- Email: [email protected]
Vulvar Venous Malformations in Premenarchal Girls: A Report of Four Cases
Oral Abstracts / J Pediatr Adolesc Gynecol 25 (2012) e49ee55
Results: Adolescent IUD users had a mean age of 19.8 1.6 years, with a racial/ethnic distribution of White (41.7%), Black (24.1%), Hispanic (29.6%). Most (73.1%) were single and non-nulliparous (97.2%) with 53.7% having 1 living child, 29.6% having 2 children. Most IUDs were inserted by physicians (75.0%) compared to nurse practitioners (18.5%), and the majority were Cu־IUDs (75.0%). Thirty percent (N¼<33) were screened for an STI within 7 days before insertion and one patient (3%) had a positive result. In the post-insertion period, 9.3% (N¼10) had an STI documented with none occurring in the first 20 days. Three patients (2.8%) had PID diagnosed post insertion with none occurring in the first 20 days. Overall, 57.4% reported a complication post-insertion. Pelvic pain (26.9%) was the most common complication followed by bleeding (25.9%), other (20.4%), cannot find IUD string (12.0%), dyspareunia (8.3%), and UTI (5,6%). Pelvic pain was reported more frequently with the Cu-IUD in comparison to the LNG-IUD (p¼ 0.029). There were no pregnancies noted during the insertion period. Non-immediate expulsions were reported by 9,3% (N¼10) with 2 occurring within 2 months, 4 within 6 months, and 6 occurring greater than 7 months post insertion. The mean length of time to expulsion was 254.2 203.5 days. Removals were seen among 33.3% (N¼36) with a mean length of 575.9 483.5 days before removal. The most common reasons for removal were discomfort (12%), vaginal bleeding (10.2%), and desired pregnancy (7.4%). Of the 108 adolescents, 47.2% (N¼51) had their IUD still in place at the end of the study period. Conclusions: Pelvic pain was the most common complication and was reported significantly more frequently with the Cu-IUD. Discomfort was the most common reason for early termination. There were no pregnancies during the insertion period while 9.3% had a STI and 2.8% had a PID. Further research should include comparing these results with an adult population and/or with a nulliparous teen population.
11. A Survey of Attitudes About Various Birth Control Methods in Young Women With and Without Eating Disorders
e53
12. Vulvar Venous Malformations in Premenarchal Girls: A Report of Four Cases Mariel A. Focseneanu MD, Diane F. Merritt MD Department of Obstetrics and Gynecology, Division of Pediatric and Adolescent Gynecology, Washington University School of Medicine, St. Louis, Missouri
Background: Vulvar venous malformations are congenital lesions that may enlarge and become symptomatic in older children or young adults. These malformations should be distinguished from vulvar varicosities, which are typically associated with pregnancy. Rapid enlargement of vascular malformations can occur following trauma, thrombosis, infection, and physiological hormonal alterations. Symptomatic venous malformations involving the external genitalia have rarely been reported in adolescent girls. Cases: We present four cases of vulvar venous malformations occurring in premenarchal girls. Comments: Vulvar venous malformations are a rare but potentially disabling occurrence in children and adolescent girls. Management consists of conservative, surgical, or sclerotic approaches. Treatment should be based on severity of the patient's symptoms; given the potential complications of sclerotherapy and surgery, (i.e. skin necrosis, disfigurement, and nerve damage) along with the possibility of spontaneous resolution, a conservative Tabel 1 Four cases of vulvar venous malformations Age
12
11
Menstrual Status
Presenting Complaint
premenarchal Swelling around vagina premenarchal Swelling & tenderness
Imaging Studies MRI
MRI
Caitlin W. Hicks MS, Samantha DeMarsh, Harjoat Singh, Laura Gillespie MD, Sarah Worley MS, Ellen S. Rome MD, MPH Cleveland Clinic, Cleveland, OH
premenarchal Swelling near vagina
MRI
venous malformations on lip and forehead
2
prepubertal
KlippelTrenaunayWeber syndrome. Venous malformation in right lower extremity
enlarged collateral veins Superficial venous malformation of the labia without extension into subcutaneous
1 month. Congenital
Venogram at age 8; MRI
and labia
Fig. 1. Vulvar venous malformation.Ă
No large feeding arteries or draining veins Venous malformation of right labia extending to right common femoral vein; no arteriovenous malformation in pelvis
Complications & Outcome
Observation
None; improved
Observation
with recurrences None; improved spontaneously over 2 months
Fluoroscopic guided ethanol
Necrosis of vulvar tissue & pain which resolved
sclerosis
over 2 months; minimal residual varicosities
tissues or pelvis.
