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.2010 acog compendium
1. THE AMERICAN COLLEGE OF
OBSTETRICIANS AND GYNECOLOGISTS
W OMEN ’ S H EALTH C ARE P HYSICIANS
COMPENDIUM
of Selected Publications
2. The Compendium of Selected Publications CD-ROM contains all Committee Opinions,
Practice Bulletins, Policy Statements, and Technology Assessments published by the
American College of Obstetricians and Gynecologists (the College) as of December 31,
2009. The information in these documents should not be viewed as establishing standards
or dictating rigid rules. The guidelines are general and intended to be adapted to many
different situations, taking into account the needs and resources particular to the locality, the
institution, or the type of practice. Variations and innovations that improve the quality of
patient care are to be encouraged rather than restricted. The purpose of these guidelines will
be well served if they provide a firm basis on which local norms may be built.
Copyright 2010 by the American College of Obstetricians and Gynecologists. All rights
reserved. No part of this publication may be reproduced, stored in a retrieval system,
posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without prior written permission from the publisher.
The American College of Obstetricians and Gynecologists
409 12th Street, SW
PO Box 96920
Washington, DC 20090-6920
ISBN: 978-1-934946-88-6
Publications can be ordered through the College Distribution Center by calling toll free
800-762-2264. To receive order forms via facsimile, call (732) 885-6364 and follow the audio
instructions. Publications also can be ordered from the College web site at www.acog.org.
The following resources from the College also contain College practice
guidelines and should be considered adjuncts to the documents in the
Compendium of Selected Publications CD-ROM.
Guidelines for Perinatal Care, Sixth Edition
Guidelines for Women’s Health Care, Third Edition
Health Care for Adolescents
Special Issues in Women’s Health
These documents are available online to members at www.acog.org
3. SEARCH
Contents
F OREWORD xi
T HE S COPE OF P RACTICE OF O BSTETRICS AND G YNECOLOGY xii
C ODE OF P ROFESSIONAL E THICS xiii
C OMMITTEE O PINIONS
C OMMITTEE ON A DOLESCENT H EALTH C ARE
302 Guidelines for Adolescent Health Research 3
310 Endometriosis in Adolescents 7
314 Meningococcal Vaccination for Adolescents 14
344 Human Papillomavirus Vaccination
(Joint with the ACOG Working Group on Immunization) 17
349 Menstruation in Girls and Adolescents: Using the Menstrual Cycle as a Vital Sign
(Joint with the American Academy of Pediatrics) 24
350 Breast Concerns in the Adolescent 30
351 The Overweight Adolescent: Prevention, Treatment, and Obstetric–Gynecologic Implications 38
355 Vaginal Agenesis: Diagnosis, Management, and Routine Care 50
392 Intrauterine Device and Adolescents 55
415 Depot Medroxyprogesterone Acetate and Bone Effects
(Joint with Committee on Gynecologic Practice) 58
417 Addressing Health Risks of Noncoital Sexual Activities
(Joint with Committee on Gynecologic Practice) 62
*448 Menstrual Manipulation for Adolescents with Disabilities 65
*451 Von Willebrand Disease in Women
(Joint with Committee on Gynecologic Practice) 69
C OMMITTEE ON C ODING AND N OMENCLATURE
205 Tubal Ligation with Cesarean Delivery 77
249 Coding Responsibility 78
250 Inappropriate Reimbursement Practices by Third-Party Payers 79
C OMMITTEE ON E THICS
297 Nonmedical Use of Obstetric Ultrasonography 85
321 Maternal Decision Making, Ethics, and the Law 87
341 Ethical Ways for Physicians to Market a Practice 98
347 Using Preimplantation Embryos for Research 102
352 Innovative Practice: Ethical Guidelines 115
358 Professional Responsibilities in Obstetric–Gynecologic Education 122
*Published in 2009
iii
4. iv COMPENDIUM OF SELECTED PUBLICATIONS
C OMMITTEE ON E THICS (continued)
359 Commercial Enterprises in Medical Practice 126
360 Sex Selection 129
362 Medical Futility 133
363 Patient Testing: Ethical Issues in Selection and Counseling 137
364 Patents, Medicine, and the Interests of Patients (Joint with Committee on Genetics) 140
365 Seeking and Giving Consultation 145
368 Adoption 150
369 Multifetal Pregnancy Reduction 154
370 Institutional Responsibility to Provide Legal Representation 159
371 Sterilization of Women, Including Those With Mental Disabilities 161
373 Sexual Misconduct 165
374 Expert Testimony 169
377 Research Involving Women 171
385 The Limits of Conscientious Refusal in Reproductive Medicine 177
389 Human Immunodeficiency Virus 183
390 Ethical Decision Making in Obstetrics and Gynecology 189
395 Surgery and Patient Choice 198
397 Surrogate Motherhood 203
401 Relationships With Industry 209
403 End-of-Life Decision Making 215
409 Direct-to-Consumer Marketing of Genetic Testing (Joint with Committee on Genetics) 222
410 Ethical Issues in Genetic Testing (Joint with Committee on Genetics) 224
422 At-Risk Drinking and Illicit Drug Use: Ethical Issues in Obstetric and Gynecologic Practice 232
*439 Informed Consent 244
C OMMITTEE ON G ENETICS
318 Screening for Tay–Sachs Disease 255
324 Perinatal Risks Associated With Assisted Reproductive Technology
(Joint with Committees on Obstetric Practice and Gynecologic Practice) 257
325 Update on Carrier Screening for Cystic Fibrosis 261
338 Screening for Fragile X Syndrome 265
393 Newborn Screening 268
399 Umbilical Cord Blood Banking (Joint with Committee on Obstetric Practice) 272
*430 Preimplantation Genetic Screening for Aneuploidy 275
*432 Spinal Muscular Atrophy 277
*442 Preconception and Prenatal Carrier Screening for Genetic Diseases
in Individuals of Eastern European Jewish Descent 280
*446 Array Comparative Genomic Hybridization in Prenatal Diagnosis 284
*449 Maternal Phenylketonuria 287
1 Genetics and Molecular Diagnostic Testing 289
*Published in 2009
Technology Assessment
5. CONTENTS v
C OMMITTEE ON G YNECOLOGIC P RACTICE
240 Statement on Surgical Assistants (Joint with Committee on Obstetric Practice) 311
253 Nongynecologic Procedures 312
278 Avoiding Inappropriate Clinical Decisions Based
on False-Positive Human Chorionic Gonadotropin Test Results 313
280 The Role of the Generalist Obstetrician–Gynecologist in the Early
Detection of Ovarian Cancer (Joint with Society of Gynecologic Oncologists) 316
