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GYN Resident Perceptions about Adolescent Health Care Training
Oral Abstracts
Conclusions: Increased endometrial thicknesses, both $12 mm and $14 mm, are strong risk factors for endometrial hyperplasia in adolescent patients with prolonged irregular menstruation especially if combined with abnormal US appearance. doi:10.1016/j.jpag.2009.01.058
Variation in Ovarian Morphology and Biochemical Markers of Hyperandrogenism in Adolescents with Polycystic Ovary Syndrome Beth W. Rackow, MD, Amanda N. Carlson, MD, Elvira J. Duran, BA, Rachel GoldbergGell, APRN, and Tania S. Burgert, MD Yale University School of Medicine, New Haven, Connecticut
Background: Perimenarchal onset of polycystic ovary syndrome (PCOS), the most common endocrinopathy of the premenopausal years, is increasingly appreciated. In adolescents meeting clinical criteria for PCOS, transabdominal pelvic ultrasonography (TAUS) is often utilized for evaluation of ovarian morphology. While polycystic appearing ovaries (PCO) constitute a diagnostic criterion for PCOS (Rotterdam criteria 2003), it remains to be determined if PCO as assessed by TAUS in adolescents tracks with other diagnostic criteria of PCOS such as biochemical hyperandrogenism. Methods: Thirty-two adolescent females were recruited from a multispecialty adolescent PCOS clinic into an ongoing IRB approved cohort study. Participants underwent a complete history and physical examination. TAUS was performed by a single trained radiologist and readings were divided into three groups: normal appearing ovaries (NAO), classic PCO (ovarian volume O10cm3 with $12 follicles measuring 2e9mm in diameter) and variant polycystic ovaries (VPO; normal ovarian volume with $12 small follicles). Biochemical measures of hyperandrogenism included total testosterone (T) and sex hormone binding globulin (SHBG); free T (%) was calculated. Statistical analyses were performed using one-way analysis of variance (ANOVA), t-test and Pearson correlation as appropriate. Data are presented as mean standard deviation.
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Results: Of the 32 adolescents (ages 15.5 1.9 years, BMI 30.4 7.6 kg/m2), 29 (91%) reported oligomenorrhea or amenorrhea; clinical features of hyperandrogenism (acne and/or hirsutism) were acknowledged by all. The mean serum T level was 52.5 29.0 ng/dl (range 10e55 ng/dl). TAUS criteria as specified identified NAO in 41% of participants (13/32), PCO in 34% (11/32) and VPO in 25% (8/32). Those with classic PCO demonstrated significantly higher serum T levels compared to VPO (70.6 27.2 ng/dl vs. 41.4 20.6 ng/dl; p 5 0.004) and to NAO (38.6 21.9 ng/dl; p 5 0.02) groups. There was no difference in total T levels between the NOA and VPO groups, nor were there any differences in free T or SHBG levels between the 3 groups (pO0.05). While no relationship was observed between BMI and total T (p50.8), those demonstrating classic PCO were significantly heavier (BMI 32.1 8.3 kg/m2) compared to those with VPO (25.3 3.2 kg/m2, p50.04). Adolescents with NAO had a similar BMI as those with classic PCO (32.5 þ 7.9 kg/ m2) and were also significantly heavier than the VPO group (p 5 0.03). Conclusions: In adolescents, TAUS is a meaningful component of the evaluation of polycystic ovary syndrome. A significant proportion of adolescents with menstrual irregularity and clinical features of hyperandrogenism had ovaries that did not demonstrate the classic PCO appearance. The VPO group had a significantly lower BMI than the NAO and PCO groups, and similar T levels as the NAO group; this group may represent a population of adolescents in whom weight gain would lead to the classic PCO phenotype. Metabolic analyses in these patients will provide further assessment of parameters that affect ovarian dysfunction. doi:10.1016/j.jpag.2009.01.059
OB/GYN Resident Perceptions about Adolescent Health Care Training Brandi Swanier, MPH, Aletha Akers, MD, MPH, and Lisa Perriera, MD University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Background: Clinical practice guidelines recommend OB/GYN physicians provide age-appropriate
e20
Oral Abstracts