Background: Minimal data exists examining the knowledge and attitudes about different methods of contraception in young women with eating disorders (EDs). Methods: Using a prospective, survey-based study of postmenarchal women aged 13-25 years with a diagnosed ED (n¼50, test group) or no prior history of disordered eating behaviors (n¼57, control group), we examined the groups’ knowledge about the risks and benefits of various forms of contraception. IRB approval was obtained prior to enrollment. Statistical analyses were performed using JMP 9.0 (SAS, Cary, NC). Results: As compared to controls, ED patients were more likely to be Caucasian (90% vs. 75%; p¼0.04), and to have completed high school (74% vs. 42%; p¼0.0009). There were no significant differences in whether ED vs. control patients were sexually active (52% vs. 39%; p¼0.16) or had had sex in the past month (26% vs. 28%; p¼0.81), or in the type of birth control method used between the two groups (p0.20). However, ED patients were more likely to incorrectly associate health risks with condoms, spermicides/gels/ foams, and the rhythm method (p0.03); identified fewer health benefits of OCPs (p¼0.05); and were less correct about the HIV protection afforded by various methods of birth control (p¼0.03) compared to controls. ED patients also underestimated the overall pregnancy risks with various methods of birth control more than controls (p¼0.005). There was a trend for ED patients to be more concerned with OCPs causing weight gain than controls but this was not statistically significant (78% vs. 61%; p¼0.06). Conclusion: despite having a higher level of education and no differences in sexual history, ED patients were less knowledgeable than controls about the health risks and benefits, effectiveness in preventing HIV, and the effectiveness in preventing pregnancy various methods of birth control. ED patients may be presumed to be “not-sexually active” while working on recovery; physicians should take extra time to educate these patients about their personal risks of unintended pregnancy, STIs and the benefits that different methods of contraception can provide.
Single prominent vessel right labia Bilateral vulvar
Management
varicosities with no arterial supply; no
of right labia 2 days 11
Findings
Sclerotherapy age 8; Excision of right labial venous malformation age 12
Necrosis of vulvar tissue after sclerotherapy. Age 12, vulvar bleeding requiring 2 surgical procedures. Continued problems now age 27 years
e54
Oral Abstracts / J Pediatr Adolesc Gynecol 25 (2012) e49ee55
approach is appropriate in a young patient with minimal symptoms. However, a more aggressive approach may be needed for debilitating symptoms.
