detecting platelet function disorders in 40% of 35 adolescents with menorrhagia, a study has shown.

All 14 teens were subsequently diagnosed with dense granule platelet storage pool deficiency by electron microscopy, Dr. Lawrence Amesse said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Normal platelet aggregation testing in this subset does not exclude additional studies, particularly if there’s a high clinical suspicion and a family history of bleeding tendencies," he said. "Further studies to consider are electron microscopy or lumi-aggregometry, if available, to identify or exclude storage pool deficiencies."

He pointed out that electron microscopy is not feasible in all patients at roughly $500 vs. just $100 for standard platelet aggregation testing, which is increasingly being used to identify platelet function disorders (PFDs) as an etiology of menorrhagia.

Still, standard aggregation testing is difficult and time consuming to conduct, is subject to a wide range of variables, and lacks standardization. Testing with at least two agonists is associated with a significantly higher likelihood of detecting true PFDs, but also creates a clinical dilemma because it would exclude patients having impaired aggregation with only one agonist, explained Dr. Amesse, professor of obstetrics and gynecology and professor of pediatrics at Wright State University in Dayton, Ohio.

He reported on a retrospective analysis of 35 adolescents with PFDs and unexplained menorrhagia who underwent light transmission aggregometry studies using a PACKS-4 (Platelet Aggregation Chromogenic Kinetics System-4) aggregometer with five standard agonists. Aggregation was considered defective when the maximum percentage for platelet aggregation responsiveness was less than reference ranges with at least one agonist.

Interestingly, the girls had normal values of hematocrit, mean corpuscular volume, platelet counts and morphology, prothrombin time, and activated partial thromboplastin time, he said. They were negative for all von Willebrand factor assay studies and had an average pictorial blood loss assessment chart score of more than 100. Their average age was 14.5 years and they began menstruating at a mean age of 11.8 years. The majority (81%) were white and 84% had a family history of bleeding tendencies.

In all, 21 girls (60%) had abnormal aggregation responsiveness with at least one agonist, Dr. Amesse said. Nine girls (43%) had impaired responsiveness with one agonist, six girls (28.6%) with two agonists, and six girls (28.6%) with three or more agonists.

Epinephrine was the most common agonist to elicit reduced aggregation responsiveness (57%), followed by adenosine diphosphate, or ADP (48%), ristocetin (38%), arachidonic acid (24%), and collagen (9.5%).

Of the 14 girls who had impaired platelet aggregation responsiveness with epinephrine, 64% also had reduced aggregation responsiveness with other agonists. The same was true for 70% of the girls who had abnormal aggregation responsiveness with ADP, and for 100% with ristocetin, 80% with arachidonic acid, and 50% with collagen.

"Impaired agonist-induced aggregation patterns showed marked variability," he said.

Overall, 14 of the 35 teens (40%) had normal platelet aggregation responsiveness with all five agonists, and, as noted, were subsequently diagnosed with dense granule storage pool deficiency using electron microscopy. Dense granule deficiency is one of four major types of congenital platelet storage pool disorders that have been identified, and is thought to result in prolonged bleeding times because of reduced release of ADP by platelet-dense granules. Clinical features of storage pool disorders include nosebleeds, menorrhagia, easy bruising, recurrent anemia, and obstetric or surgical bleeding.

An audience member asked whether the girls had other bleeding symptoms and whether they started off with normal periods and developed menorrhagia later on. Dr. Amesse replied that two-thirds had other bleeding symptoms such as nosebleeds and easy bruising, and that most began menstruating normally. He pointed out that contrary to other studies in von Willebrand’s disease, all of the girls had normal hematocrit and hemoglobin levels, suggesting a chronic rather than an acute presentation.

When asked how the girls were treated, he said they were typically treated with oral contraceptives.

Dr. Amesse reported receiving a grant from the CSL Behring Foundation.

CHICAGO – Standard platelet aggregation studies were not sufficiently sensitive in detecting platelet function disorders in 40% of 35 adolescents with menorrhagia, a study has shown.

