Board Review 4/2/2013

1. Board Review 4/2/2013 ADOLESCENT (part 2)

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

3. Eating disorders

4. Etiology • 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

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

6. 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

7. 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.

8. 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

9. Physical Exam

10. Hospitalization • 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…

11. Hospitalization • 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

12. Complications • 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

13. 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

14. 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

15. Bulimia • 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

17. 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

18. Treatment • 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

19. Prevention • 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

20. Prognosis • 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

21. 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

22. Teen pregnancy and Contraception

23. 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

24. 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

25. 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%

26. 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.”

27. 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

28. 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

29. Compliance • 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…

30. Effectiveness

31. Abstinence • 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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!

38. 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.

39. Misperceptions • 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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

46. 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

47. 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.

48. 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

49. 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

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