ADOLESCENT MEDICINE - McGraw-Hill Specialty Board Review Pediatrics, 2nd Edition

McGraw-Hill Specialty Board Review Pediatrics, 2nd Edition

Chapter 8. ADOLESCENT MEDICINE

CASE 71: A 14-YEAR-OLD GIRL WHO NEEDS A SCHOOL PHYSICAL

A 14-year-old comes into the clinic for a school physical examination. She will be entering high school in the fall. She has always been healthy. Her mother reports no new problems since the last visit to her previous pediatrician 2 years earlier. She mentions that her daughter has been showing a growing interest in boys lately but has no behavioral concerns. Menses started a year ago and have been irregular. The patient wonders whether a pelvic examination will be needed on this visit. She is an excellent student and has a “good group of friends.” She is dating but denies being sexually active; she confides that many of her friends smoke cigarettes and that she has tried cigarettes in the past but did not like them. She has never used alcohol, marijuana, or other drugs. Her review of systems is negative. She lives with her mother and 2 siblings. Her father, who had type 2 diabetes mellitus, died 3 years ago of a myocardial infarction at age 47. The family history is otherwise noncontributory.

The physical examination is normal except for mild acne. She is 5'2", weighs 136 lb, and her body mass index (BMI) is 25 (91%)

SELECT THE ONE BEST ANSWER

1. Which of the following options would you choose for conducting a physical examination in an adolescent patient?

(A) always have a parent in attendance during the physical examination

(B) never have a parent in attendance during the physical examination

(D) have a parent in attendance during the physical examination according to patient’s wishes

(E) tailor your decision according to patient’s age, level of cognitive and emotional maturity, and personal wishes

2. Which of the following statements regarding confidential care of adolescents is always true?

(A) confidential care should only be provided to emancipated minors

(B) laws regarding minors’ access to confidential health care are legislated by individual states

(C) all patients younger than 18 years need parental consent to receive mental health services, including diagnosis and treatment of substance abuse

(D) minors cannot obtain confidential reproductive services if they are younger than 15 years

(E) minors cannot consent to care for sexually transmitted diseases/human immunodeficiency virus (STD/HIV)-related issues

3. Which of the following topics would be appropriate to explore with this 14-year-old girl in her first visit?

(A) school performance

(B) history of physical and/or sexual abuse

(D) dating and need for birth control

(E) all of the above

4. Which is the most common cause of death among boys aged 15-19 years?

(A) malignancies

(B) suicide

(D) motor vehicle accidents (MVAs)

(E) homicide

5. Regarding mortality rates in teenagers, which of the following is not true?

(A) the rate of unintentional injury in 15- to 19-year-olds is more than twice as high in males as in females

(B) among white youth, suicide rates in 15-19 yearolds are more than 4 times higher in males than in females

(D) among African American youth age 15-19 years, suicide rates are higher in females than in males

(E) for both males and for females, unintentional injury is responsible for about 50% of deaths among 15- to 19-year-olds

6. What are the main elements you will need to assess in this patient’s physical examination?

(A) height, weight, blood pressure (BP), and heart rate

(B) sexual maturity rating

(D) spine examination

(E) all of the above

7. According to the American Medical Association Guidelines for Adolescent Preventive Services (GAPS), how often should an adolescent have a comprehensive examination?

(A) once a year

(B) every 6 months during the growth spurt

(D) only when it is requested

(E) every other year

8. Under what circumstances is a pelvic examination recommended in an adolescent girl?

(A) in all cases of primary dysmenorrhea

(B) newly sexually active at age 16 years

(D) before prescribing contraceptives

(E) A, C, and D

9. During her private interview the patient denies sexual activity. Her physical examination is normal. Her last menstrual period was 4 months ago. What would be the appropriate course of action in this case?

(A) no testing is needed at this time. Reassure her that a period will come soon because she has had irregular periods all along and has only been menstruating for a year

(B) have your nurse run a pregnancy test in a urine sample collected earlier in the visit to determine whether the patient may be withholding information

(C) advise the patient that it is your policy to exclude pregnancy through urine testing in all patients of reproductive age whose menses are late

(D) ask her mother privately for permission to perform a pregnancy test

(E) have the patient come back for blood testing if she has not had a period in another 3 months

10. Which of the following laboratory screening tests would be routinely recommended in an early adolescence visit?

(A) hemoglobin and hematocrit

(B) cholesterol

(D) urinalysis

(E) none of the above

11. If she has never had chickenpox or the varicella vaccine, what statement would apply?

(A) she should receive 1 dose of varicella vaccine at the present visit followed by a second dose within 4-8 weeks

(B) she will just need 1 dose of varicella vaccine

(C) there is no need to immunize her at this time because she most likely had a subclinical case of varicella during childhood; no testing is required

(D) varicella immunization should be given followed by a check of varicella titers 2 months after vaccination to document immunity

(E) varicella immunization should be given unless the patient has household members who are immunocompromised

12. She returns 48 hours later for a reading of her purified protein derivative (PPD) that indicates 10 mm of redness and 8 mm of induration. At this point you would

(A) obtain a chest radiograph and start isoniazid (INH)

(B) obtain further exposure history

(D) determine whether the patient has received the Bacille Calmette-Guérin (BCG) vaccine abroad

(E) repeat the PPD in 1 month

13. Which of the following statements regarding tuberculosis testing is not true?

(A) incarcerated teens should have annual PPD screening

(B) HIV-infected teens should be tested for tuberculosis yearly

(C) tuberculosis skin testing should be performed before initiation of immunosuppressive therapy, including prolonged steroid administration

(D) previous BCG administration is a contraindication to tuberculosis skin testing

(E) about 10% of immunocompetent children with culture-documented tuberculosis may be initially PPD negative

14. How would you counsel this patient regarding pregnancy and STD prevention?

(A) there is no need to address this issue at the present time because she is only 14 and not sexually active

(B) refer her to a gynecologist for such discussions

(D) ask her if she has any questions or concerns regarding sexuality; explain that you will be available to her in the future for further discussion of this issue, if needed

(E) A and C

15. Both the patient and her mother express some concerns about her facial acne. Of the following, which is not involved in the development of acne vulgaris?

(A) retention hyperkeratosis

(B) increased sebum production

(E) dietary factors

16. What medication would you use in the initial management of this patient’s mild comedonal acne?

(A) azelaic acid cream 20% twice a day

(B) benzoyl peroxide gel 5% once daily or topical tretinoin 0.025% once daily

(D) topical antibiotics twice daily

(E) oral tetracycline antibiotic

17. How long after starting the therapy you selected in question 16 would you like to see this patient again?

(A) 2 years

(B) 1 month

(D) 3 months

(E) 2 weeks

ANSWERS

1. (E) When considering this question it is important to bear in mind the adolescent’s age, developmental stage, and level of cognitive and emotional maturity. The presence of a parent during the physical examination is generally reassuring for younger teens and for those with developmental delays. Most middle or older adolescents prefer to have parents wait outside the room during the examination. Under such circumstances, the decision is best deferred to the patient. When performing a pelvic examination in an adolescent, it is recommended to have a chaperone in the room.

2. (B) Minors’ access to confidential health care differs state by state, so the best policy is to know your state’s laws in this area. In general, state laws require parental consent for the provision of medical care to minors. However, there are legal provisions that authorize minors to consent to health care, either because of the status of the minor or the type of services requested. All states have specific provisions that allow minors to consent to certain services, including pregnancy-related care, diagnosis and treatment of STDs, HIV/AIDS, examination and treatment of sexual assault, as well as diagnosis and treatment of mental health issues, including drug and alcohol problems.

3. (E) One of the most important goals of the adolescent visit is to assess the functional status of teens regarding their families, peer relationships, and school/work performance. A thorough clinical history in an adolescent should include the presenting complaint and its progression, past medical history, family history, and review of systems. In addition, it is essential to obtain detailed information about family composition and dynamics, major recent life changes, and specific health concerns. The provider should also address immunizations, nutrition, including diet and eating patterns, body image, school performance, relations with friends and family, vocational goals, and use of tobacco, alcohol, marijuana, inhalants, and other drugs. A developmentally appropriate, detailed sexual history should be obtained. It is also important to screen for depression, suicidal ideation, and any history of physical, emotional, and/or sexual abuse. Injury risks should be assessed with special attention to seat-belt use, helmet use, drunken driving, and use of weapons.

4. (D) In 2006, the National Center for Health Statistics reported that the leading cause of death in older teenagers is unintentional injuries, and of those, the most common was MVAs (40%). The next 4 causes of death, in order of likelihood, are homicide, suicide, malignant neoplasm, and heart disease. These data underscore the need for appropriate screening and anticipatory guidance for adolescents, particularly regarding motor vehicle safety, injury prevention, exposure to violence, alcohol and other substance use, drunken driving, and mood disorders.

5. (D) Among African American youth age 15-19 years, suicide rates in boys are more than 6 times higher than girls.

6. (E) A comprehensive physical examination of an adolescent should include the following:

• Height, weight, BP, and heart rate

• Growth assessment, plotting height, weight, growth velocity, and calculated BMI in the corresponding growth charts

• Skin examination

• Eyes, ears, nose, and throat, dental and gum examination

• Neck examination for thyromegaly or other adenopathy

• Cardiopulmonary examination

• Abdominal examination

• Genital examination and assessment of sexual maturity rating

• Breast examination

• Musculoskeletal examination

• Neurologic examination

• Vision and hearing screening

7. (C) According to the American Medical Association’s GAPS, adolescents should have a comprehensive examination once during early adolescence (age 11-14 years), once during middle adolescence (age 15-17 years), and once during late adolescence (age 18-21 years). These guidelines also recommend that BP and BMI be monitored yearly.

8. (C) A pelvic examination should be performed in adolescents with gynecologic complaints such as pelvic pain, vaginal discharge, or severe menstrual bleeding. Sexually active adolescents should also be examined to exclude STDs. However, a pelvic examination is not indicated before prescribing contraceptives in the asymptomatic, nonsexually active teen. According to the U.S. Preventive Services Task Force and National Cancer Institute, a pelvic examination including pap smear is not needed until age 21 in asymptomatic women who have not become sexually active, or within 3 years of initiating sexual activity before 21 years old. Most cases of primary dysmenorrhea are functional and, if the clinical history is highly suggestive of that diagnosis, a pelvic examination is not required.

9. (C) Despite the fact that the patient denies sexual activity, it would be prudent to document that pregnancy has been excluded as a cause of secondary amenorrhea. This should be discussed with the patient and her consent should be obtained before performing the test. Up to 50% of adolescent girls have physiologic irregular menses for the first 12-24 months, secondary to having anovulatory cycles.

10. (C) The Centers for Disease Control and Prevention (CDC) revised its HIV screening recommendations in 2006, and it now recommends annual HIV screening for patients 13-64 years old unless the practice area has a documented prevalence of undiagnosed HIV cases of less than 0.1%. Otherwise, there are no other universal recommendations regarding laboratory screening tests in asymptomatic adolescents. Several national organizations have published screening guidelines but vary widely in their advice. Although the American Academy of Pediatrics (AAP) recommends baseline anemia screening, neither the American Medical Association (AMA), Bright Futures, nor the U.S. Preventive Services Task Force endorses that view. An anemia screen would be indicated in an adolescent girl if the clinical history reveals inadequate diet or frequent or heavy periods. Cholesterol screening is performed in all adolescents with a family history of premature cardiovascular disease or hyperlipidemia. Screening for gonorrhea, chlamydia, and syphilis is recommended at least annually for sexually active teens. Diabetes screening is recommended for those with BMI higher than 85% and a family history of an immediate relative with diabetes.

11. (A) She should be immunized against varicella. Two doses, at least 1 month apart, are given to adolescents 13 years and older. Alternatively, varicella titers could be obtained followed by immunization if the titers are negative. Serologic testing is unnecessary after immunization given the high rates of seroconversion with the use of the vaccine. Varicella vaccination is not contraindicated in household members of immunocompromised patients, including those with HIV infection. Immunized persons who develop a rash should avoid contact with immunocompromised susceptible hosts for the duration of the rash.

12. (B) Tuberculin testing should be considered positive in children 4 years and older without any risk factors if the area of induration measures more than 15 mm. With an induration of 8 mm it will be important to determine whether this teen has been in close contact with a known or suspected contagious case of active or previously active tuberculosis, either untreated or inadequately treated before the exposure took place. This result would only be interpreted as positive in teens receiving immunosuppressive therapy or those with immunosuppressive conditions including HIV. The interpretation of a positive tuberculin skin test should not be influenced by a previous history of BCG administration.

13. (D) Previous BCG administration is not a contraindication to tuberculosis skin testing. Moreover, disease caused by M tuberculosis should be suspected in any symptomatic patient with a positive PPD, regardless of the history of BCG immunization. In the asymptomatic teen who has received BCG, the interpretation of a positive PPD should include consideration of the following factors: exposure to a person with contagious tuberculosis, family history of tuberculosis, immigration from a country with high prevalence of the disease, and a PPD reaction more than of 15 mm. These factors strongly suggest actual infection. Prompt radiographic evaluation of all teens with a positive PPD test is recommended regardless of their BCG immunization status.

14. (D) During the well-adolescent visit, the primary care provider has an invaluable opportunity to discuss a number of preventive health-care issues including sexual activity and its consequences. After establishing an initial rapport and adequate communication with the patient and family, the physician can elicit any questions or concerns the patient may have regarding sexuality. Pregnancy and STD prevention can then be addressed, tailoring the discussion to the teen’s level of cognitive and emotional development and to his or her sociocultural background. Knowing that in the United States approximately 30% of adolescent girls are already sexually active by ninth grade and that this percentage more than doubles by twelfth grade, it is essential to discuss pregnancy prevention, including abstinence, barrier, and hormonal methods early during adolescence. Similarly, at any given time, approximately 25% of all teens 15-19 years old have an STD.

15. (E) Acne vulgaris is the most common skin disorder in the United States (see Figure 71-1). The prevalence of comedones during adolescence approaches 100%. Four pathogenic factors play a major role in this condition: (1) retention hyperkeratosis, (2) increased sebum production, (3) proliferation of P acnes within the pilosebaceous follicle, and (4) inflammation. Follicular hyperkeratinization with increased proliferation and decreased desquamation of the keratinocytes lining the follicular orifice lead to the formation of a hyperkeratotic plug (a combination of sebum and keratin in the follicular canal). During adrenarche, there is an increased production of sebum as sebaceous glands enlarge. P acnes organisms thrive in the presence of increased sebum, hydrolyzing triglycerides into fatty acids and glycerol, which in turn, together with other factors, leads to local inflammation. According to the extent of follicular hyperkeratinization, sebum production, P acnes growth, and inflammation, the initial microcomedo will evolve into a noninflammatory closed comedo, an open comedo, or an inflammatory pustule, papular, or nodular lesion. Dietary factors play no role in the development of acne.

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FIGURE 71-1. A-D acne pathogenesis. (Reproduced, with permission, from Wolff K, Goldsmith LA, Katz SI, et al. Fitzpatrick's Dermatology in General Medicine, 7th ed. New York: McGraw-Hill; 2008: Fig. 78-1.)

16. (B) Comedolytic agents such as benzoyl peroxide and retinoids help to prevent and/or decrease keratinocyte proliferation and retention. Initial management of mild comedonal acne includes topical 5% benzoyl peroxide gel or 0.025% tretinoin topical once daily.

17. (D) It would be advisable to monitor acne treatment 3 months after initiating topical medication, stressing the need for consistent, long-term compliance to achieve adequate therapeutic results.

SUGGESTED READING

An overview of minors’ consent law. Guttmacher Institute Web site. http://www.guttmacher.org/sections/adolescents.php. Accessed September 2009.

Centers for Disease Control and Prevention. Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR. 2006;55(RR14):1-17.

Centers for Disease Control and Prevention. Recommended immunization schedules for persons aged 0 through 18 years. United States. MMWR. 2010;58(51&52).

Guide to Clinical Preventive Services. Washington, DC: United States Preventive Services Task Force (USPSTF); 2009.

Guidelines for adolescent preventive services. American Medical Association Web site. http://www.ama-assn.org/ama/pub/category/1980.html. Accessed September 2009.

Joffe A, Blythe MJ. Handbook of adolescent medicine. Adolesc Med. 2003;14:2.

Krowchuk DP, Lucky AW. Managing adolescent acne. Adolesc Med. 2001;12:355-374.

Maternal and Child Health Bureau. U.S. Public Health Services (MCHB)—Bright Futures: Guidelines for Health Care Supervision of Infants, Children, and Adolescents. 1994. Bright Futures Web site. http://www.brightfutures.org. Accessed September 2009.

Neinstein LS. Adolescent Health Care. A Practical Guide. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.

Pickering LK, Baker CJ, Kimberlin DW, Long SS. Red Book 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Ten leading causes of death and injury by age. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/injury/ wisqars/LeadingCauses.html. Accessed September 2009.

CASE 72: A 15-YEAR-OLD BOY WITH SHORT STATURE AND PUBERTAL DELAY

A 15-year-old boy is brought in to the teen clinic for evaluation of short stature. Records provided by his previous pediatrician indicate that he had been growing along the 5th percentile for height and weight until a year ago. During the past year he has grown approximately 6 cm. He is upset about being the shortest in his class and also worried about his acne and the “bumps” he recently found in his breasts.

His mother states he was born after a full-term, uncomplicated pregnancy. His birth weight was 3000 g (6 lb, 10 oz). Delivery was normal. He attained all his early developmental milestones on time. At age 18 months he was hospitalized for acute diarrhea and dehydration. His past medical history is otherwise unremarkable and the family history is noncontributory. His mother is 5'2" and his father is 5'10". The patient is an average student and has several good friends. The review of systems is negative.

On physical examination he is a pleasant, slender young man with no evidence of dysmorphism. He is 5'1" (5th percentile) and weighs 105 lb (10th percentile). His BMI is 19.5 (8th percentile). He has mild facial acne and slight bilateral gynecomastia. His genital development is at Tanner stage 3. His testicular volume is 8 mL, bilaterally. The rest of the examination shows no abnormalities.