313 The Importance of Preconception Care in the Continuum of Women’s Health Care 319
319 The Role of the Obstetrician–Gynecologist in the Assessment and Management of Obesity 321
322 Compounded Bioidentical Hormones 326
323 Elective Coincidental Appendectomy 328
332 Hepatitis B and Hepatitis C Virus Infections in Obstetrician–Gynecologists 330
334 Role of the Obstetrician–Gynecologist in the Screening and Diagnosis of Breast Masses 332
336 Tamoxifen and Uterine Cancer 334
337 Noncontraceptive Uses of the Levonorgestrel Intrauterine System 338
345 Vulvodynia (Joint with American Society for Colposcopy and Cervical Pathology) 342
372 The Role of Cystourethroscopy in the Generalist Obstetrician–Gynecologist Practice 346
375 Brand Versus Generic Oral Contraceptives 350
378 Vaginal “Rejuvenation” and Cosmetic Vaginal Procedures 352
384 Colonoscopy and Colorectal Cancer Screening and Prevention 354
387 Pharmaceutical Compounding 358
388 Supracervical Hysterectomy 360
396 Intraperitoneal Chemotherapy for Ovarian Cancer 363
405 Ovarian Tissue and Oocyte Cryopreservation 366
407 Low Bone Mass (Osteopenia) and Fracture Risk 368
408 Professional Liability and Gynecology-Only Practice
(Joint with Committees on Obstetric Practice and Professional Liability) 371
411 Routine Human Immunodeficiency Virus Screening 372
412 Aromatase Inhibitors in Gynecologic Practice 375
413 Age-Related Fertility Decline (Joint with American Society for Reproductive Medicine) 378
420 Hormone Therapy and Heart Disease 381
*434 Induced Abortion and Breast Cancer Risk 385
*440 The Role of Transvaginal Ultrasonography in the Evaluation of Postmenopasual Bleeding 387
*444 Choosing the Route of Hysterectomy for Benign Diseases 390
*450 Increasing Use of Contraceptive Implants and Intrauterine Devices to Reduce
Unintended Pregnancy (Joint with the Long Acting Reversible Contraception Working Group) 393
*452 Primary and Preventive Care: Periodic Assessments 398
4 Hysteroscopy 406
5 Sonohysterography 410
*6 Robot-Assisted Surgery 413
*Published in 2009
Technology Assessment
6. vi COMPENDIUM OF SELECTED PUBLICATIONS
C OMMITTEE ON H EALTH C ARE FOR U NDERSERVED W OMEN
307 Partner Consent for Participation in Women’s Reproductive Health Research 419
312 Health Care for Homeless Women 422
316 Smoking Cessation During Pregnancy (Joint with Committee on Obstetric Practice) 428
317 Racial and Ethnic Disparities in Women’s Health 434
343 Psychosocial Risk Factors: Perinatal Screening and Intervention 438
361 Breastfeeding: Maternal and Infant Aspects (Joint with Committee on Obstetric Practice) 447
391 Health Literacy 449
414 Human Immunodeficiency Virus and Acquired Immunodeficiency
Syndrome and Women of Color 452
416 The Uninsured 456
*423 Motivational Interviewing: A Tool for Behavior Change 460
*424 Abortion Access and Training 464
*425 Health Care for Undocumented Immigrants 468
*428 Legal Status: Health Impact for Lesbian Couples 472
*429 Health Disparities for Rural Women 476
*437 Community Involvement and Volunteerism 480
C OMMITTEE ON I NTERNATIONAL A FFAIRS
*427 Misoprostol for Postabortion Care 485
C OMMITTEE ON O BSTETRIC P RACTICE
125 Placental Pathology 491
234 Scheduled Cesarean Delivery and the Prevention of Vertical Transmission of HIV Infection 492
260 Circumcision 495
267 Exercise During Pregnancy and the Postpartum Period 497
268 Management of Asymptomatic Pregnant or Lactating Women Exposed to Anthrax 500
275 Obstetric Management of Patients with Spinal Cord Injuries 503
276 Safety of Lovenox in Pregnancy 506
279 Prevention of Early-Onset Group B Streptococcal Disease in Newborns 508
281 Rubella Vaccination 516
284 Nonobstetric Surgery in Pregnancy 517
295 Pain Relief During Labor (Joint with American Society of Anesthesiologists) 518
299 Guidelines for Diagnostic Imaging During Pregnancy 519
305 Influenza Vaccination and Treatment During Pregnancy 524
315 Obesity in Pregnancy 526
326 Inappropriate Use of the Terms Fetal Distress and Birth Asphyxia 531
333 The Apgar Score (Joint with American Academy of Pediatrics) 533
339 Analgesia and Cesarean Delivery Rates 537
340 Mode of Term Singleton Breech Delivery 539
*Published in 2009
7. CONTENTS vii
C OMMITTEE ON O BSTETRIC P RACTICE (continued)
342 Induction of Labor for Vaginal Birth After Cesarean Delivery 542
346 Amnioinfusion Does Not Prevent Meconium Aspiration Syndrome 545
348 Umbilical Cord Blood Gas and Acid-Base Analysis 548
376 Nalbuphine Hydrochloride Use for Intrapartum Analgesia 552
379 Management of Delivery of a Newborn With Meconium-Stained Amniotic Fluid 553
381 Subclinical Hypothyroidism in Pregnancy 554
382 Fetal Monitoring Prior to Scheduled Cesarean Delivery 556
394 Cesarean Delivery on Maternal Request 557
402 Antenatal Corticosteroid Therapy for Fetal Maturation 561
404 Late-Preterm Infants 564
418 Prenatal and Perinatal Human Immunodeficiency Virus Testing:
Expanded Recommendations 568
419 Use of Progesterone to Reduce Preterm Birth
(Joint with Society for Maternal Fetal Medicine) 572
421 Antibiotic Prophylaxis for Infective Endocarditis 575
*433 Optimal Goals for Anesthesia Care in Obstetrics
(Joint with American Society of Anesthesiologists) 577
*435 Postpartum Screening for Abnormal Glucose Tolerance in Women Who Had
Gestational Diabetes Mellitus 580
*438 Update on Immunization and Pregnancy: Tetanus, Diphtheria, and Pertussis Vaccination 583
*441 Oral Intake During Labor 586
*443 Air Travel During Pregnancy 587
*445 Antibiotics for Preterm Labor (Joint with Society for Maternal Fetal Medicine) 589
C OMMITTEE ON P ROFESSIONAL L IABILITY
380 Disclosure and Discussion of Adverse Events (Joint with Committee on Patient Safety and
Quality Improvement) 593
406 Coping With the Stress of Medical Professional Liability Litigation 595
C OMMITTEE ON PATIENT S AFETY AND Q UALITY I MPROVEMENT
320 Partnering With Patients to Improve Safety 599
327 “Do Not Use” Abbreviations 602
328 Patient Safety in the Surgical Environment 604
329 Tracking and Reminder Systems 609
331 Safe Use of Medication 612
353 Medical Emergency Preparedness 616
366 Disruptive Behavior 619
367 Communication Strategies for Patient Handoffs 621
398 Fatigue and Patient Safety 624
400 Technologic Advances to Reduce Medication-Related Errors 627
*447 Patient Safety in Obstetrics and Gynecology 631
*Published in 2009
8. viii COMPENDIUM OF SELECTED PUBLICATIONS
