Board review 4 2 2013
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Board Review 4/2/2013. ADOLESCENT (part 2). Test Question. True or False: My March Madness bracket was way off this year True False Um, this is the south… we only care about football. Eating disorders. Etiology.

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Board review 4 2 2013

Board Review 4/2/2013


Test question

Test Question

True or False: My March Madness bracket was way off this year

  • True

  • False

  • Um, this is the south… we only care about football

Eating disorders

Eating disorders



  • Anorexia and bulemia are fairly rare conditions with a prevalence of 0.5-2%

  • Onset

    • Anorexia: mid-adolescence

    • Bulimia: late-adolescence

    • Majority of patients report body image concerns and disordered eating before adolescence

  • Predisposing factors

    • Family history of eating disorders, obesity, mood disorder

    • Girls with early puberty or obesity (especially if teased)

    • Past history of abuse, often sexual

    • Sports that place an emphasis on thinness

Pediatrician s role

Pediatrician’s Role

  • Recognize risk factors and early signs of an eating disorder and obtain an appropriate history and physical exam to guide management.

Comorbid mental illness

Comorbid Mental Illness

  • Comorbid mental disorders are present in the majority of patients with an eating disorder.

  • Anorexia

    • Major depression

    • Anxiety disorders

      • OCD

      • Generalized anxiety disorder

      • Social phobia

  • Bulimia

    • Comorbid mood disorders (depression, bipolar disorder)

    • Anxiety disorders

    • Substance abuse disorders

    • MORE high risk behaviors due to impulsivity

Question 1

Question #1

Which of the following is NOT a criteria for the diagnosis of anorexia nervosa?

  • An intense fear of gaining weight or becoming fat.

  • The absence of 3 consecutive menstrual cycles in a post-menarchal female

  • Denial of the seriousness of low body weight

  • Refusal to maintain body weight more than 80% expected for height and age

  • An undue influence of body weight or shape on self evaluation.

Anorexia nervosa

Anorexia Nervosa

  • Restrictive type…no binge or purge behaviors; most common type

  • Binge-eating/purging type

    • Patient regularly engages in binge eating or purging behaviors

      • Vomiting

      • Laxatives/enemas

      • Diuretics

Physical exam

Physical Exam



  • Inpatient management

    • Multidisciplinary team, including medical specialist, psychiatrist, nutritionist, and social worker

    • Goals

      • Correct malnourishment

      • Promote healthy eating and weight gain

        • ½ pound increase per day

      • Correct electrolytes

      • Rule out psychiatric issues

      • Develop a discharge plan

    • Patient contracts…



  • Prevent refeeding syndrome

    • Reintroducing food to a patient with anorexia may cause a rapid fall in phosphate, magnesium, and potassium, along with an increasing extracellular volume

    • Hypophosphatemia can lead to

      • Rhabdomyolysis

      • Decreased cardiac motility, cardiomyopathy

      • Respiratory and cardiac failure

      • Edema, hemolysis, ATN, seizures, and delirium

    • Phosphate supplementation

  • DC once stable and appropriate weight gain, often to outpatient facility



  • The further patients are from their ideal body weight, the more likely they are to suffer medical complications

  • Most complications are corrected with return to ideal body weight

  • Bone loss due to hypothalamic amenorrhea or low testosterone (males) does NOT automatically return to normal with weight gain

Outpatient management

Outpatient Management

  • Establish a treatment team to monitor the patient.

    • Clear guidelines should be given to the patient with clear criteria for re-admission

    • Establish appropriate weight goals… ½-1lb gain per week

  • There are varying levels of outpatient care that can be coordinated with the help of the pediatrician.

  • For BMD loss

    • At least 400-800 IU of vitamin D

    • 1200mg elemental calcium

    • DEXA scan for those with 6 months of amenorrhea

  • NO role for psychopharmacology

  • Outpatient behavioral therapies and family therapies are beneficial

Question 2

Question #2

  • A 17-year-old girl is brought to the emergency department by her parents because of vomiting. She has no fever, headache, abdominal pain, or diarrhea. She says that over the past 3 years she has periods of time when she vomits and then she is fine for a while. She denies inducing the vomiting. Her periods are regular, and her last one was 2 weeks ago. On physical examination, you note normal vital signs, a body mass index of 28.5, a small subconjunctival hemorrhage on the right eye, and slight enlargement of her parotid glands bilaterally. Laboratory results are fairly normal. Of the following, the MOST likely explanation for these findings is

  • Acute pancreatitis

  • Bulimia nervosa

  • Cyclic vomiting

  • Diabetic ketoacidosis

  • Ectopic pregnancy



  • Patients are often of normal weight or above normal weight and can easily hide their disorder

  • Purging subtype describes an individual who engages regularly in self-induced vomiting or the misuse of laxatives/diuretics/enema

  • Nonpurging subtype describes someone who uses other excessive measures (exercise or fasting) to burn calories

Question 3

Question #3

You are seeing your 18 year old patient with a known history of bulimia. Today, you are concerned that your patient may be doing poorly with her outpatient control, as the parents are noticing more warning signs. Every month you follow the patient’s electrolytes. Which 2 electrolytes should be closely evaluated to help you decide whether or not to admit your patient to the hospital??