SELECT THE ONE BEST ANSWER

1. What is the most likely diagnosis in this case?

(A) acquired hypothyroidism

(B) vitamin deficiency

(D) constitutional delay of puberty

(E) growth hormone (GH) deficiency

2. What other clinical information will you need to assess this problem?

(A) dietary history

(B) time at onset and tempo of pubertal changes

(D) history of medication intake

(E) all of the above

3. What is this adolescent’s mid-parental height?

(A) 5'6" (168 cm)

(B) 5'7¹/₂" (171 cm)

(D) 5'9" (175 cm)

(E) 5'10" (178 cm)

4. According to his mid-parental height, what would be this young man’s target height?

(A) 5'5"-5'7" (165-170 cm)

(B) 5'6"-5'9" (168-175 cm)

(D) 5'5"-6'0" (165-183 cm)

(E) 5'5"-5'9¹/₂" (165-176 cm)

5. Which of the following elements of the physical examination will be the least valuable in the initial evaluation of this condition?

(A) evaluation of visual acuity

(B) sexual maturity rating

(D) thyroid examination

(E) arm span and upper/lower segment ratios.

6. What tests, if any, would help in the initial evaluation of this patient?

(A) no tests are needed at this time

(B) complete blood count (CBC), urinalysis, complete metabolic panel including glucose, calcium, phosphorus, kidney, and liver function tests

(D) CBC, urinalysis, erythrocyte sedimentation rate, complete metabolic panel including glucose, calcium, phosphorus, kidney and liver function tests, luteinizing hormone (LH), follicle-stimulating hormone (FSH), testosterone, thyroid-stimulating hormone (TSH), prolactin, and bone age

(E) somatomedin C and karyotype

7. Concerning bone age, which of the following statements is false?

(A) delayed bone age occurs in adolescents with chronic illness, hypothyroidism, and hypopituitarism

(B) in patients with constitutional delay of puberty, the bone age equals the chronological age

(D) in familial short stature, the bone age is advanced in relation to the height age

(E) in patients with constitutional delay of puberty, the bone age equals the height age

8. Bone maturation is controlled by

(A) adrenal androgens

(B) estrogens

(D) testosterone

(E) all of the above

9. Pubertal linear growth accounts for what percentage of final height?

(A) 10-15%

(B) 15-20%

(D) 25-30%

(E) more than 30%

10. During peak height velocity, the average linear growth in boys is

(A) 6 cm/year

(B) 8 cm/year

(D) 13 cm/year

(E) 15 cm/year

11. Which of the following statements is false?

(A) peak height velocity occurs about 18-24 months earlier in girls than in boys

(B) most linear growth occurs in boys during Tanner stages 3-4

(D) menarche usually happens during Tanner stage 2

(E) most linear growth occurs in girls before Tanner stage 3

12. The mean age of onset of puberty in boys is

(A) 11.6 years

(B) 12.5 years

(D) 14.0 years

(E) 14.5 years

13. Which of the following is not a normal finding in adolescent boys?

(A) gynecomastia during sex maturity rating (SMR) 3

(B) testicular size of 4.0 mL during SMR 4

(D) asymmetric gynecomastia

(E) facial acne at age 12 years

14. Which of the following statements concerning constitutional delay of puberty (CDP) is false?

(A) CDP is a diagnosis of exclusion

(B) a family history of CDP is usually present

(D) in CDP, bone age is delayed in relation to chronological age and typically corresponds to height age

(E) absence of any sign of puberty in a boy after the age of 12.5 years merits investigation

15. The BMI seems to play an important role in the onset of pubertal changes. What percentage body fat is typically needed to reach menarche?

(A) 8%

(B) 17%

(D) 25%

(E) 30%

16. All of the following are consistent with the diagnosis of CDP except

(A) negative detailed review of systems and evidence of adequate nutrition

(B) linear growth velocity less than 3.7 cm/year during the previous year

(C) normal findings on physical examination, including genital anatomy, sense of smell, and upper to lower body segment ratio

(D) normal CBC, electrolyte, blood urea nitrogen (BUN), and sedimentation rate

(E) delayed bone age

17. All of the following are characteristic of early adolescence except

(A) concrete thought

(B) inability to perceive long-term consequences of current decisions and acts

(D) development of a sense of omnipotence and invincibility

(E) emergence of sexual feelings

ANSWERS

1. (D) In evaluating a child with short stature, the first step is to determine the patient’s growth and developmental pattern. In this case, the growth chart indicates that he has always grown along the 5th percentile for height and weight. He has gained 6 cm during the past year indicating that, even though he has not grown to the extent expected during the growth spurt (8-14 cm/year), there has been continuous, linear growth. From his sexual maturity rating (Tanner 3) we can infer that he probably has not attained peak height velocity yet but that puberty is underway. Because there are no dysmorphic features, and there is an otherwise normal history, review of systems, and examination, familial short stature and CDP would be the 2 most common conditions to explain this patient’s presentation. Because his mid-parental height allows us to predict a normal final height, CDP would be the most likely diagnosis in this case. Acquired hypothyroidism would typically present with a pattern of attenuated or stunted linear growth, increased tiredness, weight gain, cold intolerance and dry skin, none of which are present in this patient. Klinefelter syndrome (47,XXY), the most frequent cause of primary hypogonadism, would also be unlikely. Phenotypic abnormalities in this condition include relatively long arms and legs, decreased virilization, and small firm testes leading to severely subnormal sperm counts and infertility. Behavioral changes may also be present. GH deficiency and other endocrine disorders that affect linear growth are usually associated with an increased weight-toheight ratio. In many cases, however, it may be difficult to distinguish GH deficiency from constitutional delay of puberty solely on clinical grounds, and a full endocrinology workup will be needed to confirm the diagnosis.

2. (E) The single most useful tool in the evaluation of a teenager with growth retardation is a thorough clinical evaluation. Data gathering should include a complete review of systems, a detailed description of linear growth patterns, and pubertal changes correlated with time, diet and exercise history, previous illnesses, medication, congenital abnormalities, headaches, visual disturbances, and anosmia. Information about growth and development patterns and adult height of first- and second-degree relatives should be obtained. Accurate serial measurements of height and determination of height velocity are fundamental components of the diagnostic workup.

3. (C) His mid-parental height is 5'8¹/₂". The midparental height is calculated in boys by adding 5 inches (13 cm) to the maternal height and averaging it with the paternal height. For girls, the midparental height equals the paternal height minus 5 inches averaged with maternal height.

4. (D) His target height would be 5'5"-6'0" (165-183 cm). The target height equals the mid-parental height ± 2 standard deviations (SD). Each SD equals 1.67 inches (4.25 cm).

5. (A) Sexual maturity rating is an essential element in the evaluation of growth and development during the adolescent years. Because most linear growth in boys takes place during Tanner stages 3 and 4, the finding of a genital SMR 3 in this case should be reassuring about the potential for further linear growth. Anosmia (inability to perceive smells) and hyposmia are characteristically present in patients with Kallmann syndrome, and luteinizing hormone-releasing hormone (LHRH) deficiency leading to hypogonadotropic hypogonadism. This syndrome is often associated with mid-cranial and mid-facial anomalies. A thyroid examination, arm span, and upper/lower segment ratios should also be documented as a part of the evaluation of abnormal growth and development. Visual fields and fundoscopic examination may help exclude intracranial masses such as craniopharyngiomas, which may be responsible for pituitary and hypothalamic dysfunction.

6. (D) Constitutional delay of puberty is a diagnosis of exclusion. Even though the history is highly suggestive of this diagnosis, a CBC, sedimentation rate, complete metabolic panel, bone age, and a basic hormonal workup would help exclude some other conditions included in the differential diagnosis (chronic liver or kidney failure, chronic inflammatory disorders, inflammatory bowel disease (IBD), metabolic disorders, hypothyroidism, Cushing syndrome, etc). Insulinlike growth factor (IGF)-1 and insulinlike growth factor-binding protein (IGFBP)-3 are very helpful tests to screen for GH deficiency if the condition is suspected. Karyotype determinations are needed whenever clinical and/or laboratory findings point to the possibility of chromosomal anomalies.

7. (B) In constitutional delay of puberty, the bone age is delayed compared with the chronological age but closely correlates with the height age. In patients with familial short stature, the bone age typically corresponds to the chronological age and is usually advanced for height age. Delayed bone age occurs in adolescents with chronic illness, hypothyroidism, and hypopituitarism. Bone age is a helpful tool to determine potential linear growth.

8. (E) Bone maturation is controlled by thyroid hormone, estrogen, testosterone, and adrenal androgens. During puberty, an excess of these hormones leads to accelerated bone maturation, whereas their deficiency results in delayed bone age.

9. (C) Pubertal linear growth accounts for 20-25% of final adult height, averaging 12-13 inches in boys and 10-13 inches in girls.

10. (C) During peak height velocity (PHV), the average linear growth in boys is 10 cm/year (range: 5.8-13.1 cm). At PHV, girls grow an average of 9 cm/year (range: 5.4-11 cm). The average growth spurt lasts 24-36 months.

11. (D) In most girls, breast changes, including the development of breast buds and widening of the areolae, represent the first physical sign of puberty (B2). On average, pubertal changes are completed in 4 years with a range of 1.5-8 years. Peak height velocity in girls is attained between SMR 2 and 3 at an average age of 11.6 ± 1.2 years. Menarche, however, is a relatively late pubertal event and usually occurs at SMR 3 in 20% and at SMR 4 in 56% of girls. Menarche occurs in American girls at an average age of 12.4 years with a range of 9-17 years of age, usually 1 year after PHV is attained and 3 years after the start of the growth spurt.

In boys, testicular growth is usually the earliest physical sign of puberty (G2) and occurs at an average age of 11.6 ± 1 year (range: 9.5-13.5 years). The typical sequence in adolescent boys continues with adrenarche and further genital development, whereas PHV is a relatively late event, usually happening between SMR 3 and 4. Fertility is attained at SMR 4.

12. (A) The mean age of onset of puberty in boys is 11.6 years ± 1 year.

13. (B) Pubertal gynecomastia occurs in approximately 50% of normal boys during SMR 2-3. It usually appears at an average age of 13 and persists for 6-18 months. In boys with persistent gynecomastia, etiologies, such as hypogonadism, testicular tumors, hyperthyroidism, androgen resistance syndromes, and drug use, should be investigated.

Asymmetric gynecomastia is common. Facial acne at age 12 years would not be unusual in a normal boy who is undergoing adrenarche. Testicular size increases from an average prepubertal volume of 5.0 mL at the start of puberty to a final volume of approximately 19 mL by age 20 years.

14. (E) Constitutional delay of puberty is the most common cause of delayed puberty in boys. These boys eventually progress spontaneously through puberty. However, because CDP is a diagnosis of exclusion, the absence of any pubertal changes after the age of 14 years should prompt investigation to rule out other causes of delayed puberty. A thorough evaluation should include a detailed personal and family history, physical examination, review of growth charts, laboratory testing, and imaging studies. Characteristically, the bone age in boys with CDP closely approximates the height age and both are delayed in relation to chronological age. Usually a family history of pubertal delay is obtained from the parents, older siblings, or other family members.

15. (B) A BMI of 17-18% is necessary to reach menarche, and 22% is usually required to maintain regular menstruation.

16. (B) The criteria for presumptive diagnosis of CDP include absence of a history of systemic illness, evidence of adequate nutrition, normal findings on physical examination, including genital anatomy, sense of smell, upper to lower segment ratio, normal thyroid and GH levels, normal CBC, erythrocyte sedimentation rate (ESR), electrolytes and BUN, delayed bone age, and height at the 3rd percentile or less for age with annual growth rate velocity at the 5th percentile for age (at least 3.7 cm/year). A family history of CDP is often present but is not a necessary criterion for diagnosis.

17. (D) Early adolescence marks the beginning of the process leading from dependence on parents to independent behavior. Rapid physical changes will bring up an increased preoccupation with the self and uncertainty about one’s appearance and attractiveness. As the adolescent starts to detach from his/her parents, strong emotional bonds with peers develop, usually starting with friends of the same sex. Contact with teens of the opposite sex usually happens only in the context of groups of friends. Cognitive skills remain mostly concrete during early adolescence, but there is an increasing shift toward abstract thinking (formal operational thought). During this stage the adolescent strives toward self-definition and the development of a personal value system. This often leads to a testing of authority both at home and at school. Typically the development of a sense of omnipotence and invincibility leading to increased risk-taking behaviors emerges during middle adolescence.

SUGGESTED READING

Joffe A, Blythe MJ. Handbook of adolescent medicine. Adolesc Med. 2003;14:2.

Nathan BM, Palmert MR. Regulation and disorders of pubertal timing. Endocrinol Metab Clin North Am. 2005;34:617-641.

Neinstein LS. Adolescent Health Care. A Practical Guide. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.

Rosenfield RL. Essentials of growth diagnosis. Endocrinol Metab Clin North Am. 1996;25:743-758.

Tanner JM, Whitehouse RH. Clinical longitudinal standards for height, weight, height velocity, weight velocity, and stages of puberty. Arch Dis Child. 1976;51:170-179.

CASE 73: A 16-YEAR-OLD GIRL WHO HAS NEVER HAD A MENSTRUAL PERIOD

A 16-year-old white girl comes for the first time to the teen clinic because she has never had a menstrual period. She is a competitive gymnast who was homeschooled for several years so she could pursue her athletic career. She was recently diagnosed with a stress fracture for which she is undergoing physical therapy and is now taking a break from gymnastics. She has a history of asthma and uses an albuterol inhaler as needed but has never been hospitalized. Her growth and development have always been normal. On further questioning she states that her breast development started at age 12 and that now she wears a size 34B sports bra. She noticed pubic and axillary hair about 2-3 years ago. She has grown 1¹/₂inches during the past 18 months. Her mother recalls that her own periods started at age 13.

The family history is otherwise noncontributory. She denies trying to lose weight at this time but admits to being on a strict diet during the previous spring, around the time of a big gymnastic competition. At that time her weight went down to 105 lb. Now she is back on her usual diet and estimates her caloric intake at 2000 kcal/day. She considers herself to be slightly thin, although at times she wishes she could be a little thinner. She denies ever having been sexually active or using alcohol, tobacco, or other drugs. She states that she is usually stressed around the time of athletic competitions but that she has never been depressed. She is currently a tenth grader at a public school and is a straight A student. Review of systems is negative for headaches, nausea, vomiting, abdominal pain, dysuria, or vaginal discharge.

On physical examination, she is 5'5", 112 lb, has a heart rate of 72 bpm and a BP of 110/70 mm Hg. She is at Tanner stage 3 for breast and pubic hair development. The rest of her examination is unremarkable.

SELECT THE ONE BEST ANSWER

1. Among adolescent girls, what is the average and SD age at menarche (in years)?

(A) 11.5 ± 1.2

(B) 11.8 ± 1

(D) 12.7 ± 1

(E) 13.5 ± 1.2

2. Which of the following statements is accurate?

(A) menarche occurs at sexual maturity rating (SMR) 3 in 60% of girls

(B) the peak height velocity is attained in girls before they reach Tanner stages B3 and PH2

(D) about 20% of girls start menses a year after attaining SMR 5

(E) the interval between menarche and regular periods is approximately 3 years

3. What is the definition of primary amenorrhea?

(A) no menstrual flow by age 16 years regardless of normal secondary sex characteristics

(B) no menstrual flow by age 14 years in a girl with absent secondary sex characteristics

(D) no menstrual flow 4 years after the onset of puberty

(E) all of the above

4. Among the following, which one is the most likely cause of primary amenorrhea in this patient?

(A) hypopituitarism

(B) hypothalamic amenorrhea

(D) hypothyroidism

(E) hyperprolactinemia

5. In a patient with absent breast development, which of the following would be included in the differential diagnosis of primary amenorrhea?

(A) polycystic ovarian syndrome

(B) agenesis of the müllerian structures

(D) pure gonadal dysgenesis, 46,XX with streak gonads

(E) androgen insensitivity

6. Among the causes of primary amenorrhea, which of the following does not present with hypogonadotropic hypogonadism?

(A) Kallmann syndrome

(B) eating disorders

(D) Turner syndrome

(E) chronic disease

7. Which of the following clinical characteristics would make complete androgen insensitivity syndrome an unlikely diagnosis in this case?

(A) absent menses

(B) normal breast development

(D) normal linear growth

(E) none of the above

8. Which of the following would be relevant issues to document in the clinical history?

(A) onset and tempo of pubertal changes

(B) polyuria and polydipsia

(D) headaches

(E) all of the above

9. Which component of the physical examination will be least relevant in this case?

(A) BP

(B) acne

(D) evaluation of the growth chart

(E) genu valgum

10. What is the single most important finding that will guide the laboratory workup of primary amenorrhea?

(A) degree of breast development

(B) height and weight

(D) presence or absence of a uterus, either clinically or on ultrasound

(E) upper/lower segment ratio

11. What tests are useful in the diagnosis of primary amenorrhea in this case?

(A) pregnancy test

(B) FSH

(D) bone densitometry

(E) all of the above

12. Under what circumstance would a cranial magnetic resonance imaging (MRI) be the least helpful?

(A) galactorrhea

(B) visual field defects

(D) abnormal sella visualized on a skull X-ray

(E) hypergonadotropic hypogonadism

13. Which of the following statements best apply to the female athlete?

(A) pubertal development and menarche are often delayed in thin female athletes

(B) each year of premenarchal athletic training delays age of menarche by 5 months

(D) the female athlete triad includes amenorrhea, disordered eating, and osteoporosis

(E) all of the above

14. Which of the following factors is not associated with decreased bone density in adolescent athletes?

(A) low weight

(B) low BMI

(D) delayed puberty

(E) use of combined oral contraceptives

15. Which of the following symptoms would not be suggestive of an eating disorder in this young athlete?

(A) postural dizziness

(B) diarrhea

(D) weight loss

(E) cold intolerance

16. Which of the following statements is not true regarding the relation between amenorrhea and anorexia nervosa?

(A) amenorrhea occurs in almost all patients with anorexia nervosa

(B) in half of the patients with anorexia nervosa, amenorrhea develops at the same time as weight loss

(D) weight loss follows amenorrhea in 25% of cases

(E) anorexia nervosa is never a cause of primary amenorrhea

17. All of the following are common signs of anorexia nervosa except

(A) nail pitting

(B) edema

(D) increased lanugo hair

(E) bradycardia

18. Which of the following psychosocial characteristics is not typically found in teens with an eating disorder?

(A) depression, anxiety, and obsessional thoughts

(B) perfectionism

(D) school overachievement

(E) disturbed body image

19. Assuming that this girl’s primary amenorrhea is exclusively a result of hypothalamic hypogonadotropic hypogonadism associated with strenuous athletic training, which of the following would be recommended for the management of her condition?