prevention counseling to all adolescents. In this study, we explored OB/GYN resident physician’s perceptions regarding the adequacy of their training for providing both general and reproductive health prevention counseling to adolescents. Methods: OB/GYN residents at the University of Pittsburgh who represented all four postgraduate years participated in 3 focus groups (N518) in November 2008. All participants were female. A semi-structured question guide explored resident perspectives regarding their sources of knowledge, attitudes, clinical experience and perceived self-efficacy for providing both general and reproductive health prevention counseling to adolescents. Each discussion lasted 60- to 80-minutes, was audio-recorded, transcribed and analyzed using a grounded theory approach to content analysis. Results: Adolescents aged 14 to 21 years represent a significant proportion of the population served by residents. Although they felt comfortable managing common medical problems in this age group, they were less confident in their ability to effectively counsel teens due to inadequate training in adolescent development, psychology, and interpersonal skills. Residents were generally unfamiliar with clinical practice guidelines or educational resources concerning adolescents, received few adolescent-focused didactic lectures, had no mandatory adolescent medicine clinical rotations, and reported that preceptors inconsistently model the delivery of tailored prevention messages to this cohort. Residents believed that general prevention counseling is important for this age group but prefer to refer patients to other providers for these services due to time pressures, an inability to build rapport or perceived irrelevance to their role as reproductive health providers. Substance abuse, eating disorders, and mental health issues were typically referred out. They more often provided counseling on tobacco use, obesity and nutrition because these topics could be readily connected to teens’ chief complaints and reproductive health outcomes. Residents felt reproductive health counseling is easier to provide and of greater priority because it is their area of expertise and patients who present to them expect to receive it. This counseling focused on contraception and STI prevention, the primary goal being the prevention of acute negative outcomes (i.e. pregnancy, infection) rather than building trust and shared decision-making skills. Junior residents were enthusiastic about working with adolescents while chief residents described themselves as ‘‘jaded’’ due to caring for a challenging age group in a demanding specialty with an incomplete tool set. Conclusions: Residents report multiple barriers that limit their ability to provide recommended
general and reproductive health prevention counseling to adolescents. Our data suggest that in order for OB/GYN-endorsed adolescent clinical care guidelines to be effective, OB/GYN residents need improved training in adolescent health care. doi:10.1016/j.jpag.2009.01.060
Injection Pain and Likelihood of Method Continuation among Adolescent Women Receiving Intramuscular Versus Subcutaneous Depot Medroxyprogesterone Acetate Rebekah L. Williams, MD, Devon J. Hensel, PhD, and J. Dennis Fortenberry, MD MS Indiana University School of Medicine, Indianapolis, IN
Background: Injection pain and needle phobia account for 20% of intramuscular depot medroxyprogesterone acetate (DMPA-IM) non-use, and 6% of DMPA-IM discontinuation. A lower dose, smaller volume, subcutaneous formulation (DMPA-SC) is now available, but its acceptability and use among adolescents are largely unexplored. We compared DMPA-IM and DMPA-SC with respect to injection pain and likelihood of method continuation among adolescent women. Methods: Study participants (SP) are 14e21 year old women (N533 enrolled as of 11/14/08 with goal N555) initiating DMPA. SP recruited from primary care adolescent medicine clinics in a Midwest, urban setting, are randomized to receive 150mg in 1mL DMPA-IM or 104mg in 0.65mL DMPA-SC at enrollment. Using a cross-over design, at 3-month followup they receive the alternate formulation. At 6-month follow-up they choose which formulation they receive. At 9-month follow-up SP may learn self-injection of DMPA-SC. SP complete self-administered surveys at enrollment and before and after each injection, and phone interviews 1 week after each injection. Pre-injection measures are Likert scales of injection apprehension (3 items, range 0e30, a 5 0.68) and intention to use DMPA (3 items, range 0e30, a 5 0.88). Immediate post-injection measures are single Likert items (range 0e10) of pain during injection and likelihood of