All 14 teens were subsequently diagnosed with dense granule platelet storage pool deficiency by electron microscopy, Dr. Lawrence Amesse said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Normal platelet aggregation testing in this subset does not exclude additional studies, particularly if there’s a high clinical suspicion and a family history of bleeding tendencies," he said. "Further studies to consider are electron microscopy or lumi-aggregometry, if available, to identify or exclude storage pool deficiencies."

He pointed out that electron microscopy is not feasible in all patients at roughly $500 vs. just $100 for standard platelet aggregation testing, which is increasingly being used to identify platelet function disorders (PFDs) as an etiology of menorrhagia.

Still, standard aggregation testing is difficult and time consuming to conduct, is subject to a wide range of variables, and lacks standardization. Testing with at least two agonists is associated with a significantly higher likelihood of detecting true PFDs, but also creates a clinical dilemma because it would exclude patients having impaired aggregation with only one agonist, explained Dr. Amesse, professor of obstetrics and gynecology and professor of pediatrics at Wright State University in Dayton, Ohio.

He reported on a retrospective analysis of 35 adolescents with PFDs and unexplained menorrhagia who underwent light transmission aggregometry studies using a PACKS-4 (Platelet Aggregation Chromogenic Kinetics System-4) aggregometer with five standard agonists. Aggregation was considered defective when the maximum percentage for platelet aggregation responsiveness was less than reference ranges with at least one agonist.

Interestingly, the girls had normal values of hematocrit, mean corpuscular volume, platelet counts and morphology, prothrombin time, and activated partial thromboplastin time, he said. They were negative for all von Willebrand factor assay studies and had an average pictorial blood loss assessment chart score of more than 100. Their average age was 14.5 years and they began menstruating at a mean age of 11.8 years. The majority (81%) were white and 84% had a family history of bleeding tendencies.

In all, 21 girls (60%) had abnormal aggregation responsiveness with at least one agonist, Dr. Amesse said. Nine girls (43%) had impaired responsiveness with one agonist, six girls (28.6%) with two agonists, and six girls (28.6%) with three or more agonists.

Epinephrine was the most common agonist to elicit reduced aggregation responsiveness (57%), followed by adenosine diphosphate, or ADP (48%), ristocetin (38%), arachidonic acid (24%), and collagen (9.5%).

Of the 14 girls who had impaired platelet aggregation responsiveness with epinephrine, 64% also had reduced aggregation responsiveness with other agonists. The same was true for 70% of the girls who had abnormal aggregation responsiveness with ADP, and for 100% with ristocetin, 80% with arachidonic acid, and 50% with collagen.

"Impaired agonist-induced aggregation patterns showed marked variability," he said.

Overall, 14 of the 35 teens (40%) had normal platelet aggregation responsiveness with all five agonists, and, as noted, were subsequently diagnosed with dense granule storage pool deficiency using electron microscopy. Dense granule deficiency is one of four major types of congenital platelet storage pool disorders that have been identified, and is thought to result in prolonged bleeding times because of reduced release of ADP by platelet-dense granules. Clinical features of storage pool disorders include nosebleeds, menorrhagia, easy bruising, recurrent anemia, and obstetric or surgical bleeding.

An audience member asked whether the girls had other bleeding symptoms and whether they started off with normal periods and developed menorrhagia later on. Dr. Amesse replied that two-thirds had other bleeding symptoms such as nosebleeds and easy bruising, and that most began menstruating normally. He pointed out that contrary to other studies in von Willebrand’s disease, all of the girls had normal hematocrit and hemoglobin levels, suggesting a chronic rather than an acute presentation.

When asked how the girls were treated, he said they were typically treated with oral contraceptives.

Dr. Amesse reported receiving a grant from the CSL Behring Foundation.

CHICAGO – Standard platelet aggregation studies were not sufficiently sensitive in detecting platelet function disorders in 40% of 35 adolescents with menorrhagia, a study has shown.

All 14 teens were subsequently diagnosed with dense granule platelet storage pool deficiency by electron microscopy, Dr. Lawrence Amesse said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.

"Normal platelet aggregation testing in this subset does not exclude additional studies, particularly if there’s a high clinical suspicion and a family history of bleeding tendencies," he said. "Further studies to consider are electron microscopy or lumi-aggregometry, if available, to identify or exclude storage pool deficiencies."