(A) counseling regarding appropriate activity level

(B) maintenance of adequate weight

(D) watchful waiting

(E) all of the above

ANSWERS

1. (D) The average age of menarche of American adolescents is 12.7 years with a standard deviation of 1 year. According to some studies, a minimum BMI of 17 is needed to start menarche. Young ballet dancers, long-distance runners, and gymnasts often start their pubertal development and attain menarche at an age significantly older than the average. African American girls, as a group, experience initial pubertal changes and menarche up to a year earlier than white girls.

2. (B) Breast budding in most girls signals the start of puberty. As opposed to boys, most of whom attain peak height velocity at SMR 4, the adolescent girl’s growth spurt is an early pubertal event. Peak height velocity in girls occurs before they reach SMR B3 and PH 2. Although linear growth later decelerates, the average girl is expected to grow 2-3 inches in the 2 years following menarche.

The mean interval from breast development to menarche is 2.3 years. Menarche is a relatively late event in pubertal development and occurs in 66% of girls at SMR 4. Only 25% of girls attain menarche at SMR 3. An additional 10% start menses at SMR 5. Approximately 95-97% of girls have reached menarche by age 16 years and 98% by age 18 years.

3. (E) All of the above. Primary amenorrhea is defined as the absence of spontaneous uterine bleeding by age 14 years in a girl with absence of secondary sex characteristics and by age 16 years in a girl regardless of the presence of normal secondary sex characteristics. Girls with no menstrual flow a year after attaining SMR 5 or 4 years after onset of puberty also meet criteria for the diagnosis of primary amenorrhea.

4. (B) The differential diagnosis of primary amenorrhea includes conditions resulting from hypothalamic, pituitary, or ovarian dysfunction and those resulting from abnormal development of the lower genital tract. Given this patient’s clinical presentation, the most likely diagnosis would be functional hypothalamic amenorrhea. Eating disorders, severe or prolonged illness, stress, and exercise are common contributing factors in the pathogenesis of this condition. Functional hypothalamic amenorrhea is characterized by abnormal hypothalamic secretion of gonadotropin-releasing hormone (GnRH), low or normal LH, absent LH surges, anovulation, and low serum concentrations of estradiol. Both weight loss below a certain level (approximately 10% below ideal body weight or a BMI less than 17) and exercise can lead to amenorrhea. Constitutional delay of growth and maturation, a common condition in boys, is a relatively rare cause of primary amenorrhea.

5. (D) Of the conditions listed above, only pure gonadal dysgenesis with streak gonads would present with absent breast development.

6. (D) Turner syndrome is the most common cause of primary gonadal failure in adolescent girls and is characterized by ovarian dysgenesis (accelerated stromal fibrosis and decreased or absent oocyte production), short stature, a wide variety of phenotypical abnormalities, a 45,X0 karyotype, and increased gonadotropin concentration. Stigmata of Turner syndrome include micrognathia, a higharched palate, ptosis, epicanthal folds, prominent ears, hearing loss, short webbed neck with low hairline, broad chest, coarctation of the aorta, hypertension, cubitus valgus, renal abnormalities (malrotation, horseshoe kidneys, hydronephrosis), and lymphedema (see Figure 73-1).

Eating disorders, competitive athletics, and chronic disease are among the hypothalamic causes of primary amenorrhea that therefore present with decreased levels of gonadotropins. Kallmann syndrome is a genetic defect leading to isolated GnRH deficiency. It is much more common in boys than in girls. Clinical features include delayed sexual maturation, anosmia or hyposmia, and midline facial defects.

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FIGURE 73-1. The classical phenotypic characterstics of women with Turner syndrome. (Reproduced, with permission, from Schorge JO, Schaffer JI, Halvorson LM, et al. Williams Gynecology. New York: McGraw-Hill; 2008: Fig. 16-4.)

7. (C) The complete androgen insensitivity syndrome is an X-linked recessive disorder in which 46,XY individuals appear phenotypically to be women. These patients have testosterone insensitivity because of a defect in androgen receptors and therefore do not develop testosterone-dependent male sexual characteristics. At puberty, breast development occurs, but pubic and axillary hair is sparse. Although they typically present with normallooking female external genitalia, testes may be palpable in the labia majora or inguinal area. There is regression of the müllerian structures leading to absence of the fallopian tubes, uterus, and upper third of the vagina. The diagnosis can be confirmed by the finding of elevated testosterone concentrations, XY karyotype, and pelvic ultrasonography results. Surgical excision of the testes is recommended given the increased risk of testicular cancer in this condition.

8. (E) The clinical history should include a detailed account of the onset and tempo of pubertal changes, including growth spurt, family history of pubertal delay, symptoms of virilization, galactorrhea, and medications. Headaches, visual field defects, polyuria, polydipsia, and fatigue should be investigated to exclude other hypothalamic-pituitary diseases. It is also essential to document recent stressors, changes in diet or exercise patterns, changes in body weight, and recent symptoms suggestive of severe or protracted illness.

9. (E) Adolescents with primary amenorrhea should have a complete physical examination, including current height and weight, calculated BMI, arm span, breast development, galactorrhea, and a search for signs of thyroid dysfunction. The skin should be examined for acne, hirsutism, striae, and hyperpigmentation. A growth chart review will be essential to assess progression of linear growth and its temporal relation with weight changes. A careful external genital examination is needed to evaluate pubertal development, clitoral size, and appearance of the hymen. The presence of a normal vagina, cervix, uterus, and ovaries can sometimes be determined by a gentle one-finger vaginal-abdominal or recto-abdominal examination but is more accurately defined by ultrasonography. Findings consistent with Turner syndrome and other genetic disorders should be documented. Hypertension, if present, may suggest coarctation of the aorta, one of Turner syndrome’s typical stigmata. High BP may also be a feature of 17α-hydroxylase deficiency, a rare disorder leading to decreased cortisol synthesis with increased production of adrenocorticotropic hormone (ACTH), mineralocorticoid excess, and lack of pubertal development. The presence of acne is associated with normal or increased production of adrenal and gonadal steroids.

10. (D) It is essential to confirm the presence or absence of a normal vagina, cervix, and uterus (either clinically or by ultrasound) as a first step in the workup of primary amenorrhea. If the uterus is absent, a karyotype and testosterone levels are obtained to distinguish between isolated, abnormal müllerian development with absent uterus, 46,XX karyotype that has normal testosterone levels, and androgen insensitivity syndrome. If the correct diagnosis is the last, the karyotype will be 46,XY and the testosterone levels will be elevated. If, however, the uterus is present and there are no outlet obstructions such as imperforate hymen or vaginal atresia, an endocrine evaluation should be performed.

11. (E) Pregnancy should always be excluded first by testing human chorionic gonadotropin (hCG) in serum or in urine. A CBC, complete metabolic panel, and ESR may help to exclude undiagnosed chronic illnesses leading to hypothalamic dysfunction. It is useful to obtain FSH levels, which, if elevated, will indicate primary ovarian failure and will lead to the investigation of the potential causes of hypergonadotropic hypogonadism such as Turner syndrome or mosaicism, Noonan syndrome, autoimmune oophoritis, or gonadal damage secondary to chemotherapy or radiation. Elevated FSH levels in the presence of hypertension suggest either Turner syndrome with coarctation of the aorta or 17α-hydroxylase deficiency. An elevated serum progesterone, low cortisol, low 17α-hydroxyprogesterone, and increased serum deoxycorticosterone can confirm this latter condition, a rare form of congenital adrenal hyperplasia.

Normal or low FSH levels suggest a hypothalamic dysfunction such as functional hypothalamic amenorrhea, usually secondary to weight loss, excessive exercise, stress, or severe or prolonged illness. Less common causes of hypothalamic dysfunction include inflammatory or infiltrative diseases, craniopharyngiomas and other brain tumors, cranial irradiation, or brain injury. Serum prolactin and TSH are necessary to exclude hyperprolactinemia and thyroid disorders. Testosterone and DHEA-S levels are part of the laboratory workup, particularly if there is clinical evidence of hyperandrogenism. A bone age determination will be helpful in adolescent girls with primary amenorrhea and other signs of pubertal delay to exclude constitutional delay of puberty (a condition occurring more frequently in boys than in girls) and hypothyroidism. A bone densitometry determination would be helpful in this case, given the history of primary amenorrhea, strenuous athletic training, and stress fractures.

12. (E) A cranial MRI is indicated in girls with hypogonadotropic hypogonadism, particularly in the presence of headaches, visual field defects, an abnormal sella documented on a radiograph, or any other signs of hypothalamic-pituitary dysfunction. It would be the least helpful in the workup of amenorrhea secondary to hypergonadotropic hypogonadism because the elevation of gonadotropins in that case results from ovarian failure.

13. (E) Exercise is clearly beneficial for young women because it leads to improved cardiovascular fitness, weight control, lower BP, and improved lipid profile. In addition, it promotes socialization, a greater sense of well-being, and self-esteem. There are, however, some potential problems associated with strenuous athletic training, including delayed pubertal development and menarche, eating disorders such as anorexia nervosa, bulimia, purging, binging and fasting, and hypoestrogenic amenorrhea. Disordered eating has been reported in 15-62% of young female athletes. Strenuous exercise also increases the risk of osteoporosis and stress fractures.

14. (E) In female athletes, bone mineral density correlates with weight, weight/height, and estrogen and testosterone levels. Low bone density is associated with low estrogen levels, delayed puberty and menarche, low calcium and protein intake, low weight, low BMI, low androgen levels, disordered eating, and family history of osteoporosis. Use of oral contraceptives in the postmenarchal athletic female decreases the likelihood of osteoporosis. Delayed menarche associated with hypoestrogenemia can have a significant effect on bone mineralization in adolescent athletes, given the fact that 48% of skeletal mass in women is normally attained during puberty.

15. (B) An eating disorder should be considered in the differential diagnosis of this 16-year-old girl with a history of weight loss in the past, strenuous exercise, and amenorrhea. Postural dizziness, depressive symptoms, constipation, hair loss, cold intolerance, epigastric pain, nausea, vomiting, fatigue, cramps, and muscle weakness would be among the common presenting symptoms of anorexia nervosa.

16. (E) Eating disorders are among the causes of hypothalamic dysfunction leading to primary amenorrhea. Anorexia nervosa is 10 times more common in girls than in boys. The mean age of onset is 13.7 years, but it can start in children as young as 10 years. Amenorrhea is present in almost 100% of the cases, coinciding with weight loss in half of them, following it in 25%, and preceding it in 25% of anorectic girls.

17. (C) The most common signs of anorexia nervosa are decreased weight and cachexia, decreased temperature, bradycardia, hypotension, dry, hyperkeratotic skin, edema, acrocyanosis, nail pitting, and increased lanugo hair.

18. (C) Young women with eating disorders typically have a constellation of psychological features, including low self-esteem, perfectionism, depression, anxiety, obsessional thoughts, social anxiety, and overachievement. Disturbed body image, increased preoccupation with food, and decreased sexual interest are common features in this condition.

19. (E) In this 16-year-old with strenuous athletic training leading to primary amenorrhea, in whom other etiologies have been excluded, it would be reasonable to offer counseling about decreasing physical activity to a level adequate to maintain appropriate weight and bone mineral density while at the same time increasing calcium intake to avoid osteoporosis and stress fractures. If estrogenization is thought to be adequate, in the absence of menses, a progesterone challenge test may help bring about her periods. If the response to this test is positive, a repeat progesterone challenge may be offered every 2-3 months. Some authors advocate the cyclic use of estrogens and progestins to treat girls with hypothalamic amenorrhea once an acceptable height has been attained.

SUGGESTED READING

Emans SJ, Laufer MR, Goldstein DP, eds. Pediatric and Adolescent Gynecology. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005.

Herman-Giddens ME, Slora EJ, Wasserman RC, et al. Secondary sexual characteristics and menses in young girls seen in office practice: a study from the Pediatric Research in Office Settings Network. Pediatrics. 1997;99:505-512.

Herpertz-Dahlmann B. Adolescent eating disorders: definitions, symptomatology, epidemiology, and comorbidity. Child Adolesc Psychiatr Clin North Am. 2009;18(1):31-47.

Kaplowitz PB, Oberfield SE. Reexamination of the age limit for defining when puberty is precocious in girls in the United States: implications for evaluation and treatment. Drug and Therapeutics and Executive Committees of the Lawson Wilkins Pediatric Endocrine Society. Pediatrics. 1999;104:936-941.

Neinstein LS. Adolescent Health Care. A Practical Guide. 5th ed. Philadelpha, PA: Lippincott Wilkins and Williams; 2007.

CASE 74: A 17-YEAR-OLD GIRL WITH PAINFUL MENSES

A 17-year-old girl comes to the clinic complaining of painful periods. You have been her pediatrician for several years and know that she has been a healthy, welladjusted adolescent. She started her menses at age 14 years. Her periods have been regular for the most part, although she has occasionally complained about heavy but painless periods lasting up to 6 days. Over the past year, her periods have become painful to the point that she had to miss school an average of 2 days a month. She also reports associated nausea during menses. She has tried over-the-counter pain relievers without success. She has been dating for a year but denies sexual activity. She has heard that “the pill may help with cramps” and wants to know your opinion about that. Her past medical history is noncontributory. Her mother had a history of severe menstrual cramps during adolescence. The review of systems shows that she had vomiting on 2 occasions during menses during the past 3 months. She also mentions increased nervousness, headaches, and backaches, all of which have developed over the past year and usually present together with her episodes of pelvic pain.

SELECT THE ONE BEST ANSWER

1. Which of the following statements concerning the prevalence of dysmenorrhea is not accurate?

(A) dysmenorrhea affects up to 72% of 17-year-old girls

(B) in 10% of adolescents, dysmenorrhea may be severe enough to be incapacitating for 1-3 days a month

(D) dysmenorrhea is the greatest single cause of lost school hours among adolescent girls

(E) the prevalence of dysmenorrhea doubles between SMR 3 and 5

2. All of the following elements of the clinical history are helpful in differentiating primary from secondary dysmenorrhea except

(A) acute versus gradual onset

(B) cyclic nature of symptoms

(D) duration of pain

(E) severity of pain

3. Which among the following are factors involved in the pathogenesis of primary dysmenorrhea?

(A) elevation of myometrial resting tone

(B) increased frequency of myometrial contractions

(D) dysrhythmic uterine contractions

(E) all of the above

4. Which of the following statements concerning the role of prostaglandins in primary dysmenorrhea is not true?

(A) prostaglandin F₂α causes myometrial contractions, vasoconstriction, and ischemia

(B) prostaglandins are synthesized in the endometrial tissue

(D) prostaglandin inhibitors increase dysmenorrhea

(E) patients with dysmenorrhea have higher levels of prostaglandin levels in the endometrium

5. Which of the following items would be relevant in the clinical evaluation of dysmenorrhea?

(A) age at menarche

(B) menstrual pattern

(D) vaginal discharge

(E) all of the above

6. Regarding the value of the pelvic examination in the evaluation of dysmenorrhea, all of the following statements are true except

(A) a pelvic examination is helpful in the diagnosis of endometriosis, polyps, uterine, and cervical abnormalities

(B) a pelvic ultrasound is sometimes needed to rule out pelvic pathology in virginal patients

(C) a pelvic examination is not needed in virginal patients with a history suggestive of primary dysmenorrhea who respond to prostaglandin inhibitors

(D) a pelvic examination is needed in all patients to rule out secondary dysmenorrhea

(E) a pelvic examination is mandatory in cases of acute and subacute pelvic pain

7. Which of the following conditions should be considered in the differential diagnosis of secondary dysmenorrhea?

(A) endometriosis

(B) congenital obstruction of the outflow tract

(D) ovarian cysts

(E) all of the above

8. All of the following are helpful in the treatment of primary dysmenorrhea except

(A) ibuprofen or naproxen sodium

(B) acetaminophen

(D) mefenamic acid

(E) continuous hormonal therapy

9. When using nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with primary dysmenorrhea, what are the most common pitfalls leading to failure to achieve adequate symptom relief?

(A) starting medication several hours after the pain started

(B) poor compliance because of side effects

(D) taking the medication at 12-hour intervals

(E) A and C

10. All of the following statements are true regarding the role of oral contraceptives in the treatment of primary dysmenorrhea in adolescents except

(A) combined oral contraceptives provide relief in 70% of patients with primary dysmenorrhea

(B) oral contraceptives are beneficial in primary dysmenorrhea as a result of inhibition of ovulation, endometrial hypoplasia, and reduction of menstrual flow

(C) in patients with primary dysmenorrhea but no need for birth control, “the pill” can be prescribed for 3-6 months, discontinued, and then reinstituted if a trial of NSAIDs fails to provide relief

(D) patients with severe dysmenorrhea who fail to respond to continued use of oral contraceptives should be reevaluated for organic pathology

(E) all of the above statements are true

11. Which of the following is not a typical symptom or sign of endometriosis in adolescents?

(A) cyclic, severe dysmenorrhea

(B) vaginal discharge

(D) dyspareunia

(E) pain on defecation

12. What is the most common gynecologic cause of acute pain leading to hospitalization in women of reproductive age in the United States?

(A) adnexal torsion

(B) ovarian cysts

(D) ectopic pregnancy

(E) pelvic inflammatory disease

13. Which of the following gastrointestinal conditions should be included in the differential diagnosis of acute pelvic pain in teens?

(A) appendicitis

(B) intestinal obstruction

(D) inflammatory bowel disease

(E) all of the above

14. Regarding the evaluation of acute pelvic pain in adolescents, which of the following statement is not true?

(A) a normal pelvic ultrasound excludes endometriosis and pelvic inflammatory disease (PID)

(B) a psychosocial history might reveal contributing factors such as stress or a history of sexual or physical abuse

(C) the initial laboratory workup should include a CBC with differential, sedimentation rate, C-reactive protein (CRP), urinalysis and urine culture, cervical culture, pregnancy test, and a stool guaiac test

(D) an elevated leukocyte count reflects inflammation, ischemia, or infection and may indicate ovarian torsion

(E) bone and joint inflammations and infections may present as acute pelvic pain

15. Which of the following statements apply to the evaluation of chronic pelvic pain?

(A) a normal pelvic examination and normal ultrasound are predictive of a normal laparoscopy 50% of the time

(B) the predictive value of an abnormal pelvic ultrasound is 92%

(D) no obvious cause of chronic pelvic pain is found on laparoscopy in 25% of patients

(E) all of the above

16. If her dysmenorrhea were severe enough to merit long-term use of combined oral contraceptives, which of the following conditions would you need to exclude before prescribing them?

