Pediatric Residency Training Program

3

Adolescent Medicine

Lloyd J. Brown MD

1. Adolescent Growth and Development
2. Growth

Adolescence is a time of substantial physical growth and pubertal maturation.

1. Changes in physical growth
2. The average duration of the growth spurt is 2–3 years.
3. Growthis predominantly controlled by growth hormone, although insulin, thyroid hormone, and sex steroids also influence growth.
4. Nearly 50%of ideal adult body weight and 25% of final adult height are gained during the pubertal growth spurt.
5. The growth spurtoccurs 18–24 months earlier in females than in males.
6. Development of genitalia and secondary sexual characteristics.
7. The average duration of puberty is 3–4 years.
8. Endocrinologic changes during puberty.The factor responsible for the initiation of puberty is unknown.
9. Adrenarche, the onset of adrenal androgen steroidogenesis, occurs 2 years before the maturation of the hypothalamic-pituitary-gonadal axis.
10. True pubertyis said to occur when gonadotropins, such as luteinizing hormone (LH), follicle-stimulating hormone (FSH), and gonadal sex steroids (e.g., estrogen and testosterone), increase.
11. Table 3-1lists the actions of hormones in males and females.
12. Physical changes during puberty
13. Males.Puberty begins 6–12 months later in males than in females.
14. Testicular enlargement begins between ages 11 and 12 years and is the first sign of puberty.
15. Facial and axillary hair growth begins approximately 2 years after the growth of pubic hair begins.

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Table 3-1. Actions of Sex Hormones in Both Males and Females

Hormone Action in Males Action in Females Follicle-stimulating hormone Induces spermatogenesis Stimulates development of ovarian follicles Stimulates ovarian granulosa cells to produce estrogen Luteinizing hormone Induces testicular Leydig cells to produce testosterone Stimulates ovarian theca cells to produce androgens Stimulates corpus luteum to produce progesterone Midcycle surge results in ovulation Testosterone Increases linear growth and muscle mass Induces development of penis, scrotum, prostate, and seminal vesicles Induces growth of pubic, axillary, and facial hair Deepens voice Increases libido Stimulates linear growth Stimulates growth of pubic and axillary hair Estradiol Increases rate of epiphyseal fusion Stimulates breast development Triggers midcycle luteinizing hormone surge Stimulates labial, vaginal, and uterine development Stimulates growth of a proliferative endometrium Low level stimulates linear growth High level increases rate of epiphyseal fusion Progesterone Converts endometrium to a secretory endometrium Adrenal androgens Stimulates growth of pubic hair Stimulates linear growth Stimulates growth of pubic hair Stimulates linear growth (Adapted from Neinstein LS. Adolescent Health Care, A Practical Guide. 3rd Ed. Baltimore: Williams & Wilkins, 1996.)

1. Figure 3-1shows the five stages of development of male genitalia and pubic hair as described by Tanner (Tanner staging or sexual maturity rating).
2. Females.Puberty begins with the development of breast buds (thelarche) at a mean age of 9.5 years.
3. Pubic hairgenerally follows thelarche.
4. Menarche, the onset of the first menstrual cycle, occurs at a mean age of 12.5 yearsand occurs 2–3 years after thelarche.
5. Figure 3-2and 3-3 show the development of breasts and pubic hair, respectively, as described by Tanner.
6. Psychosocial development

Adolescent development may be classified into three stages: early, middle, and late. As an adolescent passes through the stages of psychosocial development, he or she develops a sense of self, achieves increasing independence from his or her parents, increases his or her involvement with peer groups, and develops a healthy body image.

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Figure 3-1. Sexual maturity ratings for male genitalia and pubic hair development.

Figure 3-2. Sexual maturity ratings for female breast development.

Figure 3-3. Sexual maturity ratings for female pubic hair development.

1. Early adolescence(10–13 years of age)
2. Early shift to independence from parents, with declining interest in family activities, beginnings of conflicts with parents, and the presence of mood and behavior changes
3. Preoccupation with pubertal body changes

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1. Same-sex peer relationships
2. Beginnings of abstract thinkingand lack of impulse control, with risk-taking behaviors
3. Middle adolescence(14–17 years of age)
4. Increased conflictswith parents
5. Diminished preoccupationwith pubertal changes but increased preoccupation with methods to improve one's own physical attractiveness
6. Intense peer group involvementand initiation of romantic relationships
7. Increasingly abstract reasoning and risk-taking
8. Late adolescence(18–21 years of age)
9. Development of self as distinctfrom parents. Adolescents are better able to take and more likely to seek advice from parents.
10. Being comfortable with own body image
11. A shared intimate relationshipwith at least one partner
12. Well-developed abstract thought processes, with fewer risk-takingbehaviors. Adolescents are able to articulate future educational and vocational goals.
13. Adolescent Health Screening
14. Goals

are to promote optimal physical and psychosocial growth and development.

1. History

Information should be obtained directly from the adolescent alone. However, the family can also be an important source of additional information. Practitioners may choose to interview the family together with the adolescent, either before or after interviewing the adolescent alone.

1. Confidentiality, trust, and rapport are important to establish to provide effective care to adolescents. Confidentiality encourages adolescents to seek care and protects them from embarrassment and discrimination.
2. Rapportcan be best established by beginning the history with nonthreatening subjects such as favorite hobbies, interests, or activities.
3. Informationprovided by the adolescent should remain confidential, although sexual or physical abuse and suicidal or homicidal intention must be reported.
4. Most state laws allowadolescents to consent without parent approval for pregnancy-related care, diagnosis and treatment of sexually transmitted diseases (STDs), reproductive health care, counseling and treatment of drug or alcohol problems, and mental health treatment.
5. Components of the historyinclude present illness or concerns, past medical and family histories, and a psychosocial history using the HEADSS assessment (home, education andemployment, activities, drugs, sexual activity, suicide and depression; Table 3-2).
6. Physical examination

The physician should pay special attention to physical growth and pubertal development, detection of disease, and specific adolescent concerns.

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Table 3-2. HEADSS Questionnaire Used in Psychosocial Assessment of Adolescents

Home Where, and with whom, does teen live? Has teen ever run away or been arrested? How does teen interact with parents? Is there a firearm at home? Education and employment Is teen in school? What is teen's academic performance? What classes does teen enjoy? Dislike? Has teen ever been suspended? Dropped out? What are teen's career goals? Does teen have a job? Activities What are teen's hobbies? What does teen enjoy doing after school? On weekends? With whom does teen spend free time? Drugs Has teen tried any drugs? If yes, how much? How often? Has teen used tobacco? Alcohol? Steroids? Do teen's friends use drugs? Sexual activity Is teen currently sexually active? If yes, what type of contraception is used? Does teen use condoms? How many sexual partners? Any STDs? What is teen's sexual orientation? Does teen have any history of sexual or physical abuse? Suicide and depression Is teen ever sad or depressed? Has teen ever considered or attempted suicide? STD = sexually transmitted disease.

1. Height and weightshould be measured and plotted on age-appropriate growth charts.
2. Blood pressure, pulse, and vision and hearingassessments should be performed.
3. Skinshould be examined for acne and fungal infections.
4. Teethshould be examined for malocclusion and hygiene.
5. Thyroidshould be palpated for enlargement or nodules.
6. Backshould be evaluated for scoliosis or kyphosis.
7. Pubertal developmentshould be assessed, and a Tanner rating should be assigned (see Figures 3-1, 3-2 and 3-3).
8. Male genitaliashould be examined for scrotal masses and inguinal hernias. Instruction should be given on the performance of a proper testicular self-examination.
9. Female genitaliashould be examined. A complete pelvic examination should be performed annually if the patient is sexually active; if she has a history of pelvic pain, vaginal discharge, or abnormal bleeding; or if she is 18 years of age or older. In addition, instruction should be given on the performance of a proper breast self-examination.
10. Immunizations
11. Tetanus and diphtheria booster (Td)should be given between 11 and 12 years of age and every 10 years thereafter.
12. Measles, mumps, and rubella booster (MMR)and the hepatitis B vaccine series should be given if not given before adolescence. Hepatitis A vaccine should be given to those adolescents who reside in endemic areas.

