Highlights of the North American Society for Pediatric and Adolescent Gynecology (NASPAG) Annual Clinical Meeting

May 19-21; New Orleans, Louisiana

Yolanda R. Smith, MD, MS


July 05, 2005

The North American Society for Pediatric and Adolescent Gynecology (NASPAG) Annual Clinical Meeting is a venue for healthcare professionals from the medical, surgical, nursing, and psychosocial specialties to review and discuss the latest research and treatment strategies for pediatric and adolescent gynecology issues. Traditionally, this meeting has included keynote addresses by recognized experts, scientific abstracts, and clinically focused workshops targeting both basic and advanced issues. The workshops cover a wide range of clinically relevant topics, including polycystic ovary syndrome, pediatric vulvar dermatology, reproductive congenital anomalies, contraception, international healthcare models for children and teens, laparoscopic techniques, complementary medicine, sexual abuse, osteopenia in adolescents, obesity programs, and endometriosis. This report provides highlights from the meeting.

The Joseph F. Russo, MD, Lectureship was presented by Daniel D. Broughton, MD (Mayo Clinic, Rochester, Minnesota). Dr. Broughton discussed the risks to children and adolescents posed by the Internet, including exposure to sexual material, sexual solicitation, and harassment. Dr. Broughton emphasized the growth in exposure sources, including computers, mobile phones with Internet, text messaging and digital cameras, personal data assistants (PDAs), and iPods. Public efforts to address this problem have included legislation such as the Children's Online Privacy Protection Act (COPPA), Children's Internet Protection Act (CIPA), and Prosecutorial Remedies and Other Tools to End the Exploitation of Children Today Act -PROTECT Act. In addition, the congressionally mandated CyberTipline ( www.cybertipline.com , 1-800-843-5678), launched in 1998, is a reporting mechanism for cases of child sexual exploitation including pornography, online sexual enticement, molestation, sex tourism, prostitution, and unsolicited obscene material sent to a child. The National Center for Missing and Exploited Children ( www.missingkids.com ) offers educational resources for parents, law enforcement, attorneys, media, and children. This Center, along with the Boys and Girls Clubs of America, created a NetSmartz Workshop, a free, interactive, educational safety resource for kids and teens ( www.netsmartz.org ) designed to prevent victimization and increase online self-confidence. In addition, healthcare professionals may include Internet safety education during well-child visits, specifically emphasizing not to share personal information or pictures, to never arrange a meeting, and, if uncomfortable or frightened, to not respond and tell a parent.

The Alvin F. Goldfarb, MD, Lectureship was present by Paul B. Kaplowitz, MD, PhD (George Washington University and the Children's National Medical Center, Washington DC). Dr. Kaplowitz reviewed the latest trend concerning the timing of puberty in girls. Early research on this subject tended to focus on the onset of menarche. In 1997, the Pediatric Research in Office Setting (PROS) network reported on the basis of more than 17,000 girls examined in 65 pediatric practices that breast development and pubic hair were starting earlier than previously believed, and with racial variation.[1] Specifically, for white girls, the mean ages at onset of breast development, pubic hair, and menses were 9.96 years, 10.51 years, and 12.88 years, respectively; whereas for black girls, the mean ages were 8.87 years, 8.78 years, and 12.16 years, respectively. Notably, although pubertal signs were appearing earlier, menarche was not appreciably changed. This resulted in revised puberty guidelines suggesting that breast or public hair development prior to age 7 in white girls and before age 6 in black girls should initiate an evaluation.[2] Subsequently, data from the Third National Health and Nutrition Examination Survey (NHANES III) revealed less advancement in the age of puberty.[3] This study reported that for white girls the mean ages for breast development, pubic hair, and menses were 10.3 years, 10.6 years, and 12.6 years, respectively; whereas for black girls, the ages were 9.5 years, 9.5 years, and 12.2 years. Some experts believe that although pubertal development may be starting earlier, this is not a convincing argument that earlier puberty is normal or that the appearance of breast tissue before age 8 and pubic hair before age 9 is not premature.[4] Ongoing controversy exists over the appropriate age to initiate an evaluation for precocious puberty. Girls over the age of 8 years do not warrant an evaluation; however, those in the 6- to 8-year age range should be considered for an evaluation, especially if they have rapidly progressive puberty, neurologic symptoms, or behavioral issues.

Potential theories for the earlier onset of puberty include hormone exposure from food, chemicals in the environment, and the childhood obesity epidemic.[5,6] Obesity may also make it difficult for healthcare professionals to distinguish fatty tissue from breasts. Dr. Kaplowitz suggested examining girls supine to redistribute fat over the chest and palpating the tissue, as breast tissue feels firmer than fat and is located directly under the nipple.

