Current Women's Health Reviews - Volume 14, Issue 3, 2018

Background: Although teenage pregnancy rates have been declining, the teen birth rate in United States remains higher than most other industrialized nations. 80% of teen pregnancies are unplanned with significant personal and societal consequences. Recent Findings: Long-acting reversible contraception (LARC) methods have high continuation and satisfaction rates and are the first-line contraception option for adolescents. The number of intrauterine devices on the market in the United States has increased. Updates to evidence regarding the effects of progestin and combined hormonal contraceptives on bone health have been reviewed. The efficacy of contraceptive methods based on weight has also been re-evaluated recently. Until now, resources for confidentiality, sexually transmitted infection (STI) screening, and the use of social media have been provided. Conclusion: Providing contraception to adolescents encompasses communication, knowledge of local laws regarding confidentiality, and an understanding of the most effective methods for this population.

Background: Vulvovaginal complaints account for the majority of childhood visits to gynecologists. In these cases, patients most commonly present with nonspecific complaints including itching, vaginal bleeding, vulvar pain or dysuria. Because of the nonspecific nature of the presenting complaints, patients are frequently misdiagnosed or over-treated. Recent Findings: The etiology of pediatric vulvovaginitis is often nonspecific; however vaginitis in prepubertal girls may also have other treatable causes that are inflammatory (i.e. lichen sclerosus), anatomic (i.e. labial adhesions) or infectious (genital ulcers) in nature. These conditions are particularly common prior to puberty due to the hypoestrogenic vulvovaginal tissue of the girls in this age group as well as their prepubertal anatomy. Conclusion: Providers should be aware of normal prepubertal vulvovaginal anatomy as well as the most common etiologies of vulvovaginal complaints in this age group. Most of these conditions can be addressed safely on an outpatient basis if clinicians are able to appropriately diagnose them in a timely manner.

Background: Adnexal masses are commonly encountered in the pediatric and adolescent patient population. These can represent functional ovarian cysts, benign ovarian neoplasms, paratubal cysts, tubo-ovarian abscesses, or malignant neoplasms, among others. In this patient population the majority of adnexal masses are benign. However, providers should be familiar with signs, symptoms and imaging findings regarding malignancy as well as for surgical emergencies, such as adnexal torsion. Results: Findings regarding malignancy include large cyst size, presence of thick septations, large solid components or papillary projections on ultrasonography. Providers should collaborate with experts in the management of gynecologic cancers in this age group when there is a concern for malignancy. Adnexal torsion is a surgical emergency and should be suspected in any young female with an adnexal mass and acute onset of severe abdominal pain. Conclusion: Management of adnexal masses in pediatric and adolescent females should focus on preservation of the adnexa when possible.

Background: Polycystic ovary syndrome (PCOS) is a disorder of reproductive-aged women characterized by hyperandrogenism, ovulatory dysfunction, and polycystic ovary morphology. This heterogeneous disease presents as a constellation of symptoms including menstrual disturbances (amenorrhea, oligomenorrhea, and irregular menstrual cycles), clinical features of hyperandrogenism (acne/hirsutism), biochemical hyperandrogenism, polycystic ovarian morphology on ultrasound, and features of metabolic syndrome. Despite being the most common endocrine disorder of reproductive aged women, much remains controversial regarding this disorder especially in adolescents where normal puberty can overlap with PCOS phenotype. Recent Findings: Recent publications have emphasized the challenges of diagnosing PCOS in adolescents as the criteria for diagnosis can be seen during normal pubertal development. Adherence to a strict guideline and workup will help prevent over diagnosis while assuring that appropriate patients are monitored and receive therapy. A timely diagnosis of PCOS leads to awareness of this lifelong condition associated with hormonal and possibly metabolic complications. Lifestyle modification is imperative but may need to be supplemented by medical therapy. Conclusion: PCOS is a complex disorder, our understanding of the cause, diagnosis, and treatment continues to evolve. The disease process and presentation is unique in adolescents. Further research is needed to help define diagnostic criteria of PCOS in the adolescent, evaluate therapy, and study long term outcomes. A multi-disciplinary team can help assure all aspects of the disorder are properly addressed.