(A) ovarian cyst

(B) endometriosis

(D) varicose veins

(E) diastolic blood pressure higher than 100 mm Hg

ANSWERS

1. (C) In adolescent girls, dysmenorrhea is the most common gynecologic complaint. By definition, primary dysmenorrhea refers to pain associated with menstrual flow in the absence of organic pelvic pathology. Secondary dysmenorrhea indicates menstrual pain secondary to organic disease, such as ovarian cysts, adhesions, endometriosis, or PID. Primary dysmenorrhea is very common in adolescents and rarely has its onset after age 20 years. It is associated with ovulatory cycles, and therefore it typically develops approximately 2 years after menarche, once normal ovulation becomes established. Secondary dysmenorrhea may occur at any age. In adolescence, however, primary dysmenorrhea is by far the most common cause of painful menses.

2. (E) Primary dysmenorrhea usually has a gradual onset as opposed to the acute onset of most menstrual pain associated with pelvic pathology. The cyclic nature of the bleeding and cramping helps differentiate primary from secondary dysmenorrhea because in the latter there is often irregular intermenstrual bleeding. The duration of pain is an important clinical feature, lasting 1-2 days in primary dysmenorrhea (usually starting right before the period), whereas in secondary dysmenorrhea, prolonged intermenstrual pain, worsening during periods, is the rule. Nausea, vomiting, fatigue, headache, irritability, diarrhea, and backache are common in primary dysmenorrhea. In secondary dysmenorrhea there is often a history of an STD, severe abdominal pain, and dyspareunia.

3. (E) All the above myometrial factors play a role in the pathogenesis of dysmenorrhea.

4. (D) Exogenous injections of prostaglandins induce dysmenorrhea while prostaglandin inhibitors decrease menstrual pain.

5. (E) When evaluating an adolescent for dysmenorrhea, it is important to determine the age at menarche because primary dysmenorrhea usually starts a year after menarche (most commonly at ages 14-16 years) and peaks around 17-18 years. After the age of 20 years, new-onset dysmenorrhea is usually secondary to pelvic pathology. Other relevant questions include the date of the last menstrual period, the onset of pain, and characteristics of the pain such as location, radiation, duration, severity, and degree of functional impairment. A sexual history should be elicited, asking about condom use, contraception, number of sexual partners, exposure to STDs, dyspareunia, and vaginal discharge. Response to prostaglandin inhibitors is important to distinguish primary from secondary dysmenorrhea and to select appropriate further management.

6. (D) A pelvic examination is helpful in the diagnosis of organic pathologies underlying secondary dysmenorrhea. It is mandatory in cases of acute and subacute pelvic pain. Adolescent girls without a history of sexual activity and with a clinical picture consistent with primary dysmenorrhea responsive to prostaglandin inhibitors will not need a pelvic examination. Occasionally, however, a pelvic ultrasound may be needed in such patients if symptoms persist.

7. (E) The following conditions should be considered in the differential diagnosis of secondary dysmenorrhea: endometriosis, PID, pelvic abscess, ovarian cysts, neoplasias, adhesions, congenital obstruction of the outflow tract (cervical stenosis), and complications of pregnancy such as ectopic pregnancy or miscarriage.

8. (B) Prostaglandin synthetase inhibitors (NSAIDs) are the drugs of choice in the treatment of primary dysmenorrhea. NSAIDs are thought to be more effective if administered just before the onset of pain. Mefenamic acid, ibuprofen, and naproxen sodium are popular choices. NSAIDs are contraindicated in adolescents with peptic ulcer disease, hepatic or renal disease, or a bleeding disorder.

9. (E) For optimal effectiveness, NSAIDs should be started as soon as the symptoms develop and even on the day before the one when menses are anticipated in those teens with reasonably predictable periods. A loading dose is needed when using naproxen and mefenamic acid.

10. (E) Combined oral contraceptives are useful for adolescents with primary dysmenorrhea who fail to respond to a trial of NSAIDs and for those who need both relief of menstrual pain and contraception. Oral contraceptives may take 2-3 months to provide adequate relief from dysmenorrhea, and NSAIDs can be used concomitantly in the interim.

11. (B) Endometriosis is the most common cause of chronic pelvic pain lasting more than 3 months and not responding to NSAIDs or oral contraceptives. Clinical features of endometriosis include chronic pelvic pain usually worsening during menses, pain on defecation, dyspareunia, and abnormal uterine bleeding. On physical examination, tenderness over the adnexa and cul-de-sac is more common in teens than the classical finding of thickened, nodular sacrouterine ligaments often found in adult women with endometriosis.

12. (E) Adolescent girls with acute pelvic pain deserve an urgent and thorough evaluation to rule out potentially life-threatening conditions. The differential diagnosis of acute pelvic pain includes gynecologic conditions, such as PID, adnexal torsion, ovarian cysts, threatened or spontaneous abortion, and endometriosis. PID is the most common cause of acute pain leading to hospitalization in women of reproductive age in the United States. Nongynecologic causes include gastrointestinal, genitourinary, musculoskeletal, and psychological disorders.

13. (E) The list of gastrointestinal conditions responsible for acute pelvic pain in teens is quite lengthy and includes, among others, appendicitis, intestinal obstruction, gastric ulcer, inflammatory bowel disease, lactose intolerance, irritable bowel syndrome, diverticular disease, constipation, and mesenteric adenitis.

14. (A) The initial evaluation of acute pelvic pain with suspected underlying organic pathology should include a thorough clinical and psychosocial history, a physical examination, and laboratory testing. Ultrasonography is a useful procedure in the evaluation of acute pelvic pain, particularly for those in whom a thorough pelvic examination is not possible. However, a normal ultrasound does not exclude endometriosis or PID.

15. (E) Although the predictive value of an abnormal pelvic ultrasound is 92%, a normal ultrasound only has a predictive value of 50%. In a large study evaluating laparoscopic findings among adolescents with chronic pelvic pain, 75% of patients had intrapelvic pathology, whereas no obvious cause of chronic pain was found in the remaining 25%. Among those with organic pathology, endometriosis was the leading diagnosis followed by postoperative adhesions secondary to appendectomy or ovarian cystectomy.

16. (E) According to the World Health Organization (WHO) Medical Eligibility Criteria (2001), among the listed conditions, only hypertension would preclude initiation of a combined oral contraceptive.

SUGGESTED READING

Emans SJ, Laufer MR, Goldstein DP. Pediatric and Adolescent Gynecology. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005.

Johnson BE, Johnson CA, Murray JL, Apgar BS. Women’s Health Care Handbook. 2nd ed. Philadelphia, PA: Hanley & Belfus; 2000.

Neinstein LS. Adolescent Health Care. A Practical Guide. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.

CASE 75: A 14-YEAR-OLD GIRL WITH PAINFUL URINATION

A 14-year-old girl is brought in by her aunt (who is the patient’s guardian) for an urgent care visit with the complaint of acute-onset painful urination. This is the first time you have met this family. The present symptoms started about 2 days ago and are now severe enough to keep her from attending school. She has been healthy except for vague, recurrent stomachaches for several years. There is no previous history of urinary tract infection (UTI). A review of systems reveals that she has been tired, “achy,” and had a slight fever during the previous week. She started her menses 8 months before this visit and states that she has skipped her periods 2 or 3 times since then. She had her latest menstrual period 3 weeks ago. The family history is positive for arthritis in an older sister and insulin-dependent diabetes on the paternal side of the family. She lives with her aunt, her older sister, 2 cousins, and a niece. She used to be an average student, but her grades have shown a significant decline since she started high school 6 months ago. She denies cigarette smoking or alcohol use but states that she smokes marijuana with her friends on weekends. Her aunt worries about her increasing rebelliousness. After a recent confrontation she ran away from home and returned 3 days later. She is a thin, small-for-age girl who looks younger than her stated age.

SELECT THE ONE BEST ANSWER

1. The differential diagnosis of dysuria in adolescent girls includes all of the following except

(A) UTI

(B) chlamydial urethritis

(D) traumatic urethritis

(E) endometriosis

2. Among the following, which is the most common pathogen responsible for UTI in healthy, nonpregnant adolescent girls?

(A) Escherichia coli (B) Gardnerella vaginalis (C) Staphylococcus saprophyticus (D) Group B streptococci

(E) Enterococcus species

3. Which of the following conditions are included in the differential diagnosis of dysuria in adolescent boys?

(A) gonococcal urethritis

(B) nongonococcal urethritis

(D) chemical irritation from spermicides

(E) all of the above

4. The following factors predispose adolescent girls to UTIs except

(A) start of sexual activity

(B) new sexual partner

(D) poor perineal hygiene

(E) use of diaphragms

5. In taking the clinical history from this adolescent girl, which of the following is the least helpful information?

(A) use of douches, deodorant soaps, and bubble baths

(B) abnormal vaginal discharge and itching

(D) family history of hypertension

(E) history of fever and flank pain

6. In accordance with your office guidelines, you have already discussed the extent and limits of your privacy and confidentiality policy with the parent (or guardian) and the patient earlier in the visit. On interviewing the patient privately, she tells you tearfully that she had unprotected vaginal intercourse with her 15-year-old new boyfriend a week earlier. She has not discussed this with her aunt and would prefer to keep it confidential. She became sexually active at age 13 years and had 2 previous sexual partners. She is not using hormonal contraception and uses condoms inconsistently. The physical examination should include all except

(A) abdominal examination

(B) search for costovertebral angle tenderness

(D) speculum examination

(E) all of the above

7. You perform a physical examination with a chaperone in attendance. You find her to be a welldeveloped, quiet, cooperative 14-year-old girl, emotionally somewhat immature for her age. She is afebrile. There are no abnormal clinical findings on the general examination. The abdomen is soft. There are no masses, guarding, rebound, or visceromegalies. There is no costovertebral tenderness. Her pubertal development is at Tanner stage 4. The external genital examination shows normal labia and absence of inguinal lymphadenopathy. There is some scant yellowish discharge in the introitus where you also find 2 small clusters of vesicular lesions, some of them ulcerated and very tender to touch. A careful and gentle speculum examination shows a red and friable cervix and thick, foamy discharge in the cul-de-sac. The bimanual examination is poorly tolerated, but there are no obvious masses or cervical motion tenderness. All of the following tests will be necessary at this time except

(A) gonorrhea and chlamydia probe

(B) herpes culture

(D) potassium hydroxide (KOH) preparation

(E) HIV

8. On the wet preparation you are likely to find

(A) white blood cells

(B) red blood cells

(D) epithelial cells

(E) all of the above

9. The wet preparation shows large amounts of white blood cells and flagellated organisms. With the information you have so far (including history and physical examination), this patient most likely has

(A) trichomonal vaginitis

(B) herpes simplex infection

(D) a UTI

(E) all of the above

10. The following laboratory tests should now be performed except

(A) rapid plasma reagin (RPR)

(B) blood culture

(D) urine culture

(E) pregnancy test

11. Concerning chlamydia infections, which of the following statements is false?

(A) cervical ectopy is a risk factor for infection

(B) most chlamydia infections are asymptomatic

(D) 15% of all C trachomatis infections occur in young women aged 15-19 years

(E) there is a high rate of concurrent disease in adolescents with urinary tract symptomatology and C trachomatis

12. Regarding trichomonal vaginitis, which of the following statements is/are true?

(A) up to 90% of women infected with T vaginalis present with vaginal discharge

(B) partners of patients with trichomonal infection should be treated

(D) trichomonal infections in males are symptomatic in most cases

(E) all of the above

13. Regarding the clinical manifestation of primary herpes infections in adolescents, which of the following statements is false?

(A) the incubation period is 2-12 days

(B) reepithelization occurs 15-20 days after the initial outbreak

(D) cervicitis is present in up to 90% of first episodes but is less common in recurrent disease

(E) constitutional symptoms may include headaches, fever, malaise, myalgia, nuchal rigidity, and photophobia

14. The following laboratory tests are useful for the diagnosis of herpes simplex virus (HSV) infections except

(A) Tzanck smear

(B) wet mount

(D) viral culture

(E) serology

15. In gonorrhea, all of the following are true except

(A) females have a 50% chance of contracting gonorrhea from an infected male after a single sexual encounter

(B) males have a 25% chance of contracting gonorrhea from an infected female

(D) adolescent girls aged 15-19 years have the highest rates of gonorrhea infection

(E) most gonorrhea infections in adolescent girls are asymptomatic

16. Which of the following features gathered by history is associated with an increased risk of PID?

(A) use of barrier methods (eg, condoms)

(B) age younger than 24 years or smoking

(D) use of an intrauterine device (IUD)

(E) B and D

17. All of the following clinical signs are considered as minimal diagnostic criteria for the diagnosis of PID except

(A) lower abdominal tenderness

(B) fever

(D) cervical motion tenderness

(E) all are required to made a diagnosis of PID; no exception

18. Assuming her pregnancy test is negative, there is no suspicion of PID, and there are no known allergies, what would be the treatment of choice in this 14-yearold adolescent girl?

(A) ceftriaxone 125 mg intramuscularly (IM) single dose, doxycycline 100 mg orally twice a day for 7 days, acyclovir 400 mg orally 3 time a day for 5 days, metronidazole 2 g single dose orally, and symptomatic treatment for pain relief

(B) ciprofloxacin 500 mg single dose orally, doxycycline 100 mg orally twice a day for 7 days, valacyclovir 1 g orally twice a day for 7-10 days, and symptomatic treatment for pain relief

(C) ceftriaxone 125 mg IM single dose, azithromycin 1 g single dose orally, metronidazole 2 g single dose orally, valacyclovir 1 g orally twice a day for 7-10 days, and symptomatic treatment for pain relief

(D) metronidazole 2 g single dose orally, ceftriaxone 250 mg IM single dose, azithromycin 1 g, valacyclovir after herpes genitalis is confirmed by viral culture

(E) ceftriaxone 250 mg single dose orally, erythromycin base, 500 mg 4 times a day, acyclovir 200 mg orally 5 times a day, metronidazole topically for 5 days, and symptomatic treatment for pain relief

19. What other management recommendations would you offer at this visit?

(A) partner needs treatment for trichomonas, chlamydia, and gonorrhea

(B) test for HIV and syphilis

(D) discuss contraceptive options and STD prevention

(E) all of the above

ANSWERS

1. (E) Dysuria is a common symptom in adolescent girls and may be secondary to infection, trauma, or chemical irritation. The differential diagnosis includes bacterial UTI, chlamydia and gonorrhea urethritis, candida and trichomonal vulvovaginitis, bacterial vaginosis, herpes simplex infections, traumatic urethritis, vulvovaginal chemical irritation, and vulvar dermatoses. In one study of adolescents with a presenting complaint of dysuria, UTI alone was found in only 17% of the cases, and UTI and vaginitis were the diagnoses in another 17%. Of the remaining two-thirds, the diagnoses were candida vaginitis, bacterial vaginosis, trichomoniasis, gonorrhea, and chlamydia or herpesvirus infection. These data underscore the importance of obtaining a detailed gynecologic and sexual history in young adolescents with dysuria.

2. (A) E coli is responsible for up to 90% of UTIs in this age group. In most series, S saprophyticus is the second most common pathogen identified. In chronic or recurrent infections, Klebsiella species, enterococci, Proteus species, or Pseudomonas aeruginosa may be found. The incidence of group B streptococci as a causative agent for UTI increases among pregnant adolescent girls.

3. (E) Gonococcal and nongonococcal urethritis (NGU), prostatitis, and chemical irritation secondary to spermicides are the leading causes of dysuria in adolescent boys. The most common etiologic agents of NGU are C trachomatis, Ureaplasma urealyticum, Gardnerella vaginalis, HSV, Staphylococcus saprophyticus, E coli, and T vaginalis.

4. (C) Additional risk factors for UTI in girls include delayed postcoital micturition, pregnancy, and anatomic abnormalities such as vesicourethral reflux, urethral stenosis, neurogenic bladder, and nephrolithiasis.

5. (D) In evaluating an adolescent girl with dysuria, answers A, B, C, and E, should be investigated. In addition, the patient should be interviewed about

• Onset of symptoms (acute onset suggests cystitis, whereas a gradual onset is more typical of urethritis)

• Concurrent diagnoses: diabetes mellitus, HIV, pregnancy, recent use of steroids

• Symptoms of urethritis in the male partner

• Internal versus external dysuria (in the latter, the pain is triggered as urine passes over the affected skin or mucosa)

• Menstrual history including date of last menstrual period

• Use of douches, deodorant soaps, and bubble bath

• Past history of UTI, vesicoureteral reflex, and/or other abnormalities of the urinary tract

• Terminal dysuria or hematuria, which would strongly favor the diagnosis of UTI

6. (E) Weight, temperature, and BP should be documented. A general physical examination with special attention to the skin, the head, eyes, ears, nose, throat, neck, abdomen, and extremities will all be necessary. In this case, it is important to look for rashes suggestive of STDs and to perform a throat and neck examination looking for signs of infection (eg, oral sores, exudates, and lymphadenopathy). The eyes should be inspected for iritis and conjunctivitis complicating some STDs, and a musculoskeletal examination may be helpful to screen for STD-associated arthritis. An abdominal examination should be done looking for tenderness, guarding, masses, and visceromegalies. The costovertebral angles should be evaluated for tenderness and Tanner stage should be recorded. A thorough pelvic examination will be needed to establish the diagnosis; a rectal examination would only be indicated in selected cases.

7. (D) The presence of clusters of exquisitely tender vesicular and ulcerative lesions is highly suggestive of herpes infection. However, in view of the yellowish, foamy discharge found at the introitus and in the cul-de-sac, other STDs, such as gonorrhea, chlamydia, and trichomoniasis, need to be ruled out. A GC/chlamydia probe, wet prep, and herpes culture will be necessary to confirm the diagnoses. In the absence of symptoms or signs suggesting monilial vaginitis or vulvitis, a KOH prep will not be helpful. HIV testing is indicated in view of her clinical picture and sexual history.

8. (E) The clinical appearance of the discharge provides important clues to the diagnosis. Leukorrhea is a normal finding in adolescent girls and is a result of the progressive estrogenization of the vaginal mucosa, which starts a few months before menarche and continues throughout the reproductive years. There is a normal, cyclic variation in the appearance of leukorrhea throughout the month. A thick, curdy, “cottage cheese” white discharge with underlying erythema and friability of affected tissue suggests Candida infection; a thin, grayish, foul-smelling discharge is consistent with bacterial vaginosis. Trichomonas vaginitis usually has a frothy, malodorous yellow or white discharge.