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3. Varicella vaccineshould be considered if the adolescent has not had chickenpox and has not received vaccination against the disease.
4. Laboratory Studies
5. Hemoglobin and hematocritto screen for anemia.
6. Urinalysisto screen for proteinuria and hematuria.
7. Cholesterol level or fasting lipid panel(see Chapter 1, section IV for guidelines).
8. Human immunodeficiency virus (HIV) testingis not routinely indicated, but it should be offered if indicated by history or if requested. Counseling must be given regarding the benefits of testing and consequences of the results.
9. Mantoux skin test (PPD)for tuberculosis (TB) should be administered at least once during adolescence. PPD may be necessary more often if the adolescent is at high risk of exposure to TB.
10. Sexually active adolescent femalesshould be screened for the following STDs:
11. Cervical culture for Neisseria gonorrhoeae
12. Immunofluorescent antibody test or culture of cervical fluid, or urine ligase test, forChlamydia trachomatis
13. Serologic test for syphilis
14. Papanicolaou (Pap) smear for cervical cancer screeningand detection of human papillomavirus (HPV)
15. Vaginal wet mount forTrichomonas vaginalis
16. Sexually active adolescent malesshould have annual syphilis serology, routine urinalysis for pyuria, and a urine ligase test for C. trachomatis.
17. Health guidance

Counseling should be provided annually.

1. Injury prevention.Education should include counseling about alcohol and drug avoidance, firearm safety, and the use of seat belts and motorcycle and bicycle helmets.
2. Benefits of a healthy diet and physical exercise
3. Education regarding responsible sexual behaviors

III. Depression and Suicide

1. Epidemiology
2. Suicideis the third leading cause of death in adolescents 15–19 years of age, after unintentional injuries and homicide.
3. Episodes of sadness or depressed moodoccur monthly in the majority of adolescents, and 5% of teens are clinically depressed.
4. Girlsare depressed two times as often as boys.

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4. Risk factorsfor suicide or depression
5. Family or peer conflicts
6. Substance abuse
7. Significant loss, including death of a loved one
8. Divorce or separationof parents
9. Poor school performance or learning disability
10. Physical or sexual abuse
11. Family history of depression or suicide
12. Previous suicide attempt
13. Physical illness
14. Clinical features of depression
15. Teens with depressioncan have a wide range of behavioral, physical, and psychological symptoms.
16. Behavioral signs of depressioninclude missing school, change in school performance, acting out (e.g., arguing with family and friends, stealing, destruction of property), lack of interest in activities that previously were pleasurable, desire to be alone or being withdrawn, and substance abuse.
17. Physical signs of depressioninclude abdominal pain, headaches, weight loss, overeating, insomnia, anxiousness, diminished appetite, and fatigue.
18. Psychological signs of depressioninclude sadness, feelings of hopelessness, low self-esteem, excessive self-criticism, and feeling worthless.
19. The following are theDiagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) criteria for major depression: Five of nine symptoms must be presentalmost every day for at least 2 weeks and must impair ability to function normally.
20. Depressed or irritable mood
21. Diminished interest or pleasure in activities
22. Weight gain or loss
23. Insomnia or hypersomnia
24. Psychomotor agitation or retardation
25. Fatigue or energy loss
26. Feelings of worthlessness
27. Diminished ability to concentrate
28. Recurrent thoughts of death or suicide
29. Clinical features of dysthymic disorder

Dysthymia is a more chronic mood disturbance that lasts at least 1 year. The symptoms of dysthymia are milder than those of depression. The following are the DSM-IV criteria for dysthymia:

1. While depressed, two of fiveof the following symptoms must be present:
2. Poor appetite or overeating
3. Insomnia or hypersomnia

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1. Diminished energy
2. Difficulty concentrating
3. Feelings of hopelessness
4. Symptoms must last for at least 1 year.
5. Substance Abuse
6. Epidemiology

Ninety percent of high school seniors have tried alcohol, 50% have tried an illegal drug, and 60% have tried cigarettes.

1. Etiology

Use by family or peers, experimentation, stress relief, poor self-esteem, boredom, social acceptance, enhancement of ability to act socially, and acting-out behavior against authority figures are all reasons adolescents may use illegal drugs, alcohol, or tobacco.

1. Diagnosis

Substance abuse should be considered if the following factors are present: mood or sleep disturbances, truancy, decline in school performance, changes in friends and family relationships, diminished appetite or weight loss, depression, and diminished participation in school or household responsibilities.

1. Most commonly used substances: alcohol, tobacco, and marijuana
2. Alcohol is the most commonly used substance.
3. Problem drinkingis defined as having been intoxicated six or more times within 1 year or having problems in areas attributable to drinking, such as missing classes at school, arguing with teachers, classmates, or friends, or driving intoxicated.
4. Binge drinkingis defined as five or more consecutive drinks at one sitting. As many as 50% of all college students report binge drinking, and binge drinkers are more likely to fight, drive drunk, and have unplanned sexual intercourse.
5. Alcoholismis defined as a preoccupation with and impaired control over drinking, despite adverse consequences.
6. The CAGE questionnairemay be used to screen for alcoholism.
7. Have you ever felt you had to cutdown on drinking?
8. Have people annoyedyou by criticizing your drinking?
9. Have you ever felt guiltyabout drinking?
10. Have you ever had a drink first thing in the morning (eye opener)?
11. Tobacco
12. Teens who smoke tobaccoare more likely to try other drugs and have lower academic performance.
13. Nicotine is highly addictive.Most adult smokers begin smoking in their teenage years.
14. Health risks of smoking
15. Coronary artery disease and stroke
16. Cancersof the lungs, mouth, esophagus, stomach, larynx, and urinary tract

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3. Chronic lung disease and asthma
4. Peptic ulcer disease
5. Pregnancy complications, such as stillbirth, low birth weight, and higher-than-normal infant mortality
6. More than 3 million teens chew smokeless tobacco. Smokeless tobacco is associated with oral cancers, gingival recession, and low birth weight and premature delivery in mothers who use smokeless tobacco during pregnancy.
7. Marijuana is the most widely used illicit drug.It is derived from the plant Cannabis sativa. The active ingredient is tetrahydrocannabinol (THC).
8. Physical effectstypically include tachycardia, mydriasis, sleepiness, conjunctival erythema, dry mouth, auditory and visual hallucinations, increased appetite, and impaired cognition.
9. Long-term consequencesof heavy marijuana use may include asthma, impaired memory and learning, truancy, diminished interpersonal interactions, and depression.
10. Obesity and Eating Disorders
11. Obesity

is one of the most common chronic illnesses among adolescents.

1. Definition.Obesity is a body weight 20% greater than ideal body weight.
2. Body-mass index(body weight in kilograms divided by height in meters squared) greater than 95% for age and sex is considered obese.
3. Body fatcontent may also be determined by measuring skin-fold thickness at the triceps and subscapular areas.
4. Etiology.Causes are often multifactorial. Obesity is commonly the result of the interaction among genetic factors, increased caloric intake, diminished energy expenditure, and poor eating behaviors. Underlying endocrinologic or genetic causes (e.g., hypothyroidism, Cushing disease, hypogonadism, Prader-Willi syndrome) are found in only 5% of patients.
5. Health effects associated with obesity
6. Earlier pubertal development
7. Hypertension and cardiovascular disease
8. Hypercholesterolemia and elevated triglycerides
9. Type 2 diabetes mellitus
10. Gallbladder disease
11. Orthopedic problemssuch as back pain and tibia vara (bowlegs)
12. Poor body image, depression, and low self-esteem
13. Management. Treatmentis challenging and must be multifaceted. Therapies include modification of eating behaviors, promotion of healthy nutrition, a balanced weight reduction program, exercise, and psychological support.