Conclusions: Increased endometrial thicknesses, both $12 mm and $14 mm, are strong risk factors for endometrial hyperplasia in adolescent patients with prolonged irregular menstruation especially if combined with abnormal US appearance. doi:10.1016/j.jpag.2009.01.058
Variation in Ovarian Morphology and Biochemical Markers of Hyperandrogenism in Adolescents with Polycystic Ovary Syndrome Beth W. Rackow, MD, Amanda N. Carlson, MD, Elvira J. Duran, BA, Rachel GoldbergGell, APRN, and Tania S. Burgert, MD Yale University School of Medicine, New Haven, Connecticut
Background: Perimenarchal onset of polycystic ovary syndrome (PCOS), the most common endocrinopathy of the premenopausal years, is increasingly appreciated. In adolescents meeting clinical criteria for PCOS, transabdominal pelvic ultrasonography (TAUS) is often utilized for evaluation of ovarian morphology. While polycystic appearing ovaries (PCO) constitute a diagnostic criterion for PCOS (Rotterdam criteria 2003), it remains to be determined if PCO as assessed by TAUS in adolescents tracks with other diagnostic criteria of PCOS such as biochemical hyperandrogenism. Methods: Thirty-two adolescent females were recruited from a multispecialty adolescent PCOS clinic into an ongoing IRB approved cohort study. Participants underwent a complete history and physical examination. TAUS was performed by a single trained radiologist and readings were divided into three groups: normal appearing ovaries (NAO), classic PCO (ovarian volume O10cm3 with $12 follicles measuring 2e9mm in diameter) and variant polycystic ovaries (VPO; normal ovarian volume with $12 small follicles). Biochemical measures of hyperandrogenism included total testosterone (T) and sex hormone binding globulin (SHBG); free T (%) was calculated. Statistical analyses were performed using one-way analysis of variance (ANOVA), t-test and Pearson correlation as appropriate. Data are presented as mean standard deviation.
e19
Results: Of the 32 adolescents (ages 15.5 1.9 years, BMI 30.4 7.6 kg/m2), 29 (91%) reported oligomenorrhea or amenorrhea; clinical features of hyperandrogenism (acne and/or hirsutism) were acknowledged by all. The mean serum T level was 52.5 29.0 ng/dl (range 10e55 ng/dl). TAUS criteria as specified identified NAO in 41% of participants (13/32), PCO in 34% (11/32) and VPO in 25% (8/32). Those with classic PCO demonstrated significantly higher serum T levels compared to VPO (70.6 27.2 ng/dl vs. 41.4 20.6 ng/dl; p 5 0.004) and to NAO (38.6 21.9 ng/dl; p 5 0.02) groups. There was no difference in total T levels between the NOA and VPO groups, nor were there any differences in free T or SHBG levels between the 3 groups (pO0.05). While no relationship was observed between BMI and total T (p50.8), those demonstrating classic PCO were significantly heavier (BMI 32.1 8.3 kg/m2) compared to those with VPO (25.3 3.2 kg/m2, p50.04). Adolescents with NAO had a similar BMI as those with classic PCO (32.5 þ 7.9 kg/ m2) and were also significantly heavier than the VPO group (p 5 0.03). Conclusions: In adolescents, TAUS is a meaningful component of the evaluation of polycystic ovary syndrome. A significant proportion of adolescents with menstrual irregularity and clinical features of hyperandrogenism had ovaries that did not demonstrate the classic PCO appearance. The VPO group had a significantly lower BMI than the NAO and PCO groups, and similar T levels as the NAO group; this group may represent a population of adolescents in whom weight gain would lead to the classic PCO phenotype. Metabolic analyses in these patients will provide further assessment of parameters that affect ovarian dysfunction. doi:10.1016/j.jpag.2009.01.059
OB/GYN Resident Perceptions about Adolescent Health Care Training Brandi Swanier, MPH, Aletha Akers, MD, MPH, and Lisa Perriera, MD University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
Background: Clinical practice guidelines recommend OB/GYN physicians provide age-appropriate
e20
Oral Abstracts