14. Polycystic Ovary Syndrome Mimicking an Androgen-Secreting Tumor
13. Ectopic Ovary Presenting as Right Upper Quadrant Abdominal Pain in a Premenarchal Patient With a Unicornuate Uterus
Maude Veilleux-Lemieux MD, FRCPC 1, Amy Desrochers DiVasta MD, MMSc 1,2 1 Division of Adolescent and Young Adult Medicine 2 Division of Pediatric and Adolescent Gynecology, Children's Hospital Boston, Boston, Massachusetts
Saifuddin T. Mama MD, MPH Department of Ob/Gyn, Cooper University Hospital, Camden, NJ
Background: The association between unicornuate uterus and undescended ovaries has been reported in the past but is extremely rare. In many cases, the possibility is not considered or recognized and there is a significant delay in diagnosis. Of the mullerian duct anomalies, unicornuate uterus represent approximately 4% of these disorders of lateral fusion of the mullerian ducts. Case: The patient was a 12 year old premenstrual female who presented with onset of right upper quadrant pain and emesis. The patient was hospitalized for 3 days to rule out appendicitis and had resolution of her pain. The GI service after upper GI series with small bowel follow through, endoscopy and colonoscopy diagnosed possible Crohn's disease and patient was started on Pentasa and Zantac with no relief. The patient continued to have recurrent pain in the same location lasting from hours to days with a sporadic pattern of occurrence for the next 13 months. The patient was then rehospitalized for 5 days for severe pain which spontaneously resolved. Two months later the patient had a repeat hospitalization and was seen by pediatric surgery. Diagnostic laparoscopy was performed with the findings being absent right adnexa and otherwise normal pelvis. The patient was referred to pediatric gynecology. Ectopic right ovary was suspected as the cause of the pain and a right upper quadrant ultrasound revealed a 2.3 x 1.3 x 1.5 cm structure at the tip of the right liver lobe. Concomitant pelvic ultrasound revealed a normal left ovary and the right ovary was not visualized. The uterus appeared deviated to the left. A CT scan performed revealed a small multiloculated mixed density lesion at the inferior tip of the right liver lobe. Both kidneys were visualized in the normal position. The patient had a presumptive diagnosis of unicornuate uterus associated with a right ectopic ovary with the pain being intermittent torsion. The patient had a repeat laparoscopy with the right ovary noted just beneath the tip of the right liver lobe. Given the history of right upper quadrant pain likely being intermittent torsion, after consultation with the parents, the decision was made to excise the right ovary. The patient had an uneventful postoperative recovery and has remained pain free. Comments: The ovaries have an entirely separate origin from the mullerian system with primordial germ cells invading the primitive gonads on the gonadal ridge, eventually migrating from near the kidney to the true pelvis. If there are no mullerian duct derivatives or kidney on one side, i.e. failure of development of the entire urogenital ridge, including the genital ridge where the ovary forms, then the ovary may be malpositioned, located anywhere from the level of T4 to the pelvic brim. These ectopic locations for ovaries are associated with a 40% chance of associated unicornuate uterus. The failure to visualize either adnexa in a patient with unexplained pain should prompt a search for a potential ectopic location for the ovary.
Fig. 1. (B) Ectopic right ovary beneath right liver lobe.Ă
Background: Hirsutism affects approximately 5 percent of reproductiveaged women. The most common causes of hirsutism are polycystic ovary syndrome (PCOS) and idiopathic hirsutism. Rapid onset or progression of hirsutism, as well as an elevated serum total testosterone concentration higher than 200 ng/dL should prompt further investigation to exclude an androgen-secreting tumor. Case: A previously healthy 12-year-old female patient presented for the evaluation of unwanted hair growth, acne, irregular periods, deepened voice, and known elevated testosterone levels. At the time of presentation, her physical examination was remarkable for a deepened voice, obesity, mild acne, and vellous dark hair on the upper lip. Laboratory studies were significant for an elevated total testosterone of 118 ng/dL (normal: 10-60 ng/dL) and elevated free testosterone of 32.8 pg/mL (normal: 0.8-9.2 pg/mL). A pelvic ultrasound demonstrated a normal peripubertal uterus and unremarkable ovaries and adrenal glands. The laboratory studies were repeated two months later. At that time, the total testosterone was 306 ng/dL, the free testosterone was 90 pg/mL, and the fasting insulin concentration was 268.7 mcIU/mL (normal: 3.012.0 mcIU/mL). A repeat ultrasound and a pelvic MRI revealed no evidence of ovarian or adrenal mass, but bilaterally enlarged ovaries with multiple peripheral follicles. She was then referred to our clinic in March 2011. Her physical examination was now remarkable for increased hair growth over the upper lip, sideburns, lower abdomen, breasts, lower back, and inner thighs. She had marked acanthosis nigricans. Her thyroid was normal and she had no clitoromegaly. She was diagnosed with PCOS and insulin resistance, and started on continuous oral contraceptive pills containing 35 mcg ethinyl estradiol. At 4-week follow-up, androgen levels normalized. The total testosterone was 31 ng/dL and the free testosterone was 4.2 ng/dL. Metformin was added to the patient's medication regimen. At her last follow-up in September 2011, she reported mild breakthrough bleeding on continuous oral contraceptives, no change in unwanted hair growth, and minimal acne. Her voice remained deepened. She self-discontinued the metformin during a summer vacation. Comments: Our case demonstrates that PCOS may present with some signs of virilization and rapidly increasing testosterone concentrations, and that severe hyperinsulinemia contributes to this rapid progression of hyperandrogenism. The case also confirms the therapeutic effects of oral contraceptive pills in the treatment of polycystic ovary syndrome.