He pointed out that electron microscopy is not feasible in all patients at roughly $500 vs. just $100 for standard platelet aggregation testing, which is increasingly being used to identify platelet function disorders (PFDs) as an etiology of menorrhagia.

Still, standard aggregation testing is difficult and time consuming to conduct, is subject to a wide range of variables, and lacks standardization. Testing with at least two agonists is associated with a significantly higher likelihood of detecting true PFDs, but also creates a clinical dilemma because it would exclude patients having impaired aggregation with only one agonist, explained Dr. Amesse, professor of obstetrics and gynecology and professor of pediatrics at Wright State University in Dayton, Ohio.

He reported on a retrospective analysis of 35 adolescents with PFDs and unexplained menorrhagia who underwent light transmission aggregometry studies using a PACKS-4 (Platelet Aggregation Chromogenic Kinetics System-4) aggregometer with five standard agonists. Aggregation was considered defective when the maximum percentage for platelet aggregation responsiveness was less than reference ranges with at least one agonist.

Interestingly, the girls had normal values of hematocrit, mean corpuscular volume, platelet counts and morphology, prothrombin time, and activated partial thromboplastin time, he said. They were negative for all von Willebrand factor assay studies and had an average pictorial blood loss assessment chart score of more than 100. Their average age was 14.5 years and they began menstruating at a mean age of 11.8 years. The majority (81%) were white and 84% had a family history of bleeding tendencies.

In all, 21 girls (60%) had abnormal aggregation responsiveness with at least one agonist, Dr. Amesse said. Nine girls (43%) had impaired responsiveness with one agonist, six girls (28.6%) with two agonists, and six girls (28.6%) with three or more agonists.

Epinephrine was the most common agonist to elicit reduced aggregation responsiveness (57%), followed by adenosine diphosphate, or ADP (48%), ristocetin (38%), arachidonic acid (24%), and collagen (9.5%).

Of the 14 girls who had impaired platelet aggregation responsiveness with epinephrine, 64% also had reduced aggregation responsiveness with other agonists. The same was true for 70% of the girls who had abnormal aggregation responsiveness with ADP, and for 100% with ristocetin, 80% with arachidonic acid, and 50% with collagen.

"Impaired agonist-induced aggregation patterns showed marked variability," he said.

Overall, 14 of the 35 teens (40%) had normal platelet aggregation responsiveness with all five agonists, and, as noted, were subsequently diagnosed with dense granule storage pool deficiency using electron microscopy. Dense granule deficiency is one of four major types of congenital platelet storage pool disorders that have been identified, and is thought to result in prolonged bleeding times because of reduced release of ADP by platelet-dense granules. Clinical features of storage pool disorders include nosebleeds, menorrhagia, easy bruising, recurrent anemia, and obstetric or surgical bleeding.

An audience member asked whether the girls had other bleeding symptoms and whether they started off with normal periods and developed menorrhagia later on. Dr. Amesse replied that two-thirds had other bleeding symptoms such as nosebleeds and easy bruising, and that most began menstruating normally. He pointed out that contrary to other studies in von Willebrand’s disease, all of the girls had normal hematocrit and hemoglobin levels, suggesting a chronic rather than an acute presentation.

When asked how the girls were treated, he said they were typically treated with oral contraceptives.

Dr. Amesse reported receiving a grant from the CSL Behring Foundation.

CHICAGO – Transabdominal antral follicle count measurements are obtainable in girls as young as 4 years and were highly correlated with serum anti-müllerian hormone assays in a cross-sectional substudy.

"These may prove to be very useful measurements of ovarian reserve in these young girls, as they are in reproductive-aged women," lead author Dr. Amber R. Cooper said at the annual meetingof the North American Society for Pediatric and Adolescent Gynecology.

Ovarian reserve screening is frequently used to predict response to gonadotropin stimulation during assisted reproductive technology treatment and for counseling adult women on their overall chance for conception. Data are very scarce on measures of ovarian reserve in premenarchal girls, although several factors such as chemotherapeutic agents, radiation, environmental triggers, and underlying genetic conditions can potentially threaten the oocyte pool and thus fertility.

