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Pediatric and Adolescent Gynecologic Problems Continue During the COVID-19 Pandemic

      Greetings, dear readers, from shelter-in-place COVID-19 land, a very different place from where we all were (literally, and figuratively) when I wrote my last editorial on Pediatric and adolescent gynecology (PAG) in the time of a pandemic. Most of us are still reeling from the many changes that COVID-19 infections have necessitated.
      Some of you might have been infected yourselves. Others have had family members who were infected, and some of you have undoubtedly lost friends, colleagues, family members, or patients to complications of the viral infection. My heart goes out to you. This is a time of tragedies. Together we mourn.
      The economic consequences of the pandemic are also widespread and devasting, particularly to our most vulnerable populations—people of color and those who are economically disadvantaged.
      The Associated Press, AP-NORC Poll: Pandemic especially tough on people of color.
      When I chose to go to medical school, I remember thinking that I would always have a job. Illness and suffering are part of the human condition, and physicians, nurses, and other healers have been needed throughout time, and are especially needed today. Some of you who care for adults as well as children and teens are still in the thick of COVID-19 infections. I am fearful that the policies of “opening up” that are being promoted by many politicians are happening in the context of still rising rates of infection. When we listen to the authorities who base their recommendations on science, we hear that the effect will be even greater numbers of infections and deaths.
      • McNeil D.G.
      As states rush to reopen, scientists fear a coronavirus comeback. The New York Times.
      The current effect of COVID-19 on our PAG patients here in California is determined by the fear that parents have of coming to our offices and hospitals. COVID-19 infections in the San Francisco Bay Area appear to have peaked, and the surge in adult patients was mostly avoided through early shelter-in-place orders.
      Chronicle Digital Team
      Coronavirus tracker. San Francisco Chronicle.
      Fortunately, children and teens appear to have less severe infections, although concerns about specific morbidities are being raised. But unfortunately, “routine” healthcare is now being neglected, sometimes with the results that patients with emergent problems present later than they otherwise would. Although our operating rooms are now open, patients and families are still deferring the surgeries that had been postponed. I am eager to institute some of the elements of enhanced recovery after surgery that are described in this issue of the Journal of Pediatric and Adolescent Gynecology (JPAG).
      • Smith A.E.
      • Heiss K.
      • Childress K.J.
      Enhanced recovery after surgery in pediatric and adolescent gynecology: a pilot study.
      Our patients are still experiencing the usual PAG concerns that are also addressed in this issue: symptomatic labial adhesions,
      • Huseynov M.
      • Hakalmaz A.E.
      Labial adhesion: new classification and treatment protocol.
      prepubertal vaginal bleeding,
      • Ng S.M.
      • Apperley L.J.
      • Upradrasta S.
      • Natarajan A.
      Vaginal bleeding in pre-pubertal females.
      chronic pelvic pain,
      • Hung Y.-C.
      • Westfal M.L.
      • Chang D.C.
      • Kelleher C.M.
      Lack of data-driven treatment guidelines and wide variation in management of chronic pelvic pain in adolescents and young adults.
      sexually transmitted infections,
      • Daiane de Peder L.
      • Mesquita da Silva C.
      • Nascimento B.L.
      • et al.
      Prevalence of sexually transmitted infections and risk factors among young people in a public health center in Brazil: a cross-sectional study.
      issues related to contraception and induced abortion,
      • Parry R.A.
      • Sayner R.
      • Davis S.A.
      • Beznos B.Y.
      • Carpenter D.M.
      • Sleath B.L.
      Communication about contraception with adolescent females with asthma in pediatric visits.
      • Crain C.L.
      • DeFruscio A.E.
      • Shah P.T.
      • Hunt L.
      • Yoost J.L.
      The impact of an adolescent gynecology provider on intrauterine device and subdermal contraceptive implant use among adolescent patients.
      • Samy A.
      • Ali A.S.
      • Latif D.
      • Darweesh F.F.
      • Ghamry N.K.
      • Metwally A.A.
      Benefits of self-administered vaginal dinoprostone 12 hours before levonorgestrel-releasing intrauterine device insertion in nulliparous adolescents and young women: a randomized controlled trial.
      • Stein T.B.
      • Summit A.K.
      • St. Louis M.
      • Gold M.
      Patient satisfaction with IUD services in a school-based health center: a pilot study.
      • Harrison M.S.
      • Zucker R.
      • Scarbro S.
      • Sevick C.
      • Sheeder J.
      • Davidson A.J.
      Postpartum contraceptive use among denver-based adolescents and young adults: association with subsequent repeat delivery.
      • Huneeus A.
      • Capella D.
      • Cabieses B.
      • Cavada G.
      Induced abortion according to socioeconomic status in Chile.
      adnexal masses,
      • Tsunogai T.
      • Yamaoka M.
      • Ohyama W.