  • Sodium and glucose

  • Potassium and bicarbonate

  • Sodium and chloride

  • Glucose and BUN

  • Potassium and chloride



  • Outpatient management

    • Team approach

    • Promote hydration, high fiber diet, and moderate exercise

    • Monitor electrolytes…PO potassium or IV if severe hypokalemia

    • PPI if reflux

    • Similar bone care as anorexia if amenorrhea!

    • FLUOXETINE has been shown to help reduce symptoms

    • Cognitive behavioral therapy

  • Most patients respond to outpatient management, but some do meet the criteria for hospitalization



  • Pediatricians should recognize warning signs for both illnesses and intervene quickly!

    • Anorexia

      • Rapid or severe weight loss

      • Falling of growth percentiles

      • Excessive dieting or exercising

      • Constriction of food choices, calorie counting

      • Excessive concern with weight or body shape

    • Bulimia

      • Weight cycles

      • Excessive concern with weight or shape

      • Trips to bathroom after meals

      • Electrolyte abnormalities

      • Swollen parotic glands or knuckle abrasions



  • Nearly 50% recover, 30% show improvement, and 20% have a chronic course

  • Mortality rate up to 5%...worse for anorexia?

  • Prognostic indicators

    • Good

      • Onset before adulthood, especially before 14yo

      • Early, intensive treatment

      • Family support

      • Shorter duration of illness

    • Bad

      • Presence of bingeing and purging

      • Longer duration of illness before treatment

      • Poor family relations

      • Comorbid psychiatric conditions

Other disorders

Other Disorders

  • Eating disorder NOS: patient with disordered eating who does not meet the criteria for anorexia or bulimia

  • Female Athlete Triad

    • 1) Low energy availability with or without an eating disorder

    • 2) Hypothalamic amenorrhea

      • Low body fat composition that leads to low estrogen and amenorrhea

    • 3) Osteoporosis

    • Treatment is multidisciplinary

      • Increase energy availability

      • Calcium and vitamin D supplements with weight bearing exercises; DEXA scan if fracture or >6mo amenorrhea

    • Protection…maintain healthy balance between exercise, energy availability, and body weight

Teen pregnancy and contraception

Teen pregnancy and Contraception

Teen pregnancy

Teen Pregnancy

  • The US has the highest rate of teen pregnancy and births in the industrialized world

  • There are numerous social, economic, educational problems associated with teen pregnancy

Teen pregnancy1

Teen Pregnancy

  • <15yo adolescents often have the worst outcome

    • Increased prematurity

    • Lower birth weight

    • Higher neonatal death

  • Younger teens are also more likely to suffer from pregnancy-related complications themselves

  • There is often a lack of prenatal care

    • With good prenatal care and appropriate nutrition, these physiologic outcomes can be significantly improved but not eliminated

Question 4

Question #4

What percent of adolescents will become pregnant within the first six months of initiation of sexual activity if ineffective contraceptive measures are used?

  • 25%

  • 30%

  • 40%

  • 50%

  • 60%

Role of pediatrician

Role of Pediatrician

  • Teens often don’t seek contraceptive care until 6mo-1year after the initiation of intercourse…but 50% will conceive within the first 6 months.

  • Pediatricians are likely to see many children who are not yet sexually active and have a unique opportunity to intervene.

    • “All adolescents should receive health guidance annually regarding responsible sexual behaviors, including abstinence.”

Role of pediatrician1

Role of Pediatrician

  • We must educate ourselves about ALL available options to help our patients make the best decision.

  • Detailed contraceptive counseling is required for adolescents to understand proper use and the consequences of improper use of contraception

  • Emphasize that condom use during oral, vaginal, or anal sex is ALWAYS important for STD prevention…as contraceptives do NOT prevent transmission

Role of pediatrician2

Role of Pediatrician

  • Recognize barriers to contraception

    • Developmental stage of the adolescent

    • External barriers

      • Access to a clinic

      • Lack of confidential care

      • Fear of disapproval by parents or practitioners

      • Absence of adolescent-friendly services

      • Language and cultural barriers

      • Fear of the pelvic exam

      • Cost

    • Misconceptions about contraception…weight gain, future fertility, acne, and risk of cancer