Microscopic examination of the wet preparation is a helpful technique, which often provides timely information in the office setting. Normal findings include sheets of epithelial cells such as those seen in leukorrhea. Epithelial cells covered with refractile bacteria attached to their surface are known as “clue cells,” characteristic in bacterial vaginosis (see Figure 75-1). Typically, leukocytes are absent in this condition. In contrast, large numbers of leukocytes are usually seen both in trichomonal infections and in mucopurulent cervicitis. The presence of flagellated organisms will confirm the diagnosis of trichomoniasis. It is important to remember, however, that the sensitivity of the wet preparation to identify trichomonas can be as low as 50-60% and therefore almost half of patients with this diagnosis may be missed with this technique. Newer, liquid-based trichomonas culture tests exist with sensitivities higher than 90%. In this case, with a clinical picture suggestive of several coexisting genital infections and a friable cervix, the wet preparation is likely to show all the elements listed.

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FIGURE 75-1. Bacterial vaginosis. Clue cells are large epithelial cells covered with bacteria. (Reproduced, with permission, DeCherney AH, Nathan L. Current Diagnosis & Treatment: Obstetrics & Gynecology, 10th ed. New York: McGraw-Hill, Fig. 37-4.)

9. (E) Although trichomoniasis has already been confirmed on wet prep and herpes simplex infections is very likely from a clinical standpoint, concomitant bacterial cervicitis and/or UTI still need to be excluded. In several clinical series, concurrent UTI and genital infections were found in up to 20% of adolescent girls presenting with genitourinary symptoms.

10. (B) Even though the clinical picture is highly suggestive of vulvovaginitis and cervicitis, a urine culture will help rule out concomitant UTI. HIV and syphilis testing should be done in all patients with evidence of other STDs. A pregnancy test will be needed, given this patient’s history of unprotected intercourse.

11. (D) An estimated 3 million teenagers acquire an STD every year, with an approximate rate of 1 in 4 sexually active teens between the ages of 13 and 19 years. Approximately two-thirds of all cases of STDs occur in people younger than 24 years. A chlamydial infection is the most common bacterial STD at all ages. Forty percent of chlamydial infections occur in young women 15-19 years of age. In adolescent girls in this age group, the rate of chlamydial infections is 3.5 times higher than that of gonorrhea. Both chlamydia and gonorrhea have a predilection for columnar epithelium. The high prevalence of these infections in young women may be explained, at least in part, by the presence of cervical ectopy, a normal developmental finding during adolescence. It is estimated that more than 50% of females and 25% of males with chlamydial infections may be asymptomatic. Test of cure after treatment for chlamydia is only recommended if the patient is pregnant, symptoms persist after treatment, or compliance with the medication regimen is doubted. According to present CDC recommendations, all sexually active adolescent girls should be screened for C trachomatis infection every 6 months.

12. (B) As many as 50% of women and most men with trichomonal infections are asymptomatic. For those adolescent girls who present with symptoms, vaginal discharge and itching are the most common complaints. The discharge is typically yellow green and may be frothy. On physical examination, vulvar and vaginal erythema are common and a “strawberry cervix,” resulting from swollen papillae and punctuate hemorrhages, may be present. Trichomonads can be detected on wet mounts (with 50-70% sensitivity) (see Figure 75-2). Cultures and DNA amplification methods increase sensitivity to 97% and 99%, respectively. Partners of patients with a Trichomonas infection should also be treated.

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FIGURE 75-2. Trichomonas. Saline wet mount demonstrating oval-bodied, flagellated trichomonads (see arrow). They are similar in size to leukocytes and can be distinguished from them by their motility and presence of flagella. (Reproduced, with permission, from Handsfield HH. Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

13. (C) A first episode of primary genital herpes infection is defined as an infection in a patient with no prior history of genital herpes who is seronegative. The incubation period is about a week with a range of 2-12 days. Vesicular lesions subsequently appear, marking the end of the incubation period. The vesicles then evolve into ulcers that may coalesce and the virus may shed for at least 10-12 days. Reepithelization takes place in 2-3 weeks and leaves no scarring. Cervicitis is common in 70-90% of first episodes but is less common in recurrent disease. Recurrent genital herpes infections are usually milder, have less constitutional symptoms, present with fewer lesions, and heal faster. During recurrent infections viral shedding lasts for about 4 days. Up to 15% of genital herpes infections are caused by HSV-1.

14. (B) The Tzanck preparation, in which scrapings from a lesion are stained with Wright stain, may show characteristic multinucleated giant cells (see Figure 75-3). The Pap smear would show the same findings with a 60-70% sensitivity and 95% specificity. Colposcopy may reveal characteristic ulcers with a sensitivity of about 70%. Viral cultures are the test of choice for confirmation of infection. Virus detection, however, depends on the stage of the lesions: Cultures are positive in 90% of vesicles and 70% of ulcers but only on 25% of crusted lesions.

15. (C) The incubation period of gonorrhea is 3-5 days. It is estimated that 75-90% of women and 10-40% of men infected with gonorrhea are asymptomatic. Screening for gonorrhea in asymptomatic girls can be accomplished by obtaining a urine nucleic acid amplification techniques (NAAT) test or an endocervical sample for culture. Routine cultures from the pharynx and rectum in adolescents are not cost effective in asymptomatic adolescents. The currently recommended treatments are believed to be effective in gonorrhea eradication from all sites.

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FIGURE 75-3. Herpes simplex virus: positive Tzanck smear A giant, multinucleated keratinocyte on a Giemsa-stained smear obtained from a vesicle base. Compare the size of the giant cell to that of the neutrophils also seen in this preparation. (Reproduced, with permission, from Wolff K, Johnson RA. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, 6th ed. New York: McGraw-Hill; 2009: Fig. 27-27.)

16. (E) PID comprises a variety of inflammatory disorders of the upper genital tract in women, including endometritis, salpingitis, tubo-ovarian abscess, and pelvic peritonitis. It is a common condition that affects 1 million women and leads to 200,000 hospitalizations per year. Seventy-five percent of women with PID are younger than 25 years. In a quarter of affected women, PID leads to sequelae such as infertility, ectopic pregnancy, and chronic pelvic pain. Teenagers account for a fifth of all cases of PID. PID is thought to be polymicrobial, caused by aerobic and anaerobic bacteria, and results from ascending infection of bacteria from the cervix. Among the sexually transmitted infections, gonorrhea, chlamydia, and genital mycoplasma, are the most common pathogens responsible for PID. Smokers have twice the rate of nonsmokers, and there is also increased risk for PID among IUD users. The use of barrier methods and birth control pills lowers the risk for PID.

17. (B) The diagnosis of PID relies heavily on clinical judgment. Because of the lack of conclusive diagnostic indicators, the condition is correctly diagnosed on clinical and laboratory grounds in 65% of cases. The differential diagnosis is extensive and includes appendicitis, gastroenteritis, irritable bowel syndrome, cholecystitis, endometriosis, hemorrhagic ovarian cyst, ovarian torsion, nephrolithiasis, and somatization. The most frequently found clinical features are abdominal pain (100%), adnexal tenderness (90%), and cervical motion tenderness (80%). Vaginal discharge, abdominal guarding, and rebound are less common (73% and 61%, respectively). Fever is present in only 30% of cases. Minimal diagnostic criteria include abdominal pain, adnexal tenderness, and cervical motion tenderness. Fever and vaginal discharge are additional clinical features that may be helpful when present. An increased ESR, CRP, and laboratory documentation of cervical infection with gonorrhea or chlamydia will provide supportive evidence. Additional tests, such as pelvic ultrasound, are helpful to detect a pelvic abscess or an ectopic pregnancy. A pregnancy test will be needed as part of the workup.

Empirical treatment is started as soon as the diagnosis of PID is suspected. Although most women with PID are treated in the outpatient setting, adolescents may need to be hospitalized for treatment, given their often unpredictable compliance. Other indications for inpatient treatment include pregnancy as well as suspected surgical emergencies such as appendicitis, ectopic pregnancy, or pelvic abscess. Severe illnesses with nausea or vomiting also preclude outpatient management. Careful follow-up is required in all cases.

18. (C) Your findings so far confirm the diagnosis of trichomoniasis and are also highly suggestive of a first episode of genital herpes. Concurrent gonorrhea and/or chlamydia are also likely in this adolescent at risk who presents with mucopurulent cervicitis. All these infections will need to be treated to avoid short- and long-term complications. Although you could treat her for trichomonas and herpes on the first visit and ask her to return for treatment of gonorrhea and chlamydia once these infections are confirmed, follow-up may be unreliable in view of this patient’s psychosocial history. Thus it would be preferable to treat her for all suspected infections on the present visit. Antibiotic resistance has been a major problem in the treatment of gonorrhea. The 2010 CDC guidelines for the treatment of STDs state that resistance to quinolones (ciprofloxacin and ofloxacin) precludes their use in certain areas of the country, particularly in the western United States. The recommended dose of ceftriaxone for the treatment of uncomplicated gonorrhea cervicitis is 125 mg IM single dose. Regimens that include ceftriaxone or doxycycline also cover incubating syphilis. Azithromycin, doxycycline, and erythromycin will all be effective in treating chlamydia. However, azithromycin is a preferred treatment in adolescents because of its easy one time dose schedule. Several antiviral agents are available for the treatment of the first episode of genital herpes. Among them, valacyclovir is the one that requires the least frequent dosing, increasing the potential for compliance. Many experts do not prescribe antivirals for uncomplicated herpes infection. Ciprofloxacin has not been approved for patients younger than 18 years.

19. (E) This patient’s sexual partner should be treated for trichomonas, chlamydia, and gonorrhea infections. HIV and RPR testing is recommended, and the patient is advised to abstain from sexual activity until all her lesions are healed. Underlying her presenting concerns, this 14-year-old has a host of risk factors, including school failure, high risk for pregnancy and STDs, runaway behavior, and drug use. A brief initial discussion at this visit will need to be followed up with more extensive evaluation and interventions including individual and family counseling.

SUGGESTED READING

Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Atlanta, GA: CDC; 2010.

Emans SJ, Laufer MR, Goldstein DP, eds. Pediatric and Adolescent Gynecology. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005.

Neinstein LS. Adolescent Health Care. A Practical Guide. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.

Pickering LK, Baker CJ, Kimberlin DW, Long SS Red Book 2009 Report of the Committee on Infectious Diseases. 28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

Tarr ME, Gilliam ML. Sexually transmitted infections in adolescent women. Clin Obstet Gynecol. 2008;51(2):306-318.

CASE 76: A 17-YEAR-OLD GIRL WITH HEAVY, IRREGULAR MENSES

A 17-year-old girl presents to the teen clinic with her mother, complaining of irregular menstrual bleeding for the past 6 months. You have been her pediatrician for the past 4 years, and upon reviewing her chart you find that she has had mild intermittent asthma and eczema in the past but no other chronic conditions. She started her periods at age 11 years, and menses have been regular every 28 days until 6 months ago. Menstrual flow has always been heavy, and she has always been using 5 pads a day for the duration of her period. Lately her menses have been somewhat irregular, lasting up to 10 days. There is no history of dysmenorrhea. She lives with both parents and a younger sister. She is a good student and participates in many extracurricular activities. She started dating 18 months ago and has been sexually active for the past 7 months. She has been using condoms “most of the time.” Family history is remarkable for hyperlipidemia and hypertension on the maternal side of the family. Her mother had a history of heavy periods all along. The younger sister has grand mal seizures.

The physical examination is normal except for the patient being mildly overweight and moderate facial acne.

SELECT THE ONE BEST ANSWER

1. What other elements of the clinical history will you need to assess now?

(A) first day of the last menstrual period

(B) duration of bleeding

(D) abdominal pain

(E) all of the above

2. The following statements regarding the normal menstrual cycle in adolescents are true except

(A) normal duration is 2-7 days

(B) average blood loss is about 100 mL

(D) menses occur approximately 14 days after the LH midcycle surge

(E) ovulation occurs about 12 hours after the LH peak

3. Which of the following definitions of abnormal vaginal bleeding patterns is incorrect?

(A) metrorrhagia: uterine bleeding at irregular but frequent intervals

(B) polymenorrhea: uterine bleeding at regular intervals of less than 28 days

(D) hypermenorrhea: prolonged or excessive bleeding at regular intervals

(E) menometrorrhagia: prolonged or excessive bleeding at irregular intervals

4. The great majority of cases of abnormal uterine bleeding in adolescence result from

(A) STDs

(B) dysfunctional uterine bleeding

(D) coagulopathies

(E) medications and drugs

5. Which of the following conditions would be an unlikely cause of abnormal vaginal bleeding in this patient?

(A) spontaneous abortion

(B) dysfunctional uterine bleeding

(D) cervicitis

(E) blood dyscrasias

6. Which among the following elements of the physical examination would be the least relevant for the diagnosis and immediate management of this patient’s menstrual problem?

(A) pelvic examination

(B) heart rate

(D) pallor

(E) moderate acne

7. The laboratory evaluation of abnormal vaginal bleeding in adolescents requires all of the following except

(A) pregnancy test

(B) hemoglobin and red blood cell indexes

(D) endometrial biopsy

(E) gonorrhea and chlamydia probe

8. The physical examination reveals that the patient is hemodynamically stable with a BP of 110/60 mm Hg and a heart rate of 84 bpm. The pelvic examination shows moderate bleeding. There is no clinical evidence of infection. The hemoglobin comes back at 10.5 g/dL and the pregnancy test is negative. All of the following treatments will be acceptable for this patient except

(A) hospitalization (intravenous [IV] estrogens followed by conjugated estrogens orally plus medroxyprogesterone acetate orally for 7-10 days)

(B) medroxyprogesterone acetate 10 mg/day for 10-14 days

(D) any of the combined oral contraceptives 1 pill orally 4 times a day for 3-5 days to stop the bleeding followed by tapering to 1 pill a day until the pack is finished

(E) observation, menstrual calendar, and iron therapy

9. Which among the following is not a common side effect of the monophasic combined oral contraceptive pills in adolescents?

(A) weight gain

(B) nausea

(D) breakthrough bleeding

(E) headaches

10. The patient returns for follow-up 1 week later. She is now taking a combined pill containing a fixed amount of 35 micrograms of ethynyl-estradiol and 0.25 mg of norgestimate orally once a day. Her bleeding has stopped. She has not had any side effects from the medication except for some nausea during the first 2-3 days while she was taking “the pill” 3 times a day. She is also taking ferrous sulfate tablets 325 mg orally twice a day. A review of all laboratory tests obtained on the previous visit shows normal or negative results. The patient states that she is interested in long-term contraception and wants to know what methods you would recommend.

Among the following, which contraceptive method has the lowest failure rate during typical use in adolescents?

(A) combined oral contraceptives

(B) male condom

(D) periodic abstinence

(E) injectable depo-medroxyprogesterone

11. Beneficial effects of the combined oral contraceptive pills include all of the following except

(A) effective in the treatment of acne

(B) improvement of bone mineralization

(D) decreased risk of endometrial cancer

(E) decreased risk of thromboembolism

12. Combined oral contraceptive pills can be safely used by an adolescent with any of the following conditions except

(A) postabortion

(B) active viral hepatitis

(D) PID

(E) varicose veins

13. Which of the following antibiotic medications interferes with the contraceptive effectiveness of the pill?

(A) amoxicillin

(B) rifampin

(D) sulfonamides

(E) all of the above

14. All of the following medications decrease the clearance of combined oral contraceptives, potentially leading to increased estrogen levels and side effects except

(A) selective serotonin reuptake inhibitors

(B) fluconazole

(D) nefazodone

(E) carbamazepine

15. The combined oral contraceptive pill decreases the clearance of all of the following medications except

(A) benzodiazepines

(B) theophylline

(D) aspirin

(E) prednisolone

16. The mother expresses some concerns about this patient’s ability to take a pill every day. Of the following methods, which one has the lowest contraceptive failure rate in typical users?

(A) contraceptive patch

(B) progesterone IUD

(D) diaphragm

(E) medroxyprogesterone acetate IM injection

17. On discussing the benefits and disadvantages of all contraceptive options with the patient, you decide to keep her on the same combined oral contraceptive she has been on so far. She will also need to use condoms consistently to prevent STDs. All of the following statements regarding male condoms are accurate except

(A) when used as the only contraceptive method, the typical failure rate is 14%

(B) condoms with spermicide have a lower failure rate

(D) best available method for prevention of HIV

(E) condoms decrease the rate of cervical cancer

18. In patients on anticonvulsants, which of the following is the contraceptive of choice?

(A) combined oral contraceptive

(B) diaphragm with spermicide

(D) depo-medroxyprogesterone

(E) progestin-only pills

19. The patient has been on the pill for 2 weeks and now calls you to let you know she is bleeding again. After telling you emphatically that her compliance has been perfect, she explains that she has no cramping or fever and she is using about 2-3 pads a day. She has not been sexually active for the past 7 weeks and denies being on any other medication. What would you do at this time?

(A) admit her to the hospital for evaluation

(B) change the pill to one with a higher estrogen content

(D) change her to progestin-only pills

(E) B or D

ANSWERS

1. (E) The menstrual history should always include the first day of the last menstrual period, duration and amount of bleeding, interval, and regularity of menses. In this case, it will also be important to ask about ongoing abdominal or pelvic pain, any history of abnormal bleeding from other sites (purpura, epistaxis, hematuria), weight changes, stress, recent use of hormonal and nonhormonal medication, and substance abuse. The date of her most recent vaginal intercourse should be helpful for adequate interpretation of the pregnancy test.

2. (B) The normal menstrual cycle is characterized by a follicular phase, ovulation, and a luteal phase. During the follicular phase, under the influence of FSH, one follicle becomes dominant by day 7. Estradiol, the main hormone promoting endometrial growth during this phase, reaches a peak shortly before the LH surge on day 14. The follicle ruptures within 12 hours of the LH surge and about 24 hours after the estradiol peak. After ovulation, estradiol levels plummet, and progesterone, produced by the corpus luteum, becomes the dominant hormone as the luteal phase starts. Progesterone inhibits the growth of a new follicle and causes maturation of the proliferative endometrium. In the absence of fertilization, the corpus luteum degenerates over the following 14 days at which time progesterone levels decline steeply. Progesterone withdrawal is responsible for initiation of bleeding during the normal menstrual cycle. The normal menstrual cycle lasts 2-7 days, occurs at intervals of 21-35 days, and leads to an average blood loss of 35-40 mL up to a maximum of 80 mL (see Figure 76-1).

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FIGURE 76-1. The hormonal, ovarian, endomethal, and basal body temperature changes and relationships throughout the normal menstrual cycle. (Reproduced, with permission, from Carr BR, Wilson JD. Disorders of the ovary and female reproductive tract, in Isselbacher KJ, Braunwald E, Wilson JD, et al. Harrison’s Principles of Internal Medicine, 13th ed. New York: McGraw-Hill; 1998: 2101.)