15. All Is Not as It Seems: Bleeding Through Several Diagnoses in a Perimenarchal Girl Monique Collier Nickles MD 1, Jennifer M. Rosario MD 1, Alice Lee MD 2, Shanti Yogananda MD 1, Swati Dave-Sharma MD 1, Dilfuza Nuritdinova MD 1, Sandra A. Semple MD 1 1 Lincoln Medical and Mental Health Center, Weill Cornell Medical College, Bronx, New York 2 Morgan Stanley Children's Hospital of New York, Columbia College of Physicians and Surgeons, New York, New York
Background: In perimenarchal girls, irregular, painless uterine bleeding with anemia is often related to immaturity of the hypothalamic-pituitaryovarian (HPO) axis and resultant anovulatory cycles. We present a case where this initial diagnosis and three subsequent diagnoses were all incorrect and discuss diagnostic pitfalls in young adolescents. Case: A 13-year and 10-month-old virginal girl with a gynecologic age of 19 months presented to the pediatrician with myalgia and fatigue.
Results: Adolescent IUD users had a mean age of 19.8 1.6 years, with a racial/ethnic distribution of White (41.7%), Black (24.1%), Hispanic (29.6%). Most (73.1%) were single and non-nulliparous (97.2%) with 53.7% having 1 living child, 29.6% having 2 children. Most IUDs were inserted by physicians (75.0%) compared to nurse practitioners (18.5%), and the majority were Cu־IUDs (75.0%). Thirty percent (N¼<33) were screened for an STI within 7 days before insertion and one patient (3%) had a positive result. In the post-insertion period, 9.3% (N¼10) had an STI documented with none occurring in the first 20 days. Three patients (2.8%) had PID diagnosed post insertion with none occurring in the first 20 days. Overall, 57.4% reported a complication post-insertion. Pelvic pain (26.9%) was the most common complication followed by bleeding (25.9%), other (20.4%), cannot find IUD string (12.0%), dyspareunia (8.3%), and UTI (5,6%). Pelvic pain was reported more frequently with the Cu-IUD in comparison to the LNG-IUD (p¼ 0.029). There were no pregnancies noted during the insertion period. Non-immediate expulsions were reported by 9,3% (N¼10) with 2 occurring within 2 months, 4 within 6 months, and 6 occurring greater than 7 months post insertion. The mean length of time to expulsion was 254.2 203.5 days. Removals were seen among 33.3% (N¼36) with a mean length of 575.9 483.5 days before removal. The most common reasons for removal were discomfort (12%), vaginal bleeding (10.2%), and desired pregnancy (7.4%). Of the 108 adolescents, 47.2% (N¼51) had their IUD still in place at the end of the study period. Conclusions: Pelvic pain was the most common complication and was reported significantly more frequently with the Cu-IUD. Discomfort was the most common reason for early termination. There were no pregnancies during the insertion period while 9.3% had a STI and 2.8% had a PID. Further research should include comparing these results with an adult population and/or with a nulliparous teen population.