R EADING THE M EDICAL L ITERATURE 637
P RACTICE B ULLETINS
C OMMITTEE ON P RACTICE B ULLETINS —O BSTETRICS
4 Prevention of Rh D Alloimmunization 647
6 Thrombocytopenia in Pregnancy 655
9 Antepartum Fetal Surveillance 666
12 Intrauterine Growth Restriction 677
13 External Cephalic Version 689
17 Operative Vaginal Delivery 696
19 Thromboembolism in Pregnancy 704
20 Perinatal Viral and Parasitic Infections 714
22 Fetal Macrosomia 727
24 Management of Recurrent Early Pregnancy Loss 738
29 Chronic Hypertension in Pregnancy 750
30 Gestational Diabetes 759
31 Assessment of Risk Factors for Preterm Birth 773
33 Diagnosis and Management of Preeclampsia and Eclampsia 781
36 Obstetric Analgesia and Anesthesia 790
37 Thyroid Disease in Pregnancy 805
38 Perinatal Care at the Threshold of Viability 815
40 Shoulder Dystocia 823
43 Management of Preterm Labor 829
44 Neural Tube Defects 838
48 Cervical Insufficiency 849
49 Dystocia and Augmentation of Labor 858
52 Nausea and Vomiting of Pregnancy 868
54 Vaginal Birth After Previous Cesarean Delivery 881
55 Management of Postterm Pregnancy 891
56 Multiple Gestation: Complicated Twin, Triplet, and High-Order Multifetal Pregnancy
(Joint with Society for Maternal–Fetal Medicine) 899
60 Pregestational Diabetes Mellitus 914
68 Antiphospholipid Syndrome 925
71 Episiotomy 934
75 Management of Alloimmunization During Pregnancy 940
76 Postpartum Hemorrhage 948
77 Screening for Fetal Chromosomal Abnormalities
(Joint with Committee on Genetics and the Society for Maternal–Fetal Medicine) 957
78 Hemoglobinopathies in Pregnancy 968
80 Premature Rupture of Membranes 977
*Published in 2009
9. CONTENTS ix
C OMMITTEE ON P RACTICE B ULLETINS —O BSTETRICS (continued)
82 Management of Herpes in Pregnancy 990
86 Viral Hepatitis in Pregnancy 1000
88 Invasive Prenatal Testing for Aneuploidy (Joint with Committee on Genetics) 1015
90 Asthma in Pregnancy 1024
92 Use of Psychiatric Medications During Pregnancy and Lactation 1032
95 Anemia in Pregnancy 1052
97 Fetal Lung Maturity 1059
*100 Critical Care in Pregnancy 1069
*101 Ultrasonography in Pregnancy 1077
*102 Management of Stillbirth 1088
*105 Bariatric Surgery and Pregnancy 1102
*106 Intrapartum Fetal Heart Rate Monitoring: Nomenclature, Interpretation, and General
Management Principles 1111
*107 Induction of Labor 1122
251 Obstetric Aspects of Trauma Management 1134
C OMMITTEE ON P RACTICE B ULLETINS —G YNECOLOGY
11 Medical Management of Endometriosis 1143
14 Management of Anovulatory Bleeding 1156
15 Premenstrual Syndrome 1164
28 Use of Botanicals for Management of Menopausal Symptoms 1173
34 Management of Infertility Caused by Ovulatory Dysfunction 1184
35 Diagnosis and Treatment of Cervical Carcinomas 1196
39 Selective Estrogen Receptor Modulators 1209
42 Breast Cancer Screening 1219
46 Benefits and Risks of Sterilization 1231
50 Osteoporosis 1243
51 Chronic Pelvic Pain 1257
53 Diagnosis and Treatment of Gestational Trophoblastic Disease
(Joint with Society of Gynecologic Oncologists) 1274
57 Gynecologic Herpes Simplex Virus Infections 1287
59 Intrauterine Device 1294
61 Human Papillomavirus 1304
63 Urinary Incontinence in Women 1318
65 Management of Endometrial Cancer
(Joint with Society of Gynecologic Oncologists) 1331
67 Medical Management of Abortion 1344
69 Emergency Contraception 1356
72 Vaginitis 1367
73 Use of Hormonal Contraception in Women With Coexisting Medical Conditions 1379
*Published in 2009
10. x COMPENDIUM OF SELECTED PUBLICATIONS
C OMMITTEE ON P RACTICE B ULLETINS —G YNECOLOGY (continued)
81 Endometrial Ablation 1399
83 Management of Adnexal Masses 1415
84 Prevention of Deep Vein Thrombosis and Pulmonary Embolism 1429
85 Pelvic Organ Prolapse 1441
89 Elective and Risk-Reducing Salpingo-oophorectomy 1454
91 Treatment of Urinary Tract Infections in Nonpregnant Women 1465
93 Diagnosis and Management of Vulvar Skin Disorders 1475
94 Medical Management of Ectopic Pregnancy 1486
96 Alternatives to Hysterectomy in the Management of Leiomyomas 1493
99 Management of Abnormal Cervical Cytology and Histology 1507
*103 Hereditary Breast and Ovarian Cancer Syndrome (Joint with the Committee on Genetics
and the Society of Gynecologic Oncologists) 1533
*104 Antibiotic Prophylaxis for Gynecologic Procedures 1543
*108 Polycystic Ovary Syndrome 1553
*109 Cervical Cytology Screening 1567
P OLICY S TATEMENTS
AAFP—ACOG Joint Statement on Cooperative Practice and Hospital Privileges
(July 1980, Revised and Retitled, March 1998) 1581
Abortion Policy (January 1993, Reaffirmed July 2007) 1583
Access to Women’s Health Care (July 1988, Reaffirmed July 2009) 1586
Certification and Procedural Credentialing (February 2008) 1587
Cervical Cancer Prevention in Low-Resource Settings (March 2004) 1589
Home Births in the United States (May 4, 2007) 1591
Joint Statement of ACOG/AAP on Human Immunodeficiency
Virus Screening (May 1999, Reaffirmed July 2006) 1592
Joint Statement of Practice Relationships Between Obstetrician–Gynecologists
and Certified Nurse-Midwives/Certified Midwives (October 2002) 1594
Midwifery Education and Certification (February 2006, Amended February 2007) 1595
The Role of Obstetrician-Gynecologists in Cosmetic Procedures (November 2008) 1596
Tobacco Marketing Aimed at Women and Adolescents
(July 1990, Amended July 2009) 1597
A PPENDIX C ONTENTS F ROM O THER C OLLEGE R ESOURCES
Guidelines for Perinatal Care, Sixth Edition 1601
Guidelines for Women’s Health Care, Third Edition 1603
Health Care For Adolescents 1604
Special Issues in Women’s Health 1604
Committee Opinions List of Titles 1605
Practice Bulletins List of Titles 1611
*Published in 2009
11. Foreword
The Compendium of Selected Publications CD-ROM is a compilation of all Committee Opinions, Practice Bulletins,
Policy Statements, and Technology Assessments current as of December 31, 2009:
• Committee Opinions: Brief focused documents that address clinical issues of an urgent or emergent
nature or nonclinical topics such as policy, economics, and social issues that relate to obstetrics and
gynecology. They are consensus statements that may or may not be based on scientific evidence.
• Practice Bulletins: Evidence-based guidelines developed to indicate a preferred method of diagnosis
and management of a condition. The evidence is graded, and peer-reviewed research determines the
recommendations in the document.