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1. Anorexia nervosa and bulimia nervosa

typically occur in females 13–18 years of age.

1. Epidemiology. Anorexia nervosaoccurs in approximately 0.5–1% of adolescents, and bulimia nervosa occurs in approximately 1–5% of adolescents.
2. Diagnostic criteria for anorexia nervosa
3. Caloric intake is insufficientto maintain weight or growth.
4. Adolescenthas a delusion of being fat and an obsession to become thin.
5. Specific criteria
6. Refusal to maintain body weightat normal weight for age and height. Body weight is 15% below ideal body weight for age.
7. Intense fear of weight gainand denial of the seriousness of low weight or weight loss
8. Disturbed body image
9. Absence of three consecutive menstrual cycles
10. Excessive exercise, fluctuating emotions, withdrawal from peers and family, and a preoccupation with foodare often present.
11. Diagnostic criteria for bulimia nervosa
12. Eating patternincludes binge eating, in which a large volume of food is consumed in a short period of time.
13. Specific criteria
14. Recurrent episodes of binge eating at least twice weekly for 3 months
15. Lack of control over eatingduring binging. Anxiety, guilt, or sadness often occur after each binge.
16. Purgingusing vomiting, laxatives, diuretics, or enemas to prevent weight gain
17. Fasting, rigorous exercise, or diet pillsmay be used to prevent weight gain.
18. Disturbed body image
19. Physical examination and laboratory findingsare described in Table 3-3.
20. Management. Treatmentof an adolescent with anorexia nervosa or bulimia nervosa is challenging and often requires a team approach, including involvement of the family.
21. Normal nutritionmust be established, anorexic or bulimic behaviors must be relinquished, and the adolescent must gain insight into the reasons behind the disorder. Nutritional guidance and psychological counseling are often required.
22. Hospitalizationis necessary if the adolescent has evidence of severe weight loss, electrolyte abnormalities, dehydration, abnormal vital signs, suicidal thoughts, medical complications (such as seizures, cardiac arrhythmias, or pancreatitis), or failure of outpatient medical management (including food refusal).

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Table 3-3. Physical Examination and Laboratory Abnormalities in Anorexia Nervosa and Bulimia Nervosa

Eating Disorder Examination Findings Laboratory Findings Anorexia nervosa Weight ≥ 15% below ideal level Hypothermia Hypotension Bradycardia Delayed growth and puberty Malnourished (wasted, hypoactive bowel sounds, dependent edema, fine lanugo hair) Evidence of dehydration Anemia Leukopenia Low thyroxine Low glucose Low calcium Low magnesium Low phosphorus Low sex steroids High blood urea nitrogen High liver transaminases Bulimia nervosa Less ill-appearing Normal weight (usually) Hypothermia, hypotension, and bradycardia if excessive purging Sequelae of vomiting (trauma to palate and hands, loss of dental enamel, parotid swelling) Low chloride, low potassium, and high blood urea nitrogen if excessive vomiting

1. Female Reproductive Health Issues.

One half of adolescents are sexually active by the end of high school

1. Pregnancy
2. Epidemiology. One millionadolescent females (one of every nine) become pregnant every year in the United States.
3. One fifthof adolescent pregnancies occur within the first month after the teen first commences sexual intercourse.
4. Most (80%) adolescent pregnancies are unintentional.
5. One halfof adolescent pregnancies result in delivery, one third result in abortion, and one sixth result in miscarriage.
6. Associated conditions. Adolescent pregnancyis a high-risk pregnancy associated with increased incidence of:
7. Infant health problems, including low birth weightand higher-than-usual infant mortality
8. Maternal health problems, including anemia, hypertension, and preterm labor
9. Dropping out of school
10. Unemployment and need for public assistance
11. Contraception
12. One halfof all sexually active adolescents do not use any contraception for one or more of the following reasons:
13. Ignoranceof the contraceptive methods available
14. Denialof the risk of pregnancy
15. Barrierstoward obtaining contraception, including issues of confidentiality and cost

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1. Refusalby partner to use contraception
2. Religious beliefs
3. Ambivalence to, or desire for, pregnancy
4. Contraceptive methods
5. Abstinenceoffers the greatest protection and should always be discussed as a reasonable option to sexual intercourse.
6. Barrier methodsinclude the male condom, female condom, vaginal diaphragm, and cervical cap.
7. Male condomis a sheath placed onto the erect penis to prevent passage of sperm into the vagina.
8. Condoms are very important as a barrier against STDs.Only condoms made of latex protect against transmission of the HIV virus.
9. Advantagesinclude low cost and safety.
10. Disadvantagesinclude interference with spontaneity and rare allergic reactions.
11. Female condomis a polyurethane sheath placed into the vagina to prevent the passage of sperm.
12. Advantagesinclude protection against STDs.
13. Disadvantagesinclude vaginal irritation or allergy and awkwardness of placement.
14. Vaginal diaphragmis a mechanical barrier placed against the cervix and used in combination with spermicide.
15. Advantagesinclude spontaneity. It may be inserted as many as 6 hours before intercourse.
16. Disadvantagesinclude need for individual fitting by a trained health care professional, awkwardness of placement, and increased risk of urinary tract infection (UTI).
17. Cervical capis a cuplike diaphragm placed tightly over the cervix.
18. Advantagesinclude the ability to leave the cap in place for up to 48 hours.
19. Disadvantagesinclude need for individual fitting, increased risk of UTIs, and need for follow-up Pap smear to screen for cervical dysplasia, which has been associated with the cap.
20. Intrauterine devices (IUDs)can be safe, effective methods of birth control for selected adolescents. Two types of IUDs, the T38A copper-bearing and the progesterone-releasing IUDs, are available.
21. Mechanisms of actioninclude interference with sperm transport and motility (copper IUD) and induction of endometrial atrophy (progesterone IUD).
22. Advantagesinclude convenience and privacy.
23. Disadvantagesinclude lack of protection against STDs, uterine bleeding and cramping, need for insertion by a professional, initial higher cost, and possible increased risk of pelvic inflammatory disease (PID).

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3. Oral contraceptivesare either a combination of estrogen and progesterone or progesterone only.
4. Mechanisms of actioninclude inhibition of ovulation and thickening of cervical mucus, which interferes with passage of sperm.
5. Advantagesinclude decreased dysmenorrhea, regulation of menstrual bleeding, possible protection against endometrial and ovarian cancer, improved acne, and spontaneity.
6. Disadvantagesinclude headache, weight gain, amenorrhea, breakthrough bleeding, mood changes, nausea, lack of protection against STDs, and the need to remember to take the pill daily.
7. Absolute contraindicationsto taking oral contraceptives include pregnancy, breast or endometrial cancer, stroke, coronary artery disease, and liver disease. Relative contraindications include hypertension, migraine headaches, diabetes, sickle cell anemia, elevated lipids, and smoking.
8. Contraceptive injectionsinvolve the slow release of the progestin depomedroxyprogesterone acetate (Depo-Provera).
9. Advantagesinclude contraceptive protection for 3 months after each injection.
10. Disadvantagesinclude need for an intramuscular injection every 3 months, irregular bleeding, weight gain, and lack of protection against STDs.
11. Table 3-4lists the failure rate for each of the contraceptive methods.

VII. Sexually Transmitted Diseases (STDs)

Herpes simplex virus, human papilloma virus (HPV), and C. trachomatis are the three most common STDs in the United States.

1. Epidemiology
2. STDsoccur most commonly in adolescents and young adults. Diagnosis of one STD is strongly associated with the likelihood of having another STD.

Table 3-4. Contraceptive Effectiveness

Method Failure Rate (%)* Chance 85 Female condom 21–26 Spermicide alone 21 Withdrawal 19 Diaphragm with spermicide 16–18 Cervical cap 17 Male condom 12 Oral contraceptives 3–10 Intrauterine device < 1–2 Depo-Provera < 1 *Failure rate is percent accidental pregnancy during first year of typical use. (Adapted from Neinstein LS. Adolescent Health Care, A Practical Guide. 3rd Ed. Baltimore: Williams & Wilkins, 1996:678.)