11. A Survey of Attitudes About Various Birth Control Methods in Young Women With and Without Eating Disorders
e53
12. Vulvar Venous Malformations in Premenarchal Girls: A Report of Four Cases Mariel A. Focseneanu MD, Diane F. Merritt MD Department of Obstetrics and Gynecology, Division of Pediatric and Adolescent Gynecology, Washington University School of Medicine, St. Louis, Missouri
Background: Vulvar venous malformations are congenital lesions that may enlarge and become symptomatic in older children or young adults. These malformations should be distinguished from vulvar varicosities, which are typically associated with pregnancy. Rapid enlargement of vascular malformations can occur following trauma, thrombosis, infection, and physiological hormonal alterations. Symptomatic venous malformations involving the external genitalia have rarely been reported in adolescent girls. Cases: We present four cases of vulvar venous malformations occurring in premenarchal girls. Comments: Vulvar venous malformations are a rare but potentially disabling occurrence in children and adolescent girls. Management consists of conservative, surgical, or sclerotic approaches. Treatment should be based on severity of the patient's symptoms; given the potential complications of sclerotherapy and surgery, (i.e. skin necrosis, disfigurement, and nerve damage) along with the possibility of spontaneous resolution, a conservative Tabel 1 Four cases of vulvar venous malformations Age
12
11
Menstrual Status
Presenting Complaint
premenarchal Swelling around vagina premenarchal Swelling & tenderness
Imaging Studies MRI
MRI
Caitlin W. Hicks MS, Samantha DeMarsh, Harjoat Singh, Laura Gillespie MD, Sarah Worley MS, Ellen S. Rome MD, MPH Cleveland Clinic, Cleveland, OH
premenarchal Swelling near vagina
MRI
venous malformations on lip and forehead
2
prepubertal
KlippelTrenaunayWeber syndrome. Venous malformation in right lower extremity
enlarged collateral veins Superficial venous malformation of the labia without extension into subcutaneous
1 month. Congenital
Venogram at age 8; MRI
and labia
Fig. 1. Vulvar venous malformation.Ă
No large feeding arteries or draining veins Venous malformation of right labia extending to right common femoral vein; no arteriovenous malformation in pelvis
Complications & Outcome
Observation
None; improved
Observation
with recurrences None; improved spontaneously over 2 months
Fluoroscopic guided ethanol
Necrosis of vulvar tissue & pain which resolved
sclerosis
over 2 months; minimal residual varicosities
tissues or pelvis.
Background: Minimal data exists examining the knowledge and attitudes about different methods of contraception in young women with eating disorders (EDs). Methods: Using a prospective, survey-based study of postmenarchal women aged 13-25 years with a diagnosed ED (n¼50, test group) or no prior history of disordered eating behaviors (n¼57, control group), we examined the groups’ knowledge about the risks and benefits of various forms of contraception. IRB approval was obtained prior to enrollment. Statistical analyses were performed using JMP 9.0 (SAS, Cary, NC). Results: As compared to controls, ED patients were more likely to be Caucasian (90% vs. 75%; p¼0.04), and to have completed high school (74% vs. 42%; p¼0.0009). There were no significant differences in whether ED vs. control patients were sexually active (52% vs. 39%; p¼0.16) or had had sex in the past month (26% vs. 28%; p¼0.81), or in the type of birth control method used between the two groups (p0.20). However, ED patients were more likely to incorrectly associate health risks with condoms, spermicides/gels/ foams, and the rhythm method (p0.03); identified fewer health benefits of OCPs (p¼0.05); and were less correct about the HIV protection afforded by various methods of birth control (p¼0.03) compared to controls. ED patients also underestimated the overall pregnancy risks with various methods of birth control more than controls (p¼0.005). There was a trend for ED patients to be more concerned with OCPs causing weight gain than controls but this was not statistically significant (78% vs. 61%; p¼0.06). Conclusion: despite having a higher level of education and no differences in sexual history, ED patients were less knowledgeable than controls about the health risks and benefits, effectiveness in preventing HIV, and the effectiveness in preventing pregnancy various methods of birth control. ED patients may be presumed to be “not-sexually active” while working on recovery; physicians should take extra time to educate these patients about their personal risks of unintended pregnancy, STIs and the benefits that different methods of contraception can provide.