Diane F. Merritt, MD (Washington University School of Medicine, St. Louis, Missouri), reviewed the evaluation and management of genital injuries. The World Health Organization includes genital injuries in their 2004 Guideline for essential trauma care and provides recommendations for evaluation and treatment.[7] A range of genital traumas occur in children – accidental (ie, straddle injuries), non-accidental (ie, abuse), and iatrogenic (ie, instrumentation, surgical injuries).[8] The more common accidental injuries occur with bicycles, playground equipment, and furniture and by falling on objects. In sexual assault victims, the most frequent locations of genital injuries include the posterior fourchette, labia minora, hymen, and fossa navicularis. It is important to note in light of potential prosecution that more than 50% of victims examined at or after 72 hours may still have genital findings.[9]

Dr. Merritt emphasized several key points in the management of genital injuries. First, proper positioning and complete cooperation of the patient is critical, and therefore sedation or anesthesia is frequently warranted. She recommends, initially, to identify normal structures before attempting to assess the extent of injuries. Repair the deepest (most distal from the introitus) vaginal lacerations first to maximize working space and visualization. Vaginal injuries that are not actively bleeding may be packed with moistened sterile gauze. Vulvar hematomas can be treated with ice and sitz baths if they are stable and non-enlarging. However, enlarging hematomas should undergo incision and drainage to lessen pain, expedite recovery, and prevent secondary infection or tissue loss. Closed suction drainage is also recommended after hematoma evacuation. Perforations into the peritoneal cavity mandate an exploratory laparotomy or laparoscopy to evaluate the extent of injuries. For anogenital injuries, primary repair of the anal mucosa and sphincter are preferred if the rectum is intact by palpation and sigmoidoscopy; however, a diverting colostomy may be necessary. Postoperatively, topical estrogen cream applied to mucosal injuries of the vagina and introitus may decrease granulation tissue and reduce strictures. In addition, whirlpool treatments may be used to debride and cleanse the area.

The Sir John Dewhurst, MD, Lectureship was presented by Patricia E. Mitchell, President and CEO, Public Broadcasting Services. Ms. Mitchell emphasized the power of the media to focus the spotlight on women and children and to ultimately enrich their lives and communities. She provided an example of worldwide media leaders uniting to address a global health issue: the gathering of leading media companies for media leaders for the Global Media AIDS Initiative (April 2005) (See www.tpaa.net/events_120405_prelease.html .) This network has committed to mobilizing the media on a global scale to educate worldwide audiences on HIV/AIDS.

Karen Fuchs, MD, and colleagues (Women and Infants' Hospital of Rhode Island/Brown University, Providence, Rhode Island) received the Huffman Capraro Award for their research demonstrating a high rate of regression (72%) in 86 adolescents with high-grade cervical intraepithelial neoplasia (CIN) treated with expectant management. The 2001 consensus guidelines for management of women with CIN suggest that well-counseled and reliable adolescents may be considered for conservative management.[10] Previous research in this area has suggested a high rate of regression of low-grade CIN in adolescents (91% at 36 months).[11] This study reveals that a high rate of regression would also be expected in adolescents with high-grade CIN managed expectantly.

AR Giuliano, MD (The Moffitt Cancer Center and Research Institute, Tampa, Florida), and colleagues received the Evelyn Green Laufer Award for best oral abstract presentation for their dose-ranging and efficacy study of a prophylactic quadrivalent human papillomavirus (types 6/11/16/18) vaccine in young women. In this study, 1106 young women were randomized to receive 1 of 3 formulations of the vaccine or placebo. The vaccine was well tolerated and generated persistent antibody responses for 2.5 years following vaccination. Results from this study were recently published,[12] and a phase 3 study is under way.

Jill S. Huppert, MD, MPH, and colleagues (Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, and Pennsylvania State University, State College, Pennsylvania) were recipients of the first-place poster award for their prospective study of 19 pediatric and adolescent females with non-sexually transmitted vulvar ulcers. Non-sexually transmitted vulvar ulcers are a rare condition and generally cause significant concern. The differential diagnosis includes infectious etiologies, malignancy, inflammatory processes such as Behcet's disease, medications, and trauma. This study reported that the vulvar ulcers were self-limited, healed without scarring, recurred in up to one third, and were infrequently associated with confirmed Epstein-Barr virus or cytomegalovirus infection. The authors suggested that this condition may be a variant of aphthous ulcers that arise as a local inflammatory response to acute viral illness.

Frank M. Biro, MD, and Nancy L. Bloemer, RYT, LMT (Cincinnati Children's Hospital Medical Center), led a session on the use of complementary treatments in the teenage population. Complementary and alternative medicine (CAM) includes 5 domains: alternative medical systems, mind-body interventions, biologically based therapies, body-based methods, and energy therapies. Currently, herbal medicines and supplements are not regulated by the United States Food and Drug Administration and carry potential risks of toxicity, contamination, and drug interactions. A recent population-based study of adolescents 14 to 19 years of age in New York reported that 54% of adolescents had used at least 1 CAM therapy.[13] The most frequently used remedies among adolescents were massage, prayer, herbs, megadose vitamins, and special exercise. Girls were significantly more likely to use herbs, special diets, special exercise and expressive therapies, whereas boys were more likely to use natural performance-enhancing supplements. Healthcare providers should be aware of the wide use of CAM therapies among adolescents and consider screening for use so that appropriate recommendations can be given.


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