3. (B) Polymenorrhea is defined as uterine bleeding at regular intervals of less than 21 days. Metrorrhagia is defined as uterine bleeding at irregular but frequent intervals. Menorrhagia and hypermenorrhea are synonymous and describe prolonged or excessive bleeding at regular intervals. Menometrorrhagia indicate prolonged or excessive bleeding at irregular intervals.

4. (B) Dysfunctional uterine bleeding is defined as heavy, prolonged unpatterned uterine bleeding unrelated to structural or organic disease. It results from anovulation and is responsible for 90% of abnormal vaginal bleeding in adolescents. In the absence of ovulation, there will not be progestins to allow for maturation and stabilization of the endometrium. Because of the effects of unopposed estrogen, the endometrium remains in a proliferative phase, becomes unstable, and bleeds erratically. Because dysfunctional uterine bleeding is a diagnosis of exclusion, a thorough history should be obtained to rule out organic causes, including complications of early pregnancy, coagulopathies, STDs, side effects of medications and drugs among others. Regardless of the etiology, in any patient complaining of abnormal vaginal bleeding it is essential to evaluate the severity of past and ongoing bleeding and to address any potential need for hospitalization, IV fluids, or blood replacement.

5. (C) Genital cancers, although included in the differential diagnosis, would be unlikely in a 17-year-old adolescent. Most cases of abnormal vaginal bleeding in adolescence are secondary to dysfunctional uterine bleeding. However, the differential diagnosis to consider includes

• Pregnancy-related conditions: intrauterine or ectopic pregnancy, spontaneous abortion, and molar-trophoblastic disease

• Infections: vaginitis, cervicitis, endometritis, salpingitis, and PID

• Other gynecologic conditions: ovarian cysts, genital cancers, breakthrough bleeding associated with contraceptive use, ovulation bleeding, and polyps

• Systemic diseases: renal and liver failure

• Blood dyscrasias

• Direct trauma and foreign body

• Medications: anticoagulants and platelet inhibitors

6. (E) A pelvic examination is rarely indicated in a postpubertal, not sexually active patient within 18 months of menarche unless trauma is suspected. All other women with abnormal vaginal bleeding should have a pelvic examination, particularly when there is a pattern of increasing, protracted or very heavy bleeding. Blood pressure and heart rate, both in the upright and supine position, would be essential to assess hemodynamic instability and potential need for hospitalization. A complete physical examination will be needed, documenting general appearance, pallor, tachycardia, abdominal masses, guarding, rebound, or evidence of endocrinopathies. Breasts should be checked for galactorrhea. Recent weight gain or loss may play a role in dysfunctional uterine bleeding. Moderate acne, particularly in a patient with obesity and hirsutism, suggests hyperandrogenism.

7. (D) A pregnancy test will be essential to exclude complications of pregnancy as the cause of abnormal vaginal bleeding. Hemoglobin and hematocrit determinations will help determine the magnitude of chronic bleeding. Coagulation studies may reveal coagulopathies or blood dyscrasias, such as in patients with a pattern of excessive bleeding since menarche and/or in patients with a family history of abnormal vaginal bleeding. Among adolescents requiring hospitalization for this problem, 20% have coagulopathies. Testing for infections will be needed in sexually active teens with abnormal bleeding because gonorrhea, chlamydia, and trichomonal infections are common causes of protracted or irregular vaginal bleeding in adolescents who previously had regular periods. Endocrine abnormalities such as hypothyroidism and polycystic ovarian syndrome frequently present with menorrhagia or irregular bleeding. Thyroid function tests, FSH and LH, prolactin, and androgen studies will help confirm these diagnoses. Endometrial biopsy is not indicated in adolescents.

8. (A) Numerous options are available for the treatment of patients with anovulatory, dysfunctional uterine bleeding. Patients with acute, very heavy, or uncontrolled bleeding should be hospitalized and treated with IV estrogen, 25 mg every 4 hours, until bleeding abates. If bleeding is less heavy and the patient is hemodynamically stable, conjugated estrogens orally can be given in the outpatient setting until bleeding stops at which time the dose of estrogens can be reduced to 1.25-2.5 mg/day and oral medroxyprogesterone acetate 10 mg orally added for 7-10 days. On discontinuing these medications, withdrawal bleeding will occur. Patients with acute moderate bleeding can be treated with combined oral contraceptives given up to 4 times a day with gradual tapering until bleeding subsides. At that time the patient should continue to take 1 pill a day until the pack is finished. In patients with significant anemia, taking only the pharmacologically active pills in each package for 21 days, discarding the placebo pills, and starting a new package will prevent withdrawal bleeding. This method of administration may be used for 2-3 cycles to promote a faster resolution of the anemia. Iron therapy should be offered to all patients to correct iron deficiency and prevent further anemia. In this patient, any of the listed outpatient hormonal treatments can be used. In view of her moderate bleeding, hemodynamic stability, and moderate anemia, hospitalization does not seem necessary at this time.

9. (A) Weight gain is rarely a side effect of the pill. Nausea and breakthrough bleeding, however, are among the most common. Both side effects tend to abate after the first few cycles. Nausea is considered an estrogenic side effect of the pill and, if bothersome, it can be corrected by choosing a pill with a lower estrogen content. Other potential side effects of the pill include headaches, breast tenderness, hypertension, abdominal cramping or bloating, and changes in menstrual flow.

10. (E) Typical use failure rates reflect the percentage of women experiencing an unintended pregnancy during the first year of use of the method under assessment. Injectable depomedroxyprogesterone has the lowest failure rate of all hormonal contraceptive methods (0.3%), although calcium supplementation needs to be taken daily to prevent bone density loss associated with long-term use. The Food and Drug Administration (FDA) recommends seeking alternative contraceptive methods after 2 years of use. Combined oral contraceptive pills have a typical use failure rate of 2% in the general population, but those rates are much higher (7-15%) in adolescent girls aged 15-19 years, mostly as a result of poor compliance. Progestin-only pills have a somewhat higher failure rate than combined pills. For male condoms the typical failure rate is 12%; for couples using no method the chance of pregnancy climbs to 85%.

11. (E) Combined oral contraceptives have a protective effect against endometrial and ovarian cancer. They also have some other beneficial effects, including regulation of menses, decreasing the severity of dysmenorrhea, reduced iron loss, improved bone mineralization, and lowered risk of ectopic pregnancy and symptomatic PID.

12. (B) Combined oral contraceptives can safely be used in all the conditions listed except active viral hepatitis in which it is absolutely contraindicated. Other absolute contraindications include

• Pregnancy

• Breast cancer

• Migraine headaches with focal neurologic signs

• Breastfeeding within 6 weeks postpartum

• Hypertension with systolic BP higher than 160 and diastolic BP higher than 100

• History of or current deep venous thrombosis or pulmonary embolism

• Vascular disease

• Major surgery with prolonged immobilization

• History of or current ischemic heart disease or stroke

• Complicated valvular heart disease

• Diabetic retinopathy, neuropathy, nephropathy

• Benign hepatic adenoma

Relative contraindications to the use of combined oral contraceptives include mild hypertension, sickle cell disease, depression, and migraine without focal neurologic findings.

13. (B) Rifampin is known to decrease the contraceptive effectiveness of the pill.

14. (E) Carbamazepine as well as most anticonvulsants, including phenytoin, ethosuximide, felbamate, and topiramate, decreases the contraceptive effects of the pill. All other medications listed increase estrogen levels and may lead to potential side effects such as nausea, vomiting, headaches, and breast tenderness.

15. (D) Combined oral contraceptives decrease the clearance of benzodiazepines, caffeine, theophylline, tricyclic antidepressants, and prednisolone, potentially increasing their risk for toxicity. However, aspirin and morphine concentrations may decrease in users of estrogen-progestin pills.

16. (B) IUDs are an excellent method of long-term reversible contraception for women and sometimes adolescent girls in long-term, mutually monogamous relationships, and have the lowest failure rate of all contraceptive methods, 0.1%. Newer evidence shows they are safe in nulliparous women, although in this situation there is a higher expulsion rate after insertion. They are generally not recommended for women with multiple sexual partners, high risk for STDs, heavy or painful menstrual periods, or those with cervical dysplasia. In addition, IUDs have one of the highest continuation rates versus other contraception choices. The transdermal contraceptive patch (Ortho Evra; failure rate 0.3%) and the vaginal ring (NuvaRing; failure rate 0.3%) share all the indications and contraindications of the birth control pill but may be more convenient for teens because they do not require daily compliance on the part of the user. The “patch” needs to be replaced once a week; the vaginal ring, which delivers an estrogenprogestin combination absorbed through the vaginal mucosa, is replaced monthly. Medroxyprogesterone injections (failure rate 0.3%) constitute another method with a low failure rate. However, it should not be used for more than 2 years due to the potential decrease in bone mineral density, even if the patient is taking the recommended daily calcium supplementation. Diaphragms and cervical caps have high failure rates (20% and 40%, respectively).

17. (B) There is little evidence that condoms with spermicide have a lower failure rate.

18. (D) Depomedroxyprogesterone is the contraceptive of choice in adolescent girls with seizure disorders because it increases the threshold for seizures. As opposed to progestin-only pills, which should be taken daily, injectable progestins only need to be administered every 12 weeks, a regimen which facilitates compliance. Moreover, anticonvulsants decrease the contraceptive effectiveness of combined oral contraceptives but do not affect depomedroxyprogesterone metabolism. Because long-term use of this method may be associated with a decrease in bone mineral density, it is recommended that young women using this method take calcium supplements to achieve a dietary intake of 1300 mg per day.

19. (C) Breakthrough bleeding is common in the first 3 months of therapy and usually resolves spontaneously. This should be discussed with all patients before starting them on oral contraceptives to avoid unneeded anxiety and discontinuation of treatment. Pregnancy and STDs should be considered under these circumstances but are unlikely in this case because she denies sexual activity for the previous 7 weeks, had a negative pregnancy test, and no evidence of sexually transmitted diseases 2 weeks earlier. Reassurance would be appropriate at this time with close follow-up if the bleeding became persistent or bothersome. In this case, an NSAID would be effective in decreasing menstrual flow. Alternatively, she should be asked to take an extra pill a day from a different package until bleeding stops.

SUGGESTED READING

Emans SJ, Laufer MR, Goldstein DP, eds. Pediatric and Adolescent Gynecology. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005.

Hatcher RA, Trussel J, Stewart F, et al. Contraceptive Technology. 19th ed. New York, NY: Irvington; 2007.

Johnson BE, Johnson CA, Murray JL, Apgar BS. Women’s Health Care Handbook. 2nd ed. Philadelphia, PA: Hanley & Belfus; 2000.

MacIsaac L, Espey E. Intrauterine contraception: the pendulum swings back. Obstet Gynecol Clin N Am. 2007; 34:91-111.

Neinstein LS. Adolescent Health Care. A Practical Guide. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.

CASE 77: A 15-YEAR-OLD GIRL WITH ABDOMINAL PAIN, WEIGHT GAIN, AND FATIGUE

A 15-year-old adolescent girl comes in to the clinic for a “checkup.” She has been your patient for 3 years, and a brief review of her chart reminds you that she only has been seen by you for yearly physical examinations. She has no history of chronic illness, allergies, or hospitalizations. Immunizations are up to date. She had been in counseling for “anger issues” for several years and 2 years ago was seen by a psychiatrist who diagnosed oppositional defiant disorder. She lives with her maternal grandmother (and guardian), who raised her since she was 2 years old, and a 17-year-old brother. Her brother has been recently released from jail. Grandma is a diabetic and is also on medication for hypertension. In the past she had often complained about her granddaughter’s behavior, which she describes as rebellious, hostile, and argumentative. She does not feel that “the girl can be trusted.” At times, she even suspected drug use, a notion her granddaughter vehemently denies. The patient ran away from home for 3 days on one occasion last year. Her father lives out of state and is not involved in her life; her mother is “around sometimes,” having been sporadically in rehabilitation programs for drug addiction. The patient was an average student in elementary school, but her academic performance has been declining lately. She is now in the eighth grade. The review of systems reveals tiredness, nausea, vomiting, and vaguely described periumbilical pain. A careful history of the pain fails to discern any patterns in onset, duration, progression, intensity, aggravating or relieving factors, or associated symptoms. Her appetite has increased lately. Neither her fatigue nor her abdominal pain has kept her from participating in sports. She became sexually active 6 months before this visit. She states that she is not interested at all in hormonal birth control for fear of gaining weight. Her menses have been normal since menarche at age 11. Her last period started 2 weeks before this visit and lasted 3-4 days. She has had some nausea and vomiting off and on for the past few weeks but denies diarrhea or constipation. During the previous week she has noticed increased urinary frequency. Her review of systems is otherwise negative.

On physical examination, she looks well but quiet, aloof, and “testy.” She is well developed at 5'5" and 140 lb. She has gained 8 pounds since her last visit 6 months earlier. She has a large scar on her arm, the result of “a fight” about 3 years ago. Her physical examination is otherwise unremarkable except for some fullness in her lower abdomen. There is no abdominal tenderness and no guarding or rebound. There is no CVA tenderness. You ask her to empty her bladder and to return to the examination room.

SELECT THE ONE BEST ANSWER

1. What other elements of the clinical history would be important in this case?

(A) dysuria

(B) medications

(D) number of sexual partners

(E) all of the above

2. What elements of the physical examination are particularly important?

(A) eye examination

(B) cardiovascular examination

(D) pelvic examination

(E) all of the above

3. The speculum examination shows no abnormalities. There is no uterine bleeding. The bimanual examination reveals an enlarged uterus, the size of a grapefruit, almost palpable above the symphysis pubis. The cervix is soft. No adnexal masses are felt. There is no adnexal or cervical motion tenderness. The most likely diagnosis is

(A) 4-week intrauterine pregnancy

(B) 12-week intrauterine pregnancy

(D) missed abortion

(E) threatened abortion

4. Which of the following could best explain the discrepancy between uterine size and the reported date of the last menstrual period when the uterus is larger than expected for dates?

(A) inaccurate dates of the last menstrual period

(B) twin pregnancy

(D) molar pregnancy

(E) all of the above

5. Suppose you determine that the uterus is smaller than expected for dates. All of the following are consistent with your determination except

(A) inaccurate last menstrual period date

(B) incomplete or missed abortion

(D) corpus luteum cyst of pregnancy

(E) hCG-secreting tumors

6. Which of the following tests would be helpful to evaluate the cause of a discrepancy between uterine size and the last menstrual period date?

(A) pelvic ultrasonography

(B) maternal serum alpha-fetoprotein (MSAFP)

(D) measurement of fetal heart rate

(E) A and C

7. All of the following statements about hCG levels during pregnancy are true except

(A) a sensitive urine pregnancy test can detect hCG levels as low as 10-25 mIU/mL

(B) a sensitive urine pregnancy test may help diagnose pregnancy before a period is missed

(D) between 5 and 8 weeks of gestation, hCG levels should increase by 66% in 48 hours

(E) between 23 and 35 days of gestation, the mean doubling time is 1.6 days

8. All of the following would suggest the diagnosis of ectopic pregnancy except

(A) pelvic pain

(B) amenorrhea

(D) irregular bleeding

(E) adnexal mass

9. All of the following laboratory tests are indicated at this time except

(A) pregnancy test

(B) CBC, differential, and platelet count

(D) urinalysis

(E) amylase and lipase

10. The pregnancy test is positive. The patient receives that news without surprise and states she is not ready for motherhood. She does not want her grandmother to know about the pregnancy. What do you do next?

(A) discuss all her options with her

(B) suggest having her grandmother involved in the decision-making process

(D) refer to a case manager

(E) arrange a follow-up visit in 1 week

11. The following statements regarding abortion are correct except

(A) abortions after 16 weeks of gestation carry a risk for complications 15 times higher than those performed before 12 weeks

(B) abortions done between 9 and 12 weeks of gestation have a tenth of the complication rate of carrying the pregnancy to term

(D) adolescents younger than 19 account for 20% of all legal abortions

(E) 41% of teen pregnancies end in abortion

12. During the private interview with the patient, she admits to drinking “socially” on weekends, sometimes to drunkenness, and to smoking marijuana 3 times a week. All of the following statements regarding alcohol use are true except

(A) no amount of alcohol is safe in pregnancy and total abstinence is recommended

(B) the use of alcohol during pregnancy can lead to fetal alcohol syndrome or spontaneous abortion

(D) 34% of American 12th graders report having been drunk in the previous month

(E) alcohol is involved in 40% of adolescent mortality resulting from MVAs

13. Which among the following is not a physical consequence of acute heavy drinking?

(A) acute gastritis

(B) hyperthermia

(D) amnesia

(E) ataxia

14. Concerning marijuana use, all of the following statements are true except

(A) cigarette smoking is more common than marijuana use in teens

(B) up to 48% of high school graduates have used marijuana at least once

(D) the duration of action of marijuana is 3 hours if smoked

(E) the typical potency of street marijuana is 4-6%

15. All of the following symptoms and signs may be attributed to marijuana use except

(A) conjunctival hyperemia

(B) increased appetite

(D) impaired learning and cognition

(E) nausea

16. What percentage of 12th graders report ever having used an illicit drug?

(A) 3%

(B) 10%

(D) 53%

(E) 66%

17. What is the percentage of 12th graders who report ever having used an illicit drug other than marijuana?

(A) 3%

(B) 10%

(D) 50%

(E) 60%

18. Among the following, which is the most common drug of abuse (other than marijuana) used by eighth graders?

(A) smokeless tobacco

(B) amphetamines

(D) crack cocaine

(E) methylenedioxymethamphetamine (MDMA)

19. The patient returned 2 days later with her grandmother. She stated that both she and her boyfriend had decided to seek a pregnancy termination. She had not told her family about the pregnancy yet and asks you to help her do so. Her grandmother was disheartened and upset after hearing the news, but in the end, she supports her granddaughter’s decision. The patient was seen by an obstetrician and underwent a suction curettage 2 days later, without complication. She comes to see you 2 weeks later for follow-up. All of the following should be done at this time except

(A) ask about ongoing contraceptive methods

(B) ask about fever, pelvic pain, vaginal discharge, or continued bleeding

(D) check a urine pregnancy test

(E) start contraception

20. The patient wants to start depomedroxyprogesterone acetate shots. Your advice about this method should include the following except

(A) depomedroxyprogesterone acetate is one of the most effective hormonal contraceptions available

(B) the most common side effects of depomedroxyprogesterone are irregular menstrual bleeding and weight gain

(D) osteoporosis may result from long-term use

(E) it is a good method for adolescents who have difficulties with medication compliance

ANSWERS

1. (E) A history of medication and substance use should be elicited from all adolescents, and a detailed sexual history is essential in all sexually active teens. This includes, among others, age at first intercourse, types of sexual contact, sexual orientation, type of contraceptive use, number of sexual partners, use of alcohol or other drugs associated with sexual activity, and past history of STDs.

