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The Clinical and Laboratory Characteristics of Girls Presenting with Precocious Puberty in Korea
Poster Abstracts
transportation issues, and the stigma they encounter in waiting rooms. We developed an obstetrical clinic within an existing, very successful adolescent-friendly community center. The pregnant adolescent benefits from the ‘‘one stop shopping’’. By developing a satellite clinic that came to the adolescent mother, instead of having her come to the physician, we were able to achieve a 49% rate for first obstetrical visits in the first trimester compared to the 26% rate quoted in the literature. This weekly clinic, staffed by an obstetrician and an obstetrical nurse, allows the health care provider to address the risks in pregnancy and initiate appropriate interventions leading to healthier pregnancies, and improved outcomes. In the first 18 months of the program, we accumulated data on 58 completed pregnancies. The mean gestational age is 39.4 weeks, birth weight 3190 grams, rate of preterm delivery 9%, and rate of cesarean section 6.8%. Because of its overwhelming results, the pilot project became an established program in 2006. We plan to report the outcome of our unique adolescent obstetrics clinic within the next year. In 2007, we added contraception and adolescent medicine clinics at St Mary’s Home for the continued care of these young women. The monthly contraception clinic provides family planning and free contraception to adolescents in need, with the goal of decreasing the rate of repeat pregnancies. The bimonthly adolescent medicine clinic is designed for adolescents with mental health, addiction, and self esteem issues. Psychiatry and Psychology consultations are available at the hospital when indicated. We are currently working at securing these important services on-site at St. Mary’s Home. Comments: St. Mary’s Home’s community outreach program for pregnant adolescents has proven beneficial for the health of the pregnant adolescent and her unborn child. Attempts should be made to develop such centers across North America. doi:10.1016/j.jpag.2009.01.012
The Clinical and Laboratory Characteristics of Girls Presenting with Precocious Puberty in Korea Byung-Moon Kang, MD, So-Ra Kim, MD, Gyun-Ho Jeon, MD, Sa-Ra Lee, MD1, Hyang-Ah Lee, MD2, Eun-Ju Park, MD3, and Seung-Hwa Hong, MD4 Department of Obstetrics & Gynecology, College of Medicine, University of Ulsan, Asan Medical Center, Ewha Womans University Medical Center1, Kangwon National University
e31
Hospital2, Eulji University Hospital3, Chungbuk National University Hospital, Seoul, Korea4
Background: This study was performed to review the clinical and laboratory characteristics of patients with precocious puberty. Methods: We reviewed the medical records of 139 patients with premature secondary sexual characteristics from Jan. 2000 to Oct. 2006. We defined the evidence of premature secondary characteristics as the development of breast, vaginal bleeding and pubic hair. Sexual development staging, hormonal examination, pelvic ultrasonography and brain image examination were done in all patients. Precocious puberty was classified into central, peripheral, or variant type of pubertal development and central precocious puberty was classified into idiopathic or organic subgroup with brain lesions. We analyzed the clinical and laboratory characteristics. Results: Of total cases, 117 cases (84.2%) were central precocious puberty, 3 cases were peripheral precocious puberty, and 19 cases were variant type of pubertal development. Among 117 cases with central precocious puberty, 96 cases were idiopathic subgroup, 20 cases were organic subgroup with brain lesions and 1 case was hypothyroidism. The causes of organic central precocious puberty were brain tumor, hydrocephalus due to the complication of meningitis, status epilepticus, Arnold-chiari malformation, Ramsay-Hunt syndrome, and pituitary gland hyperplasia due to birth asphyxia. The most common cause of brain tumor was hamartoma on tuber cinereum. Among 3 cases with peripheral precocious puberty, 1 case was juvenile granulosa cell tumor and 2 cases were McCuneAlbright syndrome. The mean age of patients with organic central precocious puberty was significantly higher than that of patients with idiopathic precocious puberty (4.76 0.52 years vs 6.46 0.12 years, p!0.05). Except the height and serum peak LH concentration, there were no differences among the body weight, BMI and serum FSH and estradiol concentration inspection degrees. Conclusion: A review of 139 patients referred to our medical center revealed that the most common type was idiopathic precocious puberty and the age of onset in patients with organic central precocious puberty was faster than that in patients with idiopathic precocious puberty. Some patients presenting with precocious puberty have specific symptoms for underlying disease. There were, however, most patients with precocious puberty as an only symptom without specific symptoms. Therefore, close evaluation for differential diagnosis should be mandatory in any girls presenting with precocious puberty age only symptoms and physicians should manage these
