Continuous (noncyclic) combination regimens of oral estrogen and progestins (birth control pills) or other forms of combination estrogen/progestins (transdermal patch, vaginal ring) that do not include a withdrawal bleeding–placebo week (105,106).
3.
Depot formulations of progestins (DMPA), with or without concurrent estrogens (104).
4.
Gonadotropin-releasing hormone (GnRH) analogues with or without estrogen add-back therapy (105).
5.
Levonorgestrel intrauterine system (IUS) (107).
The choice of regimen depends on the presence of any contraindications (such as active liver disease precluding the use of estrogens) and the clinician’s experience. Although the goal of these long-term suppressive therapies is amenorrhea, all of these regimens may be accompanied by breakthrough bleeding. At 1 year, rates of amenorrhea approach 90% with extended cycle combination oral contraceptives, 50% with DMPA, and 50% with the levonorgestrel IUS (73,108,109). Because both DMPA and GnRH analogues are associated with disadvantageous effects on bone mineral density, the potential risks must be weighed against their medical benefits. Regular follow-up visits and continued patient encouragement are required with all of these options. Episodes of spotting and breakthrough bleeding that do not result in a lowered hemoglobin level may be managed expectantly. When breakthrough bleeding affects the hemoglobin level, it should be evaluated with respect to the underlying disease. For example, in a patient with underlying platelet dysfunction, breakthrough bleeding may reﬂect a lowered platelet count. Bleeding in a patient with hepatic disease may reﬂect worsening hepatic function. NSAIDs and supplemental low-dose hormonal therapy can be helpful in the management of excessive breakthrough bleeding that has no specific cause other than the hormone therapy (110).
Diagnosis The history and pelvic examination are critical in the diagnosis of a pelvic mass. Considerations in adolescents include the anxiety associated with a first pelvic examination, as well as issues of confidentiality related to questions about sexual activity. Techniques for history taking and the performance of the first examination are discussed in Chapter 1.
Laboratory studies should always include a pregnancy test (regardless of stated sexual activity), and a complete blood count may be helpful in diagnosing inﬂammatory masses. Tumor markers, including α-fetoprotein and human chorionic gonadotropin (hCG), may be elaborated by germ cell tumors and can be useful in preoperative diagnosis and follow-up (see Chapter 37).
As in all other age groups, the primary diagnostic technique for evaluating pelvic masses in adolescents is ultrasonography. Although transvaginal ultrasonographic examinations may provide more detail than transabdominal ultrasonography, particularly with inﬂammatory masses, a transvaginal examination may not be well tolerated by adolescents (111). Ultrasonography usually is the most helpful imaging technique for assessing ovarian masses. For cases in which the suspected diagnosis is appendicitis or another nongynecologic condition, or if the results of the ultrasonographic examination are inconclusive, CT or MRI may be helpful.
An accurate preoperative assessment of anatomy is critical, particularly in cases of uterovaginal
Figure 14.14 Adnexal mass with torsion.
Differential Diagnosis of Adolescent Pelvic Masses malformations. MRI can be useful for evaluating this group of rare anomalies (88). Adolescents who present with abdominal pain should be evaluated with some type of imaging procedure because an unexpected finding of a complex uterine or vaginal anomaly requires careful surgical planning and management.