  • C0mpliance with a contraceptive method is directly related to

    • A perceived lack of adverse effects

    • Older age of the user

    • Satisfaction with the type of contraceptive method selected

    • Desire to avoid pregnancy

  • Many adolescents are poorly compliant with contraception, especially OCPs

    • Compliance with is often influenced by peer or partner pressure

    • Cognitive maturation often affects the patient’s understanding of the consequences of misuse

  • Poor compliance alters effectiveness…





  • The pediatrician should counsel patients about abstinence

  • “Virginity pledges”

    • Ultimately sexual activity did not differ when compared to non-pledgers

    • Comparable rates of oral sex

    • No difference in sexually transmitted infection rates

    • Less condom use at first intercourse and less likely to seek treatment for infectious symptoms

  • More effective

    • Encourage youth to make personal commitments

Oral contraceptive pills

Oral Contraceptive Pills

  • Combined OCP

    • Comprised of a synthetic estrogen and progestin

      • Estrogen: typically ethinylestradiol in varying amounts (from 20mcg to 50mcg)

      • Progestin: various generations, half-life increases with each generation

      • Monophasic: same dose x 3 weeks each month

      • Triphasic: hormone amounts vary weekly

    • Estrogen: prevents ovulation by inhibiting the GNRH axis

    • Progestin: thickened cervical mucus, endometrial atrophy, and decreased effectiveness of the tubal transport mechanism.

  • Progestin only pill

Oral contraceptive pills1

Oral Contraceptive Pills

  • Combine OCPs have other, non-contraceptive uses, such as the treatment of

    • Dysfunctional uterine bleeding

    • Dysmenorrhea

    • Acne

    • Hirsutism

    • PCOS

    • Irregular menses

  • Combined OCPs also decrease the risk of uterine and ovarian cancer

Question 5

Question #5

All of the following are ABSOLUTE (Class 4) contraindications to combined oral contraceptive use EXCEPT

  • History of DVT or pulmonary embolism

  • Prior cerebrovascular event

  • Breastfeeding in the first 2 months after birth

  • Factor V Leiden mutation

  • Migraine headache with aura

Contraindications to ocp use

Contraindications to OCP Use

  • Absolute Contraindications (Class 4)

    • History of DVT or pulmonary embolism

    • Prior cerebrovascular accident

    • Known Factor V Leiden mutation or other thromobophilic condition

    • Migraine headache with aura or neurologic changes

    • **without a history of these…adolescents should be reassured that these complications are rare and that the risk of pregnancy is frequently greater than the risk associated with the pill

    • From “Laughing”: pregnancy, liver disease, elevated serum lipids, breast cancer, coronary artery disease

Contraindications to ocp use1

Contraindications to OCP Use

  • Relative Contraindications (Class 3)

    • Having gallbladder disease

    • Being fewer than 21 days postpartum

    • Breastfeeding in the first 6 months after giving birth (primary for the combined OCP)

    • Receiving medications that may interfere with the efficacy of OCP…anticonvulsants

    • From “Laughing”: HTN, depression

  • IF the combined OCP is not tolerated or there is a contraindication to using an estrogen-containing pill, the progestin only pill may be an option

    • DO NOT prevent ovulation

Initiation of ocps

Initiation of OCPs

  • NO pelvic exam needed!

    • Can screen for STDs using NAAT of the urine or vaginal swabs

    • Pap smears: NEW guidelines…first Pap smear required at the age of 21 regardless of sexual activity

  • A history, BP measurement, and negative UPT are sufficient to prescribe OCPs

  • Use of condoms should still be encouraged for STD prevention!

Adverse effects

Adverse effects

  • Progestin

    • Menstrual changes

    • Bloating

    • Mood changes

    • Increased appetite

    • Weight gain

    • Acne, hirsuitism, male-patterned baldness are rare

  • All OCPs decrease free testosterone similarly, so any of the low-dose OCPs are appropriate treatment for hyperandrogenic symptoms

  • Estrogen

    • *clot…risk increased with smoking*

    • Irregular menstrual bleeding

    • Breast tenderness

    • Fluid retention

    • Nausea

    • Increased appetite

    • Headache

    • Hypertension

  • Can be decreased by decreasing dose of estrogen, but small doses are associated with breakthrough bleeding.