e32
Poster Abstracts
patients considering factors such as the current age of patient, the extent of progression of symptom, the estimation of grown height, and the psychobehavioral problems. doi:10.1016/j.jpag.2009.01.013
Childhood Factitious DisordersdA ‘‘Hot’’ Case of Menstruation Kirsten B. Hawkins, MD, MPH, MPH, Veronica Gomez-Lobo, MD, and Adelaide Robb, MD Georgetown University Hospital, Washington, DC
Background: Factitious disorders are rarely reported in the pediatric gynecologic literature. We present a case of factitious menstruation in a ten year old prepubertal child. Case: A ten year old girl presented to her pediatrician’s office with an episode of vaginal bleeding. She reports bright red vaginal bleeding that over 4 days changed to an orange colored odorous discharge. The bleeding occured at regular intervals throughout the day. In the pediatrician’s office she was found to have a normal exam. A White Blood Cell count was 5.9 K/uL, Hemoglobin 13.3mg/dl, Hematocrit 38.8%, and the platelet count 276k. Sedimentation rate was 6 mm/hr, Thyroid Stimulating Hormone was 0.777 uIU/ml, Lutenizing Hormone 0.3 mIU/ml, Follicle Stimulating Hormone 9 mIU/ ml, Estradiol 7 pg/ml, and Free Thyroxine 1.15 ng/d. A computerized tomography (CT) scan of the abdomen and pelvis with nonionic contrast was within normal limits. There was no comment on the uterus, ovaries, or vagina. A non-contrast CT scan of the head is normal but with limited evaluation of pituitary gland. The patient was referred to an adolescent medicine specialist for further evaluation. Physical exam revealed a thin, pale prepubescent child. Breasts are prepubescent, SMR 1. Her abdomen was soft but tender to palpation in the left lower quadrant. Pubic Hair was SMR 1. Her external genitalia were normal. The hymen was annular and no discharge or erythema was present. The rectal exam was normal. A pelvic ultrasound demonstrated a prepubescent, anteverted uterus with an endometrial stripe 0.1 cm. There was no evidence of echogenic foreign body. The ovaries are normal. Gonorrhea/Chlamydia Nucleic Acid Amplification
testing was negative. A genital culture grows 3+ normal flora. The patient was seen again in conjunction with a pediatric gynecologist. The vagina is irrigated with 20cc of saline. The effluent was clear. Heme testing from pad was negative. A few days later the mother found a vial of hot sauce in the child’s book bag. When confronted, the child confesses to placing the foreign liquid on the pad. A planned exam under anesthesia is thus avoided. Comments: A high index of suspicion is required in diagnosing factitious disorders. Psychosomatic illnesses have a wide spectrum of presentation and are likely more common than realized. There are three distinct mental health disorders in which a patient intentionally produces physical symptoms or illness: Malingering, Factitious Disorder, and Factitious Disorder by proxy. In Factitious Disorder the patient produces symptoms or signs to assume the sick role. Examples include induced infections and factitious fever. Malingering differs from Factitious Disorder in that in Malingering, the individual is consciously motivated by an external incentive, such as missing school or work. In Factitious Disorder the individual is usually not aware of the motivation behind the factitious behavior and external incentives are absent. Recognizing the possibility of factitious illness in patients who present with atypical clinical manifestations is imperative to reduce unnecessary risk to the patient through continued medical evaluations and to avoid long term psychopathology. doi:10.1016/j.jpag.2009.01.014
Metformin Therapy Restores Normal Menstrual Cycles, Reduces the Ovarian Size and Volume, but Failed to Prevent Recurrent Ovarian Torsions in an Adolescent with PCOS Connie Liang, MD, and Veronica GomezLobo, MD Department of Obstetrics and Gynecology, Washington Hospital Center, Children’s National Medical Center, Washington D.C. United States
Background: Enlarged polycystic ovaries are frequently seen on pelvic sonogram among women with polycystic ovary syndrome (PCOS) and theoretically may pose an increased risk for ovarian torsion. This is the first case report of ovarian torsion associated with PCOS.
