To the Editor: Pediatric and adolescent gynecology (PAG) is a specialized branch of gynecology that focuses on reproductive health issues of women from infancy to adolescence.[1] In 1939, the Hungarian Dobszay first established the new branch. Since then, the PAG subject has begun to develop and gradually matured in the past 80 years. While PAG has witnessed significant development in western countries, a substantial unmet need persists in addressing specific health concerns among children and adolescents with gynecological disorders. In China, where the PAG discipline is still in its infancy, this situation becomes even more critical. The diseases young females experience in the gynecological field have own particularities.[1] Also, PAG shares connections with various medical disciplines, notably surgery. Investigating the inpatient disease spectrum, prevalence rates, and clinical characteristics of PAG surgical disorders is of significant clinical importance, yet no previous research has addressed this in China or other countries. Therefore, the study retrospectively analyzed the clinical data of 512 PAG inpatients aged 0–18 years who received surgical treatment at Peking University First Hospital (PKUFH) from January 2010 to May 2022, so as to comprehensively outline the inpatient disease spectrum and clinical characteristics of surgical disorders in PAG, with the aim of offering management recommendations and evidential support for future clinical work. The study was approved by the Institutional Review Board of PKUFH (No. 2022[593]) and informed consent was waived due to the retrospective nature of the study. Non-normally distributed quantitative variables are shown as median (Q1, Q3), and categorical variables as count and percentage. Comparison tests were performed using chi-square test and Fisher's exact test. The median (Q1, Q3) age of PAG surgical inpatients in the study was 16 (14, 18) years old. The youngest patient identified was a newborn diagnosed prenatally with an abdominal cyst measuring an average diameter of 72.5 mm. Merely 19 hours after birth, she underwent a laparotomy to remove a left ovarian cyst, which was later pathologically identified as a simple ovarian cyst. Within the study population, there were 32 patients (32/512, 6.25%) aged between 0 and 8 years, 133 patients (133/512, 25.97%) aged between 9 and 14 years, and 347 patients (347/512, 67.78%) aged between 15 and 18 years. Notably, adolescents who had entered puberty comprised the primary population affected by PAG diseases. The spectrum of surgical diseases among PAG inpatients encompasses various conditions, including adnexal masses (299/512, 58.39%), unwanted pregnancy (188/512, 36.72%), genital tract trauma (4/512, 0.78%), inguinal (4/512, 0.78%), retroperitoneal masses (4/512, 0.78%), abnormal uterine bleeding (AUB) (3/512, 0.59%), congenital uterine anomalies (3/512, 0.59%), uterine tumors (3/512, 0.59%), vaginal foreign bodies (3/512, 0.59%), and cervical tumors (1/512, 0.19%). Surgical interventions were performed for all patients included in the study. Adnexal masses emerged as the most prevalent cause necessitating hospitalized surgical treatment among PAG patients. The median age of patients diagnosed with adnexal masses was 15 (13, 17) years old. The age distribution shown in Table 1 underscores the higher prevalence of PAG adnexal masses in adolescents. The common types of adnexal masses included ovarian germ cell tumors (114/299, 38.13%), ovarian epithelial tumors (78/299, 26.09%), and paratubal cysts (75/299, 25.08%). These findings align with data from other PAG populations.[2] However, occurrences of ovarian sex cord stromal tumors, endometriotic cysts, and corpus luteum cysts were relatively rare. Previous research indicated that among masses requiring surgery, approximately 4–20% were malignant, constituting 1% of all pediatric malignancies.[3] In this study, the malignancy rate stood at 4.68% (14/299), with ovarian germ cell tumors exhibiting the highest malignancy rate (12/114, 10.53%) [Table 1]. Table 1 - Characteristics of adnexal masses in PAG. Type of adnexal masses Cases (N = 299) Age (years) Age distribution Overweight and obesity Menarche Elevated tumor markers† Tumor size >10 cm Malignancy 0–8 years 9–14 years 15–18 years Ovarian germ cell tumor 114 (38.1) 15 (12.0, 17.0) 12 (10.53) 39 (34.21) 63 (55.26) 40 (35.09) 91 (79.82) 40 (35.09) 18 (15.79) 12 (10.53) Ovarian epithelial tumor 78 (26.09) 15 (13.0, 17.0) 3 (3.85) 30 (38.46) 45 (57.69) 31 (39.74) 71 (91.03) 13 (16.67) 19 (24.36) 0 Ovarian sex cord stromal tumor 8 (2.7) 14.5(12.5, 16.0) 0 4 (50.00) 4 (50.00) 4 (50.00) 7 (87.50) 3 (37.50) 2 (25.00) 2 (25.00) Paratubal cyst 75 (25.08) 14 (13.0, 17.0) 0 38 (50.67) 37 (49.33) 44 (58.67) 74 (98.67) 3 (4.00) 7 (9.33) 0 Endometriotic cyst 10 (3.34) 18 (17.0, 18.0) 0 1 (10.00) 9 (90.00) 0 10 (100.00) 5 (50.00) 1 (10.00) 0 Corpus luteum cyst 6 (2.01) 15 (12.0, 15.0) 0 2 (33.33) 4 (66.67) 1 (16.67) 6 (100.00) 0 0 0 Others* 8 (2.68) 12 (4.5, 14.5) 3 (37.50) 3 (37.50) 2 (25.00) 1 (12.50) 3 (37.50) 1 (12.50) 0 0 Total 299 15 (13.0, 17.0) 18 (6.02) 117 (39.13) 164 (54.85) 121 (40.47) 262 (87.63) 65 (21.74) 47 (15.72) 14 (4.68) Data were presented as n (%) and median (Q1, Q3). *Others include ovarian follicular cyst, mesothelial cyst, simple cyst, and ovarian edema. †Tumor markers included CA125, CA199, CA153, AFP, SCC, HE4, hCG, and NSE. One or more elevated tumor markers detected was defined as "elevated." AFP: Alpha-fetoprotein; HE4: Human epididymis protein 4; hCG: Human chorionic gonadotropin; NSE: Neuron-specific enolase; PAG: Pediatric and adolescent gynecology; SCC: Squamous cell carcinoma antigen. Among PAG patients diagnosed with adnexal masses, 40.47% (121/299) were classified as overweight or obese. The prevalence of overweight and obesity among paratubal cysts was the highest, reaching 58.67% (44/75), followed by sex cord stromal tumors, epithelial tumors, and ovarian germ cell tumors. Conversely, endometriotic cysts and corpus luteal cysts were more commonly observed in adolescents with normal body weight. Compared to the 2020 report on Chinese residents, showing 11.1% overweight and 7.9% obesity rates among 6–17-year-olds, overweight and obesity are significantly higher in PAG patients with adnexal masses in the study than in the general population. Recent epidemiological studies have presented the correlation between obesity and ovarian cancer, which may be related to the increase of estrogen, insulin, and insulin-like growth factor levels caused by body fat accumulation.