• Policy Statements: Position papers on key issues approved by the Executive Board.
• Technology Assessments in Obstetrics and Gynecology: Documents that describe specific technolo-
gies and their application.
These series are developed by committees of experts and reviewed by leaders in the specialty and the College.
Each document is reviewed periodically and either reaffirmed, replaced, or withdrawn to ensure its continued
appropriateness to practice. The contribution of the many groups and individuals who participated in the process is
gratefully acknowledged.
Each section of the Compendium is devoted to a particular series, and includes those documents considered
current at the time of publication. A comprehensive table of contents has been added for ease of use with titles listed
numerically by committee. Those published within 2009 are indicated with an asterisk. Also provided are current
Committee Opinion and Practice Bulletin lists of titles, grouped by committee in order of publication.
As the practice of medicine evolves, so do College documents. As a part of the continuing process of review
and revision, many documents initially published as a separate installment of a series evolve to become a part of a
broader effort to educate and inform our Fellows. Books such Guidelines for Perinatal Care or Guidelines for Women’s
Health Care carry equal weight as practice guidelines and should be considered adjuncts to the documents in the series.
For ease of reference, the contents of these volumes are included in the appendix.
The Compendium of Selected Publications CD-ROM and the companion 2010 Compendium of Selected
Publications, which includes only 2008–2009 series documents current as of December 31, 2009, can be purchased by
calling 800-762-2264 (Compendium CD-ROM only: $104, $59 [members]; 2010 Compendium and CD-ROM: $226,
$99 [members]).
Throughout the year, new documents will be published in the College’s official journal, Obstetrics & Gynecology.
Single copies can be obtained from the Resource Center (202-863-2518), and the series are available for sale as
complete sets or subscriptions (call 800-762-2264 to order). These documents also are available to members on our web
site: www.acog.org. To verify the status of documents, contact the Resource Center or check our web site.
We are making every effort to provide health professionals with current, quality information on the practice of
obstetrics and gynecology. The Compendium of Selected Publications CD-ROM and the 2010 Compendium of Selected
Publications represent still other ways to disseminate material designed to promote women’s health.
—Ralph W. Hale, MD, Executive Vice President
xi
12. xii COMPENDIUM OF SELECTED PUBLICATIONS
The Scope of Practice of
Obstetrics and Gynecology
Obstetrics and gynecology is a discipline dedicated to the broad, integrated medical and surgical
care of women’s health throughout their lifespan. The combined discipline of obstetrics and gyne-
cology requires extensive study and understanding of reproductive physiology, including the phys-
iologic, social, cultural, environmental and genetic factors that influence disease in women. This
study and understanding of the reproductive physiology of women gives obstetricians and gyne-
cologists a unique perspective in addressing gender-specific health care issues.
Preventive counseling and health education are essential and integral parts of the practice of obste-
tricians and gynecologists as they advance the individual and community-based health of women
of all ages.
Obstetricians and gynecologists may choose a scope of practice ranging from primary ambulatory
health care to concentration in a focused area of specialization.
Approved by the Executive Board
February 6, 2005
13. Code of Professional Ethics
of the American College of
Obstetricians and Gynecologists
Obstetrician-gynecologists, as members of the medical profession, have ethical responsibili-
ties not only to patients, but also to society, to other health professionals and to themselves.
The following ethical foundations for professional activities in the field of obstetrics and
gynecology are the supporting structures for the Code of Conduct. The Code implements
many of these foundations in the form of rules of ethical conduct. Certain documents of the
American College of Obstetricians and Gynecologists also provide additional ethical rules,
including documents addressing the following issues: seeking and giving consultation,
informed consent, sexual misconduct, patient testing, human immunodeficiency virus, rela-
tionships with industry, commercial enterprises in medical practice, and expert testimony.
Noncompliance with the Code, including the above-referenced documents, may affect an
individual’s initial or continuing Fellowship in the American College of Obstetricians and
Gynecologists. These documents may be revised or replaced periodically, and Fellows should
be knowledgeable about current information.
Ethical Foundations
I. The patient–physician relationship: The welfare of the patient (beneficence) is central
to all considerations in the patient–physician relationship. Included in this relation-
ship is the obligation of physicians to respect the rights of patients, colleagues, and
other health professionals. The respect for the right of individual patients to make
their own choices about their health care (autonomy) is fundamental. The principle of
justice requires strict avoidance of discrimination on the basis of race, color, religion,
national origin, or any other basis that would constitute illegal discrimination (justice).
II. Physician conduct and practice: The obstetrician–gynecologist must deal honestly
with patients and colleagues (veracity). This includes not misrepresenting himself or
herself through any form of communication in an untruthful, misleading, or decep-
tive manner. Furthermore, maintenance of medical competence through study,
application, and enhancement of medical knowledge and skills is an obligation of
practicing physicians. Any behavior that diminishes a physician’s capability to prac-
tice, such as substance abuse, must be immediately addressed and rehabilitative
services instituted. The physician should modify his or her practice until the dimin-
ished capacity has been restored to an acceptable standard to avoid harm to patients
409 12th Street, SW (nonmaleficence). All physicians are obligated to respond to evidence of questionable
PO Box 96920 conduct or unethical behavior by other physicians through appropriate procedures
Washington, DC 20090-6920 established by the relevant organization.
xiii
14. xiv COMPENDIUM OF SELECTED PUBLICATIONS
III. Avoiding conflicts of interest: Potential conflicts of interest are inherent in the practice of medicine.
Physicians are expected to recognize such situations and deal with them through public disclosure.
Conflicts of interest should be resolved in accordance with the best interest of the patient, respecting a
woman’s autonomy to make health care decisions. The physician should be an advocate for the patient
through public disclosure of conflicts of interest raised by health payer policies or hospital policies.
IV. Professional relations: The obstetrician–gynecologist should respect and cooperate with other physicians,
nurses, and health care professionals.
V. Societal responsibilities: The obstetrician–gynecologist has a continuing responsibility to society as a
whole and should support and participate in activities that enhance the community. As a member of soci-
ety, the obstetrician–gynecologist should respect the laws of that society. As professionals and members
of medical societies, physicians are required to uphold the dignity and honor of the profession.
Code of Conduct
I. Patient–Physician Relationship
1. The patient–physician relationship is the central focus of all ethical concerns, and the welfare of the
patient must form the basis of all medical judgments.
2. The obstetrician–gynecologist should serve as the patient’s advocate and exercise all reasonable
means to ensure that the most appropriate care is provided to the patient.
3. The patient–physician relationship has an ethical basis and is built on confidentiality, trust, and hon-
esty. If no patient–physician relationship exists, a physician may refuse to provide care, except in
emergencies. Once the patient–physician relationship exists, the obstetrician–gynecologist must
adhere to all applicable legal or contractual constraints in dissolving the patient–physician relation-
ship.
4. Sexual misconduct on the part of the obstetrician–gynecologist is an abuse of professional power and
a violation of patient trust. Sexual contact or a romantic relationship between a physician and a cur-
rent patient is always unethical.
