Central precocious puberty (CPP) is a condition where the hypothalamus-pituitary-gonadal axis is activated earlier than normal, leading to premature development of secondary sexual characteristics before eight years of age in girls and nine years of age in boys. The purpose of this study was to critically and systematically evaluate the literature regarding CPP rise during the COVID-19 pandemic. We searched PubMed and Google Scholar for relevant articles using the following MeSH terms: "COVID-19, "precocious puberty," "early puberty," "pediatric endocrinology," and "pandemic effects." We included studies calculating the risk of CPP before and during the COVID-19 pandemic. We excluded studies looking at patients with an identifiable cause for CPP or with peripheral precocious puberty. The primary outcome was the prevalence of central precocious puberty during the pandemic compared to the pre-pandemic period. We analyzed data regarding anthropometric, biochemical, and pelvic ultrasound data between the two groups. Overall, 16 studies with 2.175 subjects were included, of which 1.818 were diagnosed with CPP. There was a rise in the number of new diagnoses of CPP during the COVID-19 pandemic (985 subjects) compared with the pre-pandemic period (833 subjects). The mean age of diagnosis in the first group was 7.42 years versus 7.54 years in the second group. Notably, CPP during the pandemic was associated with a higher body mass index (BMI) compared with the group of the pre-pandemic period (17.50 versus 17.08). The pandemic and lockdowns led to changes in lifestyle habits, social isolation, sleep disturbance, excess screen time, and increased stress levels. We hypothesize that these alterations influenced the increase in CPP frequency.

PURPOSE: Variants in the GNB1 gene, which encodes for the beta-1 subunit of G proteins, have been associated with intellectual development disorder (OMIM: 616973), characterized by developmental delay, infantile hypotonia, seizures, and psychiatric problems. GNB1 variants may also cause a multisystem disorder, with symptoms such as hearing and vision impairment, gastrointestinal disorders, genitourinary abnormalities, and growth delay. CASE PRESENTATIONS: We present two pediatric patients with two novel GNB1 variants. The first patient is a 12-year old Caucasian European female with a history of neonatal hypotonia, feeding difficulties, and failure to thrive for the first 2 years of life. Subsequently, she developed grade 3 obesity, hyperphagia, and autoimmune thyroiditis. Whole Exome Sequencing (WES) revealed a novel likely pathogenic variant in the GNB1 gene (NM{\_}002074.5:c.93{\_}94del, p.Gln32AspfsTer46), which is predicted to result in a loss or disruption of normal protein function through nonsense-mediated decay (NMD) or protein truncation. The second patient is a 2-year old Roma female with severe failure to thrive during infancy, congenital hypothyroidism, and transient hyperoxaluria. No developmental delay was identified. Genetic testing excluded primary hyperoxaluria and WES revealed to be a novel likely pathogenic variant {\{}NM{\_}002074.5:c.183G {\textgreater} T (NP{\_}002065.1:p.Met61Ile), which is predicted to have a damaging effect on the gene or gene product. CONCLUSION: We present two rare pediatric cases with novel GNB1 variants which highlight the phenotypic variability associated with disrupted GNB1 expression. GNB1 may serve as a candidate gene for severe early onset obesity, hyperphagia, neurodevelopmental delay, and other metabolic and endocrine disorders.}

OBJECTIVE: Nutritional guidelines for postmenopausal women differ. This study aimed to assess postmenopausal women's knowledge, beliefs, and practices regarding nutrition during menopause and their dietary habits. METHODS: This cross-sectional study was conducted in a menopause clinic, and data from 105 women were analyzed. A nutrition knowledge, attitudes, and perceptions (KAP) questionnaire was designed, structured, and piloted before implementation, based on the Hellenic dietary guidelines. International Physical Activity Questionnaire-Greek version, MedDietScore, and Menopause-specific Quality of Life questionnaires were administered. RESULTS: The mean ± SD age of the women was 56.9 ± 4.6 years. The mean ± SD KAP score was 12.2 ± 3.5. Those who lived in rural areas had lower KAP scores than those who lived in urban areas ( P = 0.004). Of all the women, 74.5{%} knew the Mediterranean diet pyramid, whereas 9.8{%} knew the Hellenic dietary guidelines. Women who had read the guidelines showed better knowledge of Mediterranean diet food groups (Pearson, 0.309; P = 0.039). Knowledge of dairy services was correlated with consumption of dairy products ( P = 0.002). Furthermore, 76.4{%} were willing to participate in nutrition education programs. The International Physical Activity Questionnaire score was positively correlated with years of smoking ( P = 0.002). Physical activity correlated with adherence to the Mediterranean diet ( P = 0.044). CONCLUSIONS: The majority of postmenopausal Greek women in this study were unaware of the Hellenic dietary guidelines. In general, women's knowledge of nutrition during menopause was moderate. Greek postmenopausal women are willing to participate in nutrition education programs, which should raise awareness of healthy lifestyles through nutrition, exercise, and smoking cessation.

INTRODUCTION: Tanzania has a high adolescent birth rate and many sexually active adolescents do not have access to effective contraception. Teenage pregnancy is considered a high-risk pregnancy. Furthermore, it leads to social inequalities for both mother and offspring. METHODS: We conducted semistructured interviews with 12 adolescent mothers during their stay in the postnatal ward of the maternity department of a tertiary hospital in Zanzibar. The study took place between November and December 2022. Data were then analyzed qualitatively. RESULTS: The main theme that emerged from the interview data was that pregnancy seemed to affect the lives of young girls in a negative way. The majority of pregnancies were unplanned, and the girls reported low family planning uptake. Another recurring theme was that girls had many οbstacles in their education prior to pregnancy, which left them uncertain about their future. Finally, despite the advice of local doctors, the majority of the girls received minimal prenatal care, mostly because they did not regard obstetric care to be a priority. CONCLUSIONS: Adolescent pregnancy remains an important public health issue in Tanzania, despite significant measures by authorities to reduce it. Educational changes and professional opportunities as well as family planning services may enable young girls to achieve professional and personal goals while delaying motherhood into adulthood.

OBJECTIVES: An increasing number of women living with HIV are transitioning through midlife and menopause. Women living with HIV may experience earlier menopause and a higher symptom burden than women without HIV, but more evidence is needed. Data collection on menopause in women living with HIV is scarce and often not standardized. We sought to assess how menopause data are collected in cohorts and studies of women living with HIV. METHODS: This was a literature review conducted within the PubMed database. We included original studies and cohorts assessing menopause and/or menopausal symptoms in women living with HIV. Study characteristics and menopause data collection, including the definition of menopause, symptom assessment tools, and measurement of biomedical parameters, were noted and summarized systematically in data tables. RESULTS: We included 40 articles describing 37 separate studies published between 2000 and 2023; 27 of these were conducted in high-income countries, the majority in the USA (n = 16). Ten studies were from low- and middle-income countries; four of these were conducted in Brazil. In 20 studies, menopause was defined according to the World Health Organization's definition of over 12 months of amenorrhea. Twelve studies used the Menopause Rating Scale to characterize menopausal symptoms, five studies used other specified symptom assessment tools, and 12 studies used a study-specific tool. CONCLUSIONS: Menopause data collection in women living with HIV is heterogeneous. We propose that standardized tools should be used to enable comparisons between studies and countries, thereby improving the quality of research and clinical treatment. Further research into the validity of menopausal symptom scoring tools is warranted.

Genital graft-versus-host disease (GVHD) after hematopoietic stem cell transplantation (HSCT) is an underdiagnosed manifestation of chronic GVHD. Few articles have been published in pediatric populations, and there are no established guidelines for the management of this condition in children. This study aims to provide a systematic literature review of the published studies and cases of genital (vulvovaginal) GVHD in girls and adolescents post HSCT, with a focus on the time of diagnosis and clinical manifestations. The authors searched for English-language articles published after 1990, which included full patient details. Thirty-two cases of female patients under 20 years of age were identified. The median time of diagnosis was 381 days (IQR: 226-730 days), and 83{%} of patients developed Grade 3 vulvovaginal GVHD. Based on these observations, an early pediatric gynecologic examination of these patients, soon within the first year after HSCT, could be suggested for early diagnosis, treatment initiation and prevention of long-term complications.

INTRODUCTION: Functional Hypothalamic Amenorrhea (FHA) has been associated with excessive-chronic stress, eating disorders, and weight loss. A common feature is the increased serum cortisol, but its measurement has many limitations. Currently, salivary cortisol (SC) has been proposed as a more sensitive and adequate index. AIM: To investigate the SC alterations through a 24-h period and the possible correlation with the severity of stress in women with FHA. METHODS: Between July 2019 and March 2021, 12 FHA women and 12 healthy controls of comparable age were included. Psychological, eating, and physical abnormalities were evaluated by applying equivalent validated self-questionnaires. RESULTS: No significant differences were found between FHA women and healthy individuals with respect to morning (8:00 am) serum cortisol and ACTH (522.5 ± 162.2 vs 442 ± 138.5 nmol/l; p = 0.204 and 37 ± 44.8 vs 17.4 ± 10.8 pg/ml; p = 0.186, respectively). Women with FHA had statistically significant higher morning SC compared to control subjects (21.8 ± 5.9 nmol/l vs 12.8 ± 3.8 nmol/l; p {\textless} 0.001), while no significant differences were found regarding the afternoon (4:00 pm) and midnight (12:00 am) SC. A significant positive correlation was found between morning SC and morning serum cortisol (rho = 0.532; p = 0.007), EAT-26 (rho = 0.527; p = 0.008) and HADS-Anxiety score (rho = 0.471; p = 0.02). Additionally, a significant negative correlation between morning SC and BMI was observed (rho = -0.53; p = 0.009). CONCLUSION: Compared to serum cortisol, SC seems to express better the hypercortisolemic state of women with FHA and correlates well with the underlying contributing factors. Larger studies are needed in order to confirm these results and validate the optimal SC cut-off value associated with the development of FHA.