2. (E) Because the differential diagnosis of abdominal pain is quite extensive, a comprehensive physical examination will be needed. The recent onset of sexual activity and frequent urination in an adolescent girl who has been an unreliable historian in the past point to the need for a pelvic examination even if her menses are reported as normal. The pelvic examination would help to rule out pregnancy and STD as a cause of her abdominal pain. Given the history of possible marijuana use, one should look for signs of acute or chronic intoxication. For example, in acute intoxication, conjunctival hyperemia, and an abnormal neurologic examination with decreased coordination, sleepiness, slow reaction times, decreased postural stability, increased body sway, and dilated pupils are characteristic. Tachycardia may be present and orthostatic hypotension may develop at larger doses. Clinical signs suggestive of other substance use should be explored.

3. (B) In the absence of any clinical sign of abnormal early pregnancy, it is likely that the reported date of the last menstrual period was inaccurate. A uterus that is palpable in the abdomen just at or above the symphysis pubis signifies a pregnancy of approximately 12 weeks. The uterine fundus reaches the navel at 20 weeks and the rib cage at 40 weeks.

4. (E) Any of the above could explain the finding of a uterus larger than expected for dates.

5. (D) In ectopic pregnancy, incomplete or missed abortion, and hCG-secreting tumors (a very uncommon occurrence), the uterus is smaller than expected for dates. However, in the presence of a corpus luteum cyst of pregnancy the uterus may seem to be larger than expected for gestational age.

6. (E) A transvaginal pelvic ultrasound will help determine fetal size and viability. A serial hCG measurement to assess doubling times is needed for the diagnosis of threatened abortion or ectopic pregnancy. Abdominal ultrasonography allows visualization of a gestational sac around the time hCG levels reach 4000-6000 mIU/mL, whereas transvaginal ultrasonography can detect it at 1000-1500 mIU/mL, approximately 6 weeks from the last menstrual period. MSAFP is a marker for the detection of open neural tube defects and Down syndrome and would not be useful to explain the discrepancy between uterine size and dates.

7. (C) Low levels of hCG early in pregnancy can result from intrauterine or ectopic pregnancy. Serial hCG measurements in conjunction with clinical assessments are helpful to distinguish ectopic or failed pregnancies from normal ones. After the hCG level is 100 mIU/mL, the normal doubling time is 2.3 days in early pregnancy, 1.6 days from day 23 to 35, 2.0 days from day 35 to 42, and 3.4 from 41 to 50 days. To facilitate the calculations, it is helpful to remember that in weeks 5-8 of pregnancy, hCG levels increase by 29% in 24 hours, 66% in 48 hours, 114% in 72 hours, 175% in 96 hours, and 255% in 120 hours. Up to 15% of normal pregnancies may show a lag in doubling time, and up to 13% of ectopic pregnancies may present with physiologic increases in hCG levels.

8. (C) Ectopic pregnancy is the leading cause of maternal death during the first trimester. This condition is more common among women age 35-44 years. However, 15 to 24-year-old women have the highest mortality rate compared with other age groups. Predisposing factors include the use of an IUD, use of progestin-only pills, and tubal abnormalities secondary to a history of tubal surgery, PID, or previous ectopic pregnancy. Pelvic pain, amenorrhea followed by irregular vaginal bleeding, and the presence of an adnexal mass strongly suggest the possibility of an ectopic pregnancy. Rebound tenderness is present in up to 50% of cases.

9. (E) A pregnancy test is most important at this time to confirm the clinical suspicion of pregnancy. A wet mount prep and cervical swabs for gonorrhea and chlamydia are obtained during the pelvic examination to exclude STDs. A urinalysis and culture are needed to rule out UTI and/or glycosuria in this patient with abdominal pain, increased tiredness, frequent urination, and family history of diabetes. A CBC with differential leukocyte count, sedimentation rate, and CRP would be ordered if the physical examination reveals abdominal, adnexal, and/or cervical motion tenderness suggestive of PID. In pregnant girls, additional blood testing should include HIV, RPR, and Rh determinations. Serum amylase and lipase levels would be needed to rule out pancreatitis or cholangitis, which seem unlikely given the clinical presentation.

10. (A) The first step is to discuss the options available to her including

• Continuing pregnancy and becoming a parent

• Continuing pregnancy and giving the baby up for adoption

• Pregnancy termination

The patient’s feelings should be explored in the context of her present social situation, educational goals, financial status, and expectations about family support. She should be counseled about the potential effects of preexistent medical conditions, ongoing medication, smoking, alcohol, and other drugs on pregnancy outcomes. Counseling should be nonjudgmental and realistic but always supportive of the teen’s choice. Even though by virtue of her pregnancy the patient is now an emancipated minor, she should be encouraged to involve her family in the decision-making process. Legal requirements for parental notification vary from state to state, and health providers must be familiar with the laws applying to their specific geographic area to counsel their patients correctly.

The decision to involve the family is best made after an individualized assessment of the patient’s and family needs. Most teenagers need time to consider their options and it is helpful to arrange for a follow-up visit within a week with frequent telephone contact if needed. This is especially true for younger or emotionally immature adolescent girls. In this case, because she is already about 12 weeks pregnant, she needs to know that a decision has to be made in a matter of days rather than weeks. In the meantime, she should be referred to a case manager for further counseling. An appointment with an obstetrician should be arranged either for prenatal care or for pregnancy termination.

11. (C) Elective abortion is the most commonly performed surgical procedure in the United States. Of the almost 1 million teens who get pregnant every year, close to 50% carry pregnancy to term, 41% choose to have an abortion, and the rest end in miscarriages.

Teenagers are more likely to have a secondtrimester abortion than older women often because of failure to recognize the symptoms of pregnancy, ambivalence, fear of disclosure, and lack of awareness of available services. Morbidity and mortality from the procedure increase with gestational age and the risk doubles every 2 weeks after the eighth week. Suction curettage is the most widely used method (97% of cases) and may be performed up to a gestational age of 14 weeks. The procedure has a risk of death in 1:262,000 pregnancies when done before the eighth week and in 1:100,000 pregnancies in weeks 9-12. The comparable risk of death in carrying a pregnancy to term is 1:10,000. Dilation and evacuation (D&E) is used whenever abortion is performed between 13 and 16 weeks of pregnancy (in some places up to 20 weeks). The percentage of adolescents undergoing abortion in relation to the total number of abortions performed has declined significantly since the 1970s, and teens now account for about 20% of all abortions reported.

12. (C) Alcohol is the most common substance of abuse in adolescence. In 2002, the monthly prevalence of any alcohol use in high school seniors was 48%; their annual prevalence of any use was 71%. There has been a modest decline in reported alcohol use during the past decade. Yet almost a third of 12th graders report drinking 5 or more drinks in a row in the previous 2 weeks. Motor vehicle accidents (MVAs) are the leading cause of death among young people of age 15 to 24 years. About 40% of these accidents are alcohol related. Alcohol is also a contributing factor in a substantial proportion of homicides and suicides, violence and injuries, impairment in school functioning, and deterioration in interpersonal relations. By age 15, a fifth of adolescent boys and a sixth of adolescent girls report they are problem drinkers. Fewer than 5% of adolescents can be categorized as alcoholics. Adolescents who drink daily, have a family history of alcoholism, have blackouts or withdrawal symptoms, and continue to drink despite experiencing damaging consequences in their family, school, and social life, fit into that category. The vast majority of teens who use alcohol but do not meet those criteria are considered problem drinkers. Problem drinkers have been drunk 6 or more times a year and at least twice a year have suffered negative consequences of alcohol use, including drunken driving and problems with family, friends, school, or police because of drinking. These teens are at especially high risk for MVAs and other unintentional injuries and for emotional, social, and academic difficulties. Alcohol use, particularly in early pregnancy, is responsible for fetal alcohol syndrome, a condition characterized by abnormal facies, microcephaly, thin upper lip, short palpebral fissures, hypoplastic maxilla, heart, kidney and skeletal defects, and mental retardation.

13. (B) Mild alcohol intoxication produces euphoria, slurred speech, and ataxia. Hypoglycemia may be present. With more severe intoxication, bradycardia, hypotension, hypothermia, stupor, coma, and death may occur.

14. (C) Marijuana is the most common illicit drug used by adolescents, ranking a close third after alcohol and cigarette smoking. During the 1990s the prevalence of use within the past month tripled for eighth graders (from 3.2% to 10.2%) and almost doubled for twelfth graders (from 13.8% to 23.7%). In the class of 2002, 48% of twelfth graders reported ever having used marijuana. D-9-tetrahydrocannabinol (THC) is primarily responsible for the neurophysiologic, biochemical, and behavioral changes induced by marijuana. Currently, most marijuana is obtained from a hybrid plant (Cannabis sativa x indica), and only the seedless buds of female plants (sinsemilla) are considered worth smoking. The concentration of THC has increased dramatically in the past 25 years from 2% to 10%. The dose delivered varies with the supplier. The drug may sometimes be adulterated by addition of PCP. The effects of marijuana start from seconds to minutes after inhalation and from 30 to 60 minutes after oral ingestion, peaking at 20 minutes and lasting for 3 hours. Marijuana induces feelings of well-being and relaxation and, at higher doses, it is a hallucinogen. Its serum half-life is 19 hours. It is primarily metabolized in the liver. Twothirds of the cannabinoid metabolites are excreted in the feces and one-third in the urine. After single use it can be detected in urine for up to 5 days and for up to 1-2 months in chronic users.

15. (E) At low doses, marijuana causes euphoria, relaxation, time distortion, vision and hearing distortion or enhancement, increased appetite, tachycardia, dry mouth, and sleepiness. At higher doses, it may cause dysphoric reactions including distortions in body image, disorientation, mood fluctuation, depersonalization, paranoia, and acute panic reactions. Although delirium and hallucinations may occur with high doses of THC, they may indicate the drug has been adulterated with PCP. Conjunctival hyperemia and increased appetite are common. The major effects of marijuana use are behavioral. Long-term use may impair memory, learning ability, and perception. Performance of tasks requiring coordination is significantly affected. The same is true for tracking ability, reaction time, and visualperceptive functioning, all important considerations when driving a car or operating complicated machinery. Attention and short-term memory are affected even in moderate doses. The existence of an “amotivational syndrome” secondary to marijuana remains controversial. Apathy, loss of energy, passivity, absence of drive, loss of effectiveness, impaired concentration and memory, and decreased interest in work and school performance and lack of concern about it have been described as characteristic of the amotivational syndrome, but it is difficult to discern whether marijuana use is the cause or a consequence of preexisting behavioral problems. Nausea is not among the symptoms of marijuana intoxication. THC has antiemetic properties. Adolescent boys that are heavy marijuana users may present with gynecomastia and decreased sperm counts.

16. (D) In 2002, the annual prevalence of use of any illicit drug during their lifetime among 12th graders was 53%. This percentage has been stable since 1997.Twenty-five percent of eighth graders reported ever having used an illicit drug. This includes use of marijuana, LSD, other hallucinogens, crack, other cocaine, heroin, amphetamines, barbiturates, or tranquilizers.

17. (C) In 2002, almost a third of 12th graders reported ever having used an illicit drug other than marijuana. The most commonly used illicit drugs in this category include hallucinogens, amphetamines, MDMA, narcotics (including oxycodone and oxycodone/ acetaminophen), and tranquilizers. Of note, 9.6% of 12th graders reported having used oxycodone plus acetaminophen during the previous year.

18. (C) In 2002, a nationwide survey of the lifetime prevalence of use of various drugs by eighth graders indicated that 25% of them had ever used an illicit drug. If inhalants are included, that percentage climbs to 31%. Nineteen percent of eighth graders reported having used marijuana. After marijuana, inhalants are the most frequent drug of abuse with a lifetime prevalence of 15% and an annual prevalence of 7.7%. Inhalants are more likely to be used by younger than older adolescents. Frequently used inhalants include model glue, gasoline, aerosols used as propellants for cleaning fluids, fabric guard, correction fiuid, deodorants, and spray paint. Toluene is the most common hydrocarbon found in paints and model glues. Inhalation of toluene may result in renal and hepatic damage, neuropathy, seizures, and encephalopathy. Sudden death attributable to cardiac arrhythmias has been reported. Amphetamines rank third with a lifetime prevalence of 8.7%. Almost half of all eighth graders reported they had ever used alcohol, and 1 in 5 report ever having been drunk. About 31% of teens have tried cigarettes and 11.2% have tried smokeless tobacco.

19. (D) All of the above will be necessary except for a pregnancy test, which may remain positive for up to 4 weeks after a pregnancy termination. Complications of first-trimester abortion may include excess blood loss, infection, and failed abortion. Pelvic infection should be excluded. Fever and bleeding 3-7 days postabortion and uterine or adnexal tenderness suggest that diagnosis. Contraception is usually initiated at the time of the procedure. It will be important to reexamine the several psychosocial risk factors discussed on the previous visit (alcohol and marijuana use, poor school performance, anger issues) and to refer for appropriate counseling.

20. (C) With a typical failure rate of 0.3%, depomedroxyprogesterone is one of the most effective hormonal contraceptive available to teens. This failure rate compares very favorably with the one of combined oral contraceptives, which has a failure rate of about 2% in typical adult users and up to 6-7% in teens. It is an excellent method for teens who have difficulties with medication compliance, those who have significant dysmenorrhea or dysfunctional uterine bleeding, those that cannot tolerate estrogens, and particularly those with seizures undergoing anticonvulsant therapy. Irregular bleeding is a common occurrence during the first 3-9 months of use after which most patients will develop amenorrhea for as long as they remain on the medication. Weight gain is a common complaint, particularly in those teens who are overweight when the treatment is started. Osteoporosis may result from long-term use, and a daily calcium supplement should be taken to help prevent this adverse effect. Depomedroxyprogesterone can be started immediately after pregnancy termination.

SUGGESTED READING

Emans SJ. Teenage pregnancy. In: Emans SJ, Laufer MR, Goldstein DP, eds. Pediatric and Adolescent Gynecology. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2005.

Hatcher RA, Trussell J, Nelson AL, Cates W, Steward FH, Kowal, D. Contraceptive Technology. 19th rev. ed. New York, NY: Ardent Media; 2007.

Joffe A, Blythe MJ. Handbook of adolescent medicine. Adolesc Med. 2003;14:2.

Johnson BE, Johnson CA, Murray JL, Apgar BS. Women’s Health Care Handbook. 2nd ed. Philadelphia, PA: Hanley & Belfus, 2000.

Neinstein LS. Adolescent Health Care: A Practical Guide. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.

Schydlower M, ed. Substance Abuse: A Guide for Health Professionals. 2nd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2001.

CASE 78: A 15-YEAR-OLD GIRL WITH OBESITY, ACNE, NO MENSES IN 3 MONTHS, AND POSSIBLE DEPRESSION

A 15-year-old adolescent girl comes to the clinic with a history of deteriorating school performance. Her past medical history indicates that she was a full-term 8-lb 10-oz baby born by cesarean delivery after a pregnancy complicated by gestational diabetes. She attained all her developmental milestones on time. She was never hospitalized and has no chronic illnesses except for seasonal bouts of allergic rhinitis. She is always congested and has been told that her tonsils are “too big.” She started her menses at age 11 years. They have been irregular, with no excessive cramping. Her last menstrual period was 3 months ago. She has a few friends but spends most of her free time at home watching TV. Her family history reveals that her maternal grandmother died 6 months ago at age 56 years, of complications of diabetes and hypertension. Both parents are obese. While interviewing the patient alone and after being assured confidentiality, she tells you she has never been sexually active but wants to start birth control “just to be on the safe side.” She denies smoking cigarettes or using alcohol or other drugs. She has been sleepy lately and sometimes she may even fall asleep in class. She feels tired and quite irritable most of the time. She is unhappy about her appearance and frustrated about her lack of success with several of the diets she tried in the past. She admits to being a “loner” and feels hopeless at times. When asked about suicidal ideation she states that the thought has crossed her mind in the past but she never devised a plan.

On physical examination she is 5'5" tall and weighs 215 lb. The BMI is 40 and the BP is 128/82. She has significant comedonal acne and a small amount of facial hair on sideburns and upper lip. She has moderate acanthosis nigricans on the back of her neck. She has boggy turbinates and enlarged tonsils and breathes mostly through her mouth. The abdominal examination is normal. She has completed her pubertal development (SMR 5).

SELECT THE ONE BEST ANSWER

1. All of following statements regarding adolescent obesity are correct except

(A) higher birthweight predicts increased risk of overweight in adolescence

(B) genetic factors play a significant role in the development of adolescent obesity

(D) obesity in adolescents is usually the result of endocrinopathies

(E) no exception. All of the above are correct

2. All of the following syndromes are associated with obesity except

(A) Prader-Willi

(B) pseudohypoparathyroidism

(D) Kallmann syndrome

(E) Klinefelter syndrome

3. What is the current definition of overweight/obesity in children and adolescents?

(A) BMI greater than the 95th percentile for sex and age

(B) BMI greater than the 85th percentile for age and sex

(D) weight for height greater than the 95th percentile

(E) body weight of 30% greater than the ideal body weight

4. Which of the following conditions are associated with increased adiposity in adolescence?

(A) increased rate of valvular disease

(B) pseudotumor cerebri

(D) hypertension

(E) B, C, and D

5. Regarding the epidemiology of obesity in adolescents, which one of the following statements is not accurate?

(A) the prevalence of obesity among adolescents has tripled during the past 2 decades

(B) adolescent boys and girls have the same prevalence of obesity

(D) the prevalence of obesity in Latino boys is 12%

(E) the prevalence of obesity in African American girls aged 12-19 years is 26.6%

6. Among the elements of the clinical history you need to explore now, which would be most relevant?

(A) detailed dietary history

(B) type, intensity, and duration of exercise

(D) medication

(E) all of the above

7. Among the following, which clinical finding will be the least helpful to distinguish endogenous from exogenous causes of obesity?