5. The obstetrician–gynecologist has an obligation to obtain the informed consent of each patient. In
obtaining informed consent for any course of medical or surgical treatment, the obstetrician–gyne-
cologist must present to the patient, or to the person legally responsible for the patient, pertinent
medical facts and recommendations consistent with good medical practice. Such information should
be presented in reasonably understandable terms and include alternative modes of treatment and the
objectives, risks, benefits, possible complications, and anticipated results of such treatment.
6. It is unethical to prescribe, provide, or seek compensation for therapies that are of no benefit to the
patient.
7. The obstetrician–gynecologist must respect the rights and privacy of patients, colleagues, and others
and safeguard patient information and confidences within the limits of the law. If during the process
of providing information for consent it is known that results of a particular test or other information
must be given to governmental authorities or other third parties, that must be explained to the
patient.
8. The obstetrician–gynecologist must not discriminate against patients based on race, color, national
origin, religion, or any other basis that would constitute illegal discrimination.
II. Physician Conduct and Practice
1. The obstetrician–gynecologist should recognize the boundaries of his or her particular competencies
and expertise and must provide only those services and use only those techniques for which he or she
is qualified by education, training, and experience.
15. CODE OF PROFESSIONAL ETHICS xv
XV
2. The obstetrician–gynecologist should participate in continuing medical education activities to main-
tain current scientific and professional knowledge relevant to the medical services he or she renders.
The obstetrician–gynecologist should provide medical care involving new therapies or techniques only
after undertaking appropriate training and study.
3. In emerging areas of medical treatment where recognized medical guidelines do not exist, the obste-
trician–gynecologist should exercise careful judgment and take appropriate precautions to protect
patient welfare.
4. The obstetrician–gynecologist must not publicize or represent himself or herself in any untruthful,
misleading, or deceptive manner to patients, colleagues, other health care professionals, or the public.
5. The obstetrician–gynecologist who has reason to believe that he or she is infected with the human
immunodeficiency virus (HIV) or other serious infectious agents that might be communicated to
patients should voluntarily be tested for the protection of his or her patients. In making decisions
about patient-care activities, a physician infected with such an agent should adhere to the fundamen-
tal professional obligation to avoid harm to patients.
6. The obstetrician–gynecologist should not practice medicine while impaired by alcohol, drugs, or phys-
ical or mental disability. The obstetrician–gynecologist who experiences substance abuse problems or
who is physically or emotionally impaired should seek appropriate assistance to address these prob-
lems and must limit his or her practice until the impairment no longer affects the quality of patient
care.
III. Conflicts of Interest
1. Potential conflicts of interest are inherent in the practice of medicine. Conflicts of interest should be
resolved in accordance with the best interest of the patient, respecting a woman’s autonomy to make
health care decisions. If there is an actual or potential conflict of interest that could be reasonably con-
strued to affect significantly the patient’s care, the physician must disclose the conflict to the patient.
The physician should seek consultation with colleagues or an institutional ethics committee to deter-
mine whether there is an actual or potential conflict of interest and how to address it.
2. Commercial promotions of medical products and services may generate bias unrelated to product
merit, creating or appearing to create inappropriate undue influence. The obstetrician–gynecologist
should be aware of this potential conflict of interest and offer medical advice that is as accurate, bal-
anced, complete, and devoid of bias as possible.
3. The obstetrician–gynecologist should prescribe drugs, devices, and other treatments solely on the
basis of medical considerations and patient needs, regardless of any direct or indirect interests in or
benefit from a pharmaceutical firm or other supplier.
4. When the obstetrician–gynecologist receives anything of substantial value, including royalties, from
companies in the health care industry, such as a manufacturer of pharmaceuticals and medical
devices, this fact should be disclosed to patients and colleagues when material.
5. Financial and administrative constraints may create disincentives to treatment otherwise recom-
mended by the obstetrician–gynecologist. Any pertinent constraints should be disclosed to the
patient.
IV. Professional Relations
1. The obstetrician–gynecologist’s relationships with other physicians, nurses, and health care profes-
sionals should reflect fairness, honesty, and integrity, sharing a mutual respect and concern for the
patient.
2. The obstetrician–gynecologist should consult, refer, or cooperate with other physicians, health care
professionals, and institutions to the extent necessary to serve the best interests of their patients.
20. 4 COMPENDIUM OF SELECTED PUBLICATIONS
or the participant’s legally authorized representative. minor can begin to consent (6). Researchers in ado-
Informed consent is the ability to understand the lescent health should be familiar with current state
risks and benefits of one’s participation in a research statutes regarding age of majority and emancipation,
activity and to authorize one’s participation in this as well as with minor consent statutes. An up-to-date
activity freely (2). General requirements for in- listing of these statutes can be found online at
formed consent are described in 45 CFR Part 46, http://www.guttmacher.org/pubs/spib.html.
Section 116 (1). Finally, the regulations require that
the research plan makes adequate provisions for
ensuring the safety of research participants and that Regulations
adequate provisions are made to protect the privacy In the federal regulations governing research, chil-
of research participants and to maintain the confiden- dren are defined in 45 CFR 46 Section 102(a) as
tiality of data. Subpart D of 45 CFR Part 46 contains “persons who have not attained the legal age for
special protections for children who participate as consent to treatments or procedures involved in the
subjects in research. research, under the applicable law of the jurisdiction
Research involving adolescents, especially in which the research will be conducted”(1). This
regarding behaviors related to sexuality, often raises definition refers to laws, primarily state laws related
questions about how to obtain adequate informed to consent for treatment of minors, age of majority,
consent and protection of the research participants’ and emancipation status.
confidential receipt of health care services. The Federal regulations governing human subject
Society for Adolescent Medicine provided early research require parental permission and child
leadership to address these concerns. In 1995, they assent for subjects who meet the regulatory defini-
led the development of consensus guidelines to pro- tion of “children,” ie, those who are younger than the
mote the ethical conduct of health research involv- state-mandated age at which people may give legal-
ing adolescents as research participants (3). The ly effective informed consent for treatments or pro-
society recently issued a revised position statement cedures involved in the research. Assent means a
to support the guidelines (4); the Society for child has given affirmative agreement to participate
Adolescent medicine also established a code of in research. Mere failure to object should not, absent
research ethics to encourage, enhance, and promote affirmative agreement, be construed as assent.
ethical standards for the conduct of research in ado- Assent is required when, in the judgment of the IRB,
lescent health (5). the children are capable of providing it (1).The fed-
When considering the legal complexities of ado- eral regulations deliberately use the terms “permis-
lescent health research, it is important to recognize sion” and “assent” to differentiate this process from
that the age of majority in almost every state is 18 the usual informed consent process. An individual
years, and all states recognize the concept of eman- can provide consent only for himself or herself.
cipated minors, who generally are allowed to consent Therefore, parents give only permission for their
for their own health care. In addition, every state has child to be involved in research, not consent. Assent
enacted some minor consent laws that allow minors recognizes the importance of the emerging capacity
to consent for their own health care, whether or not of children to give informed consent for themselves,
they are legally emancipated. Such laws may be as well as the ethical importance of obtaining their
based on the status of the minor or the services they agreement to participate even if they are not legally
are seeking. Minors who may consent for their own authorized to give informed consent.
health care based on their status include those who In 1977, the National Commission for the
are married, are members of the armed forces, live Protection of Human Subjects of Biomedical and
apart from their parents, and are parents of a child. In Behavioral Research recommended that individual
addition, all states allow adolescents who are minors IRBs be allowed to determine that parental permis-
to consent for some categories of health care such as sion is not appropriate in certain research studies,
sexually transmitted disease (STD) services (all including research involving assessment for or care
states), drug and alcohol care (almost all states), con- related to contraception and drug abuse (7).
traceptive services and pregnancy related care (a According to the federal regulations (1), informed
majority of states), outpatient mental health counsel- consent may be waived under 45 CFR Part 46
ing (about one half of states), or sexual assault care Section 116(d) and parental permission may be
(a few states). Some states specify the age at which a waived under 45 CFR Part 46 Section 408(c).