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2. Risk factorsfor STDs
3. Lack of barrier contraception
4. Young ageat initiation of sexual intercourse
5. Spontaneous sexual encounters
6. Multiple sexual partners
7. Concurrent substance abuse
8. Perceived lack of risk
9. Incarceration
10. Teen pregnancy
11. Teens who are homosexual or bisexual
12. Cervical ectopy in adolescent females.In general, these individuals are at a higher risk because of the presence of cervical ectopy (the presence of cervical columnar epithelium) to which C. trachomatis and N. gonorrhoeae preferentially attach.
13. Clinical features
14. Vaginitis.This disorder may be sexually transmitted, in the case of Trichomonas vaginalis, or may be caused by bacterial vaginosis or candidal infection, diseases not associated with sexual transmission.
15. T. vaginalis, a protozoan, accounts for 15–20%of cases of adolescent vaginitis.
16. Clinical findings
17. Malodorous, profuse, yellow-green discharge
18. Cervix may be friable and covered with petechiae (strawberry cervix).
19. Vulvar inflammation and itching
20. Dyspareunia(pain during sexual intercourse)
21. T. vaginalisis asymptomatic in 50% of males and females.
22. Diagnosis
23. Wet-mount saline microscopyis usually sufficient for diagnosis. It demonstrates motile flagellated protozoa.
24. Positive culturefor T. vaginalis
25. Vaginal pH > 4.5
26. Managementincludes oral metronidazole. Alcohol ingestion while taking this medication may result in an Antabuse-type reaction with severe vomiting. Partners should also be treated.
27. Bacterial vaginosisis the most common cause of vaginitis in adolescents and is caused by a change in the vaginal flora because of a reduction of lactobacilli, which are normally present. Fewer lactobacilli result in increased concentration of Gardnerella vaginalis, Mycoplasma hominis, andanaerobic Gram-negative rods.
28. Clinical findings
29. Gray-white thin vaginal dischargethat may adhere to the vaginal wall
30. Pungent “fishy” odor
31. Little vaginal or vulvar inflammation

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2. Diagnosis
3. Positive “whiff test”in which the “fishy” odor is enhanced on addition of 10% potassium hydroxide solution to vaginal secretions
4. Presence of “clue cells”on wet-mount saline microscopy (vaginal epithelial cells covered with adherent bacteria, which results in a hazy, granular appearance to the cell borders)
5. Typical vaginal discharge
6. Vaginal pH > 4.5
7. Managementincludes oral metronidazole or topical intravaginal therapy with 2% clindamycin or 0.75% metronidazole gel. Partners do not require treatment.
8. Candidal vulvovaginitisis usually caused by Candida albicans.
9. Clinical findings
10. Severe itchingand a white, curdlike discharge
11. Vulvar and vaginal inflammation
12. Diagnosis
13. Clinical signs and symptoms
14. Fungal hyphaeseen on wet-mount saline or potassium hydroxide microscopy
15. Normal vaginal pH (< 4.5)
16. Positive culturefor yeast
17. Managementincludes oral fluconazole or topical intravaginal antiyeast therapies. Partners do not require treatment.
18. Cervicitis.This inflammation of the mucous membranes of the endocervix is most commonly caused by C. trachomatis or N. gonorrhoeae. Other causes include herpes simplex virus and syphilis.
19. C. trachomatisis an intracellular bacterium that infects the cervical columnar epithelium.
20. Clinical findings
21. Purulent endocervical discharge
22. Friable, edematous, erythematous cervix
23. Dysuria and urinary frequency
24. Fifty percent of males and as many as seventy-five percent of females are asymptomatic.
25. Diagnosis
26. Cultureof the endocervix is the “gold standard.”
27. Nonculture tests, including rapid antigen detection by direct fluorescent antibody staining or enzyme immunoassay, are very sensitive but have high false-positive rates.
28. Newer highly sensitive and specificnoninvasive tests, such as polymerase chain reaction (PCR), ligase chain reaction, and nucleic acid hybridization, may be performed on urine or cervical specimens.
29. Complicationsinclude PID, tuboovarian abscess (TOA), infertility, ectopic pregnancy, chronic pelvic pain, Fitz-Hugh-Curtis syndrome (perihepatitis), and neonatal conjunctivitis and pneumonia.

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1. Management of uncomplicatedC. trachomatis cervicitis includes oral doxycycline, erythromycin, or azithromycin. Partners should also be treated.
2. N. gonorrhoeaeis a Gram-negative intracellular diplococcus that infects the cervical columnar epithelium.
3. Clinical findings
4. Mucopurulent endocervical discharge, sometimes with vaginal bleeding
5. Dysuria and urinary frequency
6. Dyspareunia
7. Asymptomatic infectionin females is common, and males may also be asymptomatic.
8. Diagnosis
9. Cultureof endocervical discharge inoculated immediately onto modified Thayer-Martin media is the “gold standard.”
10. Gram staindemonstrating intracellular Gram-negative diplococci may be considered evidence of infection in symptomatic patients.
11. Nonculture testssuch as urine PCR, or cervical or urethral nucleic acid hybridization, may also be useful.
12. Complicationsinclude PID, TOA, chronic pelvic pain, neonatal conjunctivitis, Fitz-Hugh-Curtis syndrome, and infertility. Disseminated infection may occur in up to 3% of patients and is characterized by asymmetric polyarthritis, papular and pustular skin lesions, and, rarely, meningitis, endocarditis, and septicemia.
13. Managementof uncomplicated cervicitis caused by N. gonorrhoeae includes intramuscular ceftriaxone or single-dose oral therapy with ofloxacin, cefixime, or ciprofloxacin, and treatment for presumptive co-infection with C. trachomatis [see VII.B.2.a.(4)]. Partners should also be treated.
14. Pelvic inflammatory disease(PID). This STD is an ascending infection in which pathogens from the cervix spread to the uterus and fallopian tubes.
15. Epidemiology
16. PID is polymicrobial and may be caused by N. gonorrhoeae, C. trachomatis, and nongonococcal, nonchlamydial aerobes and anaerobes.
17. PID is more common in the first half of the menstrual cycle, because menstruation enhances the spread of infection from the lower genital tract.
18. Clinical findings and diagnosis.The occurrence of particular signs and symptoms confirms the diagnosis.
19. Allof the following must be present:

. Lower abdominal pain and tenderness

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1. Uterine or cervical motion tenderness
2. Unilateral or bilateral adnexal tenderness
3. One of the following should also be present:

. Fever

1. White blood cell (WBC) count > 10, 500 cells/mm³
2. Inflammatory pelvic masson bimanual examination or ultrasound
3. Elevated erythrocyte sedimentation rate or C-reactive protein
4. Laboratory evidence ofN. gonorrhoeae or C. tracho-matis in the endocervix
5. Management
6. Indications for hospitalizationinclude presence of an adnexal mass, uncertainty regarding diagnosis or compliance, pregnancy, or failed outpatient therapy.
7. Inpatient treatmentincludes intravenous cefoxitin plus oral doxycycline, or intravenous clindamycin plus intravenous gentamicin.
8. Outpatient treatmentincludes 14-day therapy with ofloxacin and clindamycin or single-dose intramuscular ceftriaxone and 14 days of doxycycline.
9. Urethritis.This condition, which is defined as inflammation of the urethra, occurs more commonly in males. Females with urethritis typically have associated cervicitis.
10. Urethritis is characterized as gonococcal (caused by N. gonorrhoeae) or nongonococcal (most commonly caused by C. trachomatis). Other causes of nongonococcal urethritis include Ureaplasma urealyticum, Mycoplasma genitalium, herpes simplex virus, and T. vaginalis.
11. Clinical findings
12. Dysuria and increased urinary frequency
13. Mucopurulent urethral discharge
14. Asymptomatic infections are common.
15. Presumptive diagnosis
16. Mucopurulent urethral discharge
17. Greater than five WBCs per high-power fieldon Gram stain of urethral secretions
18. Greater than 10 WBCs per high-power fieldon first-void urine specimen
19. Positive leukocyte esteraseon first-void urine specimen
20. Definitive diagnosis(C. trachomatis or N. gonorrhoeae). Analysis of material obtained by swabbing the urethra or by examination of discharge or urine using methods described in sections VII.B.2.a.(2) or VII.B.2.b.(2) confirms the diagnosis.
21. Management.Treatment is the same as described in sections VII.B.2.a.(4) or VII.B.2.b.(4).