      • Honda T.
      • Kusuhara A.
      • Akiyama M.
      Aggressive B-cell lymphoma involving the appendix and bilateral ovaries in an 11-year-old girl.
      ,
      • Zvizdic Z.
      • Bukvic M.
      • Murtezic S.
      • Skenderi F.
      • Vranic S.
      Giant paratubal serous cystadenoma in an adolescent female: case report and literature review.
      differences of sex development,
      • Bruno Z.V.
      • Nogueira C.S.
      • de Lima Saintrain M.V.
      • et al.
      Disorder of sex development: a case of late-diagnosed ovotestis and its postsurgical follow-up.
      and Müllerian anomalies,
      • Chmel R.
      • Cekal M.
      • Pastor Z.
      • et al.
      Assisted reproductive techniques and pregnancy results in women with Mayer-Rokitansky-Küster-Hauser syndrome undergoing uterus transplantation: the Czech experience.
      ,
      • Chu K.
      • James D.
      • McNamara K.
      • Jongco B.
      • Velcek F.
      Resection of longitudinal vaginal septum using a surgical stapler.
      among many other problems. The NASPAG Position Statement, published in this issue, highlights the ongoing reproductive health needs of adolescents during a pandemic, including the need for contraception and confidential healthcare, even when using telehealth platforms.
      • Tyson N.
      • Berlan E.
      • Hewitt G.
      In collaboration with the NASPAG Advocacy Committee members: Case R Fisher M Gray S Harrison M Huneeus A Kaufman S McCarcken K Strickland J. Provision of Reproductive Health for Teens During a Pandemic.
      This issue's Review article on dating violence and its implications for girls' sexual health provides definitions of dating violence and its many manifestations, estimates of prevalence, and reminders of the severe consequences of morbidity and mortality, but also the complex links with behaviors.
      • Joppa M.C.
      Dating violence in adolescence: implications for girls’ sexual health.
      The author notes that adolescent girls with a history of sexual coercion are more likely to engage in sexual risk behaviors and vice versa.
      This review reminded me of past PAG patients. I recall from years ago, the saga of a physician's daughter who was terrified of her ex-boyfriend, who was stalking her. The psychological aggressions that she described included manipulation and coercion, which she ultimately recognized. Reproductive coercion might not always be recognized. One of the reasons that I devised my structure of a first gynecologic visit in which I speak first with the adolescent and her parent (usually mom), then with the parent(s) without the teen, and subsequently with the adolescent confidentially, completing the visit all together, with a summary of the visit (sometimes with parameters elicited from the teen about what is permissible to share with the parent), is that I learned how valuable the parent's perspective can be.
      • Rosenthal S.L.
      • Kohen S.S.
      • Burklow K.A.
      • Hillard P.A.
      Family involvement in the gynecologic care of adolescents.
      I remember one of the first moms who opened my eyes to the value of a parent's perspective when mom described her daughter's boyfriend as belittling her and undermining her daughter's self-esteem. I realized that had I spoken only to the daughter, I might not have heard that assessment.
      Experts tell us that during the pandemic, intimate partner violence and child abuse may be more easily hidden with families in isolation.
      • Bosman J.
      Domestic violcence calls mount as restrictions linger: ‘no one can leave’. The New York Times.
      ,
      • Agarwal N.
      The coronavirus could cause a child abuse epidemic. The New York Times.
      The pandemic is clearly leading to high levels of stress, and more domestic violence might be the result. We need to keep these issues in mind; as physicians, we might be the only ones to observe these effects.
      Please continue to stay safe in COVID-19 times. May JPAG inform your clinical care.

      References

      1. The Associated Press, AP-NORC Poll: Pandemic especially tough on people of color.
        The New York Times., 2020
        • McNeil D.G.
        As states rush to reopen, scientists fear a coronavirus comeback. The New York Times.
        2020 (Accessed May 11, 2020)
        • Chronicle Digital Team
        Coronavirus tracker. San Francisco Chronicle.
        2020 (Accessed May 11, 2020)
        • Smith A.E.
        • Heiss K.
        • Childress K.J.
        Enhanced recovery after surgery in pediatric and adolescent gynecology: a pilot study.
        J Pediatr Adolesc Gynecol. 2020; 33: 403-409
        • Huseynov M.
        • Hakalmaz A.E.
        Labial adhesion: new classification and treatment protocol.
        J Pediatr Adolesc Gynecol. 2020; 33: 343-348
        • Ng S.M.
        • Apperley L.J.
        • Upradrasta S.
        • Natarajan A.
        Vaginal bleeding in pre-pubertal females.
        J Pediatr Adolesc Gynecol. 2020; 33: 339-342
        • Hung Y.-C.
        • Westfal M.L.
        • Chang D.C.
        • Kelleher C.M.