BACKGROUND: Males with 5$\alpha$-reductase deficiency experience oligospermia or azoospermia, resulting in fertility problems. OBJECTIVE: The aim of the present systemic review was to assess the fertility status of males with 5$\alpha$-reductase type 2 deficiency and explore how reproduction can be achieved in these patients. STUDY DESIGN: An extensive search of two databases (Pubmed and SCOPUS) was performed. Studies with original clinical data in patients with 5$\alpha$-reductase deficiency evaluating the impact of the disease on semen quality and quantity and pregnancy outcomes through assisted or natural conception methods were eligible to be included in this systematic review. RESULTS: A total of nine cases were identified based on the eligibility criteria, all of which included reports of successful reproduction in males with 5$\alpha$-reductase type 2 deficiency. DISCUSSION: In five individuals, assisted reproduction technology was used to achieve conception, highlighting its importance in solving the fertility problems that males with 5$\alpha$-reductase deficiency are facing. Potential future fertility is a further indication for assigning the male gender in diagnosed newborns. CONCLUSION: In order to achieve this, the development of a management plan starting at birth is crucial for these patients, so that spermatogenesis and potential fertility can be preserved. In adulthood, semen analysis and mutation screening may also help in guiding these patients to select the correct fertilization method for their individual genetic and phenotypic characteristics.

Cosmetic labiaplasty is a form of Female Genital Cosmetic Surgery (FGCS) that is performed with the deliberate intent to alter the appearance and morphology of the external genitalia in the absence of medical concerns. Over the last decade, there is an increasing demand for FGCS and the industry behind it is constantly growing. Adolescents comprise an extremely vulnerable population, with labiaplasties in this particular age group having also increased. However, labiaplasty has been widely contested due to the irrevocable alteration of a psychosexually significant body part on minors too young to consent. Besides, the changes that occur during pubertal development in the genital area can significantly alter pediatric surgical results. Genital anatomy is more diverse than we previously thought and there is evidence to suggest that the labia minora with their rich innervation play an important role in sexual arousal and pleasure. Education regarding the wide range of normal genital appearance suffices in most cases to dissolve concerns regarding body self-image. Mental health issues should always be explored and, if identified, the girl should be referred to an experienced professional for their resolution. Postponing labiaplasty until adulthood is strongly recommended to help adolescents achieve a well-informed decision regarding an irreversible procedure with possible adverse esthetic and functional outcomes.

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is a congenital condition characterizing females with absence of the uterus and part of the vagina. Several genetic defects have been correlated with the presence of MRKH; however, the exact etiology is still unknown due to the complexity of the genetic pathways implicated during the embryogenetic development of the Müllerian ducts. A systematic review (SR) of the literature was conducted to investigate the genetic causes associated with MRKH syndrome and Congenital Uterine Anomalies (CUAs). This study aimed to identify the most affected chromosomal areas and genes along with their associated clinical features in order to aid clinicians in distinguishing and identifying the possible genetic cause in each patient offering better genetic counseling. We identified 76 studies describing multiple genetic defects potentially contributing to the pathogenetic mechanism of MRKH syndrome. The most reported chromosomal regions and the possible genes implicated were: 1q21.1 (RBM8A gene), 1p31-1p35 (WNT4 gene), 7p15.3 (HOXA gene), 16p11 (TBX6 gene), 17q12 (LHX1 and HNF1B genes), 22q11.21, and Xp22. Although the etiology of MRKH syndrome is complex, associated clinical features can aid in the identification of a specific genetic defect.

OBJECTIVE: To assess the risk for obstetric complications in women with congenital uterine anomalies and the risk in each main class of uterine anomaly (U2 [septate], U3 [bicorporeal], U4 [hemi-uterus]), based on the 2013 classification by the ESHRE (European Society of Human Reproduction and Embryology) and the ESGE (European Society for Gynaecological Endoscopy). DATA SOURCES: MEDLINE, Scopus, and ClinicalTrials.gov were searched from inception until January 2021. The reference list of all included articles and previous systematic reviews were also screened to identify potential additional articles. METHODS OF STUDY SELECTION: Comparative and noncomparative studies that investigated the obstetric outcomes of women with any type of known congenital uterine anomaly were considered eligible for inclusion. Screening and eligibility assessment was performed independently by two reviewers. TABULATION, INTEGRATION, AND RESULTS: Forty-seven studies were included. The quality of included comparative studies was assessed using the Newcastle-Ottawa Quality Assessment Scale. Odds ratios (ORs), pooled proportions of each obstetric outcome, and 95{%} CIs were calculated in RevMan and Stata accordingly, using random effects models. Congenital uterine anomalies were associated with increased risk of preterm birth (OR 3.89, 95{%} CI 3.11-4.88); cervical insufficiency (OR 15.13, 95{%} CI 11.74-19.50); prelabor rupture of membranes (OR 2.48, 95{%} CI 1.38-4.48); fetal malpresentation (OR 11.11, 95{%} CI 5.74-21.49); fetal growth restriction (OR 3.75, 95{%} CI 1.88-7.46); placental abruption (OR 5.21, 95{%} CI 3.34-8.13); placenta previa (OR 4.00, 95{%} CI 1.87-8.56); placental retention (OR 1.71, 95{%} CI 1.16-2.52); and cesarean birth (OR 4.52, 95{%} CI 2.19-9.31); when compared with those without anomalies. Pooled estimated risks were 25{%} for preterm birth, 40{%} for fetal malpresentation, 64{%} for cesarean birth, 12{%} for prelabor rupture of membranes, 15{%} for fetal growth restriction, 4{%} for placental abruption, 5{%} for preeclampsia, 13{%} for cervical insufficiency, and 2{%} for placenta previa. Classes U2 (septate), U3 (bicorporeal), and U4 (hemi-uterus) were also associated independently with preterm birth, fetal malpresentation, cesarean birth, and placental abruption. CONCLUSION: Congenital uterine anomalies are associated with obstetric complications across all examined ESHRE and ESGE classifications. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42021244487.

Global exposure of children to sexual abuse is widespread. Disclosure may be extremely upsetting for both families and medical professionals. This review provides medical practitioners with practical tips for a stepwise approach of the child who discloses sexual abuse. Having secured a private examination room, the physician should approach the child and caregivers separately to determine the level of concern for abuse and the urgency of the situation. The medical evaluation is based on the information gathered, including a complete physical examination, inspection of the genitalia, collection of forensic evidence, and testing for sexually transmitted diseases. On a case-by-case basis, the need for surgical intervention, prophylactic treatment, and immunization is discussed. Finally, important questions for the medical team to address are outlined with the goal of supporting the child and his/her family and ultimately stopping the abuse.

Background: The regenerative efficacy of platelet-derived products has been recently investigated in the treatment of pelvic floor disorders (PFDs). We aimed to synthesize the current evidence of platelet-rich plasma (PRP) products used in urogynaecological disorders including vaginal atrophy, pelvic organ prolapse (POP), urinary incontinence, vaginal fistulas and vaginal mesh exposure. Methods: A meticulous search of the currently available literature on the use of PRP for the management of PFDs was performed using 3 electronic databases. Results: PRP could be a feasible alternative modality for the management of vaginal atrophy with favourable outcomes in vaginal atrophy parameters and patients' satisfaction, especially when hormone therapy is contraindicated. In patients with POP, an increase in collagen concentration after PRP application was observed while the use of PRP resulted in improvement of stress urinary incontinence symptoms. A considerable proportion of vesicovaginal fistulas were treated after application of PRP-based injections. Conclusions: There is only limited evidence of the use of PRP for PFDs. Platelet-rich plasma appears to be a promising, easy to apply, cost-effective and feasible alternative therapeutic modality for the management of various urogynaecological disorders. Future randomized trials are needed to confirm the efficacy of PRP in the treatment of urogynaecological disorders.

OBJECTIVE: The objective of this research was to evaluate how menstrual tracking applications can promote gynaecological health. MATERIALS AND METHODS: We performed a systematic review in Medline and Scopus, for papers evaluating menstrual tracking mobile applications. We excluded review articles and those not written in English. RESULTS: We identified 14 articles measuring the outcome resulting from the use of a single Fertility Tracking Application (FTA). Eight studies evaluated 2 different applications used as a contraception method. One study assessed a fecundity enhancing application. Five studies referred to applications, used to treat or monitor various gynaecologic issues. All studies reported efficacy for their intended use or a high satisfaction rate. DISCUSSION: There is a plethora of FTAs, however a minority of them are appraised by medical experts. Several safety and privacy concerns have been expressed regarding their use and these issues should be addressed in the future. All studies identified in our search demonstrated that FTAs can facilitate users in terms of contraception, fertility, and menstrual awareness. CONCLUSION: Menstrual tracking applications can serve as a valuable health tool, nevertheless, their content should be more vigorously evaluated.