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4. Genital ulcers.These lesions are most commonly caused by herpes simplex virus types 1 and 2, Treponema pallidum (syphilis), or Haemophilus ducreyi (chancroid). Clinical features, diagnosis, and management are described in Table 3-5.
5. Genital warts
6. Epidemiology.Genital warts are the most common STD.
7. Genital wartsare caused by HPV and are transmitted by direct contact.
8. HPV strains 16 and 18may cause cervical carcinoma but often do not cause visible warts.
9. Externalgenital warts are also termed condylomata acuminata.
10. Clinical findings
11. Itching, pain, and dyspareunia
12. Possibly visible on external genitalia
13. May be asymptomatic
14. Diagnosis
15. Wartsare diagnosed on direct visual inspection.
16. Cervical cancer–causing HPVis detected by Pap smear and by 3% acetic acid wash during colposcopy, which colors HPV lesions white.
17. Management. Treatment is often difficult, and recurrence is common.Therapies include topical podophyllin and trichloroacetic acid, cryotherapy, and surgical and laser removal. Twenty-five percent of genital warts spontaneously disappear within 3 months.

Table 3-5. Genital Ulcers: Clinical Features, Diagnosis, and Management

HSV -1 and -2 Primary Syphilis Chancroid Clinical features Painful, multiple shallow ulcers Constitutional symptoms Inguinal adenopathy Painless, single ulcer with well-demarcated border and clean base (chancre) Painful inguinal adenopathy Painful, multiple ulcers with red, irregular borders and purulent bases Painless inguinal adenopathy; nodes may be fluctuant Diagnosis Typical lesions and one of the following: Positive Tzanck smear Positive HSV culture from lesion Positive DFA for HSV from lesion Elevated HSV-1 or -2 antibodies HSV on Pap smear Typical lesion and one of the following: Reactive nontreponemal tests (VDRL or RPR) Reactive treponemal test (FTA-ABS) Treponema pallidum on darkfield microscopy, biopsy, or DFA of exudate or tissue Typical lesions and positive culture forHaemophilus ducreyi Management Oral acyclovir until resolution Severe infection with disseminated disease requires intravenous acyclovir Intramuscular penicillin or oral doxycycline if allergic to penicillin Oral azithromycin, erythromycin, or intramuscular ceftriaxone HSV = herpes simplex virus; DFA = direct fluorescent antibody; Pap = Papanicolaou; VDRL= Venereal Disease Research Laboratory; RPR= rapid plasma reagin; FTA-ABS= fluorescent treponemal antibody absorption.

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VIII. Menstrual Disorders

1. Normal Menstrual Cycle
2. Characteristicsof the normal menstrual cycle.
3. Lengthof menstrual cycle: 21–35 days
4. Durationof menstrual flow: 2–8 days
5. Blood lossduring menstruation: 30–80 mL
6. Three phases of menstrual cycle(Figure 3-4)
7. Follicular (proliferative) phasebegins with the onset of menstrual flow and ends with ovulation. This phase lasts 7–22 days.
8. This phase begins with the pulsatile release of gonadotropin-releasing hormone (GnRH) from the hypothalamus, which in turn causes release of LH and FSH from the pituitary.
9. FSHinduces maturation of ovarian follicles, which produce increasing amounts of estradiol, which in turn causes endometrial thickening (proliferation).

Figure 3-4. The menstrual cycle: pituitary, ovarian, and endometrial correlations. FSH = follicle-stimulating hormone; LH = luteinizing hormone. (Reprinted with permission from Sakala PE. Obstetrics and Gynecology (Board Review Series). Baltimore: Williams & Wilkins, 1997, p. 9)

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3. Ovulationphase occurs at midcycle after a surge in LH release secondary to peaking estradiol levels. The ruptured ovarian follicle develops into a functioning corpus luteum.
4. Luteal (secretory) phasebegins after ovulation and ends with menstrual flow. This phase lasts 12–16 days.
5. Progesterone, produced by the functioning corpus luteum, creates a secretory endometrium.
6. Without fertilization, the corpus luteum involutes. This leads to diminished progesterone and estradiol production, which in turn causes endometrial sloughing and GnRH release from the hypothalamus to start the cycle again.
7. Menstrual cyclesare usually irregular for 1–2 years after menarche because of the lack of consistent ovulation.
8. Dysmenorrhea

This condition is the most common menstrual disorder.

1. Definitions.Dysmenorrhea is defined as pain associated with menstrual flow.
2. Primary dysmenorrhearefers to pain that is not associated with any pelvic abnormality. It is the most common type of dysmenorrhea during adolescence.
3. Secondary dysmenorrhearefers to pain associated with a pelvic abnormality, such as endometriosis, PID, uterine polyps or fibroids, or a bicornuate uterus with obstruction of menstrual flow.
4. Etiology.Primary dysmenorrhea is caused by increased production of prostaglandins by the endometrium, which results in excessive uterine contractions and systemic effects.
5. Clinical findings
6. Spasms of painin the lower abdomen
7. Nausea, vomiting, diarrhea, headache, or fatigue
8. Management.Prostaglandin inhibitors, such as nonsteroidal anti-inflammatory agents, or oral contraceptives may be useful.
9. Amenorrhea
10. Definitions.Amenorrhea is the absence of menstrual flow.
11. Primary amenorrhearefers to the absence of any menstrual bleeding by age 16 in an adolescent with normal secondary sexual characteristics, or the absence of menstrual bleeding by age 14 in an adolescent without secondary sexual characteristics.
12. Secondary amenorrhearefers to the absence of menses for either three menstrual cycles or 6 months after regular menstrual cycles have occurred.
13. Etiology.Causes may be categorized on the basis of the presence or absence of normal genitalia and normal secondary sexual characteristics (Table 3-6).
14. Clinical evaluation
15. Thorough history and physical examination, including a pelvic examination

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Table 3-6. Causes of Amenorrhea

Cause Findings Primary amenorrhea with normal genitalia and pubertal delay Turner syndrome (46, XO) Ovarian failure caused by gonadal dysgenesis High FSH and LH Ovarian failure before puberty caused by radiation, chemotherapy, or infection High FSH and LH Hypothalamic or pituitary failure before puberty Low FSH and LH Primary amenorrhea with absent uterus and normal pubertal development Testicular feminization syndrome (46, XY) X-linked defect in androgen receptor leading to inability to respond to testosterone Female genital appearance; vagina ends in blind pouch; inguinal or intra-abdominal testes Low FSH and LH Mayer-Rokitansky-Küster-Hauser syndrome (46, XX) Vagina and uterus are congenitally absent Normal FSH and LH Primary or secondary amenorrhea with normal genitalia and normal pubertal development Hypothalamic suppression Medications and drug abuse Stress and chronic illness Exercise or weight loss Low FSH and LH Polycystic ovary syndrome High LH and high LH/FSH ratio Obesity, hirsutism, and acne Pituitary infarction (Sheehan's syndrome) or pituitary failure Low FSH and LH Prolactinoma Low FSH and LH, high prolactin; prolactin inhibits GnRH release Headache, visual field defect Outflow tract obstruction Imperforate hymen Transverse vaginal septum Uterine adhesions Normal FSH and LH Premature ovarian failure Pregnancy Endocrine disorders Thyroid disease Diabetes mellitus High FSH and LH FSH = follicle-stimulating hormone; LH = luteinizing hormone; GnRH = gonadotropin-releasing hormone.