  • Are common and can result in poor compliance

    • Weight gain

      • May cause increased appetite

      • No documented evidence of true weight gain

    • Acne actually improves during OCP therapy

    • Mood changes are rare

      • Most often associated with the progestin component

      • If concerned, type of progestin can be varied

Question 6

Question #6

  • Drospirenone, the progestin component of the combined OCP Yasmin, should not be used in patients at risk for

  • hyperglycemia

  • hypokalemia

  • hypernatremia

  • hyponatremia

  • hyperkalemia

Newer oral contraceptives

Newer Oral Contraceptives

  • Drospirenone

    • New progestin in the combined OCP Yasmin

    • 17-alpha-spironolactone derivative that possesses diuretic and anti-androgenic activity, favoring use in PCOS

    • Favorable profile in its effects on BP, weight, cholesterol

    • Do NOT use in patients at risk for hyperkalemia

      • Renal, hepatic, or adrenal insufficiency

      • Medications: ACE inhibitors, ARBs, NSAIDs

  • Chewable pill (Femcon Fe) for young patients who find it difficult to swallow a pill

Newer oral contraceptives1

Newer Oral Contraceptives

  • Extended-cycle regimens

    • Seasonale: monophasic, withdrawal bleed every 3 months

    • Adverse effects due to hormone withdrawal are reduced

      • Premenstrual symptoms

      • Headaches and migraines

      • Mood swings

      • Heavy or painful monthly bleeding

    • Initial increase in breakthrough bleeding improves after 6 months

  • Low-dose formulations (Yaz) containing 20-35mcg of estrogen

Transdermal contraception

Transdermal Contraception

  • Permeation of estrogen and progesterone directly through the skin (Ortho Evra)

  • Adverse effects

    • Skin irritation and rash at site of application

    • Increased incidence of breast symptoms and dysmenorrhea compared to OCP users

  • FDA warning

    • Women are exposed to 60% more estrogen than those taking 35mcg EE OCP

    • FDA stated that this increased estrogen exposure might increase the risk of blood clots but that it was unknown whether users would actually experience increased risks

Injectable contraception

Injectable Contraception

  • DMPA: depot medroxyprogesterone acetate

    • Intramuscular injection every 3 months

    • Subcutaneous version available, as well

    • Progestin only: Inhibits ovulation, thickens cervical mucus, thins the endometrium to prevent implantation

  • HIGH discontinuation rates…75% stop by 1 year

  • Adverse effects include menstrual irregularities, weight gain, and reduction in bone mineral density.

    • Loss of BMD should be mentioned but kept in context

      • Likely recovery upon discontinuation

      • Low risk of fractures

      • Benefits of preventing pregnancy likely outweigh risks

  • Return to fertility may take up to 10 months

Vaginal rings

Vaginal Rings

  • NuvaRing

    • Combined estrogen and progestin ring that inserts into the vagina and does not depend on daily compliance

    • Use

      • Inserted on last day of menstrual cycle for 3 weeks

      • Removed for 1 week, during which withdrawal bleed occurs

  • More than 90% compliance over a 1 year period

  • Adverse effects

    • Irregular bleeding but LESS than OCPs

    • Vaginitis, leukorrhea, vaginal discomfort

    • Headache

    • Nausea

Subdermal implants

Subdermal Implants

  • Hormone-containing rods/capsules

  • Surgically inserted beneath the skin

    • ALL are progestin-only implants

      • Suppresses ovulation but not follicular activity

      • Estrogen concentrations remain almost normal….less concern about effect on cholesterol and BMD

    • Return to fertility occurs promptly after removal

  • Adverse effects

    • Irregular bleeding is common (as with all Progestin-only agents)

    • Typically diminishes within 6-9 months

Intrauterine device

Intrauterine Device

  • Progestin (LNG)-releasing…Mirena

    • Acts locally to thicken cervical mucus, inhibit sperm motility and function, and cause endometrial atrophy

    • Can be used for up to 5 years; rapid return to fertility

  • Recommended mainly for parous women

    • Women at HIGH risk for PID are NOT good candidates!

    • Contraindicated in women with history of or at risk for ectopic pregnancy

    • Can reduce menstrual flow in adolescents with heavy periods

  • Adverse effects

    • Bleeding disturbances…but amenorrhea by 1yr in up to 50%

    • Acne, dizziness, HA, breast tenderness, weight gain, nausea, vomiting, and ovarian cysts.

Question 7

Question #7

  • While working in the ER last night, you took care of a patient who was recently sexually assaulted while at a party. She was scared to come to the hospital initially, so some time has elapsed. So that you can treat your patient and help her prevent pregnancy, you ask EXACTLY when the assault happened. Ideally, within how many hours after the assault should emergency contraception be administered to remain effective ?