BACKGROUND: Vaginal agenesis, most commonly referred as Mayer-Rokitansky-Küster-Hauser (MRKH) Syndrome, is mostly diagnosed as primary amenorrhea in teenage girls; although there is plenty of literature concerning the formation of a neovagina, limited research has focused on the psychological burden of this diagnosis to the girls. AIM: To enlighten health providers into the finer aspects of sexuality through the own words and experiences of girls with MRKH under our care. METHODS: Women currently undergoing vaginal dilation or who had completed vaginal dilation within the past year were recruited from February 2019 to January 2020. A gynecologist with training in Sexual Medicine conducted a semistructured interview, which was recorded and then transcribed to identify common themes among interviewees. OUTCOMES: The main outcome explored was the narrative experiences of women with MRKH. RESULTS: 7 women participated, with a mean age of 19.7 (range 17-22 years). None of the girls felt stigmatized, however one reported significant distress at diagnosis, stemming from the attitude of health care professionals and exacerbated by an earlier age at disclosure. All girls accepted that VDT was successful, when it was initiated after they had felt sexual interest and arousal. Exact quantification of the vaginal length at onset, worried 4 as they felt pressurized to achieve a specific length. A few girls reported anxiety over sharing the diagnosis with an intimate partner. All of them pretended at some point to have menses. Childbearing was an important issue for most of the interviewees, but it did not concern them for the time being. All girls had supporting families. However, 5 did not want to share information about VDT with them. One girl reported that openness in discussing genital anatomy, VDT and sexuality, helped her both in completing treatment and adapting in a sexual relationship. CLINICAL IMPLICATIONS: A multidisciplinary team should aim for age-appropriate disclosure and consultation and guide women through VDT and their sexual relations. STRENGTHS AND LIMITATIONS: This is a thorough account of women's perceptions regarding VDT and sexuality in MRKH. However, our conclusions may be limited by the small number of participants. CONCLUSION: Gradual provision of information at disclosure and adjusted timing at VDT may reduce stress in girls with MRKH. Tsitoura A, Michala L. The Sexuality of Adolescents and Young Women With MRKH Syndrome: A Qualitative Study. J Sex Med 2021;18:2012-2019.

BACKGROUND: Greece has a mean age of first motherhood at 31.5 years, higher than the European average age of 29.4. Delaying conception, however, may be an important non-reversible cause of infertility. The aim of this study was to identify possible knowledge deficits regarding fertility in young adults. METHODS: This was an online survey of young adults, regarding information on intention to parenthood and knowledge on issues affecting fertility. This study was conducted from February to December 2020, aiming for a representative sample of Greek men and women aged 18 and 26 years. The questionnaire was designed by a multidisciplinary group based on the Cardiff Fertility Knowledge Scale, which contained 22 multiple-choice or Likert-scale questions. RESULTS: We obtained responses from 1875 young adults, whose mean age was 22.1 years. About 91.8{%} of men and 94.0{%} of women declared an intention to have children, out of which 44.0{%} wanted to have two and 29.0{%} three children. About 52.0 and 50.8{%} men and women, respectively, aimed to start a family between 31 and 35 years. Residents of rural areas and those with a lower education level more likely aimed to have children before the age of 30. The most prevalent answers for age of ideal parenthood were between 26 and 30 years for a woman and 31-35 years for a man. Smoking, alcohol consumption and sexually transmitted infections were identified as factors affecting both female and male fertility. Half of men and women, respectively, overestimated general success rates of reproductive techniques. CONCLUSION: The knowledge of fertility, particularly with regards to assisted reproductive techniques' success rates, may be overestimated as more young adults plan for having children after the age of 30.

Polycystic ovary syndrome (PCOS) is the most common endocrine condition affecting 6-18{%} of adolescents and is strongly associated with obesity and cardiovascular risk factors, enhancing the risk of atherosclerosis. Thirty-two adolescents with newly diagnosed PCOS were evaluated for lipid profile disorders, insulin resistance, inflammation, non-alcoholic fatty liver disease (NAFLD), and subclinical atherosclerosis through measurements of carotid intima-media thickness (cIMT). The relationships of the above markers with increased body mass index and abdominal obesity were investigated. Twenty-three adolescents (72{%}) were overweight (OW) or obese (OB). The OW/OB group had significantly higher insulin, HOMA-IR, high-sensitive C-reactive protein (hsCRP), visceral adiposity index (VAI), and lipid accumulation product (LAP) levels; and lower glucose-per-insulin ratios and HDL-C levels compared to the healthy weight group. The cIMT and small dense low-density lipoprotein cholesterol (sdLDL-C) levels did not differ between the two groups. Similarly, cIMT and sdLDL-C levels did not differ between PCOS-adolescents and healthy controls. CIMT was positively correlated with systolic blood pressure and waist circumference per height ratio. In conclusion, OW/OB PCOS-adolescents have a cluster of adverse factors predisposing them to atherosclerotic cardiovascular disease. Therefore, early cardiovascular risk assessment, as well as timely and targeted interventions, are necessary for prevention.

BACKGROUND: Juvenile cystic adenomyomas (JCAs) are rare uterine lesions. Differential diagnosis might be difficult. We present the case of an adolescent who was diagnosed with JCA and was managed with laparoscopic excision. CASE: A 14-year-old patient with complaint of menarche with excruciating dysmenorrhea, was diagnosed using magnetic resonance imaging with a uterine anomaly consisting of a normal right hemiuterus, and a left cystic lesion with surrounding hypotense myometrium. She was managed with laparoscopic excision of the left side, and uterine reconstruction. Histology was suggestive of JCA, associated with diffuse adenomyosis. Dysmenorrhea improved considerably after surgery. SUMMARY AND CONCLUSION: Differential diagnosis between cystic uterine lesions relies on clinical, imaging, and perioperative clues that might assist in their formal classification. Doubt might still remain in some cases.

PURPOSE: To ascertain the role of deranged eating behaviours (DEBs) in the development of functional hypothalamic amenorrhoea (FHA) and the reciprocal role of psychopathological traits on both disorders. METHODS: A prospective case-control study was conducted spanning the period January 2016 to April 2018. Forty-one consecutive FHA females and 86 healthy controls were recruited. We assessed the DEBs and other FHA predisposing factors via self-reported questionnaires. Possible correlations amongst the variables were examined using the Spearman's correlation coefficient (rho), whilst multivariate logistic regression was carried out to identify independent predictors of DEBs. RESULTS: Mean scores on Eating Attitudes Test-26 (EAT-26) were significantly higher in females with FHA (p {\textless} 0.0001). Women with FHA were characterised by significantly higher scores at the sub-scale items of dieting (p = 0.03) and bulimia and food preoccupation (p {\textless} 0.001) compared to healthy controls. Significant difference was also observed between the mean scores of the two groups in all other questionnaires: State-Trait-Anxiety-Inventory (STAI) (p {\textless} 0.0001), Multidimensional Body-Self-Relations Questionnaire (MBSRQ) (p {\textless} 0.0001) and International Physical Activity Questionnaire (IPAQ) (p = 0.004). EAT-26 scores were positively correlated with scores on STAI ($\rho$ = 0.26, p = 0.04), MBSRQ ($\rho$ = 0.79, p {\textless} 0.0001) and IPAQ ($\rho$ = 0.35, p = 0.03). High scores on IPAQ and STAI were correlated with a 12.2-fold (p = 0.008) and 4.3-fold (p = 0.04) increased risk for high scores on EAT-26 respectively. CONCLUSIONS: DEBs may occur in FHA populations at a higher frequency compared to the general population. Anxiety and overweight preoccupation may underlie and independently contribute to development and maintenance of both DEBs and FHA. This evidence may have future implications for both screening and interventions that target DEBs and other psychological factors.

Genital dissatisfaction in healthy young women is on the rise. Pubic hair removal reveals genital tissue previously hidden, while social trends promote the absence of any protruding genital tissue as the feminine ideal. Information with regard to the natural diversity of external genitalia anatomy, and lifestyle changes to improve physical symptoms related to labial tissue may suffice to reassure a distressed adolescent. Female genital cosmetic surgery is rarely supported, before attaining genital maturity. However, genital dissatisfaction may lead to significant embarrassment and anxiety, requiring formal psychological counselling. Sexual education needs to counterbalance perceived normal anatomy, portrayed in pornography or female genital cosmetic surgery advertisements.

OBJECTIVE: The objective of this study was to translate the Menopause-specific Quality of Life (MENQOL) questionnaire in Greek and validate it for usage in the Greek population both in written and electronic form. METHODS: The original English questionnaire MENQOL with 1-month recall period was translated by our team. According to instructions by Mapi Research Trust, the questionnaire was forward and back-translated, followed by patient testing and proofreading. Then it was transcripted electronically. Validation was performed with the following tests: internal consistency (reliability), stability (test-retest reliability) with Cronbach's alpha correlations, independent and paired t tests, and Pearson's correlation coefficients. RESULTS: A total of 105 women, the majority recently menopausal, participated in the study. Internal consistency using the Cronbach's alpha showed high reliability ranging between 0.833 (physical domain) and 0.896 (vasomotor domain) for the written, and 0.720 (physical domain) and 0.868 (vasomotor domain) for the online form. Test-retest reliability was also high for both forms. The sexual domain of MENQOL had the higher mean, indicating the highest impact on quality of life (3.80 ± 2.35). CONCLUSIONS: The Greek version of MENQOL is a reliable instrument for evaluating menopausal women. Availability of an online form will allow wider dissemination of the questionnaire. Further use of the questionnaire in Greece may lead to better understanding of the bothersome symptoms of menopause; a prerequisite to develop intervention studies for amelioration of quality of life.