Background: Both the American Academy of Pediatrics and American College of Obstetricians and Gynecologist endorsed the use of the menstrual cycle as a vital sign, emphasizing the importance of talking to females about their periods. Irregular menses is one of the most common complaint of adolescents presenting to the gynecologist and may be the symptom of a more serious diagnosis. Heavy menstrual bleeding (HMB) is common among adolescents with up to 37% reporting heavy bleeding. The workup that is done should be tailored to the individual patient. There are several treatment options based on the etiology of HMB. Recent Findings: The appropriate workup for adolescents who complain of heavy menstrual bleeding continues to be evaluated and re-defined. Underlying bleeding disorders need to be considered in these patients. Federal programs have made proper evaluation and referral an objective for Healthy People 2020. A number of non-surgical therapeutic options exist. Tranexamic acid and the levonorgestrel intrauterine device have had very favorable outcomes for treatment of HMB. Conclusion: Heavy menstrual bleeding is common among adolescents and may be a sign of a more significant underlying medical problem so proper evaluation is imperative. Regardless of the etiology, effective treatment can drastically improve symptoms.

Background: Cervical cancer is a preventable malignancy, given the availability of primary and secondary prevention, via human papillomavirus (HPV) vaccination or screening, respectively. Despite this fact, racial disparities HPV vaccination and screening still exist. Objective: To review the data on primary and secondary prevention strategies for cervical cancer, HPV vaccination and screening, respectively and their projected impact on both cervical cancer rates and in reducing the disparity gap. Method: Literature review. Results: A disproportionate number of underserved minority women are not vaccinated and screened. Conclusion: Cervical cancer is a preventable disease. In the US, the burden is largely shouldered by underserved women with limited or no access to primary and secondary prevention. Although it is not possible at this time to measure the impact of vaccination and continued screening on this disparity, it remains clear that this inequity will not be mitigated unless; access, coverage and participation in HPV vaccination and cervical cancer screening programs improve for these women.

Background: The interpregnancy interval (IPI) defines the time between two consecutive gestations. In the general population, women with IPIs that fall outside the recommended 18-24 month range appear to be at modestly increased risk for adverse obstetric outcomes. Objective: The aim of this review was to assess the impact of extremes in IPI in populations with an increased baseline risk for adverse obstetric outcomes due to disparities in health and health care, including racial and ethnic groups, adolescents, and those of lower socioeconomic status. Methods: We conducted a MEDLINE/Pubmed literature search in February 2016. Identified articles were reviewed and assigned a level of evidence. Results: The 24 studies included in our final review were mainly retrospective with considerable heterogeneity in definitions and outcomes that prevented a quantitative meta-analysis. Conclusion: The results of our review suggest that at-risk populations may have an increased frequency of shortened IPIs though the impact appears to be moderate and inconsistent. There was insufficient evidence to draw meaningful conclusions regarding a prolonged IPI or the effect of interventions. Based on the current literature, underserved populations are more likely to have a shortened IPI which increased the incidence of prematurity and low birth weight in some groups though the effect on additional obstetric outcomes is difficult to assess.

Infertility has become an important public health issue, with over 12% of the U.S. population being affected. Moreover, the role of race and ethnicity has become increasingly recognized as an important contributor to health outcomes. Despite in vitro fertilization (IVF) playing a significant role in helping many women achieve their reproductive goals, data show disparities in IVF outcomes among racial and ethnic minority groups. This review examines the literature on disparities in IVF outcomes among black, Asian, and Hispanic women. Data analyzed show that black and Asian women have decreased clinical pregnancy and live-birth rates compared to white women and increased rates of pregnancy loss and fetal growth restriction. While consistent findings have not been identified among Hispanic women, likely due to inadequate studies among Hispanic women, limited epidemiologic data suggest decreased clinical pregnancy and live-birth rates among Hispanic women, while clinic based studies show no differences in outcomes when compared to white women. The biological plausibility associated with these disparate outcomes suggests a role for obesity, fibroids, and impaired endometrial hormonal milieu affecting outcomes among black women, while variation in ovarian reserve and endometrial hormonal milieu may contribute to poorer outcomes among Asian women.