21. COMMITTEE OPINIONS 5
Four criteria set forth by 45 CFR Part 46 116(d) adolescents. It is important to note that if these sur-
allow an IRB to waive the requirement to obtain the veys are conducted in a school setting, federal edu-
informed consent for adult research subjects or per- cational law governing certain research conducted in
mission of a parent or guardian for research subjects schools may apply. Health researchers working in
who are children if: 1) the research involves no more schools are, therefore, advised to become knowl-
than “minimal risk” (which means that the probabil- edgeable about these laws.
ity and magnitude of harm or discomfort anticipated Section 408(c) of 45 CFR Part 46 also may be
in the research are not greater in and of themselves used to waive parental permission for research areas
than those ordinarily encountered in daily life or including STDs, birth control usage, high-risk
during the performance of routine physical or psy- behaviors, HIV prevention, and situations in which
chologic examinations or tests [1]), 2) the waiver obtaining parental consent may be dangerous to the
will not adversely affect the rights and welfare of the child (abuse situations). Finally, in certain research
subjects, 3) the research could not practically be car- studies, adolescent minors would not be considered
ried out without a waiver, and 4) whenever appropri- children and parental permission would not be
ate, the subjects will be provided with additional required. Such research includes certain clinical
pertinent information after participation (1). This studies involving pregnancy, family planning, and
section is commonly used when waiving informed treatment of STDs where the adolescent minor can
consent for research involving existing data such as legally consent to such services. Again, familiarity
medical records. with current state statutes on the rights of minors to
In addition, 45 CFR Part 46 Section 408(c) consent to health care services is essential.
specifically allows for a waiver of parental permis- Researchers conducting and IRBs reviewing
sion under Subpart D, which addresses research with research involving adolescents should be knowl-
children. Section 408(c) of 45 CFR Part 46 states: edgeable of the federal regulations and the ethical
“…if an IRB determines that a research protocol is principles that underlie these regulations. They
designed for conditions or a subject population for should understand when parental permission is
which parental permission is not a reasonable required and when it may be waived. Personal
requirement to protect subjects (eg, neglected or beliefs and attitudes should not enter into this deci-
abused children), it may waive consent requirements sion. The Society for Adolescent Medicine’s
provided an appropriate mechanism for protecting Guidelines for Adolescent Health Research (4) pro-
the children who will participate as research subjects vide a comprehensive approach to understanding
is substituted and provided the waiver is not incon- these issues. Parental permission should not be a
sistent with federal, state, or local law…. The choice barrier to the inclusion of adolescents in studies that
of an appropriate mechanism would depend on the meet federal regulations and are designed to
nature and purpose of the activities described in the improve their health.
protocol, the risk and anticipated benefit to the
research subjects, and their age, maturity, status, and
condition” (1). In discussing the waiver of parental Conclusions
permission, the National Commission cited as exam-
ples of when the requirement might not be a reason- 1. Researchers developing study protocols and
able one: “…[r]esearch designed to identify factors materials for submission for IRB review and
related to the incidence or treatment of certain con- approval and the IRBs themselves should be
ditions in adolescents for which, in certain jurisdic- familiar with, and adhere to, current federal reg-
tions, they legally may receive treatment without ulations, 45 CFR Part 46 (1), and federal and
parental consent; [and] research in which the sub- state laws that affect research (including laws
jects are ‘mature minors’ and the procedures regarding age of majority and emancipation,
involved entail essentially no more than minimal minor consent statutes, and federal educational
risk that such individuals might reasonably assume law governing certain research conducted in
on their own…” (7). schools).
Based on these criteria, either 45 CFR Part 46 2. Investigators will communicate better with IRB
Section 408(c) or 45 CFR Part 46 Section 116(d) panels regarding the involvement of adolescent
may be used to waive parental permission in a vari- participants in research if they understand the
ety of studies, including, for example, surveys of purpose of human subject protection regulations
22. 6 COMPENDIUM OF SELECTED PUBLICATIONS
with respect to minors and review the guidelines 2. American College of Obstetricians and Gynecologists.
provided by the Society for Adolescent Ethics in obstetrics and gynecology. 2nd ed. ACOG:
Washington, DC; 2004.
Medicine (3–5). 3. Guidelines for adolescent health research. 1995. Society
3. Under the following circumstances it is reason- for Adolescent Medicine. J Adolesc Health 2003;33:
able to waive parental permission when adoles- 410–5.
cents are involved in studies: a) the waiver 4. Santelli JS, Smith Rogers A, Rosenfeld WD, DuRant RH,
Dubler N, Morreale M, et al. Guidelines for adolescent
would not adversely affect the rights and wel- health research: A position paper of the Society for
fare of the adolescent, b) the study poses no Adolescent Medicine. J Adolesc Health 2003;33:
more than a minimal risk to adolescents, c) the 396–409.
study could not be practically carried out with- 5. Code of Research Ethics: position paper of the Society for
out a waiver, and d) requiring permission may Adolescent Medicine. J Adolesc Health 1999;24:277–82;
discussion 283.
not be reasonable to protect subjects. Parental 6. English A, Kenney KE. State minor consent laws: a sum-
permission is not a requirement for research mary. 2nd Ed. Chapel Hill (NC): Center for Adolescent
involving the provision of health care for which Health & the Law; 2003.
adolescents do not legally need parental con- 7. The National Commission for the Protection of Human
sent. It is important to review 45 CFR Part 46 Subjects of Biomedical and Behavioral Research.
Research involving children: report and recommenda-
for the necessary details. tions. Bethesda (MD): U.S. Department of Health Educa-
tion and Welfare; 1977.
References
1. Protection of human subjects. 45 C.F.R §46 (2003). Avail-
able at http://www.access.gpo.gov/nara/cfr/cfr-tablesearch.
html#page1. Retrieved July 8, 2004.