BACKGROUND: Transverse vaginal septum is a rare Müllerian anomaly that can coexist with other defects. CASE: A 12-year-old patient was referred to our clinic for cyclic, lower abdominal pain. Magnetic resonance imaging revealed the presence of a transverse vaginal septum, a hemiuterus with a nonfunctioning rudimentary horn, and left unilateral ureter and kidney. The septum was excised laparoscopically assisted by a vaginal dilator to guide the dissection. The mucosal gap of the vagina was then bridged with sutures using the perineal approach. The postoperative course was uneventful and the patient was discharged with instructions for vaginal dilations. SUMMARY AND CONCLUSION: Early identification of a transverse vaginal septum and careful planning of the operation can improve the outcome of corrective surgery and prevent possible complications.

© 2020 Informa UK Limited, trading as Taylor {&} Francis Group. Labial fusion in adolescence is uncommon and is usually secondary to other skin disorders or trauma of the vulvar area. In a five-year period, we treated five patients with labial fusion in our facility with a mean age of 16.4 years. Based on clinical presentation and biopsy of the vulvar skin, lichen sclerosus (LS) was the causative factor. Four out of five had urinary problems and one suffered from an inflamed inclusion cyst. All of them had a long history of pruritus. In all cases, blunt separation of the labia minora under general anaesthesia was performed, followed by local application of a potent glucocorticoid cream and an emollient agent. One patient received additionally oral and local antibiotics. One recurrence was noted, which resolved after re-separation and more meticulous treatment. Early identification and treatment of LS are crucial to prevent distortion of the vulvar anatomy.Impact StatementWhat is already known on this subject? Labial fusion is an uncommon problem in adolescence and an underlying cause should always be investigated. Lichen sclerosus typically affects the anogenital area and can lead to fusion of the labia minora. What do the results of this study add? Urinary symptoms may be the presenting feature of LS in adolescents. What are the implications of these findings for clinical practice and/or further research? Delay in diagnosis and appropriate treatment can result in irreversible changes to the vulva.

© 2019, Hellenic Endocrine Society. Premature ovarian insufficiency (POI) is typically diagnosed when amenorrhea is combined with high gonadotrophins and hypoestrogenemia in a woman under 40 years of age, although, more rarely, POI can develop in adolescence and present with delayed puberty or amenorrhea, depending on the timing of follicular depletion or insult to the ovary. In a proportion of girls, the diagnosis may be made at an early stage of POI, presenting with abnormal uterine bleeding, when some follicular function is still retained. The natural history of POI in this group of patients is not clear; however, they could represent a subgroup with a unique opportunity for early intervention and thus the provision of fertility preservation options. While the etiology of POI in a large number of girls remains unknown, a growing number will be identified as carriers of genetic mutations, offering clinicians a yet greater opportunity to provide genetic counseling to other female family members. The aim of this review is to provide information regarding the etiology, diagnosis, and treatment of POI in adolescents while detailing the new options for fertility preservation when POI is diagnosed at an early stage.

© 2019 Walter de Gruyter GmbH, Berlin/Boston 2019. Bisphosphonates (BPs) are potent inhibitors of osteoclast mediated bone resorption. These drugs are widely used in the management of osteoporosis and other diseases, characterized by high bone turnover. The effect of BPs on gestation and lactation, when they are used as therapeutic agents in premenopausal women, is yet unknown. We conducted a detailed literature review and identified the cases of BPs use in young women, as well as, the effects of this therapy on the gestation and the embryo. The published data, regarding the use of BPs in premenopausal women and their effects on the pregnancy outcome, are limited. However, we could identify the outcomes of 40 pregnant women, who had received BPs prior to or during pregnancy, that have been documented in the literature. All women had valid indications to receive BPs for serious bone metabolism conditions. We could not identify any prospective trials, which focus on pregnancy outcomes following after the in-utero exposure to BPs. In total, no serious adverse effects were reported. Problems related to the offspring, such as hypocalcemia and a tendency for low body weight (LBW), were self-resolving. In addition, no serious adverse outcomes were reported for women having completed pregnancy. Nevertheless, follow-up was limited for both outcomes suggesting the necessity of national and international registries.

© 2019, The International Urogynecological Association. Introduction and hypothesis: Fractional CO2 and vaginal erbium lasers have emerged as potential treatment options for genitourinary syndrome of menopause (GSM) in breast cancer (BC) survivors. Methods: We conducted a systematic review of the literature to ascertain whether available evidence supports the efficacy and safety of laser treatment for GSM in BC patients. MEDLINE, Scopus and Cochrane Library databases were systematically searched from inception until March 2019 for studies on laser treatment for GSM in BC patients. Results: We yielded six observational studies meeting the inclusion criteria. The studies were of moderate quality. Taken together, the studies suggest that laser treatment may significantly alleviate or resolve the GSM-related symptoms and improve sexual function. Furthermore, a significant increase of the vaginal health index was reported. Positive effect was maintained up to 12 months. The safety and tolerability profile is encouraging, given that no adverse effects were reported, while only few patients discontinued laser treatment, owing to reported discomfort. Conclusions: Our findings suggest that lasers appear to be effective and practical treatment options in BC survivors suffering from GSM. Evidence concerning long-term effects is lacking. The rationale for repeated treatment remains uncertain. Randomized controlled trials that collate different frequencies, intensities and durations are warranted to ascertain a dose-response relationship and adherence.

© 2019 Walter de Gruyter GmbH, Berlin/Boston. Polycystic ovary syndrome (PCOS) in adolescence, a disorder of exclusion, has proved to be a timeless diagnostic challenge for the clinician. Since 1990, several attempts to provide clear diagnostic criteria have been published, most of the time leading to inconsistencies. We attempted to elucidate the controversies and convergences of this subject by conducting a systematic review of the literature concerning official guidelines or proposed criteria for the diagnosis of PCOS in adolescent girls. Based on a term search sequence via electronic databases such as Pubmed, Cochrane, Embase, Scopus and a hands-on review of references and learned societies, all available data were classified and analyzed. Single case reports, original studies with adult population or articles with incomplete diagnostic guidelines were excluded. Twelve reports dated from 2006 to 2018 fulfilled the inclusion criteria. Seven of them were endorsed or published by learned societies. All suggested a stricter diagnosis than in adulthood. Polycystic ovarian morphology was used as a necessary criterion only in three guidelines, and there was a tendency for a more objective diagnosis of hyperandrogenism, defined either by clinical features or by biochemical hyperandrogenemia, although in one case both were required. Irregular menstrual cycles, allowing for an interval of at least 2 years postmenarche, and hyperandrogenism, usually reinforced by biochemical confirmation, are the main accepted features for PCOS diagnosis in adolescence. Discrepancies among endocrine and reproductive medicine societies still remain, although recent intensified attempts at reaching a consensus should allow for more universally accepted diagnostic criteria.

{© 2019 Objective: To assess sleep disorders (SleD)in women with functional hypothalamic amenorrhoea (FHA)and to identify possible associations with known FHA predisposing factors. Study design: We conducted a prospective case-control study spanning the period January 2016 to April 2018. We recruited forty-one FHA women and 86 healthy controls. We assessed SleD and other FHA predisposing factors via self-reported questionnaires. The Spearman's correlation coefficient (rho)was used to examine possible correlations among the different variables. Multivariate logistic regression analysis was conducted to identify independent factors associated with SleD. Results: Women with FHA reported having higher SleD (p = 0.004), abnormal eating attitudes (p {\textless} 0.0001), higher anxiety levels (AL)(p {\textless} 0.0001), overweight preoccupation (P {\textless} 0.0001)and increased weekly physical activity (p = 0.004). There was a significant positive correlation between SleD and AL (rho = 0.88, p {\textless} 0.0001). Significant correlation was also found between AL and several Athens insomnia scale constituents, including sleep induction (rho = 0.53

© 2019 North American Society for Pediatric and Adolescent Gynecology Study Objective: The purpose of this prospective study was to assess the effectiveness of norethisterone (NET) in the management of abnormal uterine bleeding (AUB) in adolescents in a tertiary care center. Design: This was a prospective audit focused on administering high doses of NET in female adolescents with complaints of AUB. Setting: We included female adolescents who presented to our Emergency Gynecological Department or Adolescent Gynecological Outpatient Department from October 2016 to January 2019. Participants: The study included 29 female adolescents aged 11-17 (mean, 13.14) years. Interventions: Patients were administered a daily dose of 10-30 mg, depending on the severity of the condition, bleeding duration, and patient weight. Main Outcome Measures: Cessation of vaginal bleeding. Results: Mean age at menarche of our patient sample was 11.4 years (range, 10.7-14 years). AUB presented at a mean time of 24.6 months after menarche (range, 0-79 months). Blood transfusion was deemed necessary in 9 patients. Bleeding stopped at a mean of 46.1 (range, 8-120) hours after onset of treatment with NET. No serious adverse events were reported with NET administration, with only 3 cases of minor side effects. Conclusion: The use of NET is an effective and reliable treatment option among adolescents for whom control of AUB is desired in the acute setting.