  • 36 hours

  • 48 hours

  • 60 hours

  • 72 hours

  • 84 hours

Emergency contraception

Emergency Contraception

  • Should be available to all adolescents

  • ALL victims of sexual assault should be offered EC

  • Initiation within the first 72 hours after unprotected intercourse decreases pregnancy risk by at least 75%

    • Progestin-only EC (Plan B) consists of 2 pills taken 12 hours apart

    • “Yuzpe Regime”: combined OCPs at higher doses, significant nausea and vomiting due to the estrogen

  • Adverse effects: HA, nausea, breast tenderness, dizziness, fatigue, vaginal spotting

  • Contraindications: pregnancy, allergy, undiagnosed genital bleeding



We didn’t go into OB/GYN for a reason…



  • Typically occurs at SMR 4 breast development

  • Average age of menarche: 12.4 yrs

    • Range: 11-14 yrs

  • Physiologic leukorrhea precedes menses by 3-6 months

    • Provide reassurance, normal hygiene, sitz baths if it is bothersome

  • Immature hypothalamic-pituitary-gonadal axis at the beginning of menstruation

    • 50% of menstrual cycles are anovulatory in first 2 years after menarche

    • Can cause menstrual irregularity that is normal

Menstrual irregularity

Menstrual Irregularity

  • Irregularity is common in first 1-2 years of menses

    • Typically does not warrant a work-up

  • But should still investigate any unusual degree of irregularity regardless of time from menarche:

    • Missing a period for 90 days

    • Bleeding for more than 7 days or very heavy bleeding

      • Bleeding for more than 10 days is NOT physiologic

    • Failure to establish a regular period by 2 years

Question 8

Question #8

You are evaluating a 16 yo female in your office for secondary amenorrhea. She states menarche was at age 11, she typically bleeds for 4-5 days, using 3-4 pads or tampons per day. She has an interval of 21-28 days between her periods. Her last period was 3 months ago. She denies any abdominal pain, weight changes, or medication use but does complain of excessive hair growth on her face and abdomen. On exam, her vitals are all stable and her BMI is 35. Of the following, which is the FIRST step in your evaluation?

  • Pelvic ultrasound

  • Serum LH and FSH levels

  • Serum testosterone levels

  • Urine pregnancy test

  • Refer her for diet and weight education

Primary amenorrhea

Primary Amenorrhea

  • Lack of menses by 15-16 years; or within 2-3 years of thelarche

  • Differential diagnosis

    • Anatomic abnormalities

      • Can present with abdominal pain, constipation, urinary retention, abdominal mass

      • Imperforate hymen, transverse vaginal septum, vaginal or uterine agenesis

    • Pregnancy

    • Ovarian pathology

    • Hypothalamic/pituitary disorders

    • Adrenal disease

Question 9

Question #9

You are seeing a 15yo girl for her annual health visit. Menarche was at 12yrs and she had normal menses for 2 years. Over the last year her menses became more irregular and stopped 4 months ago. Her mother notes that she is very health conscious. She has gained no weight over the past 3 years. On exam, her BMI is 17, heart rate is 55 bpm, she has no acne or hirsutism, and she is at SMR 5 genital development. Of the following, the most likely cause for her amenorrhea is:

  • Heart disease

  • PCOS

  • Exercise regimen

  • Anabolic steroid use

  • Gonadal failure

Secondary amenorrhea

Secondary Amenorrhea

  • Definition: Cessation of menstrual periods for ≥ 90 days

  • Differential Diagnosis

    • Pregnancy!!

    • Functional hypothalamic amenorrhea

    • PCOS

    • Ovarian insufficiency

    • Thyroid, adrenal disorders

Functional hypothalamic amenorrhea

Functional Hypothalamic Amenorrhea

  • Most common cause of Hypogonadotropichypogonadism

    • Suppression of GnRHpulsatility

    • No anatomic or organic disease is found

  • Caused by stress, weight loss, excessive exercise

  • Leads to low estrogen state  low bone mass

    • Also seen in ovarian failure

  • Female athlete triad:

    • Energy insufficiency, amenorrhea, low bone density

  • Treat with weight gain, estrogen replacement (OCP)

    • Other areas being studies: leptin replacement, androgens, estrogen alone

Question 10

Question #10

A 15yo girl is concerned about irregular menses and acne. Menarche was at 11 years and 9 months and she developed pubic hair around age 7. On exam, her BMI is 32.3, she has facial comedonal and pustular acne, as well as darkening of her neck and axilla. She has hypopigmented stretch marks on her abdomen and hair in a linear distribution from her umbilicus to the pubic symphosis. She is at SMR 5. Of the following, the most likely diagnosis is:

  • Cushing Syndrome

  • Hypothyroidism

  • Metabolic syndrome

  • Physiologic anovulation

  • Polycystic ovary syndrome

Polycystic ovary syndrome pcos

Polycystic Ovary Syndrome (PCOS)

  • Most common endocrinopathy in young women

  • Common cause of secondary amenorrhea OR abnormal vaginal bleeding

  • Present with amenorrhea (or oligomenorrhea) and signs of hyperandrogenism (hirsutism, acne)

    • Often, not always, overweight

  • Abnormal LH pulsatility and secretion

    • Leads to increased androgen production and anovulation

  • Evaluation:

    • LH, FHS, TSH, prolactin, serum testosteron, free testosterone, and DHEAS

      • Increased LH/FSH ratio

    • If evidence of virilizaton exclude late-onset CAH

Board review 4 2 2013


  • Associated with insulin resistance in 50% of cases

  • Increased risk of endometrial cancer

  • Treatment:

    • Cyclic use of progestins

    • Estrogen-containing contraceptives

    • Metformin

Abnormal vaginal bleeding aka dysfunctional uterine bleeding

Abnormal vaginal bleeding (AKA dysfunctional uterine bleeding)

  • Normal period:

    • Lasts 3-7 days

    • Interval: 21-45 days

      • more commonly 21-35 days

    • Total blood loss: 35-40ml

  • Menorrhagia: large quantity of bleeding

    • > 7 days of bleeding or > 80ml blood loss

  • Metorrhagia: irregular bleeding

  • Menometorrhagia: irregular heavy bleeding

Abnormal vaginal bleeding

Abnormal Vaginal Bleeding

  • Due to delay of maturation of negative feedback loop

    • Anovulatory cycles

    • Constantly proliferating endometrium with irregular shedding

    • Diagnosis of exclusion

  • Differential diagnosis

    • Threatened abortion

    • Ectopic pregnancy

    • Bleeding disorder

    • Infection (PID)

    • Endocrinopathy (PCOS, thyroid disorder)

Question 11

Question #11

A 14 yo girl, who has had irregular bleeding since menarche at age 11 years, presents with painless menstrual bleeding of 14 days’ duration. She is using 8 to 10 pads per day. She is tired and is upset with the number of days of bleeding. The only finding on physical examination is mild pallor. Her heart rate is 82, blood pressure is 120/80, with no postural changes. Labs show a hemoglobin of 9.4 g/dL, normal platelet count, PT, PTT, and von Willebrand panel. Of the following, the MOST appropriate treatment for this girl is

  • Iron-rich diet

  • A daily dose of oral progesterone pills

  • Combined oral contraceptive pills and iron supplementation

  • Gynecologic referral for surgical treatment

  • Tracking with a menstrual calendar and follow-up appointment in 3 months

Abnormal bleeding treatment

Abnormal Bleeding: Treatment

  • Evaluation: UPT, CBC with retic, TSH

    • Must screen for anemia/iron deficiency

    • Other labs based on differential diagnosis

  • Treatment:

    • Surgical intervention is RARELY necessary

    • Depends on severity of anemia

      • Admit if severe

      • Treat any anemia with iron replacement

    • Goal: stabilize endometrium

      • Estrogens for initial hemostasis

      • Progestins for endometrial stability

    • Most cases: treat with combination OCP

    • GnRH analogs for prophylactic (not acute) treatment

Question 12

Question #12

A 15 yo girl presents for treatment of menstrual cramps. She had menarche 3 years ago and over the last year she began having pain with her cycle. The pain is worse on the first day and she occassionally misses school due to the pain. Of the following, which is the BEST initial treatment?

  • Acetaminophen

  • Calcium channel blocker

  • Combined OCP

  • Omega-3 fatty acids

  • Ibuprofen



  • Pain associated with menstrual cycle

  • Primary(functional): occurs in absence of pelvic disease

    • Pain in lower abdomen, back, thighs

    • Caused by prostaglandin E2 and F2a secretion

    • Treatment:

      • 1st line: NSAIDS

        • If no help after 2-3 cycles, consider next step

      • 2nd line: OCP

        • If no help after 3-6 months, reconsider secondary causes

  • Secondary: due to pathologic process

    • IUD, PID, endometriosis, pregnancy

Consequences of sexual behavior

Consequences of Sexual Behavior

Mucopurulent cervicitis


  • Inflammation of the cervix

  • Caused by

    • Chlamydia trachomatis

    • Neisseriagonorrhoeae

    • Trichomonasvaginalis

    • HSV

  • Signs/Symptoms:

    • Vaginal discharge, itching, irregular bleeding, dyspareunia, friability of cervix

    • Lower abdominal pain or cervial/adenexal tenderness suggest PID

Mucopurulent cervicitis1


  • Evaluation

    • NAATs for gonorrhea or chlamydia

    • Wet prep, HIV, syphilis

    • Treat based on test results unless unsure of follow-up

    • High risk adolescents should be screened for GC and chlamydia every 6 months

      • Multiple sexual partners, prior history of STI

  • Treatment

    • Gonorrhea:

      • Ceftriaxone 250mg IM x1 (125mg for <45kg) or

      • Cefixime 400mg PO x1

      • Allergic to cephalosporin?