Single prominent vessel right labia Bilateral vulvar
Management
varicosities with no arterial supply; no
of right labia 2 days 11
Findings
Sclerotherapy age 8; Excision of right labial venous malformation age 12
Necrosis of vulvar tissue after sclerotherapy. Age 12, vulvar bleeding requiring 2 surgical procedures. Continued problems now age 27 years
e54
Oral Abstracts / J Pediatr Adolesc Gynecol 25 (2012) e49ee55
approach is appropriate in a young patient with minimal symptoms. However, a more aggressive approach may be needed for debilitating symptoms.
14. Polycystic Ovary Syndrome Mimicking an Androgen-Secreting Tumor
13. Ectopic Ovary Presenting as Right Upper Quadrant Abdominal Pain in a Premenarchal Patient With a Unicornuate Uterus
Maude Veilleux-Lemieux MD, FRCPC 1, Amy Desrochers DiVasta MD, MMSc 1,2 1 Division of Adolescent and Young Adult Medicine 2 Division of Pediatric and Adolescent Gynecology, Children's Hospital Boston, Boston, Massachusetts
Saifuddin T. Mama MD, MPH Department of Ob/Gyn, Cooper University Hospital, Camden, NJ
Background: The association between unicornuate uterus and undescended ovaries has been reported in the past but is extremely rare. In many cases, the possibility is not considered or recognized and there is a significant delay in diagnosis. Of the mullerian duct anomalies, unicornuate uterus represent approximately 4% of these disorders of lateral fusion of the mullerian ducts. Case: The patient was a 12 year old premenstrual female who presented with onset of right upper quadrant pain and emesis. The patient was hospitalized for 3 days to rule out appendicitis and had resolution of her pain. The GI service after upper GI series with small bowel follow through, endoscopy and colonoscopy diagnosed possible Crohn's disease and patient was started on Pentasa and Zantac with no relief. The patient continued to have recurrent pain in the same location lasting from hours to days with a sporadic pattern of occurrence for the next 13 months. The patient was then rehospitalized for 5 days for severe pain which spontaneously resolved. Two months later the patient had a repeat hospitalization and was seen by pediatric surgery. Diagnostic laparoscopy was performed with the findings being absent right adnexa and otherwise normal pelvis. The patient was referred to pediatric gynecology. Ectopic right ovary was suspected as the cause of the pain and a right upper quadrant ultrasound revealed a 2.3 x 1.3 x 1.5 cm structure at the tip of the right liver lobe. Concomitant pelvic ultrasound revealed a normal left ovary and the right ovary was not visualized. The uterus appeared deviated to the left. A CT scan performed revealed a small multiloculated mixed density lesion at the inferior tip of the right liver lobe. Both kidneys were visualized in the normal position. The patient had a presumptive diagnosis of unicornuate uterus associated with a right ectopic ovary with the pain being intermittent torsion. The patient had a repeat laparoscopy with the right ovary noted just beneath the tip of the right liver lobe. Given the history of right upper quadrant pain likely being intermittent torsion, after consultation with the parents, the decision was made to excise the right ovary. The patient had an uneventful postoperative recovery and has remained pain free. Comments: The ovaries have an entirely separate origin from the mullerian system with primordial germ cells invading the primitive gonads on the gonadal ridge, eventually migrating from near the kidney to the true pelvis. If there are no mullerian duct derivatives or kidney on one side, i.e. failure of development of the entire urogenital ridge, including the genital ridge where the ovary forms, then the ovary may be malpositioned, located anywhere from the level of T4 to the pelvic brim. These ectopic locations for ovaries are associated with a 40% chance of associated unicornuate uterus. The failure to visualize either adnexa in a patient with unexplained pain should prompt a search for a potential ectopic location for the ovary.