1. Pregnancy testto confirm or rule out pregnancy
2. Thyroid-stimulating hormoneand thyroxine levels to confirm or rule out thyroid disorders
3. Fasting prolactin levelto identify a prolactinoma. If the prolactin level is high, neuroimaging is necessary to exclude a tumor of the sella turcica.
4. FSH and LH levels

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1. High FSH and LH levelsindicate ovarian failure. Chromosomal analysis should be performed to evaluate for Turner syndrome.
2. Low FSH and LH levelsindicate hypothalamic or pituitary suppression or failure. Visual fields and neuroimaging of the sella turcica should be performed to exclude tumor.
3. Abnormal Vaginal Bleeding
4. Definitions
5. Dysfunctional uterine bleeding (DUB)causes 90% of abnormal vaginal bleeding in adolescents. DUB describes a syndrome of frequent, irregular menstrual periods, often associated with prolonged, painless bleeding.
6. Polymenorrheais uterine bleeding that occurs at regular intervals of < 21 days.
7. Menorrhagiais prolonged or excessive uterine bleeding that occurs at regular intervals.
8. Metrorrhagiais uterine bleeding that occurs at irregular intervals.
9. Menometrorrhagiais prolonged or excessive uterine bleeding that occurs at irregular intervals.
10. Oligomenorrheais uterine bleeding that occurs at regular intervals but no more often than every 35 days.
11. Etiology
12. DUBmay result from anovulatory cycles.
13. The endometriumbecomes excessively thickened and unstable because of unopposed estrogen production.
14. Ovulation does not occur, so progesterone is not available to stabilize the endometrium.
15. Bleedingoccurs spontaneously and frequently, and it is often prolonged because of weaker-than-usual uterine and vascular contractions.
16. Many conditionsthat cause amenorrhea, such as stress, drug abuse, chronic illness, thyroid disease, weight loss, excessive exercise, and polycystic ovary syndrome, may also cause DUB.
17. Complications of pregnancy, including threatened or incomplete abortion, and ectopic pregnancy
18. Infectionssuch as PID and cervicitis
19. Blood dyscrasiassuch as von Willebrand disease and immune thrombocytopenic purpura
20. Cervical or vaginal polypsand hemangiomas
21. Uterine abnormalities, including leiomyoma and endometriosis
22. Medications, including salicylates, oral contraceptives, and anabolic steroids
23. Foreign bodiessuch as IUDs or retained condoms or tampons
24. Trauma or sexual assault
25. Clinical evaluation
26. Historyshould document the dates of the last three menstrual cycles, age at menarche, prior menstrual patterns, presence or absence of pain, and amount of bleeding.

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1. Physical examinationshould include a pelvic examination if bleeding is painful, prolonged, or associated with anemia, or if the adolescent is sexually active.
2. Laboratory testing, in most cases, should include a complete blood count, pregnancy test, evaluation for N. gonorrhoeaeand C. trachomatis, and evaluation for a blood dyscrasia if very heavy bleeding is present.
3. Management. Treatment of DUBinvolves cessation of bleeding and prevention of endometrial hyperplasia.
4. Hormonal therapy should be used for all bleeding associated with anemia.Combination oral contraceptives or progestin-only contraceptives are used to stabilize the endometrium and convert it to a secretory form. Intravenous hormonal therapy may be required for severe bleeding.
5. Ironshould be prescribed for patients with anemia.
6. Dilation and curettageis also effective but should only be used if hormonal therapies fail.
7. Reproductive Health Issues in Males
8. Gynecomastia

is a bilateral or unilateral increase in the glandular and stromal breast tissue normally found in up to 60% of male adolescents.

1. Etiology is unknown.However, gynecomastia is probably caused by increased sensitivity to estrogen or increased peripheral conversion of adrenal androgens to estrogen.
2. Although gynecomastia is usually normal, the differential diagnosisincludes side effects of medications, testicular tumors, and thyroid and liver disease.
3. Laboratory studies are not necessaryif growth is normal, the adolescent is healthy, and puberty has begun.
4. Managementinvolves reassurance. Gynecomastia usually resolves within 12–15 months.
5. Painful Scrotal Masses
6. Torsion of the spermatic cordis the most common and most serious cause of acute painful scrotal swelling.
7. Clinical findings
8. Sudden onsetof scrotal, inguinal, or suprapubic pain, often accompanied by nausea and vomiting
9. Swollen, tender testicleand scrotal edema with absent cremasteric reflex on the affected side
10. Pain reliefon elevation of twisted testicle, although this is often unreliable
11. Diagnosis is usually made by history and physical examination alone, although torsion may be confirmed by decreased uptake on technetium 99m pertechnetate radionuclide scan or absent pulsations on Doppler ultrasoundof the scrotum.

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1. Managementincludes surgical detorsion of the involved testicle and fixation of both testes within the scrotum (the opposite testicle also has a high likelihood of torsion). Detorsion is a urologic emergency that must be performed within 6 hours to reliably preserve testicular function.
2. Torsion of testicularappendage may be confused with torsion of the spermatic cord.
3. Clinical findings
4. Acute or gradual onsetof pain in testicular, inguinal, or suprapubic areas. Tenderness is most pronounced at the upper pole of the testicle.
5. “Blue dot sign”on examination of the scrotum. This represents the cyanotic appendage visible through the skin of the scrotum.
6. Diagnosisis usually made by history and physical examination alone. Doppler ultrasound and radionuclide scans are normal or show increased flow or uptake.
7. Managementincludes rest and analgesia. Pain usually resolves within 2–12 days.
8. Epididymitisis infection and inflammation of the epididymis, occurring most commonly in sexually active males.
9. Etiology.Epididymitis is most commonly secondary to infection with N. gonorrhoeaeor C. trachomatis.
10. Clinical findings
11. Acute onsetof scrotal pain and swelling associated with urinary frequency, dysuria, or urethral discharge.
12. Swollen, tenderepididymis
13. Diagnosisis made by urinalysis demonstrating increased WBCs, a positive Gram stain, and a positive culture of urethral discharge. Doppler ultrasound shows increased flow, and a radionuclide scan demonstrates increased uptake.
14. Managementis similar to that for cervicitis [see VII.B.2.a.(4) and VII.B.2.b.(4)]. In addition, analgesics and bed rest are appropriate.
15. Painless Scrotal Masses
16. Testicular neoplasmsoriginate from germ cells within the testicle and are one of the most common malignant solid tumors in males 15–35 years of age. Cryptorchidism refers to testes that fail to descend into the scrotum. This condition is associated with a higher risk of malignancy.
17. Clinical findings
18. Firm, irregular, painlessnodule on testicle
19. Solid massseen on scrotal transillumination
20. Diagnosis and evaluation
21. Doppler ultrasoundof scrotum

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2. Evaluation for serum tumor markers human chorionic gonadotropinand α-fetoprotein
3. Evaluationfor distant metastasis
4. Management includes surgery, radiation, and chemotherapy.
5. Indirect inguinal herniaoccurs when the processus vaginalis fails to obliterate. This results in a defect within the abdominal wall that allows bowel to extend through the internal inguinal ring.
6. Clinical findingsinclude a painless inguinal swelling. Bowel sounds may be present on auscultation of the scrotum.
7. Diagnosisis based on history and physical examination.
8. Managementincludes referral for elective repair. Emergent referral is necessary if evidence of bowel incarceration is noted (erythema of overlying skin, pain, and tenderness).
9. Hydroceles.These are collections of fluid within the tunica vaginalis.
10. Clinical findingsinclude the presence of a painless, soft, cystic scrotal mass that may be smaller in the morning and larger in the evening.
11. Diagnosisis based on history and physical examination. Transillumination of scrotum reveals a cystic mass.
12. Managementincludes reassurance. If the hydrocele is very large or painful, referral for surgical repair is indicated.
13. Varicocelesresult from dilation and tortuosity of veins in the pampiniform plexus. Varicoceles occur in 10–20% of male adolescents.
14. Clinical findings
15. Most commonly found in the left halfof the scrotum
16. Characterized as a “bag of worms”appreciated on palpation, which diminishes in size when the patient is supine and enlarges with standing and with the Valsalva maneuver.
17. Diagnosisis based on history and physical examination.
18. Managementincludes reassurance. If the varicocele is painful or very distended, or is associated with a small testicle (indicative of diminished blood flow), a urology referral is indicated.