        • Desensitize or Azithromycin 2g PO x1 (resistance is growing)

    • Chlamydia:

      • Doxycycline 100mg PO BID x 7days or

      • Azithromycin 1g PO x1



  • Inflammation of the vaginal tissue

    • Vuvlovaginalcandidiasis

    • Bacertialvaginosis

      • More common in sexually active females

    • Trichomonasvaginalis

      • Sexually transmitted

  • Signs/symptoms

    • Vaginal discharge, pruritis/irritation

    • Consistency of discharge can give clue to diagnosis

Question 13

Question #13

You are seeing a 16 yr old girl for complaints of malodorous vaginal discharge. No abdominal pain or urinary symptoms. GC and chlamydia testing 3 months ago were negative and she has not been sexually active since. On exam there is a homogenous gray discharge, normal cervix, no tenderness. A wet mount shows the following. What is the most likely diagnosis?

  • Bacterial vaginosis

  • Chemical vaginitis

  • Chlamydialcervicitis

  • Physiologic leukorrhea

  • Vaginal candidiasis

Bacterial vaginosis

Bacterial Vaginosis

  • Risk factors

    • Increasing number of sexual partners, a new sex partner, lack of condom use, douching, cigarette smoking, IUD

  • Organism(s)

    • Polymicrobial; changes in vaginal flora

    • Increase concentration of: Gardnerellavaginalis, genital mycoplasmas, anaerobic bacteria

      • Gardnerella is normal flora…but seen more commonly in sexual active youth**

    • Decrease in concentration of hydrogen peroxide-producing Lactobacillus

  • Presentation

    • Thin, white/grey, homgenous, adherent vaginal discharge; fishy odor

    • 60% are asymptomatic but can have:

      • Abdominal pain, dysuria, pruritis

  • Complications

    • Increases the risk for PID

Bacterial vaginosis1

Bacterial Vaginosis

  • Diagnosis

    • Presence of 3 or more of the following (Amsel criteria):

      • Homogenous, thin grey or white, noninflammatory vaginal discharge that smoothly coats the vaginal walls

      • Vaginal fluid pH greater than 4.5

      • A fishy odor (amine test) of vaginal discharge before or after addition of 10% potassium hydroxide (ie, the “whiff test”)

      • Presence of “clue cells” on microscopic examination of at least 20% of vaginal epithelial cells.

  • Treatment

Question 14

Question #14

You are seeing a 15-year-old sexually active girl who complains of vague lower abdominal pain and a vaginal discharge. She has no systemic symptoms but has experienced intermittent dysuria over the past week. She believes that she needs only a prescription for a yeast infection because she was treated for this a few weeks ago but the discharge did not resolve completely. Of the following, the MOST appropriate next step is to:

  • Obtain a vaginal swab for a wet mount evaluation only

  • Perform a speculum and bimanual examination

  • Perform an external genital inspection only

  • Provide an antifungal prescription

  • Send a urine specimen for culture only

Indications for a pelvic exam

Indications for a pelvic exam

  • Sexually active with complaints (discharge, pain)

  • Menstrual disorders such as delayed onset of menarche, lack of or excessive bleeding, or severe menstrual cramps

  • Unexplained pelvic pain

  • Pregnancy-related complaints

  • Suspected abuse

Board review 4 2 2013


  • Serious consequence of STDs

  • Can result in infertility, ectopic pregnancy, chronic pelvic pain

  • Polymicrobial infection

  • Presentation

    • Lower abdominal pain, discharge, irregular bleeding, dysuria, n/v, fever, malaise

    • RUQ pain  perihepatitis

      • Can be seen in either GC or chlamydial infection

Board review 4 2 2013


  • Diagnosis:

    • Must have abdominal tenderness, adnexal tenderness or cervical motion tenderness

    • Must do pelvic exam!

  • Labs/studies:

    • NAAT for GC, chlamydia

    • Wet prep

    • Other STD testing (HIV, syphillis)

    • CBC, ESR/CRP

    • +/- Ultrasound

Pid treatment

PID: Treatment

  • Hospitalize?

    • Suspicion for a surgical emergency (appendicitis, ovarian torsion)

    • Severe illness

    • Pregnancy

    • TOA

    • Inability to tolerate PO meds

    • Failure of outpatient management



  • STD syndrome characterized by inflammation of the urethra

  • Signs/symptoms

    • Urethral discharge (mucoid or purulent), itching, dysuria, urinary burning and frequency

    • *routine screening finds many asymptomatic infections*

      • Especially with trichomonas



  • Diagnosis:

    • Must have objective clinical or laboratory evidence of urethral inflammation

      • Visualization of discharge; WBCs or LE on urethral sample

    • Send NAAT for GC and chlamydia

    • HIV and syphilis testing as well

  • Management

    • Empiric treatment for those unlikely to follow-up

    • Try to differentiate between gonocococcal and NGU urethritis

    • NGU: Azithro 1g PO x1 or doxycyline 100mg PO BID x 7d

    • Positive gonorrhea: ceftriaxone or cefixime

    • If recurrent/persistent: add coverage for trichomonas

      • Metronidazole 2g PO x 1 plust erythromycin

Question 15

Question #15

An 18 yo boy comes to your office with complaints of burning with urination over the past 24 hours. He also complains of low back pain for 48 hours. He denies rash, but states his eyes are a little irritated. He is sexually active. On exam, he is afebrile, his conjunctivae are mildly injected, and his back is tender over the lower lumbar area. There is no CVA tenderness. Genital exam reveals no scrotal tenderness and scant yellow discharge at the urethral orifice. Of the follow, what is the most likely cause of his symptoms?

  • Chlamydia trachomatis

  • Gardnerellavaginalis

  • Neisseriagonorrhoeae

  • Treponemapallidum

  • Trichomonasvaginalis

Urethritis complications

Urethritis: Complications

  • Disseminated gonorrhea infection

    • Arthritis, tenosynovitis, dermatitis

  • Reiter Syndrome (reactive arthritis)

    • Associated with chlamydia

    • More common with HLA-B27 haplotypes

    • Urethritis/cervicitis, arthritis/synovitis, conjunctivitis/uveitis, mucocuatneous inflammation

    • “Can’t see, Can’t pee, Can’t climb a tree”

Extra content specs

Extra Content Specs

Genital warts

Genital Warts

  • Organism?

    • Human papillomavirus

      • Type 16 and 18 most frequently associated with cervical cancer**

      • Type 6 and 11 most frequently associated with genital warts**

  • Presentation?

    • Condylomataacuminata

    • Skin colored warts with cauliflower-like surface

      • Can be pedunculated

      • Range from a few mm to a few cm in size

    • Males: penis, scrotum, anus (males often asymptomatic**)

    • Females: vulva, perineal area (less commonly vagina or cervix)

    • Typically painless

      • Can cause burning, itching, local pain, or bleeding

Genital warts1

Genital Warts

  • Complications?

    • Cervical cancer

    • Vuvlar, vaginal, penile, anal, oropharyngeal cancer

    • Risk of cancer greater in patient with HIV and cellular immunodeficiences

  • Treatment?

    • Podophylin, Trichloroacetic acid, Podofilox, Imiquimod**

    • Cryotherapy, laser therapy, surgical removal**

    • Screening!

      • Pap tests every 3 years starting at age 21

    • Vaccination!

Genital herpes

Genital Herpes

  • Painful vesicular or ulcerative lesions of the male or female genital organs/perineum

  • After primary infection, HSV persists for life in a latent form

    • Recurrences are often asymptomatic

    • Symptomatic recurrences may be heralded by a prodrome of burning or itching at the site  can be useful in instituting antiviral therapy early

Genital herpes1

Genital Herpes

  • Treatment

    • There is no available treatment to eradicate herpes simplex virus

    • Antiviral agents can control the symptoms and signs

      • Acyclovir, valacyclovir, famciclovir

      • Acyclovir 400 mg PO TID x 10 days; or 200 mg PO 5 times/day for 10 days

        • Shortens duration of illness and viral shedding by 3-5 days

Chronic illness

Chronic Illness

  • Adherence to medical regimens can be improved in chronically ill youth when it is discussed rather than dictated.

  • Barriers to adherence in chronically ill patients

    • Time

    • Financial costs

    • Pain

    • Inconveniene

    • Embarrassment

    • Acknowledgment of personal vulnerability

Behavioral health

Behavioral Health

  • Adolescent delinquent behavior risk factors

    • Parental psychiatric illness

    • ADHD

    • Learning disability

    • Serious behavioral problems (setting fires, cruelty to animals) before the age of 5 years

    • Serious head trauma

  • Common health problems of delinquent youth

    • Injury

    • Sexually transmitted infections

    • Dental problems

    • Cigarette use

    • Alcohol and/or drug abuse

Behavioral health1

Behavioral Health

  • Parental involvement with their adolescent’s school and extracurricular activities and knowledge about their child’s friends are protective factors for delinquency

  • Firearms are a leading cause of death in adolescents



  • Emancipated minors in Louisiana…in terms of giving medical consent

    • Legally emancipated by the court system

    • Married (even if now divorced)

    • NOT having your own child

  • Confidentiality is important when caring for adolescent patients

    • Parents MUST be advised of a child’s condition if

      • Serious suicidal/homicidal ideation or other potentially lethal behaviors

      • Physician discretion used in other scenarios

  • Anticipatory guidance topics should include drinking and driving, seatbelt use, bicycle helmet use, and firearm safety

Yay we re done

YAY! We’re done 

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