© 2017 Elsevier Ltd. Turner's syndrome, one of the most common sex chromosome abnormalities in females, is caused by loss of part or all of an X chromosome. We report a case of mosaic Turner's syndrome, posted for elective cesarean delivery under low-dose sequential combined spinal epidural anesthesia. The unique features of this case were the combination of an anticipated difficult airway and both short stature and scoliosis in the lumbar region. A titrated combined spinal-epidural technique was performed in order to avoid hemodynamic instability, which could have been exacerbated in the presence of cardiovascular deformities that accompany this syndrome in many cases. The patient was managed successfully under regional anesthesia, which is generally a preferred technique to general anesthesia, to avoid sympathetic stimulation during intubation and emergence. Further, this technique may avoid potential complications associated with difficult airway management.

© 2017 American Society for Reproductive Medicine Objective: To systematically review and appraise the existing evidence in relation to the efficacy and safety of pulsatile gonadotropin-releasing hormone (pGnRH) for the treatment of women with hypothalamic amenorrhea (HA). Design: Systematic review and meta-analysis. Setting: Not applicable. Patient(s): A total of 35 studies (three randomized and 32 observational) encompassing 1,002 women with HA. Intervention(s): None. Main Outcome Measure(s): Primary outcomes: ovulation rate (OvR), pregnancy per ovulatory cycle rate (POR), and live birth per ovulatory cycle rate (LBOR). Secondary outcomes: multiple gestation (MG), ovarian hyperstimulation syndrome (OHSS), and superficial thrombophlebitis (ST) rates. The summary measures were expressed as proportions and 95{%} confidence intervals (CI). Result(s): Pulsatile GnRH treatment appears to achieve high OvRs. A trend toward high PORs and LBORs among women with HA is demonstrated. SC pGnRH achieves comparable OvR compared with IV pGnRH. The incidence of OHSS is low and of mild severity. Treatment with pGnRH is associated with low but slightly higher MG rates compared with the general population. IV administered pGnRH is rarely associated with ST. Conclusion(s): The high OvRs leading to a high rate of singleton pregnancies and the low likelihood of OHSS render the pGnRH treatment modality both effective and safe for the treatment of women with HA of either primary or secondary origin.

© 2018 North American Society for Pediatric and Adolescent Gynecology Background: Bone marrow transplantation is a lifesaving procedure for a range of serious benign or malignant hematological conditions. A proportion of patients, however, will develop graft vs host disease (GVHD), acute or chronic, with serious long-term sequalae. Cases: We present 2 cases of hematocolpos that developed in adolescence because of vaginal synechiae due to GVHD. The condition was initially asymptomatic, resolved spontaneously at first and recurred. In 1 girl blunt lysis of the adhesions was performed with the patient under general anesthesia, followed thereafter by local hydrocortisone and estriol treatment. Summary and Conclusion: Genital symptoms might not be readily reported by adolescents after bone marrow transplantation. Physicians should be aware of possible late effects of GVHD on genitalia, inquire about symptoms, and be acquainted with addressing complications, such as vaginal obstruction.

© 2016, Springer-Verlag Berlin Heidelberg. Purpose: The levonorgestrel-releasing intrauterine system (LNG-IUS) is an effective method of contraception, while also providing various non-contraceptive benefits. Although targeted primarily to adults, there is increasing experience in its use in adolescence. The aim of this review is to assess the available information on LNG-IUS usage in adolescence. Methods: We conducted an online search on MEDLINE and SCOPUS from inception to May 24, 2015. All studies that examined LNG-IUS use in teen populations were eligible for inclusion. Primary outcome measures included description of indications for LNG-IUS usage and relevant efficacy. Secondary outcomes included complications, such as device-related problems (perforation and expulsion) and other adverse events (pelvic inflammatory disease, PID). Acceptability of the LNG-IUS was also estimated through evaluation of continuation rate and reasons for removal were assessed. Results: Twenty-one studies met our inclusion criteria. We identified only one randomized controlled trial (RCT). All other twenty studies were observational. Pregnancy rates ranged from 0 to 2.7{%}. Management of heavy or/and painful periods was successful in 92–100{%}. Menstrual manipulation in patients with developmental delay was achieved in over 93{%} of cases. Expulsion rates ranged from 0 to 13{%} and pelvic infection/cervicitis between 0 and 2.7{%}. There were no reported uterine perforations. Conclusion: Usage of the LNG-IUS in teen populations appears to be safe and efficacious both in terms of contraception and menstrual management. However, more robust evidence is needed so as to provide firm confirmation on benefits and potential side effects.

© Springer-Verlag GmbH Germany 2017. Lichen sclerosus is a chronic skin disease, mainly localised at the introitus and perineum. When the condition remains untreated, gradual atrophy of skin structures leads to permanent scarring, making early diagnosis and treatment crucial. We reviewed all patients diagnosed with lichen sclerosus presenting to a tertiary referral centre for paediatric and adolescent gynaecology between January 2011 and December 2015 to assess disease presentation and response to treatment. We identified 15 cases, with a mean age at diagnosis of 8.8 years. Their main presenting symptoms were vulvar pruritus and vulvar soreness. Seven girls had already atrophic changes, and in four girls, this amounted to clitoral phimosis, labial resorption or labial adhesion formation. The median delay in diagnosis was 7 months. Thirteen patients received local treatment with potent corticosteroids, responding well to treatment. However, 4 girls relapsed within 2 to 36 months. Two adolescents required surgical treatment, one because of urinary retention and the second because of dyspareunia caused by clitoral entrapment. Conclusions: There was a delay in diagnosis in most patients and this resulted in irreversible genital skin changes, which would have been preventable, had treatment been instituted promptly. The response to treatment with local corticosteroids was usually effective, leading to both symptom alleviation and prevention of disease progression. Atrophic changes and skin complications however were not reversed.

© Journal of Reproductive Medicine®, Inc. BACKGROUND: Menstrual disorders are common in adolescence and are usually caused by an immature hypothalamic-pituitary-ovarian axis. Occasionally, suppressed gonadotropins or a raised prolactin may raise suspicion for a central organic cause of amenorrhea. CASE: We present the cases of 3 adolescents with menstrual irregularities or amenorrhea who were found to have hypothalamic gliomas (2 cases) and a craniopharyngioma (1 case). An MRI of the brain revealed the diagnosis in all 3 cases. CONCLUSION: Although rare, brain disease should be included in the differential diagnosis of menstrual irregularities, particularly in cases of central delayed puberty, moderately raised prolactin, and hypothalamic amenorrhea with no clear functional cause, such as disturbed dietary habits, excessive exercise, or stress.

© 2017 North American Society for Pediatric and Adolescent Gynecology Study Objective To study the presentation and causes of premature ovarian insufficiency (POI) in adolescents. Design Retrospective notes review. Setting Tertiary referral outpatient clinic for pediatric and adolescent gynecology. Participants Adolescents with POI. Interventions Standard POI evaluation. Main Outcome Measures Age and clinical symptoms at presentation, causative factors for POI, if identified. Results We identified 22 girls with POI, with a mean age of 15.6 years. Eight of them presented with delayed puberty, 3 with primary amenorrhea, and the remainder presented with either irregular bleeding (n = 9) or secondary amenorrhea (n = 2). For those who presented with delayed puberty, only 3 were found to have a sex chromosome abnormality. A clear cause for the POI was identified in 3 further cases. Conclusion Although POI in adolescents traditionally is associated with primary amenorrhea and delayed puberty, a proportion of girls will present with irregular bleeding that might be mistaken for expected menstrual disturbances of puberty, thus delaying the diagnosis. We identified a clear cause for POI in 6 cases. Although there were no familial cases of POI, it remains a possibility that genetic reasons might be involved in the pathogenesis.

Purpose of investigation: To describe a novel approach for longitudinal vaginal septum (LVS) resection. Materials and Methods: Two cases of young girls with a uterus didelphys and a longitudinal vaginal septum. The technique consisted in grasping the vaginal septum with a laparoscopic 33-cm long bipolar cutting forceps, five-mm in diameter, and divided it to its midportion towards the two cervices. Results: In both cases, the procedure was straightforward, uncomplicated, completed within three minutes and the patients were discharged four hours later. It was associated with minimal blood loss, short recovery time, absence of local ischemia, and optimum healing process. Conclusion: The authors believe that surgical safety, efficacy and operative result make bipolar cutting forceps a tailored option for LVS resection.

© 2015 North American Society for Pediatric and Adolescent Gynecology. Study Objective: Precocious pseudopuberty in girls occurs as a result of peripheral estrogen production, most commonly through an autonomous ovarian cyst or in patients with McCune Albright syndrome. Current management is either conservative or surgical. The aim of this study was to identify available literature on presentation, course and treatment of such cases. Design: We performed a medline literature search using the key words 'ovarian autonomous cyst' and 'pseudopuberty'. We included articles published in English, from 1980 to date relating to females aged 2 to 8 years. We excluded papers on other endocrine conditions resulting in premature puberty. Outcome Measures: Type of management, time of resolution, recurrence, progression to Central Precocious Puberty and McCune Albright Syndrome. Results: We identified 9 articles referring to 26 cases of autonomous ovarian cysts. All patients had suppressed LHRH testing and had simple ovarian cysts producing estradiol. Median age of patients was 5 years (range 2.2-8) and size of cyst was 41.5mm (9-60). Ten patients underwent cystectomy or oophorectomy, three were given cyproterone acetate and 13 were managed conservatively. Nine of 13 patients that were managed conservatively and two of those that had a cystectomy had a recurrence. There were three cases that progressed to central precocious puberty (CPP) and one case that was then identified to have McCune Albright (MCA) syndrome. One further case with multiple recurrences was given long term treatment with letrozole. Conclusion: We conclude that although a conservative approach should always be proposed in the first instance, one should be aware of the risk of recurrence and progression to CPP or MCA. Antiestrogen treatment appears promising; however data comparing it with surgical options and particularly long term consequences with regards to future reproductive outcomes are not available.