[4] Previous investigations have also observed the correlation between paratubal cysts and obesity. The mechanism could be the activation of WNT/CTNNB1 (wingless-related mouse mammary tumor virus (MMTV) integration site gene family/beta-catenin 1) signal pathway, which awaits further studies. The results highlight the significance of weight management during the initial stages of the female life cycle. The most prevalent initial symptom observed in PAG patients with adnexal masses was abdominal pain, encompassing both chronic and acute abdominal discomfort. Immediate assessment of children and adolescents with adnexal masses and abdominal pain is essential to identify serious complications like adnexal torsion or tumor rupture, which could result in ovarian necrosis or intraperitoneal hemorrhage. In our study, surgical confirmation revealed that 17.73% of the adnexal masses experienced torsion, with 13 cases (24.53%) necessitating adnexectomy due to ovarian ischemic necrosis. Earlier research has indicated a higher likelihood of torsion occurrence when the tumor diameter exceeds 5 cm.[2] Notably, our study established a statistical correlation between the risk of tumor torsion and tumor size (χ2 = 6.20, P = 0.045). Specifically, tumors ranging from 5 to 10 cm bore the highest torsion risk at 21.82% (36/165). However, no statistically significant correlation was found between tumor size and malignancy risk (χ2 = 1.99, P = 0.37). Preserving fertility and ovarian function should remain the primary objective for this demographic. Hence, early diagnosis is imperative to mitigate the risk of ovarian torsion and to enhance prognosis. Second to adnexal mass, the proportion of unwanted pregnancy was 36.72% (188/512). The rate of adolescent pregnancy has been steadily declining over the last 10 years.[5] In the US, the 2020 birth rates for teenagers aged 15–17 years and 18–19 years were respectively down 6% and 7% from 2019. Nevertheless, the number is still terrifying and remains a significant public health concern. Adolescent pregnancy increases the risk of complications like preeclampsia, preterm birth, and infant mortality. It can negatively affect the health development of young mothers, including potential infertility from induced abortions and higher sexual transmitted infection exposure from unprotected sex.[5] In Beijing's well-educated region, Unwanted pregnancies still lead to significant adolescent gynecologic surgeries, underscoring the urgent need for effective prevention. This includes delaying sexual activity, and promoting reliable contraceptive use. AUB is a common menstrual symptom among female adolescents. The average menarche age in well-nourished populations is around 12–13 years, with irregular cycles common in the initial 2–3 years.[6] Up to 95% of adolescents with AUB experience ovulatory dysfunction due to an immature hypothalamic-pituitary-ovarian axis. Treatment focuses on preserving fertility, with medical therapy as the primary approach. Despite menstrual disorders being common in adolescents, most are managed with medical treatment and outpatient follow-up. Only a few, with severe symptoms like heavy bleeding and anemia, require hospitalization for surgical intervention. The study's three AUB cases, treated with either hysteroscopy, curettage, or a levonorgestrel intrauterine device, highlight that adolescent AUB seldom necessitates surgery. Thus, medical treatment is preferred for adolescent AUB, reserving surgery for critical situations.[6] The study included three PAG cases with uterine anomalies requiring surgery, even though uterine anomalies are relatively common in the general population, with a prevalence of 3.2–5.5%. Most cases do not need surgical intervention in youth. Surgery in adolescence, such as for a hemi-uterus with a non-communicating functional rudimentary cavity, is very rare. Surgical treatment for uterine anomalies is typically reserved for childbearing years due to infertility, menorrhagia, or pelvic masses, highlighting the difference in gynecological disease management between children/adolescents and adults. The PAG surgical spectrum also covered rare cases like genital tract trauma, inguinal and retroperitoneal masses, vaginal foreign bodies, and uterine and cervical tumors. Such conditions are infrequent and sporadic, with surgery being the recommended treatment. In conclusion, PAG is an essential aspect of women's health throughout their life cycles. The most prevalent surgical disease is adnexal mass and its symptoms are mainly acute or chronic abdominal pain. It is imperative for medical professionals and society at large to prioritize health education for underage women, facilitate physical examinations, and promote healthy lifestyles and weight management. These efforts are essential for enhancing reproductive health and overall quality of life as these individuals transition into adulthood.
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Huang et al. (2024) studied this question.
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