Fig. 1. (B) Ectopic right ovary beneath right liver lobe.Ă
Background: Hirsutism affects approximately 5 percent of reproductiveaged women. The most common causes of hirsutism are polycystic ovary syndrome (PCOS) and idiopathic hirsutism. Rapid onset or progression of hirsutism, as well as an elevated serum total testosterone concentration higher than 200 ng/dL should prompt further investigation to exclude an androgen-secreting tumor. Case: A previously healthy 12-year-old female patient presented for the evaluation of unwanted hair growth, acne, irregular periods, deepened voice, and known elevated testosterone levels. At the time of presentation, her physical examination was remarkable for a deepened voice, obesity, mild acne, and vellous dark hair on the upper lip. Laboratory studies were significant for an elevated total testosterone of 118 ng/dL (normal: 10-60 ng/dL) and elevated free testosterone of 32.8 pg/mL (normal: 0.8-9.2 pg/mL). A pelvic ultrasound demonstrated a normal peripubertal uterus and unremarkable ovaries and adrenal glands. The laboratory studies were repeated two months later. At that time, the total testosterone was 306 ng/dL, the free testosterone was 90 pg/mL, and the fasting insulin concentration was 268.7 mcIU/mL (normal: 3.012.0 mcIU/mL). A repeat ultrasound and a pelvic MRI revealed no evidence of ovarian or adrenal mass, but bilaterally enlarged ovaries with multiple peripheral follicles. She was then referred to our clinic in March 2011. Her physical examination was now remarkable for increased hair growth over the upper lip, sideburns, lower abdomen, breasts, lower back, and inner thighs. She had marked acanthosis nigricans. Her thyroid was normal and she had no clitoromegaly. She was diagnosed with PCOS and insulin resistance, and started on continuous oral contraceptive pills containing 35 mcg ethinyl estradiol. At 4-week follow-up, androgen levels normalized. The total testosterone was 31 ng/dL and the free testosterone was 4.2 ng/dL. Metformin was added to the patient's medication regimen. At her last follow-up in September 2011, she reported mild breakthrough bleeding on continuous oral contraceptives, no change in unwanted hair growth, and minimal acne. Her voice remained deepened. She self-discontinued the metformin during a summer vacation. Comments: Our case demonstrates that PCOS may present with some signs of virilization and rapidly increasing testosterone concentrations, and that severe hyperinsulinemia contributes to this rapid progression of hyperandrogenism. The case also confirms the therapeutic effects of oral contraceptive pills in the treatment of polycystic ovary syndrome.
15. All Is Not as It Seems: Bleeding Through Several Diagnoses in a Perimenarchal Girl Monique Collier Nickles MD 1, Jennifer M. Rosario MD 1, Alice Lee MD 2, Shanti Yogananda MD 1, Swati Dave-Sharma MD 1, Dilfuza Nuritdinova MD 1, Sandra A. Semple MD 1 1 Lincoln Medical and Mental Health Center, Weill Cornell Medical College, Bronx, New York 2 Morgan Stanley Children's Hospital of New York, Columbia College of Physicians and Surgeons, New York, New York
Background: In perimenarchal girls, irregular, painless uterine bleeding with anemia is often related to immaturity of the hypothalamic-pituitaryovarian (HPO) axis and resultant anovulatory cycles. We present a case where this initial diagnosis and three subsequent diagnoses were all incorrect and discuss diagnostic pitfalls in young adolescents. Case: A 13-year and 10-month-old virginal girl with a gynecologic age of 19 months presented to the pediatrician with myalgia and fatigue.