© Springer-Verlag London 2015. Aim: To present the technique and the results of treatment of vaginal aplasia with the use of Frank's Dilators and to critically report its potential advantages and limitations.Brief description of the reviewed data: Vaginal dilation involves the insertion of graduated dilators in the vaginal dimple and applying pressure. It is recognized as the first line method for creating a vagina in women with Mayer Rokitansky Kuster Hauser syndrome (MRKH) and Complete Androgen Insensitivity Syndrome (CAIS). An 80 {%} success rate is reported with improvement of sexual satisfaction and anxiety scores. There are only few complications reported in the literature making it a low risk and low cost method to create a vagina. Clinical implications: Vaginal dilation therapy should be offered to all women presenting with MRKH or CAIS prior to embarking on a surgical vaginoplasty. Adequate psychological support during the process is likely to improve success rates as well as the overall wellbeing of patients diagnosed with uterovaginal aplasia.Open issues for further research: More research is required on long term outcomes of vaginal dilation therapy as well as on the comparison between surgical and conservative methods to create a vagina.

© 2015 North American Society for Pediatric and Adolescent Gynecology. Introduction: Minor breast concerns in childhood and adolescence are common and lead to increased anxiety among young patients and their families, particularly due to high correlation with breast cancer. However, most breast services aim at managing adults and triaging patients with breast cancer, whereas adolescent medicine specialists or pediatricians are usually not appropriately trained to identify and treat breast pathology. Methods: We reviewed hospital records of all patients attending a pediatric and adolescent gynecology or breast clinic of a tertiary referral hospital, with a breast related symptom, between January 2009 and December 2011. We collected information regarding age at presentation, age at menarche, diagnosis, management and outcome. Results: We identified 81 patients of which 11 presented with an abnormal nipple or areolar secretion, 33 had a palpable lump, 20 had mastitis, and 16 had unequal breast development. One patient presented with virginal breast hypertrophy. Three out of 11 of the patients with an abnormal secretion had a cyst identified on ultrasonography. Out of the palpable lumps 12 were fibroadenomas, 3 were phyllodes tumors, and 14 were cystic in nature. The phyllodes tumors and half of the fibroadenomas were removed. The remaining fibroadenomas remain under regular ultrasonographic follow-up. All cases of mastitis were treated conservatively and resolved with broad spectrum antibiotic treatment. Conclusion: In our series, no malignancies were identified. Although 8 patients required surgical treatment, the majority of cases were treated conservatively.

© 2015 by John Wiley {&} Sons Ltd. All rights reserved. Female genital reconstruction remains a highly controversial and emotive topic. Whilst short-term surgical complications of such procedures occur and are important to manage correctly, it is the long-term complications that have caused such concern and debate. Correlation of any particular surgical procedure to its later success or failure can be almost impossible. Complications of genital surgery such as vaginal stenosis may make intercourse painful or impossible, but the pediatric surgeon responsible for the initial vaginal reconstruction will never have the opportunity to follow patients into adult life when such complications become apparent. The success of genital reconstruction in sexual function and reproduction is often not tested until many years after the procedure. Surgeons and procedures change and adult patients may have had operations that have long been modified or abandoned in favor of something else.

© Springer-Verlag London 2015. Aim: To critically evaluate treatment options for patients with vaginal aplasia and present an algorithm taking into account the complexity, the advantages and the potential risks of each vaginoplasty method.Brief description of the reviewed data: Current available techniques for creating a neovagina range from conservative to complex surgical. No comparative studies exist between methods and at present most centers appear to prefer one method over another. Based on the best available evidence, it seems that vaginal dilation, being risk free and non-invasive, is the first line treatment option for patients with a vaginal dimple present and no previous perineal surgery. Patients with failed vaginal dilation should be directed to surgical traction techniques or peritoneal vaginoplasty depending on the presence or not of a vaginal dimple and on the familiarity of the surgical team with these techniques. Peritoneal vaginoplasty could be also applied in cases of failed surgical traction. Skin and intestinal vaginoplasties should be kept only for failures of other surgical techniques and for complex cases.Clinical implications: While the superiority of each method remains to be assessed objectively, we propose indications for each available method and a treatment algorithm.Open issues for further research: Evidenced based comparisons in the form of randomized controlled trials are required in order to objectively assess the place and superiority of each available method.

© 2014 Informa UK Ltd. The phenotype of polycystic ovarian syndrome (PCOS) is known to worsen with weight gain, increased ingestion of carbohydrates and a sedentary lifestyle. The purpose of this study was to assess the dietary habits in a group of adolescent girls with PCOS. Adolescents with PCOS were recruited and asked to complete a questionnaire on their eating habits and a recall dietary diary, from which their caloric and macronutrient intake was calculated. Results were compared with those from a group of normal controls. Thirty-five women with PCOS and 46 controls were included. Girls with PCOS were less likely to have cereals for breakfast (20.7 versus 66.7{%}) and as a result consumed less fibre than controls. They were more likely to eat an evening meal (97.1 versus 78.3{%}) and eat this over an hour later when compared to controls. Despite having comparable body mass indexes, girls with PCOS ate a daily surplus calorie average of 3{%} versus controls that had a negative calorie intake of 0.72{%} (p=0.047). Ameliorating eating habits early in adolescence in girls with PCOS may improve future metabolic concerns related to a genetic predisposition and worsened by an unhealthy lifestyle.

Adolescent gynaecology is increasingly recognized as an area in which specific knowledge and expertise is required to ensure that patients achieve the best outcome. Gynaecological problems in adolescents are common, and although serious pathology is rare, distress and discomfort can be significant. Adolescent girls are under greater pressure than ever before, particularly in terms of examination performance; they find menstrual dysfunction particularly difficult to manage. Careful and sympathetic assessment is crucial, and simple treatment remedies may be all that is required. However, complex and rare medical conditions can also occur and must not be missed. Some congenital disorders present for the first time in adolescence. Early detection and appropriate treatment will ensure the best possible outcomes in terms of sexual function and potential fertility. © 2014 Elsevier Ltd.

The Chicago consensus statement of 2005 was created at the point of cumulative criticisms and debates around the clinical practice of childhood genital surgery. It was drawn up at a time when it had become clearer that medically non-essential paediatric genital operations were associated with poor adult cosmetic outcomes and sexual functioning. However, data were not available for non-intervention. Therefore, parents and clinicians had no reliable information on how a child growing up with atypical genitalia might fare. The most positive recommendation in the consensus statement was the strong recommendation for decisions to be reached by a multidisciplinary team in collaboration with affected families. Importantly, the value of user groups was likewise formally acknowledged. For many services, there has been a sea change in the way surgeons work. Whilst some surgeons may continue with the standard practice of childhood genital surgery, it is becoming clearer that with adequate support, more individuals and families choose to postpone elective interventions. However, these are our observations only. Authoritative evidence must be based on high-quality multi-centre multidisciplinary research to prospectively monitor the long-term multiple outcomes of surgery and no surgery. There is as yet no obvious move towards such an endeavour. © 2013 © 2013 Taylor {&} Francis.

© 2014 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved. (S.M. Creighton). Objective: In 2001, this team published an observational study of the clinical outcomes of a cohort of adolescent girls born with ambiguous genitalia. The poor outcomes observed represented a major scientific challenge to the standard practice of childhood feminising genital surgery. That publication was one of several contributing to a call for change in surgical practice, which culminated in the publication of the Chicago Consensus Document in 2006. The aim of this current study was to repeat the same evaluation of clinical outcomes on a recent cohort of adolescent girls and compare the two cohorts to identify differences in adolescent outcomes which may indicate a change in paediatric surgical practice. Methods: This was an observational study of a current cohort of adolescent girls treated in childhood for ambiguous genitalia and referred to a specialist adolescent disorders of sex development (DSD) service for assessment. Data were collected on surgical history, genital examination findings and treatment recommendations for 30 consecutive adolescents over a 5-year period. Findings were compared with those of a similar cohort of adolescent girls published over a decade previously. Results: Clitoral surgery remained common (93{%} vs 100{%}, current cohort vs historical cohort). However, concomitant vaginoplasty was performed less frequently (80 vs 100{%} current vs historical). Vaginoplasty revision surgery was also less commonly required (65 vs 81{%}), although 24{%} of the recent cohort still required major revision surgery prior to intercourse. There was some improvement to the cosmetic outcomes as deemed by the surgical team using the same criteria as the previous report. Conclusions: This study provides someslight evidence of recent practice change.Therewas asmall reduction in the number of vaginoplasties performed in childhood and an improvement in vaginoplasty outcomes and cosmesis.However, therewas no identifiable change inmanagement of clitoromegaly and the numbers of clitoral reduction operations remained high. This is surprising given the clear evidence of a detrimental impact of surgery on clitoral sensation and sexual function.