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Review Questions and Answers

1. A 12-year-old boy has been brought to your office by his mother, who is concerned that her son has not developed any signs of puberty. She recalls that her older daughter began pubertal development when she was younger than her son is now. Which of the following is correct regarding the normal sequence of pubertal development in males and females?

(A) Pubic hair growth is the first sign of puberty in females.

(B) Pubic hair growth is the first sign of puberty in males.

(C) Puberty begins in males 6–12 months later than in females.

(D) Facial hair growth in males begins at the same time as pubic hair growth.

(E) Menarche occurs at the same time as thelarche.

2. A 15-year-old girl presents for a routine health care visit. During your HEADSS assessment (home, education and employment, activities, drugs, sexual activity, suicide and depression), she reveals that she has been sexually active with one partner (her current boyfriend). You emphasize the importance of effective contraception. Which one of the following methods of contraception is associated with the highest failure rate with typical use?

(A) Oral contraceptive

(B) Intrauterine device

(C) Depomedroxyprogesterone acetate

(D) Vaginal diaphragm

(E) Male condom

3. A healthy-appearing short 15-year-old girl presents with primary amenorrhea, normal genitalia, and delayed pubertal development. Follicle-stimulating hormone and luteinizing hormone levels are high. Which of the following tests is most useful in diagnosing the most likely cause of her amenorrhea?

(A) Karyotype

(B) Prolactin level

(C) Thyroid function tests

(D) Pregnancy test

(E) Computed tomography scan of her sella turcica

4. A 15-year-old boy has had worsening left scrotal pain for the past 24 hours, a tender left testicle, and a bluish discoloration visible through his scrotal skin. Which of the following is correct regarding the evaluation and management of his scrotal pain?

(A) Urinalysis will demonstrate increased white blood cells.

(B) Cremasteric reflex will be absent on the affected side.

(C) Pain medication should be prescribed and bed rest recommended because this condition will resolve without surgical intervention.

(D) Immediate surgical intervention is indicated.

(E) Technetium 99m pertechnetate scan will show decreased uptake.

5. You are evaluating a 16-year-old girl who has had vaginal discharge for 5 days. Examination reveals purulent endocervical discharge. Her abdomen is nontender, she is afebrile, and she denies abdominal pain. Gram stain of the discharge reveals intracellular Gram-negative diplococci. Which of the following is the most appropriate treatment?

(A) Oral azithromycin

(B) Intramuscular ceftriaxone

(C) Hospitalization and treatment with intravenous clindamycin and intravenous gentamicin

(D) Intramuscular ceftriaxone plus oral azith-romycin

(E) Oral penicillin plus oral doxycycline

6. A 15-year-old boy presents for a routine health maintenance visit. On examination you note bilateral breast enlargement and Tanner stage 5 pubertal development. The remainder of the examination is unremarkable. Which of the following is the most appropriate next step in management?

(A) Order chromosomal analysis.

(B) Order studies of thyroid function.

(C) Order studies of hepatic function.

(D) Order a serum estrogen level.

(E) Order no tests and provide reassurance that the condition will resolve spontaneously.

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7. A sexually inactive 14-year-old girl presents with concerns that her current menstrual period, which is painless, has lasted 13 days and is associated with a moderate amount of bleeding. This menstrual period began 2 weeks after her previous period stopped; it lasted 15 days. A complete blood count reveals moderate anemia. Which of the following statements is correct regarding the management of this problem?

(A) Reassure her that her menstrual cycle is normal for her age and prescribe an iron supplement.

(B) Perform a complete pelvic examination, and if it is normal, reassure her that her condition is normal and no treatment is required.

(C) Perform a complete pelvic examination, and if it is normal, prescribe a progestin-only contraceptive.

(D) Prescribe combination oral contraceptives. (A pelvic examination is not necessary.)

(E) Perform a dilation and curettage.

8. A 15-year-old girl is 9 weeks pregnant with her first child. She does not want to terminate the pregnancy and would like advice and pregnancy-related care. Which of the following statements regarding her pregnancy is correct?

(A) She is at no higher risk than other teens to eventually require public assistance.

(B) She would be expected to have a lower-than-usual risk of having a sexually transmitted disease.

(C) Her parents must be informed and provide consent for medical management of her pregnancy.

(D) Her infant would not be expected to have a higher-than-usual risk of neonatal problems.

(E) Despite her young age, she is at higher-than-usual risk of hypertension and preterm labor.

9. A 17-year-old girl is brought to your office at her parents' request. They are worried because she has had diminished interest in family activities, has been fighting more often with her parents, and is spending more time alone in her room. During the past 6 months, her school performance has worsened, and her school principal recently telephoned her parents about school absenteeism. In addition, parents have noticed that she is hanging out with a new group of friends and that her appetite seems diminished. Which of the following statements regarding the management of this adolescent is most likely to be correct?

(A) She has major depressive disorder and should be seen urgently by a psychiatrist.

(B) Reassurance should be provided; her behavior is normal for age and psychosocial development.

(C) She should see a nutritionist with expertise in eating disorders.

(D) She should be evaluated for possible substance abuse.

(E) She and her parents should be interviewed together to uncover the cause of her problems.

10. A 16-year-old runaway adolescent presents to the free clinic with complaints of diffuse abdominal pain, fever, and nausea. She denies dysuria or vaginal discharge. On further questioning, she indicates she has had five sexual partners during the past year and most of the time uses condoms for protection. Pelvic examination reveals moderate lower abdominal tenderness and tenderness on palpation of her cervix and right ovary. No adnexal mass is appreciated. Which of the following statements regarding diagnosis and management is correct?

(A) Hospitalization and treatment with intravenous cefoxitin and oral doxycycline are warranted.

(B) Wet-mount saline microscopy will demonstrate motile protozoa, and oral metronidazole should be prescribed.

(C) Outpatient treatment with oral doxycycline for 2 weeks, along with one dose of intramuscular ceftriaxone, is indicated.

(D) Oral azithromycin alone should be prescribed for presumptive diagnosis of Fitz-Hugh-Curtis syndrome.

(E) Outpatient treatment with single-dose oral ofloxacin and oral azithromycin is warranted after attempts are made to obtain parental consent.

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11. A 14-year-old girl is brought to the office for a routine health maintenance visit. She appears very thin, yet believes she is overweight and needs to lose 15–20 pounds. Her mother is concerned that her daughter frequently skips breakfast and eats only a small portion of her dinner, usually alone in her bedroom. She argues often with her parents, and she immediately goes to her room on coming home from school or the gym. You believe that she may have an eating disorder. Which of the following is correct regarding the expected diagnosis?

(A) Her menstrual cycles would be unaffected and normal.

(B) Physical examination would demonstrate a lower-than-normal sexual maturity rating for age.

(C) Withdrawal from friends would not occur because she will use them for support.

(D) With further discussion at a subsequent medical visit, it is likely she will gain insight into her illness and will seek treatment.

(E) Her weight is likely to be 10% below her ideal body weight for age.

The response options for statements 12 and 13 are the same. You will be required to select one answer for each statement in the set.

For each patient, select the most likely causative organism.

12. An 18-year-old adolescent female with a single painless genital ulcer with a well-demarcated border, and painless inguinal adenopathy.