24. 8 COMPENDIUM OF SELECTED PUBLICATIONS
toms decreases, the number of doctors having to be When evaluating an adolescent for suspected
seen to reach a diagnosis increases. Specifically, an endometriosis or dysmenorrhea, the clinician should
average of 4.2 doctors were seen for patients whose aim to rule out a pelvic mass or a congenital anom-
symptoms began before age 15 years compared with aly of the reproductive tract. A bimanual examina-
an average of 2.64 doctors for patients whose symp- tion may not be necessary to evaluate pelvic pain,
toms began between the ages of 30 years and 34 especially in adolescents who are virgins. If a bi-
years. There are, on average, 9.28 years from the manual examination cannot be performed or is
onset of symptoms to the diagnosis (8). Endome- declined, a rectal–abdominal examination in the dor-
triosis is believed to be a progressive disease be- sal lithotomy position may be helpful to determine if
cause the prevalence and severity of the stage of the a pelvic mass is present, and a cotton-tipped swab
disease significantly increase with age (9, 10). With can be inserted into the vagina to evaluate for the
early diagnosis and treatment, it is hoped that dis- presence of a transverse vaginal septum, vaginal
ease progression and infertility can be limited, but agenesis, or agenesis of the lower vagina. If a biman-
this remains to be proved with prospective research. ual examination is performed, the clinician should
check for the existence of both diffuse and focal
pelvic tenderness, and evaluate the pelvis for a dis-
Presentation and Characteristics placed uterus or an adnexal mass. An ultrasound
The typical presentation of an adolescent with examination may be helpful in evaluating the pelvis
endometriosis may be different from that of an adult. of a young adolescent who declines a bimanual or
One significant difference is that adolescents pri- rectal–abdominal examination.
marily seek medical attention because of pain rather
than a concern for infertility. The most common Imaging Studies and Serum Markers
symptom noted among published reviews is Ultrasonography and magnetic resonance imaging
acquired or progressive dysmenorrhea, which was are helpful in evaluating anatomical structures, but
encountered in 64–94% of patients (4, 11). Other are not specific for diagnosing endometriosis. An
common symptoms included acyclic pain (36–91%), adolescent will rarely have a pelvic mass from an
dyspareunia (14–25%), and gastrointestinal com- endometrioma or uterosacral nodularity. CA 125,
plaints (2–46%) (11). Adolescents found to have although very sensitive, is not specific and, thus, is
endometriosis most commonly present with both not helpful in the diagnosis of adolescent endo-
cyclic and acyclic pain (62.6%), as opposed to metriosis. No data exist regarding the use of CA 125
acyclic pain alone (28.1%), or cyclic pain alone to monitor the clinical progression or regression of
(9.4%) (11). disease in adolescents with endometriosis.
In young women, pelvic pain associated with
endometriosis often interferes with school atten- Empiric Therapy
dance as well as physical and social activities.
Prompt diagnosis and adequate therapy, therefore, If an adolescent younger than 18 years has persistent
may return normal psychosocial development and pain while taking combination hormone therapy and
self-esteem, improve scholastic performance, and NSAIDs, endometriosis should be suspected and she
lead to a return to normal daily activities. should be offered a laparoscopic evaluation (discus-
sion follows in section on “Surgical Diagnosis”). If,
however, she is older than 18 years and had a nega-
Diagnosis tive assessment for an ovarian mass or tumor, she
can be offered an empiric trial of gonadotropin-
History and Physical Examination releasing hormone (GnRH) agonist therapy (12, 13).
A thorough review of history and physical examina- If the pain subsides with the use of GnRH agonist,
tion are necessary to assess a variety of differential then a diagnosis of endometriosis can be made. An
diagnoses of pelvic pain such as appendicitis, pelvic empiric trial of GnRH agonist is not routinely
inflammatory disease, müllerian anomalies or out- offered to patients younger than 18 years because
flow obstruction, bowel disease, hernias, musculo– the effects of these medications on bone formation
skeletal disorders, and psychosocial complaints. and long-term bone density have not been ade-
Pelvic examination may be difficult, especially in quately studied. For patients younger than 18 years
patients who have not had vaginal intercourse. or who decline empiric therapy, diagnostic and ther-
25. COMMITTEE OPINIONS 9
apeutic laparoscopy can be initiated. An algorithm ommended for diagnosing and treating presumed
for therapy is provided in Figure 1 (14). endometriosis in an adolescent. Laparoscopy can be
safely performed in adolescents. At the time of sur-
Surgical Diagnosis gical diagnosis, most adolescents have Stage I dis-
After a comprehensive preoperative evaluation and ease as classified by the American Society for
trial of combination hormone therapy and NSAIDs Reproductive Medicine classification system (15).
to treat dysmenorrhea, laparoscopy should be rec- Goldstein et al commented that almost 60% of the
History
Physical examination
Consider radiologic imaging
Pain diary
Cyclic CHT and NSAIDs
If persistent pain Empiric GnRH agonist (if older than 18 years)
If improved—diagnosis is endometriosis
Laparoscopy
Diagnosis of endometriosis by visualization or biopsy
Surgical treatment (ablation/resection/laser)
of endometriosis
Endometriosis identified visually or by pathology No endometriosis—visually and histologically negative
<16 years >16 years
Continuous CHT GnRH agonist Gastrointestinal or urologic evaluation
Symptoms persist (± add-back)* Pain management service
OR
Continuous CHT
Continuous CHT
No pain Continued pain
Continue CHT Laparoscopy with resection of endometriosis
and/or
Long-term GnRH agonist with add-back
and
Pain management service
Complementary or alternative therapies
Abbreviations: NSAIDs, nonsteroidal antiinflammatory drugs; CHT, combination hormone therapy (oral contraceptive pills, estrogen/progestin
patch, estrogen/progestin vaginal ring, norethindrone acetate, medroxyprogesterone acetate); GnRH, gonadotropin-releasing hormone.
*Add-back indicates use of estrogen and progestin or norethindrone acetate alone.
Fig. 1. Protocol for evaluation and treatment of adolescent pelvic pain and endometriosis. (Modified with permission
from Bandera CA, Brown LR, Laufer MR. Adolescents and endometriosis. Clin Consult Obstet Gynecol 1995;7:206.)
26. 10 COMPENDIUM OF SELECTED PUBLICATIONS
patients in their cohort had Stage I disease (1), of endometriosis. The goal of therapy for adolescent
whereas 80% of the cases reported by other endometriosis should be suppression of pain, sup-
researchers had minimal to mild disease (4). pression of disease progression, and preservation of
Gynecologic surgeons who perform laparoscopy in fertility. Consequently, after surgery, all adolescents
adolescents with pelvic pain should be familiar with who have endometriosis should be treated with med-
the typical lesions of endometriosis in adolescents, ical therapy until they have completed child bearing
which tend to be red, clear, or white (15) as opposed to suppress pain, progression of disease, and result-
to the powder-burn lesions seen commonly in adults ing potential infertility.