© Clinical and Experimental Rheumatology 2014. With current advances in medical treatment, reproductive issues have become more important for women with chronic immune-mediated diseases. Most, if not all, patients report that their disease affects their personal relationships, their decision to have children, and the size of their family. These decisions are multi-factorial, influenced mainly by concerns over the effect of pregnancy on the rheumatic disease, the impact of disease activity during pregnancy on foetal health, the patient's ability to care for the child, and the possible harmful effects medication could have on the child, both pre- and post-natally during breastfeeding. Apart from that, women's health issues tend to be overlooked in favour of the management of the underlying rheumatic disease. To this end, we convened an expert panel to review the published literature on women's health and reproductive issues and provide evidence- and eminence-based points to consider for the treating physicians. We conclude that there is a need for a change in mind-set from one which "cautions against pregnancy" to one which "embraces pregnancy" through the practice of individualised, pre- and post-conceptual, multi-disciplinary care.

When a healthy woman expresses concerns about her vulva, the doctor's response should be informed by clinical knowledge. For many doctors, accumulation of such knowledge would have begun with undergraduate teaching and medical textbooks. The aim of this study is to examine the information on female genital morphology in medical textbooks. A total of 59 gynaecology and anatomy textbooks were searched for information on the dimensions of vulval constitutent parts. No textbook gave measurements for all vulval structures. Vaginal length was reported in 21/59 textbooks, clitoral size in 15/59 and labia minora in 1/59. Where measurements appear, they suggest narrower ranges than recent reports. Information of vulval morphology is scanty and inaccurate in medical textbooks. The general lack of professional resources means that doctors may consciously or non-consciously rely upon personal experiences and popular culture to form their opinions, as do their patients. © 2013 Informa UK, Ltd.

Introduction and hypothesis: Congenital vaginal aplasia is a condition with devastating implications for fertility and sexuality. However, little is known on whether urinary symptomatology is more common prior and following vaginal lengthening procedures in these women. Methods: We performed a prospective observational study of 19 women with vaginal agenesis before and after vaginal dilation treatment or a laparoscopic Vecchietti procedure. All women completed the ICIQ FLUTS questionnaire before and after treatment in order to assess incidence and changes in urinary symptomatology. Results: Urinary symptoms were present in 53{%} of women prior to treatment. The majority of bladder symptoms were not significantly altered by treatment, except for incomplete bladder emptying. Women following the Vecchietti procedure had increased urinary hesitancy and a poorer steam compared with those completing dilation treatment. The longer the vaginal length, the greater the urinary frequency. Conclusion: Women with vaginal agenesis had significant levels of urinary symptoms and to our knowledge this has not been reported before. The majority of symptoms were not altered by treatment. © 2012 The International Urogynecological Association.

Background: A cross sectional study to investigate HPV prevalence according to age and cytology.Methods: Women presenting to a gynaecological outpatient clinic for a Pap smear test were included in the study (n=3177). All women had cervical cytology and HPV testing.Results: Overall prevalence of any 24 HPV type analysed was 33.1{%} (95{%} CI 31.5{%} to 34.7{%}) and HPV 16 and HPV 42 were the most frequent (6.7{%} (95{%} CI 5.8{%} to 7.6{%}), 6.8{%} (95{%} CI 5.9{%} to 7.6{%})), in total samples. Multiple HPV infection rate was 12.9{%} (95{%} CI 11.8{%} to 14.1{%}). High risk HPV (hrHPV) types were present in 27.4{%} (95{%} CI 25.8{%} to 28.9{%}) of the samples.HPV prevalence was highest among 14 to 19 y.o (46.6{%} (95{%} CI 40.7{%}-52.4{%})) and second highest among 30-34 y.o. (39.7{%}, 95{%} CI 35.4{%}-44{%}). HPV 16 was highest among 20-24 (9.0{%} (95{%} CI 6.4{%}-11.6{%})) and second highest among 50 to 54 y.o. (6.3{%} (95{%} CI 2.9{%} to 9.8{%}).In Low-grade Squamous Intraepithelial Lesions (LgSIL) cytology samples, the most frequently detected hrHPV types were: 16 (14.5{%} (95{%} CI 12.1{%} to 16.9{%})), 51 (13.0{%} (95{%} CI 10.7{%} to 15.3{%})) and 53 (9.1{%} (95{%} CI 7.2{%} to 11.1{%})) and in High-grade Squamous Intraepithelial Lesions (HgSIL) were: HPV 16 (37.2{%} (95{%} CI 26.5{%} to 47.9{%})), HPV 51 (17.9{%} (95{%} CI 9.4{%} to 26.5{%})) and HPV 18 (12.8{%} (95{%} CI 5.4{%} to 20.2{%})).Conclusions: In the population studied, HPV 16 and 51 were the most frequent detected hrHPV types. HPV positivity, hrHPV and multiple HPV types infections were higher in young women, while HPV prevalence declined with increasing age and presented two peaks a higher (14-19 y.o.) and a lower one (30-34 y.o.) These results may contribute to the creation of a national screening programme. © 2013 Argyri et al.; licensee BioMed Central Ltd.

{Objective: To identify the websites most visited by patients regarding polycystic ovary syndrome (PCOS), and to evaluate the quality of information provided by these websites. Study design: We sought data regarding the popularity of sites providing information about PCOS regardless of the way the visitors reached the site. We then scrutinized the top sites for predefined quality check points to evaluate the quality of information provided, including Health on Net Foundation (HON) accreditation. Finally, we searched for the expansion of these sites in social networks (Facebook and Twitter). Results: Of the top 15 sites, 8 were HONcode certified. The mean performance of content presence for all sites was 7.33 (min = 4

Study Objective: The purpose of this study was the recording of physical activity and sedentary habits of adolescents with polycystic ovarian syndrome (PCOS). Methods: We performed a structured interview to assess the level of physical activity and sedentary habits of girls with PCOS. We used a group of healthy adolescents as controls. All girls had their age, height, weight, hip and waist circumference measured and their BMI calculated. Results: 81 girls (35 with PCOS and 46 controls) participated in the study. Girls with PCOS engaged in physical activities less than controls. Even when they did, the frequency and intensity of exercise was less. Also, girls with PCOS were less likely to be aware of the positive effects of exercise on their health. Girls in both groups were sedentary in excess of the 4 hours per day limit, which has been linked with obesity. Conclusion: Healthy teenagers were involved in a sporting activity more often and more frequently than the PCOS group. Athletic and sedentary habits of adolescents with PCOS may interact with other factors leading to obesity. © 2012 North American Society for Pediatric and Adolescent Gynecology.

Purpose: Adolescents are a vulnerable group with regard to sexually transmitted infections, including Human Papilloma Virus (HPV). This is thought to be both because of their more liberal sexual behavior and also the relative immaturity of their genital tract. The aim of the study was to examine trends in HPV infection among sexually active adolescents attending for a sexual health screen. Methods: Sexually active adolescents were offered cervical screening, HPV typing and conventional genital cultures as part of a sexual health prevention protocol. Participating adolescents also completed a sexual health questionnaire. Results: Between January 2008 and July 2011, 149 sexually active girls were examined for reproductive health issues (mean age 17.3 years). 62 (42{%}) tested positive for HPV DNA, 30 were infected by multiple types and 54 had at least one high risk type identified. The most commonly identified HPV DNA was for low risk type 42 (15 cases, 7.8{%}), followed by high risk types 51 (14 cases, 7.3{%}) and 59 (11 cases, 5.7{%}). E6-E7 mRNA expression was detected in 16 girls (11{%}), of which half were for HPV 16. Girls who tested positive for HPV DNA and mRNA had similar age at sexual debut with those that tested negative (15.1 years in all groups) but had on average more sexual partners (4.1 vs1.9 p = 0.007). Only 9 girls in this cohort had been vaccinated against HPV. Approximately half of the girls reported using inadequate or no contraception. Conclusions: HPV infection rate was high in our sample. Furthermore a high percentage was infected with high risk types and a proportion of girls demonstrated mRNA HPV expression. As age at first sexual intercourse drops, vaccination against HPV and sexual education should be instituted in early adolescence, in order to reduce long term reproductive sequelae of unsafe sexual practices. © 2012 Elsevier Inc. All rights reserved.

A large proportion of vaginal and vulvar squamous cell carcinomas (SCCs) and intraepithelial neoplasias (VAIN and VIN) are associated with HPV infection, mainly type 16. The purpose of this study was to identify HPV genotypes, as well as E6/E7 mRNA expression of high-risk HPVs (16, 18, 31, 33, and 45) in 56 histology samples of VAIN, VIN, vaginal, and vulvar SCCs. HPV was identified in 56 of VAIN and 50 of vaginal SCCs, 71.4 of VIN and 50 of vulvar SCCs. E6/E7 mRNA expression was found in one-third of VAIN and in all vaginal SCCs, 42.9 of VIN and 83.3 of vulvar SCCs. Our data indicated that HPV 16 was the commonest genotype identified in VAIN and VIN and the only genotype found in SCCs of the vagina and vulva. These findings may suggest, in accordance with other studies, that mRNA assay might be useful in triaging lesions with increased risk of progression to cancer. Copyright © 2012 Elpida Tsimplaki et al.

Adolescent gynaecology is increasingly recognized as an area in which specific knowledge and expertise is required to ensure that patients achieve the best outcome. Gynaecological problems in adolescents are common, and although serious pathology is rare, distress and discomfort can be significant. Adolescent girls are under greater pressure than ever before, particularly in terms of examination performance; they find menstrual dysfunction particularly difficult to manage. Careful and sympathetic assessment is crucial, and simple treatment remedies may be all that is required. However, complex and rare medical conditions can also occur and must not be missed. Some congenital disorders present for the first time in adolescence. Early detection and appropriate treatment will ensure the best possible outcomes in terms of sexual function and potential fertility. © 2011 Elsevier Ltd.