(A) Haemophilus ducreyi

(B) Treponema pallidum

(C) Herpes simplex virus type 2

(D) Human papillomavirus

(E) None of the above

13. A 16-year-old adolescent female with multiple painful ulcers with a purulent-appearing base and irregular borders as well as painful inguinal adenopathy.

(A) Haemophilus ducreyi

(B) Treponema pallidum

(C) Herpes simplex virus type 2

(D) Human papillomavirus

(E) None of the above

Answers and Explanations

1. The answer is C[I.A.2]. Both puberty and somatic growth begin earlier in females. Puberty occurs 6–12 months later in males and begins with testicular enlargement. Puberty in females begins with breast development. Pubic hair begins to grow after the beginnings of breast development in females and testicular enlargement in males. Facial and axillary hair growth begins in males 18–24 months after pubic hair. Menarche, the start of menstrual cycles, occurs an average of 2–3 years after thelarche, the beginnings of breast development.
2. The answer is D[VI.B.2.b and Table 3-4]. The vaginal diaphragm has the highest rate of failure with typical use among the methods listed. Failure is often related to lack of use during each episode of intercourse, lack of knowledge regarding proper placement, lack of use of spermicide, and improper fit. Depomedroxyprogesterone acetate and oral contraceptives are very effective contraceptive agents with low failure rates. Intrauterine devices and male condoms have a higher failure rate than hormonal contraception but are usually more effective in practice than the vaginal diaphragm.
3. The answer is A[VIII.C and Table 3-6]. This girl has primary amenorrhea, which is defined as the absence of menstrual bleeding either after age 16 in a girl with normal secondary sexual characteristics or, as in this case, after age 14 in a girl with delayed pubertal development. Disorders characterized by primary amenorrhea, normal genitalia, and delayed puberty include Turner syndrome, ovarian failure, and hypothalamic or pituitary failure. In this healthy-appearing, short girl, Turner syndrome (46, XO) is most likely, and thus a karyotype would be most useful for diagnosis. A prolactinoma and thyroid disease may result in either primary or secondary amenorrhea, but the follicle-stimulating hormone (FSH) level would be decreased or normal. A pituitary lesion would also usually result in normal or low FSH, and thus computed tomography or magnetic resonance imaging of the brain would be less useful. Pregnancy would be unlikely given the presence of pubertal delay.
4. The answer is C[IX.B.2]. This boy presents with classic findings of torsion of the left testicular appendage, which is characterized by acute or gradual onset of scrotal pain, tenderness at the upper pole of the testicle, and a “blue dot sign” reflecting the cyanosis and torsion of the testicular appendage. This condition normally resolves without surgery, and rest and pain medication are indicated. Urinalysis is normal, and the cremasteric reflex is still present. Doppler ultrasound demonstrates normal or increased blood flow, and radionuclide imaging demonstrates normal or increased uptake on the affected side, unlike torsion of the spermatic cord.
5. The answer is D[VII.B.2.b]. The presence of Gram-negative intracellular diplococci confirms the diagnosis of Neisseria gonorrhoeaecervicitis. The correct treatment for uncomplicated cervicitis caused by N. gonorrhoeae includes intramuscular ceftriaxone, oral ofloxacin, oral ciprofloxacin, or oral cefixime. However, any patient with N. gonorrhoeaealso requires treatment for Chlamydia trachomatis because coinfection is very common. Thus, the most appropriate treatment includes therapy against N. gonorrhoeaeand either oral azithromycin, erythromycin, or doxycycline for the treatment of presumptive C. trachomatis. Hospitalization is not indicated for uncomplicated cervicitis. The absence of abdominal pain or tenderness excludes pelvic inflammatory disease. Because of drug resistance, oral penicillin is inadequate for the treatment of N. gonorrhoeae.
6. The answer is E[IX.A]. Gynecomastia, the development of breast tissue, occurs in up to 60% of males during adolescence. If a male adolescent is healthy and has progressed normally through puberty, as in this case, no laboratory tests are necessary, and reassurance alone is sufficient management. Neither an estrogen level nor a karyotype would be useful in light of a male sexual maturity rating of Tanner stage 5. Although thyroid and liver disorders may result in breast enlargement, other signs or symptoms suggesting a systemic disease would likely be apparent on physical examination.
7. The answer is C[VIII.D.3 and VIII.D.4]. This girl likely has dysfunctional uterine bleeding (DUB), the cause of 90% of abnormal vaginal bleeding in adolescence. She also is anemic and, as a result, needs hormonal therapy to regulate her menstrual cycles. Because of her moderate anemia, a pelvic examination should be performed to rule out other causes of abnormal vaginal bleeding before prescribing hormonal therapy. Either a daily progestin-only contraceptive or combination oral contraceptives would be effective in stopping her bleeding. Dilation and curettage is only performed when other therapies fail.
8. The answer is E[VI.A.2]. Adolescent pregnancy dramatically affects both mother and infant. Teens who are pregnant are at higher-than-usual risk of hypertension, anemia, and preterm labor. In addition, adolescent mothers have a high rate of not completing high school, have a higher-than-normal rate of unemployment, and often need welfare assistance. Adolescents who are pregnant are also at a higher risk for sexually transmitted disease. In the majority of states, adolescents are entitled to seek pregnancy-related care without parental consent. Their infants are at higher-than-usual risk for health problems, such as low birth weight.
9. The answer is D[IV.C]. The signs and symptoms of substance abuse include disturbance in mood or sleep, decline in school performance, truancy, alterations in family relationships and peer groups, and diminished appetite. These behaviors are not normal at any age. This adolescent does not meet the criteria for major depressive disorder, although depression can occur with, and result from, substance abuse. Decreased appetite alone is insufficient to diagnose anorexia nervosa or bulimia nervosa. Although both the adolescent and her parents may be interviewed jointly, she should also be interviewed independently to facilitate rapport and discussion of confidential issues.
10. The answer is A[VII.B.3]. The constellation of clinical findings, including lower abdominal pain and tenderness, adnexal tenderness, and cervical motion tenderness, are sufficient to make a diagnosis of pelvic inflammatory disease (PID). Although many cases of PID can be effectively treated as an outpatient with oral medications, hospitalization is indicated for situations in which compliance with therapy may be problematic, as in a homeless or runaway adolescent. In addition, hospitalization is warranted for pregnant teens with PID, for those who have an adnexal mass suggesting a tuboovarian abscess, or for those who fail outpatient management. This patient's clinical findings are not consistent withTrichomonas vaginalis, which is diagnosed by a wet-mount saline preparation, nor with Fitz-Hugh-Curtis syndrome (perihepatitis), which presents with right upper quadrant pain.
11. The answer is B[Table 3-3 and V.B]. This girl's history of low body weight, disturbed body image, and withdrawal from her family are consistent with anorexia nervosa. In addition to these characteristics, patients with anorexia nervosa also have amenorrhea, a weight 15% below ideal body weight for age, an intense fear of gaining weight, delays in puberty and growth, and a preoccupation with food and sometimes with exercise in order to burn calories. In addition to withdrawal from family, teens with anorexia nervosa often withdraw from friends. Insight into the illness is lacking, and management of eating disorders is very challenging. Input from nutritionists and therapists and the involvement of a supportive family are essential.

12, 13. The answers are B and A, respectively [Table 3-5]. Genital ulcers may be caused by chancroid (infection with Haemophilus ducreyi), syphilis (infection with Treponema pallidum), or herpes simplex virus types 1 and 2. Syphilis is characterized by a single painless ulcer that has a well-demarcated border and a nonpurulent base (a chancre). In contrast, chancroid is characterized by painful ulcers that have irregular borders and a purulent base. Inguinal adenopathy is present in both diseases; however, it tends to be painful in chancroid and painless in syphilis. Herpes simplex virus also causes multiple painful shallow ulcers, but the base is nonpurulent. Human papillomavirus causes genital warts, not ulcers.