Background: The three pillars of any health care system are cost, quality, and access to care. Health disparity is a deeply rooted problem shared amongst different ethnic groups in the United States. Differences in the incidence, prevalence, morbidity and mortality of diseases, however, vary widely among and between these groups. Frequent changes in health policies and insurance regulations directly influence access to care and can further increase existing disparities particularly for women and minority populations at greatest risk. Objectives: The objective of this review is to examine existing disparities among women, and other at-risk populations, as they relate to access to care and current health policies. Methods: Literature review we reviewed data from PUBmedusing PubMed and database search engine for the terms: disparity reproductive health, infertility, uterine fibroids, endometriosis, polycystic ovary syndrome, pelvic inflammatory disease, health policy, welfare reform and affordable care act. Results: Disparities in health care among women and at-risk populations still persist. There is evidence to suggest that both the pathophysiology of disease and clinical outcomes may differ among different ethnic groups. Inequality in access to care increases this disparity. Conclusion: Changes in health policy should reflect the population's need to provide access to quality and affordable health care. In order to provide the best care possible for all women and atrisk populations, increased efforts needed to promote more research on determining barriers to medical care and the evaluation of their efficacy. Equally important is increasing access to proven diagnostic evaluations, as well as greater representation of diverse racial and ethnic groups in clinical studies. Inequities in health care access and quality of care can be addressed using targeted policy changes.

Background: Despite a clear indication in many cases for the less invasive procedure, previous studies that have looked at the trends in the national distribution of laparoscopic hysterectomies have found that there remains a gap in the distribution of laparoscopic hysterectomies with regard to age, race, median income and insurance type. Objective: The purpose of this study was to examine the impact of race and military rank on access to the type of surgery performed and the use of minimally invasive surgery in the military. Method: Retrospective cohort study. Results: There was a marked disparity in racial utilization of surgical procedures. After controlling for age (OR=1.01/year, p <.001) and encounter year, total abdominal hysterectomy was less likely in White patients than Black patients (OR=.43, p<.0001) or Asian patients (OR=.428, p<.0001), but of equivalent likelihood in Black and Asian patients (OR=1.02, p=.98). Models testing the effect of rank for each of the surgical procedures revealed no effect on the rates of laparoscopic hysterectomy( LH) (OR=1.13, p=.09), total vaginal hysterectomy(TVH) (OR=.96, p=.60) or total abdominal hysterectomy(TAH) (OR=.91, p=.21). Conclusion: Future research should carefully consider whether the access to laparoscopic hysterectomy is related to race, ethnicity or socioeconomic status. Other circumstances, such as etiology of disease, uterine weight, and BMI may also be contributing factors in disparities in the utilization of laparoscopic hysterectomies. Further investigation is warranted to study the existing disparities.

Background: Uterine fibroids may be associated with heavy menstrual bleeding (HMB), pressure symptoms, and occasionally pain. The National Institute for Health and Care Excellence recommends a levonorgestrel intrauterine system (LNG-IUS) as first-line treatment of HMB, which is effective even in women with uterine fibroids. When HMB occurs in association with fibroids >3 cm in diameter, uterine artery embolisation and myomectomy are recommended. However, some women prefer conservative management, particularly those close to menopause. A case series was undertaken to determine the effectiveness of ulipristal acetate (Esmya), a potent selective progesterone receptor modulator, possibly followed by insertion of a LNG-IUS, to treat HMB in women close to menopause. Methods: Women presenting to a community gynaecology service with HMB who were suitable for ulipristal acetate followed by insertion of LNG-IUS are included in this case series. Fibroid size was measured at presentation and three months after treatment with ulipristal acetate. Other outcomes and side effects were recorded. Results: This case series included 15 women. Mean reduction in fibroid size in 14 women was 35.0% (range 2.6–73.3%). Nine women were fitted with a LNG-IUS following ulipristal acetate, three were referred to secondary care for consideration for surgical treatment, one had repeated courses of ulipristal acetate, one became amenorrhoeic due to the menopause, and one incidentally developed breast cancer and had no further treatment for HMB. Conclusions: Ulipristal acetate followed by LNG-IUS significantly reduces HMB, with variable reductions in fibroid size, often controlling symptoms to such a degree that surgery may be avoided.