"There are a lot of patients that you can potentially consider using ovarian reserve screening [for], and in a much younger age group than you probably anticipated," she said. "Those that may have a larger threat to their oocyte pool may ultimately, as technology progresses, warrant discussion about fertility preservation options."

Dr. Cooper and her colleagues screened ovarian reserves at scheduled intervals over a 2-year period in 41 premenarchal girls, aged 4-14 years, who were enrolled in an ongoing prospective study of juvenile and adult rheumatoid arthritis. The girls were subdivided into prepubertal and pubertal based on the onset of breast development. Antral follicle counts were obtained using transabdominal ultrasonography (2-5 MHz) when the patients had a full bladder, and were compared with mean ovarian volume, serum anti-müllerian hormone (AMH) level measured by Elisa assay, and follicle stimulating hormone level. Data from the ongoing parent trial on 31 menarchal girls, within 3 years of menarche, were also used for comparison.

The mean age was 7.2 years for the 28 prepubertal girls (range, 4-12 years); 10.8 years for the 13 pubertal girls (range, 8-13 years); and 13.7 years for the early menarchal girls (range, 10-16 years). The girls had a mean body mass index (BMI) of 16 kg/m², 23.5 kg/m², and 22.8 kg/m², respectively.

The mean antral follicle count was 15.9 in the prepubertal group, 21.5 in the pubertal group, and 20.4 in the early menarchal group, said Dr. Cooper of the division of reproductive endocrinology and infertility at Washington University in St. Louis.

One ovary was visualized on ultrasound in 94% of prepubertal girls and 86% of pubertal girls, and both ovaries were visualized in 71% and 57%. By comparison, a single ovary was visualized in 94% of girls with early menarche and two ovaries in 83%.

The mean AMH level was 2.97 ng/mL in the prepubertal group and 3.46 ng/mL in the pubertal group, vs. 3.74 ng/mL in the early menarchal girls.

Same-day AMH level was correlated with antral follicle count in all premenarchal girls, with a correlation coefficient, or r value, of 0.6, she said. The r value was 0.7 for the menarchal girls and 0.6 for reproductive-age women in the parent trial.

In multivariable regression analysis that controlled for BMI, hormonal contraception, and number of ovaries visualized, the AMH level was significantly associated with the antral follicle count (P value less than .001).

When asked by the audience whether the researchers controlled for variability that exists between sonographers, Dr. Cooper replied that the study used three dedicated sonographers and that intra- and intersonography correlation was very good when analyzed.

Another attendee questioned whether transabdominal antral follicle count data are transferable to data obtained with transvaginal scans.

Dr. Cooper replied, "I just don’t think we have enough data yet to say we can use transabdominal scans in these young girls, and that’s intentionally why I tried to correlate it with the same-day AMH measure to show that these measures are correlated," she said. "I think it is something that we can consider and further study."

An international group of specialist reproductive medicine clinicians and scientists recently convened to provide practical recommendations addressing the considerable variability that exists in the clinical definitions and technical methods used to count and measure antral follicles in research trials and clinical practice (Fertil. Steril. 2010;94:1044-51). In clinical practice, they recommend selecting patients with regular menstrual cycles, counting follicles between days 2 and 4 of a spontaneous menstrual or oral contraceptive cycle, and including all antral follicles 2-10 mm in diameter. It is suggested that a limited number of staff, adequately trained in transvaginal sonography, should perform antral follicle counts using real-time, two-dimensional imaging with a transvaginal transducer and a probe with a minimum frequency of 7 MHz.

Dr. Cooper said she has received study support for the ongoing study from Washington University and the National Institutes of Health. Provision of the serum assays to an independent lab was provided by Beckman Coulter.

CHICAGO – Transabdominal antral follicle count measurements are obtainable in girls as young as 4 years and were highly correlated with serum anti-müllerian hormone assays in a cross-sectional substudy.

"These may prove to be very useful measurements of ovarian reserve in these young girls, as they are in reproductive-aged women," lead author Dr. Amber R. Cooper said at the annual meetingof the North American Society for Pediatric and Adolescent Gynecology.