(A) height for age

(B) linear growth rate

(D) pigmented striae

(E) myxedema

8. In this patient, any of the following conditions could explain her menstrual delay except

(A) thyroid dysfunction

(B) pregnancy

(D) polycystic ovarian syndrome (functional ovarian hyperandrogenism)

(E) androgen insensitivity

9. All of the following tests should be ordered at this time except

(A) fasting glucose and lipid profile

(B) estradiol and progesterone

(D) pregnancy test

(E) dehydroepiandrosterone sulfate (DHEA-S)

10. The laboratory results indicate that her LH-to-FSH ratio is 5:1. Her testosterone level is 75; DHEA-S is 215. All other hormonal tests were within the normal range. A lipid profile showed a total cholesterol of 190 mg/dL and an LDL of 125 mg/dL. All of the following therapeutic interventions may be indicated at this time except

(A) weight management

(B) combined oral contraceptives

(D) insulin sensitizers

(E) statins

11. Regarding the treatment of her moderate comedonal acne, all of the following are true except

(A) a single daily application of 5% benzoyl peroxide will be effective in most cases of mild comedonal and inflammatory acne

(B) 13-cis-Retinoic acid may be associated with severe teratogenic effects

(D) depomedroxyprogesterone acetate is effective in controlling mixed comedonal-inflammatory acne

(E) some oral antibiotics used for the treatment of acne may lead to photosensitivity reactions

12. All of the following could explain this patient’s increased tiredness and deteriorating school performance except

(A) depression

(B) obstructive sleep apnea

(D) pregnancy

(E) hyperandrogenism

13. Depression should be considered in the differential diagnosis of this adolescent with a history of excessive tiredness, social isolation, and declining school performance. Regarding the epidemiology of depression in adolescents, all of the following are correct except

(A) the incidence of major depressive disorder (MDD) increases from 2% in children to 4-8% in adolescents

(B) the cumulative incidence of MDD is 15-20%

(D) depression is more common in adolescent boys than in girls

(E) bipolar disorder develops in 20-40% of children and adolescents with MDD

14. Depression in children and adolescents is associated with increased risk of suicidal behaviors. Which of the following statements about the epidemiology of suicidal ideation and attempts during adolescence is/are true?

(A) suicide is the third leading cause of death among 15- to 24-year-olds

(B) the rate of completed suicides in adolescents is higher for girls than for boys

(D) A and C

(E) all of the above

15. All of the following are common symptoms suggestive of MDD in adolescents except

(A) irritable mood

(B) feeling of worthlessness

(D) difficulty concentrating

(E) hallucinations

16. Which among the following is a predisposing factor for depression in adolescence?

(A) family history of depression in first-degree relatives

(B) prior depressive illness

(D) family dysfunction

(E) all of the above

17. What circumstances would indicate urgent psychiatric referral for an adolescent with depression?

(A) history of suicidal attempt or present suicidal ideation

(B) psychosis

(D) family unable to monitor teen’s safety

(E) all of the above

ANSWERS

1. (D) It has been shown that higher birthweight predicts increased risk of overweight in adolescence and that having been born to a mother with gestational diabetes is associated with increased likelihood of being overweight in adolescence. However, the effect of gestational diabetes on an offspring’s obesity is controversial. Adjustment for a mother’s own BMI decreases the likelihood of a causal role for abnormal maternal-fetal glucose metabolism as a cause of obesity in the offspring. Dissatisfaction with body image is a common occurrence during adolescence, particularly among girls. It usually leads to unhealthy weight control practices and eating patterns and in some studies was found to predict the onset of depression. In most instances, obesity is a chronic multifactorial disease. Only 3% of obese adolescents have underlying endocrinopathies such as hypothyroidism, Cushing syndrome, or hypothalamic/pituitary diseases and pseudohypoparathyroidism. An additional 2% of obese adolescents have rare genetic syndromes associated with obesity. Obesity associated with mental retardation, short stature, cryptorchidism or hypogonadism, dysmorphism, and ocular or auditory defects should suggest a genetic origin. Prader-Willi syndrome is the most frequent of the genetic disorders associated with obesity. The remaining 95% of obesity in adolescents results from a combination of genetic and environmental factors not fully elucidated. Genetic factors play a significant role in the development of obesity and are known to explain 30-50% of its variability. Studies show that if one parent is obese, the risk of obesity for the offspring is 30%; if both parents are obese, the risk increases to 70%. Although some of these findings may be explained by environmental factors, there is a high correlation between the BMI of identical twins, even when reared in different households. Also, a strong correlation has been shown between the BMIs of adoptees and their biological parents, whereas none exists between those of adoptees and their adoptive parents.

2. (E) Alstrom syndrome is a rare disease with autosomal recessive inheritance. Retinal degeneration, truncal obesity, diabetes mellitus, and sensorineural hearing loss are characteristic features of this condition. Further variable symptoms include chronic hepatitis, asthma, and an impaired glucose tolerance test. Pseudohypoparathyroidism (PHP) is associated with biochemical hypoparathyroidism (eg, hypocalcemia and hyperphosphatemia) because of parathyroid hormone (PTH) resistance rather than with PTH deficiency. In this condition, target renal cells are unresponsive to PTH, leading to increased reabsorption of phosphate. PHP type 1 is the most common form and is associated with a combination of skeletal and developmental features known as Albright hereditary osteodystrophy. Clinical characteristics of this syndrome include short stature, obesity, round facies, short neck, brachydactyly, and mental retardation. Prader-Willi syndrome is characterized by early onset of obesity with hyperphagia, infantile hypotonia, hypogonadism, cryptorchidism, and mental retardation. Short stature, small hands and feet, strabismus, and increased incidence of diabetes mellitus are common findings in this condition. The incidence of the syndrome is 1:16,000. It results from deletions of a segment of the paternal chromosome 15. Klinefelter syndrome occurs in men who have an extra X chromosome leading to a 47,XXY karyotype. Its clinical features include small, firm testes, azoospermia, variable degrees of eunuchoidism, gynecomastia, mental abnormalities, and hypergonadotropic hypogonadism. A slim, tall body habitus is characteristic in this condition.

3. (A) The BMI is used to identify overweight and those at risk of overweight in children and adolescents. This index is calculated by dividing weight by squared height.

A BMI at the 95th percentile or higher identifies children or teenagers who are overweight; children with a BMI between the 85 and 95th percentiles for age and gender are categorized as at risk for being overweight. Current investigations suggest the threshold may change from 95% to 85% to categorize overweight in children. A potential limitation to the use of the BMI results from the fact that the index is based on weight and height. Because weight is not always a measure of adiposity and may result from increased muscle or bone mass, a definitive clinical definition of obesity may require an additional measurement such as the triceps skinfold thickness. Nevertheless, the vast majority of children with BMI higher than the 95th percentile for age and sex are also found to have increased percentage of body fat by other methods. BMI not only identifies children who have increased body fat but also helps predict associated risk factors such as elevated BP or increased insulin levels.

Because, before adulthood, adiposity varies with age and gender, BMI is age and gender specific in children and adolescents. BMI charts provide a reference that allows for longitudinal follow-up of adiposity from age 2-20 years. They can be used to track body size throughout childhood and adolescence.

4. (E) Obesity during adolescence is associated with numerous short-term and long-term health consequences, including hypertension, hyperlipidemia, type 2 diabetes mellitus, sleep apnea, gallbladder disease, pseudotumor cerebri, and orthopedic conditions such as slipped femoral capital epiphysis and tibia vara or Blount disease. Obese adolescents may suffer from low self-esteem, poor body image, social isolation, and increased incidence of depression. Long-term consequences include a higher mortality risk for cardiovascular and cerebrovascular disease during adulthood, tibia vara, gallstones, osteoarthritis, and increased risk for certain cancers (colon, rectum, prostate). Unfavorable social outcomes such as lower education levels, lower incidence of marriage, lower household income, and a higher rate of poverty as a consequence of pervasive cultural stereotypes have also been documented.

5. (D) National statistics from 1999-2000 showed that the overall prevalence of obesity among adolescents increased from 5% to 15% in the past 2 decades. Both adolescent girls and boys have an overall prevalence of 15.5%. However, minority adolescents have the highest prevalence of obesity with rates as high as 27.7% in Mexican boys and 26.6% in African American girls. Several factors seem to play a role in these discouraging statistics, including increased food availability and portion sizes, sedentary lifestyles, television viewing, time spent on computer games, aggressive marketing of fast food to young people, and decreased opportunity for sports and other outdoor activities in schools and within communities.

6. (E) A thorough clinical history will help identify endogenous causes of obesity and determine exogenous contributing factors and existing or potential complications. A detailed dietary history should include, among other items, the types of food preferred, portion sizes, numbers of meals a day, and patterns of food consumption. Given the importance of physical activity in maintaining normal weight and in view of the increasingly sedentary habits of adolescents, it is essential to take a detailed exercise history. Medications such as tricyclic antidepressants, antipsychotics, depomedroxyprogesterone, and corticosteroids are associated with significant weight gain.

7. (C) A comprehensive physical examination in overweight adolescents should include height, weight, BP, pulse, and respiratory rate. It is essential to review the growth chart because overweight patients with underlying endocrinopathies are usually short for age, whereas those with exogenous obesity have either normal or above-normal height for age. A decline in height velocity is typically found in teens with endogenous causes of obesity. The skin examination may reveal acne, acanthosis nigricans, intertrigo, or striae. Although striae are a common finding in overweight teens, purplish striae suggest underlying hypercortisolism. Acne is present in a large percentage of teenagers independent of the presence of obesity. Within a clinical scenario of obesity, irregular menses, and hirsutism in an overweight girl, significant acne could be an additional indicator suggesting hyperandrogenism. Although acanthosis nigricans is associated with uncomplicated obesity, it is also recognized as a marker of insulin resistance and thus possibly a harbinger of type 2 diabetes mellitus. Intertrigo is a common finding in overweight adolescents regardless of etiology. A thorough cardiopulmonary, musculoskeletal, and neurologic assessment is needed, looking for evidence of hypertension, cor pulmonale, degenerative changes of the joints, slipped capital femoral epiphysis, and pseudotumor cerebri.

8. (E) Obesity, thyroid dysfunction, hypothalamic amenorrhea, and functional adrenal or ovarian hyperandrogenism could explain this young woman’s 3-month history of amenorrhea. Androgen insensitivity would not be in the differential diagnosis because the patient had normal menses in the past.

9. (B) Even though there is no history of sexual activity, it is always important to exclude pregnancy in any adolescent with secondary amenorrhea. In this patient, because of her obesity and positive family history for diabetes and hyperlipidemia, she is at higher than normal long-term risk for cardiovascular disease. A fasting glucose and lipid profile should be ordered. TSH and prolactin level would help exclude hypothyroidism and hyperprolactinemia; total and free testosterone and DHEA-S levels will be useful to assess the cause of her clinical hyperandrogenism.

10. (E) Because obesity and resulting insulin resistance play a prominent role in the pathogenesis of polycystic ovarian syndrome, therapeutic interventions should first address weight management. In patients with signs of hyperandrogenism who do not desire to get pregnant, combined oral contraceptives are effective in controlling the clinical manifestations. Topical acne medication should also be recommended. Insulin sensitizers have been found useful in the treatment of patients with polycystic ovary syndrome because they correct insulin resistance, androgen excess, and clinical manifestations of hyperandrogenism.

11. (D) Oral contraceptives, particularly those with low androgenic effects, are effective in the treatment of acne because they decrease biologically active free testosterone and reduce ovarian androgen production. In contrast, depomedroxyprogesterone and long-acting progestin implants often worsen acne. Mild comedonal acne can be successfully treated with 5% benzoyl peroxide gel in most cases; moderate comedonal acne may require daily applications of tretinoin cream or gel in concentrations from 0.025% to 0.05%. Topical antibiotics are effective in the treatment of moderate inflammatory and mixed acne. They work best when combined with benzoyl peroxide. Severe acne may respond to tretinoin cream or gel but, if inflammatory, will often require oral antibiotics. If there is no response, the patient should be referred to a dermatologist. In this patient, who will also receive combined oral contraceptives to treat other manifestations of hyperandrogenism, topical 5% benzoyl peroxide with or without topical antibiotics would be helpful as initial therapy.

12. (E) Several elements of the history suggest the possibility of depression, including her increased tiredness, dissatisfaction with body image, deteriorating school performance, and limited social interactions. There has been a recent death in the family for which she may be appropriately grieving. She does not admit to feeling sad or depressed and specifically denies suicidal ideation. Nevertheless, depression is still a consideration in this girl and should be explored further. Obstructive sleep apnea is a likely possibility given her morbid obesity and enlarged tonsils. Additional history taking may reveal loud snoring, brief periods of apnea while asleep with continuing respiratory effort, and daytime somnolence. A polysomnogram will be needed to confirm the diagnosis. Hypothyroidism should be considered in the differential diagnosis of any adolescent with obesity, increased tiredness, and deteriorating school performance. Early pregnancy may lead to increased somnolence and weight gain.

13. (D) Depression is, by far, one of the most prevalent forms of psychopathology in adolescents. Its broad clinical spectrum spans from transient depressive mood, which could be a justified response to the frustrations of daily life, to major depressive disorders requiring hospitalization. Despite the fact that depression is a major cause of morbidity and mortality during the second decade of life, it is estimated that two-thirds of adolescents with clinical depression go unrecognized and untreated. Moreover, depression is often associated with significant comorbidities. It has long-term effects on psychosocial functioning and, importantly, is a major risk factor for suicide. The risk of MDD increases from 2-8% from childhood to adolescence. Although among children there is no gender difference in the risk of significant depression, during the second decade of life, the female-to-male ratio for MDD becomes 2:1, a difference that will persist throughout life. Bipolar disorder develops in 20-40% of children and adolescents with MDD.

14. (D) Suicide is the third leading cause of death among 15- to 24-year-olds in the United States after MVAs and homicide. Twelve percent of deaths in this age group are due to suicide. The rates of completed suicides are about 5 times higher in males than in females (15:100,000 and 3.3:100,000, respectively). Up to 20% of high school students report having had suicidal ideation in the previous 12 months, and up to 8% of the students in the same survey had attempted suicide one or more times during that time period. It is estimated that 500,000 teens make a suicide attempt each year. The rates of suicidal attempts are higher among girls than among boys, whereas the rates of completion are higher in boys and in girls because boys tend to use more violent and lethal means. Rates of attempted suicide are higher in gay/lesbian and bisexual youth. Among adolescents who develop MDD, up to 7% may commit suicide in the young adult years. These data emphasize the need to screen all adolescents for emotional disorders, specifically for depressed mood and suicidal ideation during the well-teen visit. Early diagnosis and treatment of depression, accurate evaluation of suicidal ideation, and limiting access to lethal agents—including firearms and medications—are valuable strategies in the prevention of suicide in adolescents.

15. (E) Even though the diagnostic criteria of MDDs are the same in adolescents as in adults, the recognition of the disorder is often more difficult in young people. In teens, irritability and acting out are more common presenting features of depression than depressed mood. Symptoms of depression include

• Persistent sad or irritable mood

• Loss of interest in activities once enjoyed

• Significant change in appetite or body weight

• Difficulty sleeping or oversleeping

• Psychomotor agitation or retardation

• Loss of energy

• Feelings of worthlessness or inappropriate guilt

• Difficulty concentrating

• Recurrent thoughts of death or suicide

Five or more of these symptoms must persist for 2 weeks or more for the diagnosis of major depression to be established. The symptoms must cause significant distress or impairment and represent a change from previous functioning. They must not be attributable only to substance abuse, or medication, or medical condition, or accounted for by bereavement. A fundamental prerequisite for the diagnosis is to exclude a history of manic, manic-depressive, or hypomanic episodes. Either depressed and/or irritable mood or loss of interest in almost all previously pleasurable activities should be present most of the day, nearly every day for 2 or more weeks, with the others occurring during the same time period. Other signs of depression in adolescents include

• frequent vague nonspecific physical complaints such as headaches, muscle aches, stomachaches, or tiredness

• frequent absences from school or poor performance in school

• talk of or efforts to run away from home

• outbursts of shouting, complaining, unexplained irritability or crying

• being bored; lack of interest in playing with friends

• alcohol or substance abuse

• social isolation

• poor communication

• fear of death

• extreme sensitivity to rejection or failure

• increased irritability, anger, or hostility

• reckless behavior

• difficulty with relationships.

However, decreased need for sleep, grandiosity, and overinflated sense of self, if present, suggest the diagnosis of bipolar disorder.

16. (E) All of the following are considered predisposing factors for depression in adolescence: family history of depression in first-degree relatives, history of prior depressive episode, chronic illness, family dysfunction, peer problems, academic difficulties, learning disabilities, early losses, history of anxiety disorders or attention deficit hyperactivity disorder (ADHD), history of abuse or neglect, stress, breakup of a romantic relationship, traumatic events (eg, exposure to violence, natural disasters).

17. (E) All the above conditions would indicate the need for urgent psychiatric evaluation and treatment. Treatment for depressive disorders in children and adolescents often involves short-term psychotherapy, medication, or a combination of both, together with targeted interventions involving the home and school environment. Optimal treatment of a teen with depression calls for counseling in all cases. Certain types of short-term psychotherapy, particularly cognitive-behavioral therapy (CBT), have been helpful to relieve depression in children and adolescents. However, the use of antidepressant medication in children and adolescents remains controversial. Medication should be considered in adolescents with moderate to severe depression, severe vegetative symptoms, marked functional impairment, presence of psychotic symptoms, strong family history of depression, depressed phase of bipolar disorder, or failed psychotherapeutic intervention.

SUGGESTED READING

American Academy of Child and Adolescent Psychiatry. Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry. 2001;40:24S.

Suicide and suicide attempts in adolescents. Committee on Adolescents. American Academy of Pediatrics. Pediatrics. 2000;105:871-874.

Bonin L. Depression in adolescents: epidemiology, clinical manifestations, and diagnosis. Up-to-Date Web site, 2004. http://www.uptodateonline.com. Accessed June 2010.

Anderson RN. Deaths: leading causes for 2000. Natl Vital Stat Rep. 2002;50(16):1-85.

Dietz WH, Robinson TN. Overweight children and adolescents. N Engl J Med. 2005;352(20):2100-2109.

Joffe A, Blythe MJ. Handbook of adolescent medicine. Adolesc Med. 2003;14:2.

Kennebeck S, Bonin L. Epidemiology and risk factors for suicidal behavior in children and adolescents. Up-to-Date Web site, 2004. http://www.uptodateonline.com. Accessed June 2010.

Neinstein LS. Adolescent Health Care: A Practical Guide. 5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.

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