who have endometriosis. The use of a liquid medium First-line treatment modalities should involve
in the pelvis may facilitate the identification of clear the use of NSAIDs and hormone therapy. Because
lesions, which are very common in adolescents (11). red lesions have been shown to be active producers
of prostaglandins, and adolescents with endometrio-
Müllerian Anomalies and Endometriosis sis typically report severe dysmenorrhea, NSAIDs
The development of endometriosis in adolescent may be used in conjunction with hormonal men-
patients has been associated with müllerian anom- strual suppressive therapy to provide sufficient
alies with outflow tract obstruction. The published relief. Most pharmacologic agents bring about relief
incidence of anomalies of the reproductive system by inducing an anovulatory or a hypoestrogenic
and associated endometriosis has been reported to state or both. Continuous combination hormone
be as high as 40%, but most studies quote a rate of therapy (OCPs, combination hormonal contracep-
5–6%. The clinical outcome in patients with outflow tive patch, or vaginal ring) for menstrual suppression
tract obstructions has been reported to differ from can be used to create a “pseudopregnancy” state,
those without such obstruction because regression of which was described more than 40 years ago (17).
disease usually has been observed once surgical cor- This method routinely has been promoted for ado-
rection of the anomaly has been accomplished (16). lescents who have endometriosis. Although this
method may provide effective relief, the Cochrane
Database Review 2003 provided data suggesting
Treatment that further studies are needed to prove long-term
The premise for treating the symptomatic adolescent benefits (18). Most clinicians advocate continuous
is based on the concept that endometriosis has been use of combination hormone therapy to induce
shown to be a progressive disease without a known amenorrhea, but this modality can result in signifi-
cure. A physician treating an adolescent with endo- cant breakthrough bleeding. One randomized con-
metriosis should adopt a multidimensional approach trolled trial compared a 28-day regimen with contin-
and consider the use of the following components: uous combination oral contraceptives and found no
surgery, hormonal manipulation, pain medications, increase in spotting days after 9 months of therapy,
mental health support, complementary and alterna- with fewer total bleeding days in the group taking
tive therapies, and education. continuous combination oral contraceptives (19).
Patients younger than 18 years with persistent Thus, continuous use of combination hormone ther-
pelvic pain while taking combination hormone ther- apy is believed to be both safe and effective for ado-
apy should routinely be offered a laparoscopic pro- lescents with endometriosis-related pain and, thus, is
cedure for diagnosis and surgical management of the first-line hormone therapy for adolescents
endometriosis. The gynecologic surgeon must be younger than 16 years with endometriosis. Gonado-
familiar with the appearance of endometriosis in tropin-releasing hormone agonists are not offered as
adolescents and should remove or destroy all visi- first-line therapy for adolescents in this age range.
ble lesions of endometriosis. Only procedures that Progestin-only protocols have been used for the
preserve fertility options should be applied; oophor- treatment of adult endometriosis with mixed results.
ectomy or hysterectomy should not be offered to In a recent critical review, progestins were shown to
adolescents. be as effective as danazol or GnRH agonists (20).
Long-term follow-up studies of treatments for Common side effects include irregular bleeding and
adolescent endometriosis have not been performed. weight gain. Some studies suggest that these side
Current treatments for adolescents have been extrap- effects are well tolerated (20), however in a data set
olated and adapted from the literature of adult cases of 3,751 women who have endometriosis, treatment
27. COMMITTEE OPINIONS 11
with medroxyprogesterone acetate or depot medroxy- progesterone acetate (0.625/2.5 mg per day) can
progesterone acetate was the least well tolerated and help preserve bone density (26, 27). Add-back ther-
was the least effective in treating pain compared apy has been shown not to influence the primary
with combination OCPs, GnRH agonists, and pain therapeutic effect and resulted in less bone loss
medications (8). Furthermore, depot medroxyprog- 12 months after cessation of therapy in adult
esterone acetate used for longer than 2 years has women. There is some evidence in adults to suggest
been shown to decrease bone density in adolescents that immediate add-back therapy may result in even
(21, 22, 23). The U.S. Food and Drug Administra- less bone loss (28). No data exist on the long-term
tion has warned against the long-term use of depot effects of GnRH agonist use with add-back therapy
medroxyprogesterone acetate because of adverse in the adolescent population and, thus, it should be
affects on bone density (24). reserved for adolescents refractory to continuous
Danazol, an androgenic and antiestrogenic combination hormone therapy (14, 29). Lifestyle
agent, is extremely effective in treating symptomatic modifications, such as adequate physical exercise
endometriosis in adults. Doses of 400–800 mg daily and calcium and vitamin D intake, also are essential
have been advocated for 6 months followed by con- to maintaining proper bone health when taking
tinuous OCP use for maintenance suppression of the GnRH agonists (with or without add-back therapy).
hypothalamic–pituitary ovarian axis. This choice of Aside from medical management, surgery also
pharmacotherapy was more common in the 1980s, has proved to be an effective form of treatment for
but the androgenic side effects have made this a poor adult patients with pain (30). Surgery for the man-
option for adolescents. agement of endometriosis-related pain is an impor-
Gonadotropin-releasing hormone agonists cre- tant option for adolescents, but clearly, radical
ate a hypoestrogenic state by downregulating the procedures (oophorectomy, bilateral oophorectomy,
hypothalamic–pituitary axis. Whereas these agents or hysterectomy) should be avoided in this age
are greatly effective in the treatment of endometrio- group, even in rare cases of severe endometriosis. A
sis-related pain in adolescents, their use alone (with- double-blinded randomized controlled trial com-
out add-back therapy described in the following pared laser vaporization of endometriosis and laser
paragraph) usually is limited to 6 months because of uterosacral nerve ablation with controls in 63 adult
the resultant profound hypoestrogenic state and its patients with proven endometriosis. At 6 months of
subsequent effect on bone mineralization. This is a follow-up, 63% of patients reported significant relief
major issue for an adolescent who is accruing peak compared with 23% of controls (31). Patients with
bone mineral density. Therefore, it has been suggest- more advanced disease had better outcomes in pain
ed that this therapy not be offered as a first-line treat- management compared with those with minimal dis-
ment for adolescents younger than 16 years (14). At ease. At 1-year follow-up, 90% of those in the treat-
6 months, GnRH agonist induces a 5% loss in tra- ment arm who initially responded had continued
becular bone mineral density and a 2% loss in pain relief (32). Among the symptomatic controls,
femoral neck bone mineral density in adult women. an even distribution of patients was noted to have
In a cross-sectional study, researchers collected bone progression, regression, and maintenance of disease.
mineral density test results of 265 females, aged Both new and recurrent disease was noted at second
8–50 years (25). They determined that the majority look. In a Cochrane review of these data, adult
of bone mass growth is achieved by age 20 years and patients were almost 5 times more likely to benefit
that after the age 18 years, no significant differences from surgical management of endometriosis com-
in bone mass or bone mineral density were noted at pared with controls (33). One study demonstrated, in
most skeletal sites. This emphasizes that a drug- a prospective review of 643 patients with pain, or
induced hypoestrogenic state could significantly infertility, or both, that there was a significant rela-
affect peak bone mineralization that occurs during tionship between pain and the depth of infiltration of
adolescence, particularly in females younger than 16 the endometriosis implants (9). This study also con-
years. firmed that red implants were more common in
Investigators have determined that to reduce the younger patients and that the depth of invasion
symptoms and bone loss related to a hypoestrogenic increased with age, suggesting that endometriosis is
state, add-back therapy with norethindrone acetate a progressive disease. The concept that endometrio-
(5 mg per day) or conjugated estrogens/medroxy- sis is a progressive disease supports the recommen-