Ovarian reserve screening is frequently used to predict response to gonadotropin stimulation during assisted reproductive technology treatment and for counseling adult women on their overall chance for conception. Data are very scarce on measures of ovarian reserve in premenarchal girls, although several factors such as chemotherapeutic agents, radiation, environmental triggers, and underlying genetic conditions can potentially threaten the oocyte pool and thus fertility.

"There are a lot of patients that you can potentially consider using ovarian reserve screening [for], and in a much younger age group than you probably anticipated," she said. "Those that may have a larger threat to their oocyte pool may ultimately, as technology progresses, warrant discussion about fertility preservation options."

Dr. Cooper and her colleagues screened ovarian reserves at scheduled intervals over a 2-year period in 41 premenarchal girls, aged 4-14 years, who were enrolled in an ongoing prospective study of juvenile and adult rheumatoid arthritis. The girls were subdivided into prepubertal and pubertal based on the onset of breast development. Antral follicle counts were obtained using transabdominal ultrasonography (2-5 MHz) when the patients had a full bladder, and were compared with mean ovarian volume, serum anti-müllerian hormone (AMH) level measured by Elisa assay, and follicle stimulating hormone level. Data from the ongoing parent trial on 31 menarchal girls, within 3 years of menarche, were also used for comparison.

The mean age was 7.2 years for the 28 prepubertal girls (range, 4-12 years); 10.8 years for the 13 pubertal girls (range, 8-13 years); and 13.7 years for the early menarchal girls (range, 10-16 years). The girls had a mean body mass index (BMI) of 16 kg/m², 23.5 kg/m², and 22.8 kg/m², respectively.

The mean antral follicle count was 15.9 in the prepubertal group, 21.5 in the pubertal group, and 20.4 in the early menarchal group, said Dr. Cooper of the division of reproductive endocrinology and infertility at Washington University in St. Louis.

One ovary was visualized on ultrasound in 94% of prepubertal girls and 86% of pubertal girls, and both ovaries were visualized in 71% and 57%. By comparison, a single ovary was visualized in 94% of girls with early menarche and two ovaries in 83%.

The mean AMH level was 2.97 ng/mL in the prepubertal group and 3.46 ng/mL in the pubertal group, vs. 3.74 ng/mL in the early menarchal girls.

Same-day AMH level was correlated with antral follicle count in all premenarchal girls, with a correlation coefficient, or r value, of 0.6, she said. The r value was 0.7 for the menarchal girls and 0.6 for reproductive-age women in the parent trial.

In multivariable regression analysis that controlled for BMI, hormonal contraception, and number of ovaries visualized, the AMH level was significantly associated with the antral follicle count (P value less than .001).

When asked by the audience whether the researchers controlled for variability that exists between sonographers, Dr. Cooper replied that the study used three dedicated sonographers and that intra- and intersonography correlation was very good when analyzed.

Another attendee questioned whether transabdominal antral follicle count data are transferable to data obtained with transvaginal scans.

Dr. Cooper replied, "I just don’t think we have enough data yet to say we can use transabdominal scans in these young girls, and that’s intentionally why I tried to correlate it with the same-day AMH measure to show that these measures are correlated," she said. "I think it is something that we can consider and further study."

An international group of specialist reproductive medicine clinicians and scientists recently convened to provide practical recommendations addressing the considerable variability that exists in the clinical definitions and technical methods used to count and measure antral follicles in research trials and clinical practice (Fertil. Steril. 2010;94:1044-51). In clinical practice, they recommend selecting patients with regular menstrual cycles, counting follicles between days 2 and 4 of a spontaneous menstrual or oral contraceptive cycle, and including all antral follicles 2-10 mm in diameter. It is suggested that a limited number of staff, adequately trained in transvaginal sonography, should perform antral follicle counts using real-time, two-dimensional imaging with a transvaginal transducer and a probe with a minimum frequency of 7 MHz.

Dr. Cooper said she has received study support for the ongoing study from Washington University and the National Institutes of Health. Provision of the serum assays to an independent lab was provided by Beckman Coulter.

CHICAGO – Transabdominal antral follicle count measurements are obtainable in girls as young as 4 years and were highly correlated with serum anti-müllerian hormone assays in a cross-sectional substudy.