        Lack of data-driven treatment guidelines and wide variation in management of chronic pelvic pain in adolescents and young adults.
        J Pediatr Adolesc Gynecol. 2020; 33: 349-353
        • Daiane de Peder L.
        • Mesquita da Silva C.
        • Nascimento B.L.
        • et al.
        Prevalence of sexually transmitted infections and risk factors among young people in a public health center in Brazil: a cross-sectional study.
        J Pediatr Adolesc Gynecol. 2020; 33: 354-362
        • Parry R.A.
        • Sayner R.
        • Davis S.A.
        • Beznos B.Y.
        • Carpenter D.M.
        • Sleath B.L.
        Communication about contraception with adolescent females with asthma in pediatric visits.
        J Pediatr Adolesc Gynecol. 2020; 33: 372-376
        • Crain C.L.
        • DeFruscio A.E.
        • Shah P.T.
        • Hunt L.
        • Yoost J.L.
        The impact of an adolescent gynecology provider on intrauterine device and subdermal contraceptive implant use among adolescent patients.
        J Pediatr Adolesc Gynecol. 2020; 33: 377-381
        • Samy A.
        • Ali A.S.
        • Latif D.
        • Darweesh F.F.
        • Ghamry N.K.
        • Metwally A.A.
        Benefits of self-administered vaginal dinoprostone 12 hours before levonorgestrel-releasing intrauterine device insertion in nulliparous adolescents and young women: a randomized controlled trial.
        J Pediatr Adolesc Gynecol. 2020; 33: 382-387
        • Stein T.B.
        • Summit A.K.
        • St. Louis M.
        • Gold M.
        Patient satisfaction with IUD services in a school-based health center: a pilot study.
        J Pediatr Adolesc Gynecol. 2020; 33: 388-392
        • Harrison M.S.
        • Zucker R.
        • Scarbro S.
        • Sevick C.
        • Sheeder J.
        • Davidson A.J.
        Postpartum contraceptive use among denver-based adolescents and young adults: association with subsequent repeat delivery.
        J Pediatr Adolesc Gynecol. 2020; 33: 392-397
        • Huneeus A.
        • Capella D.
        • Cabieses B.
        • Cavada G.
        Induced abortion according to socioeconomic status in Chile.
        J Pediatr Adolesc Gynecol. 2020; 33: 415-420
        • Tsunogai T.
        • Yamaoka M.
        • Ohyama W.
        • Honda T.
        • Kusuhara A.
        • Akiyama M.
        Aggressive B-cell lymphoma involving the appendix and bilateral ovaries in an 11-year-old girl.
        J Pediatr Adolesc Gynecol. 2020; 33: 421-424
        • Zvizdic Z.
        • Bukvic M.
        • Murtezic S.
        • Skenderi F.
        • Vranic S.
        Giant paratubal serous cystadenoma in an adolescent female: case report and literature review.
        J Pediatr Adolesc Gynecol. 2020; 33: 438-440
        • Bruno Z.V.
        • Nogueira C.S.
        • de Lima Saintrain M.V.
        • et al.
        Disorder of sex development: a case of late-diagnosed ovotestis and its postsurgical follow-up.
        J Pediatr Adolesc Gynecol. 2020; 33: 425-428
        • Chmel R.
        • Cekal M.
        • Pastor Z.
        • et al.
        Assisted reproductive techniques and pregnancy results in women with Mayer-Rokitansky-Küster-Hauser syndrome undergoing uterus transplantation: the Czech experience.
        J Pediatr Adolesc Gynecol. 2020; 33: 410-414
        • Chu K.
        • James D.
        • McNamara K.
        • Jongco B.
        • Velcek F.
        Resection of longitudinal vaginal septum using a surgical stapler.
        J Pediatr Adolesc Gynecol. 2020; 33: 435-437
        • Tyson N.
        • Berlan E.
        • Hewitt G.
        In collaboration with the NASPAG Advocacy Committee members: Case R Fisher M Gray S Harrison M Huneeus A Kaufman S McCarcken K Strickland J. Provision of Reproductive Health for Teens During a Pandemic.
        J Ped Adol Gynecol. 2020; 33: 331
        • Joppa M.C.
        Dating violence in adolescence: implications for girls’ sexual health.
        J Pediatr Adolesc Gynecol. 2020; 33: 332-338
        • Rosenthal S.L.
        • Kohen S.S.
        • Burklow K.A.
        • Hillard P.A.
        Family involvement in the gynecologic care of adolescents.
        J Pediatr Adolesc Gynecol. 1996; 9: 59-65
        • Bosman J.
        Domestic violcence calls mount as restrictions linger: ‘no one can leave’. The New York Times.
        2020 (Accessed May 15, 2020)
        • Agarwal N.
        The coronavirus could cause a child abuse epidemic. The New York Times.
        (Opinion)2020 (Accessed April 7, 2020)