transportation issues, and the stigma they encounter in waiting rooms. We developed an obstetrical clinic within an existing, very successful adolescent-friendly community center. The pregnant adolescent benefits from the ‘‘one stop shopping’’. By developing a satellite clinic that came to the adolescent mother, instead of having her come to the physician, we were able to achieve a 49% rate for first obstetrical visits in the first trimester compared to the 26% rate quoted in the literature. This weekly clinic, staffed by an obstetrician and an obstetrical nurse, allows the health care provider to address the risks in pregnancy and initiate appropriate interventions leading to healthier pregnancies, and improved outcomes. In the first 18 months of the program, we accumulated data on 58 completed pregnancies. The mean gestational age is 39.4 weeks, birth weight 3190 grams, rate of preterm delivery 9%, and rate of cesarean section 6.8%. Because of its overwhelming results, the pilot project became an established program in 2006. We plan to report the outcome of our unique adolescent obstetrics clinic within the next year. In 2007, we added contraception and adolescent medicine clinics at St Mary’s Home for the continued care of these young women. The monthly contraception clinic provides family planning and free contraception to adolescents in need, with the goal of decreasing the rate of repeat pregnancies. The bimonthly adolescent medicine clinic is designed for adolescents with mental health, addiction, and self esteem issues. Psychiatry and Psychology consultations are available at the hospital when indicated. We are currently working at securing these important services on-site at St. Mary’s Home. Comments: St. Mary’s Home’s community outreach program for pregnant adolescents has proven beneficial for the health of the pregnant adolescent and her unborn child. Attempts should be made to develop such centers across North America. doi:10.1016/j.jpag.2009.01.012
The Clinical and Laboratory Characteristics of Girls Presenting with Precocious Puberty in Korea Byung-Moon Kang, MD, So-Ra Kim, MD, Gyun-Ho Jeon, MD, Sa-Ra Lee, MD1, Hyang-Ah Lee, MD2, Eun-Ju Park, MD3, and Seung-Hwa Hong, MD4 Department of Obstetrics & Gynecology, College of Medicine, University of Ulsan, Asan Medical Center, Ewha Womans University Medical Center1, Kangwon National University
e31
Hospital2, Eulji University Hospital3, Chungbuk National University Hospital, Seoul, Korea4
Background: This study was performed to review the clinical and laboratory characteristics of patients with precocious puberty. Methods: We reviewed the medical records of 139 patients with premature secondary sexual characteristics from Jan. 2000 to Oct. 2006. We defined the evidence of premature secondary characteristics as the development of breast, vaginal bleeding and pubic hair. Sexual development staging, hormonal examination, pelvic ultrasonography and brain image examination were done in all patients. Precocious puberty was classified into central, peripheral, or variant type of pubertal development and central precocious puberty was classified into idiopathic or organic subgroup with brain lesions. We analyzed the clinical and laboratory characteristics. Results: Of total cases, 117 cases (84.2%) were central precocious puberty, 3 cases were peripheral precocious puberty, and 19 cases were variant type of pubertal development. Among 117 cases with central precocious puberty, 96 cases were idiopathic subgroup, 20 cases were organic subgroup with brain lesions and 1 case was hypothyroidism. The causes of organic central precocious puberty were brain tumor, hydrocephalus due to the complication of meningitis, status epilepticus, Arnold-chiari malformation, Ramsay-Hunt syndrome, and pituitary gland hyperplasia due to birth asphyxia. The most common cause of brain tumor was hamartoma on tuber cinereum. Among 3 cases with peripheral precocious puberty, 1 case was juvenile granulosa cell tumor and 2 cases were McCuneAlbright syndrome. The mean age of patients with organic central precocious puberty was significantly higher than that of patients with idiopathic precocious puberty (4.76 0.52 years vs 6.46 0.12 years, p!0.05). Except the height and serum peak LH concentration, there were no differences among the body weight, BMI and serum FSH and estradiol concentration inspection degrees. Conclusion: A review of 139 patients referred to our medical center revealed that the most common type was idiopathic precocious puberty and the age of onset in patients with organic central precocious puberty was faster than that in patients with idiopathic precocious puberty. Some patients presenting with precocious puberty have specific symptoms for underlying disease. There were, however, most patients with precocious puberty as an only symptom without specific symptoms. Therefore, close evaluation for differential diagnosis should be mandatory in any girls presenting with precocious puberty age only symptoms and physicians should manage these