Magnetic resonance imaging is considered the gold-standard imaging technique in cases of Müllerian and vaginal anomalies, however, vaginal delineation often proves difficult, owing to the fact that vaginal walls are normally collapsed and in close proximity. Instilling gel through the introitus allows for better depiction of the distal vagina. © 2011 American Society for Reproductive Medicine.

Measurements of clitoral length and clitoral to urethral distance were made and analysed for a relationship in a group of 19 women with complete androgen insensitivity syndrome (CAIS) attending a specialist clinic for adult women with disorders of sexual development. These were compared with a control group of 50 women attending hospital for a gynaecological procedure. There was a positive correlation between clitoral length and clitoral to urethral distance for women with CAIS. In contrast, a negative correlation was seen between clitoral length and clitoral to urethral distance for women in the control group. Women with CAIS had a reduced mean clitoral length compared with controls (P = 0.001), but no difference was observed for the clitoral to urethral distance between the two groups (P = 0.116). © RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology.

Objective To assess clinical characteristics and expectations in well women requesting elective labial reduction surgery. Design Prospective study of women attending an outpatient gynaecology clinic. Setting General gynaecology clinic at a Central London teaching hospital. Sample Women requesting labial reduction surgery and referred by their general practitioner. Methods The labia minora width and length were measured for all participants for comparison with published normal values. The presenting complaint was recorded, along with demographic details, expectations of surgery and sources of information regarding appearance of the labia. Main outcome measures Labial measurements, reported symptoms and expectations of surgery. Results The labia of all participants were within normal published limits, with a mean (SD) of 26.9 (12.8) mm (right labia), and 24.8 (13.1) mm (left labia). The majority of complaints were regarding appearance or discomfort. Expectations were to alter the appearance with surgery. Conclusions All women seeking surgery had normal-sized labia minora. Clear guidance is needed for clinicians on how best to care for the worried well woman seeking surgery. © 2011 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2011 RCOG.

There is a wide variety in the appearance of normal female external genitalia. Nevertheless a specific prototype is promoted by the media, leading to a false sense that all other appearances are abnormal. As adolescents become sexually aware at an earlier age, most of them are worried about the appearance of their genitalia, especially when labia minora protrude beyond labia majora. This is a prospective audit of adolescents presenting for assessment of their perceived abnormal genitalia. Sixteen girls aged 10.2 to 17.8 years presented between June 2009 and December 2010 to a specialist adolescent gynecology service. Their mean labial width was 36 mm (range: 2055 mm). In six girls, the reason for attending the service was inequality of the size of labia ranging between 6 mm and 35 mm (mean of 20 mm). Among the remaining 10 girls, the concern had arisen through comparison with a prepubescent sibling (one case), change of genitalia during puberty (four cases), looking at internet pictures (four cases), and looking at an anatomy book (one case). Risks of Female Genital Cosmetic Surgery (FGCS) have not been adequately documented, especially with regards to sexual function and long-term patient satisfaction. External genitalia are likely to change during puberty and therefore, any genital operation in the absence of clear pathology should be deferred until adulthood. Even then, women should have clear expectations of what will be achieved with the operation in terms of appearance and function. © 2011 Informa UK, Ltd.

Objective: Anorexia nervosa (AN) affects a large number of women, usually in their adolescence. One of the primary manifestations of the disease is menstrual irregularity, and the presence of a menstrual cycle is often used as a sign of recovery among patients. Women with AN are likely to seek medical advice from a gynecologist with regards to their period problems. The role of the gynecologist is therefore crucial in identifying and referring these patients promptly to specialised centers. Study design: A brief anonymous questionnaire was completed by 94 gynecologists practising in Athens. Results: Approximately half of the responders felt that the conditions were rarer than it really is, and 25{%} thought that the disease primarily affects women in their early twenties. Although 56{%} of gynecologists would not prescribe the combined oral contraceptive in women with AN in order to restore their periods, the remainder of gynecologists were in favour of prescribing hormone replacement with a view to reducing the risk of osteopenia. This is despite the fact that emerging evidence shows there is no benefit. Ten percent of gynecologists never weigh their patients during evaluation of amenorrhoea and 72{%} felt that their level of knowledge as far as anorexia nervosa is concerned is inadequate. Conclusion: More education is required among gynecologists on the subject of anorexia nervosa, in order to identify and refer patients in the early stages of the disease process. © 2010 Elsevier Ireland Ltd.

Uterine agenesis is one of the differential diagnoses in adolescent girls with delayed menstruation. It may also be suspected earlier in childhood during investigations for other genitourinary conditions. However, accurate confirmation that the uterus is absent can be extremely difficult before puberty because of its small size. We describe ten girls referred to a specialist centre with a presumed diagnosis of an absent uterus which was later found to be incorrect. We conclude that imaging should be undertaken by clinicians with experience in management of this age group and in some girls it may be necessary to delay final diagnosis until after puberty. © 2009 RCOG BJOG An International Journal of Obstetrics and Gynaecology.

This review investigates the quality and content of published reports relating to labial surgery for well women. Electronic databases were searched for relevant articles between 1950 and April 2009. Forty articles were identified, 18 of which included patient data. The specification of the study design was unavailable in 15 of the 18 papers; the remaining three were retrospective reports. No prospective, randomised or controlled studies were found. All reports claimed high levels of patient satisfaction and contained anecdotes pertaining to success. Medically nonessential surgery to the labia minora is being promoted as an effective treatment for women's complaints, but no data on clinical effectiveness exist. © RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology.

Gynaecological problems are rare in childhood and adolescence but can cause signifi cant distress to affected children and their families. These children may first visit paediatric surgeons and paediatricians who may not be familiar with gynaecological ailments. It is important that paediatric surgeons are aware of these problems to ensure correct management with appropriate referral if necessary. This chapter describes common gynaecological conditions occurring in children. © 2009 Springer Berlin Heidelberg.

The benefits of a minimally invasive approach are now well documented in adult women, and thus surgeons have embraced the notion of expanding such expertise in adolescence with measured enthusiasm and a great sense of responsibility. Faster recovery is likely to have a positive impact on schooling, while less adhesion formation may reduce future fertility issues. Gynaecologists performing minimally invasive procedures in adolescents ought to be aware of the steep learning curve required for achieving proficiency with complex laparoscopic surgery. In the group of rare congenital anomalies and advanced endometriosis, the best surgical results can only be achieved after careful preoperative planning by a multidisciplinary team © 2008 The Authors.

Adolescent gynaecology is increasingly recognized as an area in which specific knowledge and expertise is required to ensure the best outcome. Gynaecological problems in adolescents are common and, although serious disease is rare, distress and discomfort can be significant. Adolescent girls are under great pressure, particularly in terms of examination performance, and problems such as menstrual dysfunction can be particularly difficult to manage. Careful and sympathetic assessment is crucial, and simple treatment remedies may be sufficient. Complex and rare medical conditions can also occur and must not be missed. Some congenital disorders present for the first time in adolescence. Early detection and appropriate treatment ensures the best possible outcome in terms of sexual function and potential fertility. © 2008 Elsevier Ltd. All rights reserved.

Objective: To establish the spectrum of presentation, natural history and gynaecological outcomes in women with Swyer syndrome. Design: Retrospective notes review. Setting: Tertiary referral centre for disorders of sex development. Population: A total of 29 adult women with Swyer syndrome. Methods: Information was collected on age at diagnosis, biometric characteristics, timing of gonadectomy, histology of gonad, bone mineral density, uterine size and fertility. Main outcome measures: Age at diagnosis, risk of gonadal malignancy, bone mineral density, uterine size. Results: With regard to presentation, 26/29 (90{%}) women in this series presented with delayed puberty, and the median age at diagnosis was 17.2 years (range 0-55 years). The median age at gonadectomy was 18 years (range 9-33 years). Histology of the gonad was available in 22 women and demonstrated streak gonads with no evidence of malignancy in 12, dysgerminoma in 7 and gonadoblastoma in 3. The youngest patient diagnosed with dysgerminoma was 10 years old. The median height of the women was 1.73 m (range 1.54-1.95 m). Twelve out of the 20 (60{%}) women had evidence of osteopenia on dual energy X-ray absorptiometry scan. The uterine size and shape was assessed in eight women after completion of induction of puberty, and the uterine cross-section was found to be significantly lower than that in normal controls. Fertility was achieved with ovum donation in three women, all of whom had live births and one subsequently had a second successful pregnancy. Conclusion: Early diagnosis of Swyer syndrome is necessary in view of the risk of dysgerminoma that can develop at an early age. Adequate hormone replacement is required to maintain bone mineral density and may improve the uterine size and shape. © 2008 The Authors.

Transfusion-related lung injury (TRALI) is the leading cause of mortality following transfusion of blood products. Despite increasing awareness, the condition often remains unrecognised and therefore underreported. A 28-year-old with moderate preeclampsia had a post-partum haemorrhage following emergency caesarean section. Shortly after receiving three units of packed red cells she went into respiratory failure, which progressed to cardiac arrest. She was successfully resuscitated and made a slow but full recovery. Investigation through the National Blood Service confirmed the diagnosis of TRALI. TRALI is an increasingly common life-threatening complication of blood transfusion and should be included in the differential diagnosis of collapse in an obstetric patient who has recently received a blood product transfusion. © 2007 Elsevier Ltd. All rights reserved.