"These may prove to be very useful measurements of ovarian reserve in these young girls, as they are in reproductive-aged women," lead author Dr. Amber R. Cooper said at the annual meetingof the North American Society for Pediatric and Adolescent Gynecology.

Ovarian reserve screening is frequently used to predict response to gonadotropin stimulation during assisted reproductive technology treatment and for counseling adult women on their overall chance for conception. Data are very scarce on measures of ovarian reserve in premenarchal girls, although several factors such as chemotherapeutic agents, radiation, environmental triggers, and underlying genetic conditions can potentially threaten the oocyte pool and thus fertility.

"There are a lot of patients that you can potentially consider using ovarian reserve screening [for], and in a much younger age group than you probably anticipated," she said. "Those that may have a larger threat to their oocyte pool may ultimately, as technology progresses, warrant discussion about fertility preservation options."

Dr. Cooper and her colleagues screened ovarian reserves at scheduled intervals over a 2-year period in 41 premenarchal girls, aged 4-14 years, who were enrolled in an ongoing prospective study of juvenile and adult rheumatoid arthritis. The girls were subdivided into prepubertal and pubertal based on the onset of breast development. Antral follicle counts were obtained using transabdominal ultrasonography (2-5 MHz) when the patients had a full bladder, and were compared with mean ovarian volume, serum anti-müllerian hormone (AMH) level measured by Elisa assay, and follicle stimulating hormone level. Data from the ongoing parent trial on 31 menarchal girls, within 3 years of menarche, were also used for comparison.

The mean age was 7.2 years for the 28 prepubertal girls (range, 4-12 years); 10.8 years for the 13 pubertal girls (range, 8-13 years); and 13.7 years for the early menarchal girls (range, 10-16 years). The girls had a mean body mass index (BMI) of 16 kg/m², 23.5 kg/m², and 22.8 kg/m², respectively.

The mean antral follicle count was 15.9 in the prepubertal group, 21.5 in the pubertal group, and 20.4 in the early menarchal group, said Dr. Cooper of the division of reproductive endocrinology and infertility at Washington University in St. Louis.

One ovary was visualized on ultrasound in 94% of prepubertal girls and 86% of pubertal girls, and both ovaries were visualized in 71% and 57%. By comparison, a single ovary was visualized in 94% of girls with early menarche and two ovaries in 83%.

The mean AMH level was 2.97 ng/mL in the prepubertal group and 3.46 ng/mL in the pubertal group, vs. 3.74 ng/mL in the early menarchal girls.

Same-day AMH level was correlated with antral follicle count in all premenarchal girls, with a correlation coefficient, or r value, of 0.6, she said. The r value was 0.7 for the menarchal girls and 0.6 for reproductive-age women in the parent trial.

In multivariable regression analysis that controlled for BMI, hormonal contraception, and number of ovaries visualized, the AMH level was significantly associated with the antral follicle count (P value less than .001).

When asked by the audience whether the researchers controlled for variability that exists between sonographers, Dr. Cooper replied that the study used three dedicated sonographers and that intra- and intersonography correlation was very good when analyzed.

Another attendee questioned whether transabdominal antral follicle count data are transferable to data obtained with transvaginal scans.

Dr. Cooper replied, "I just don’t think we have enough data yet to say we can use transabdominal scans in these young girls, and that’s intentionally why I tried to correlate it with the same-day AMH measure to show that these measures are correlated," she said. "I think it is something that we can consider and further study."

An international group of specialist reproductive medicine clinicians and scientists recently convened to provide practical recommendations addressing the considerable variability that exists in the clinical definitions and technical methods used to count and measure antral follicles in research trials and clinical practice (Fertil. Steril. 2010;94:1044-51). In clinical practice, they recommend selecting patients with regular menstrual cycles, counting follicles between days 2 and 4 of a spontaneous menstrual or oral contraceptive cycle, and including all antral follicles 2-10 mm in diameter. It is suggested that a limited number of staff, adequately trained in transvaginal sonography, should perform antral follicle counts using real-time, two-dimensional imaging with a transvaginal transducer and a probe with a minimum frequency of 7 MHz.

Dr. Cooper said she has received study support for the ongoing study from Washington University and the National Institutes of Health. Provision of the serum assays to an independent lab was provided by Beckman Coulter.