e32
Poster Abstracts
patients considering factors such as the current age of patient, the extent of progression of symptom, the estimation of grown height, and the psychobehavioral problems. doi:10.1016/j.jpag.2009.01.013
Childhood Factitious DisordersdA ‘‘Hot’’ Case of Menstruation Kirsten B. Hawkins, MD, MPH, MPH, Veronica Gomez-Lobo, MD, and Adelaide Robb, MD Georgetown University Hospital, Washington, DC
Background: Factitious disorders are rarely reported in the pediatric gynecologic literature. We present a case of factitious menstruation in a ten year old prepubertal child. Case: A ten year old girl presented to her pediatrician’s office with an episode of vaginal bleeding. She reports bright red vaginal bleeding that over 4 days changed to an orange colored odorous discharge. The bleeding occured at regular intervals throughout the day. In the pediatrician’s office she was found to have a normal exam. A White Blood Cell count was 5.9 K/uL, Hemoglobin 13.3mg/dl, Hematocrit 38.8%, and the platelet count 276k. Sedimentation rate was 6 mm/hr, Thyroid Stimulating Hormone was 0.777 uIU/ml, Lutenizing Hormone 0.3 mIU/ml, Follicle Stimulating Hormone 9 mIU/ ml, Estradiol 7 pg/ml, and Free Thyroxine 1.15 ng/d. A computerized tomography (CT) scan of the abdomen and pelvis with nonionic contrast was within normal limits. There was no comment on the uterus, ovaries, or vagina. A non-contrast CT scan of the head is normal but with limited evaluation of pituitary gland. The patient was referred to an adolescent medicine specialist for further evaluation. Physical exam revealed a thin, pale prepubescent child. Breasts are prepubescent, SMR 1. Her abdomen was soft but tender to palpation in the left lower quadrant. Pubic Hair was SMR 1. Her external genitalia were normal. The hymen was annular and no discharge or erythema was present. The rectal exam was normal. A pelvic ultrasound demonstrated a prepubescent, anteverted uterus with an endometrial stripe 0.1 cm. There was no evidence of echogenic foreign body. The ovaries are normal. Gonorrhea/Chlamydia Nucleic Acid Amplification
testing was negative. A genital culture grows 3+ normal flora. The patient was seen again in conjunction with a pediatric gynecologist. The vagina is irrigated with 20cc of saline. The effluent was clear. Heme testing from pad was negative. A few days later the mother found a vial of hot sauce in the child’s book bag. When confronted, the child confesses to placing the foreign liquid on the pad. A planned exam under anesthesia is thus avoided. Comments: A high index of suspicion is required in diagnosing factitious disorders. Psychosomatic illnesses have a wide spectrum of presentation and are likely more common than realized. There are three distinct mental health disorders in which a patient intentionally produces physical symptoms or illness: Malingering, Factitious Disorder, and Factitious Disorder by proxy. In Factitious Disorder the patient produces symptoms or signs to assume the sick role. Examples include induced infections and factitious fever. Malingering differs from Factitious Disorder in that in Malingering, the individual is consciously motivated by an external incentive, such as missing school or work. In Factitious Disorder the individual is usually not aware of the motivation behind the factitious behavior and external incentives are absent. Recognizing the possibility of factitious illness in patients who present with atypical clinical manifestations is imperative to reduce unnecessary risk to the patient through continued medical evaluations and to avoid long term psychopathology. doi:10.1016/j.jpag.2009.01.014
Metformin Therapy Restores Normal Menstrual Cycles, Reduces the Ovarian Size and Volume, but Failed to Prevent Recurrent Ovarian Torsions in an Adolescent with PCOS Connie Liang, MD, and Veronica GomezLobo, MD Department of Obstetrics and Gynecology, Washington Hospital Center, Children’s National Medical Center, Washington D.C. United States
Background: Enlarged polycystic ovaries are frequently seen on pelvic sonogram among women with polycystic ovary syndrome (PCOS) and theoretically may pose an increased risk for ovarian torsion. This is the first case report of ovarian torsion associated with PCOS.