prevention counseling to all adolescents. In this study, we explored OB/GYN resident physician’s perceptions regarding the adequacy of their training for providing both general and reproductive health prevention counseling to adolescents. Methods: OB/GYN residents at the University of Pittsburgh who represented all four postgraduate years participated in 3 focus groups (N518) in November 2008. All participants were female. A semi-structured question guide explored resident perspectives regarding their sources of knowledge, attitudes, clinical experience and perceived self-efficacy for providing both general and reproductive health prevention counseling to adolescents. Each discussion lasted 60- to 80-minutes, was audio-recorded, transcribed and analyzed using a grounded theory approach to content analysis. Results: Adolescents aged 14 to 21 years represent a significant proportion of the population served by residents. Although they felt comfortable managing common medical problems in this age group, they were less confident in their ability to effectively counsel teens due to inadequate training in adolescent development, psychology, and interpersonal skills. Residents were generally unfamiliar with clinical practice guidelines or educational resources concerning adolescents, received few adolescent-focused didactic lectures, had no mandatory adolescent medicine clinical rotations, and reported that preceptors inconsistently model the delivery of tailored prevention messages to this cohort. Residents believed that general prevention counseling is important for this age group but prefer to refer patients to other providers for these services due to time pressures, an inability to build rapport or perceived irrelevance to their role as reproductive health providers. Substance abuse, eating disorders, and mental health issues were typically referred out. They more often provided counseling on tobacco use, obesity and nutrition because these topics could be readily connected to teens’ chief complaints and reproductive health outcomes. Residents felt reproductive health counseling is easier to provide and of greater priority because it is their area of expertise and patients who present to them expect to receive it. This counseling focused on contraception and STI prevention, the primary goal being the prevention of acute negative outcomes (i.e. pregnancy, infection) rather than building trust and shared decision-making skills. Junior residents were enthusiastic about working with adolescents while chief residents described themselves as ‘‘jaded’’ due to caring for a challenging age group in a demanding specialty with an incomplete tool set. Conclusions: Residents report multiple barriers that limit their ability to provide recommended
general and reproductive health prevention counseling to adolescents. Our data suggest that in order for OB/GYN-endorsed adolescent clinical care guidelines to be effective, OB/GYN residents need improved training in adolescent health care. doi:10.1016/j.jpag.2009.01.060
Injection Pain and Likelihood of Method Continuation among Adolescent Women Receiving Intramuscular Versus Subcutaneous Depot Medroxyprogesterone Acetate Rebekah L. Williams, MD, Devon J. Hensel, PhD, and J. Dennis Fortenberry, MD MS Indiana University School of Medicine, Indianapolis, IN
Background: Injection pain and needle phobia account for 20% of intramuscular depot medroxyprogesterone acetate (DMPA-IM) non-use, and 6% of DMPA-IM discontinuation. A lower dose, smaller volume, subcutaneous formulation (DMPA-SC) is now available, but its acceptability and use among adolescents are largely unexplored. We compared DMPA-IM and DMPA-SC with respect to injection pain and likelihood of method continuation among adolescent women. Methods: Study participants (SP) are 14e21 year old women (N533 enrolled as of 11/14/08 with goal N555) initiating DMPA. SP recruited from primary care adolescent medicine clinics in a Midwest, urban setting, are randomized to receive 150mg in 1mL DMPA-IM or 104mg in 0.65mL DMPA-SC at enrollment. Using a cross-over design, at 3-month followup they receive the alternate formulation. At 6-month follow-up they choose which formulation they receive. At 9-month follow-up SP may learn self-injection of DMPA-SC. SP complete self-administered surveys at enrollment and before and after each injection, and phone interviews 1 week after each injection. Pre-injection measures are Likert scales of injection apprehension (3 items, range 0e30, a 5 0.68) and intention to use DMPA (3 items, range 0e30, a 5 0.88). Immediate post-injection measures are single Likert items (range 0e10) of pain during injection and likelihood of