Adolescent medicine and gynecology-XXIV

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height velocity in and around puberty: F: before 5-6cm/yr. PHV 5-11(av. 9) cm/yr occures 6-12 mo prior to menses. 2yr decel to epiphysial closure

M: before 5-6cm/yr. PHV 6-13 (10) cm/yr
Order of puberty: F: growth spurt, 1yr later thelarche and tanner 2, 1yr later PHV, 0-6mo later menarche, 2yrs more growth.

M: PHV around tanner 4-5
no periods, when worry: Primary amenorrhea: no menses by 16 with nl dev.
Different but concerning if:
no menses and no dev by 14
no breast buds by 13
no menses 2yrs after tanner 4
median age of menarche, US: 12.7
percent of females who achieve menarche by tanner 4: 90%
No tanner 2 by what age warrants investigation in females: 13yrs
Most common cause of persistant irregular menses: polycystic ovary syndrome
average age between thelarchy and menarche: 2 yrs
average cycle: 21-35 days
average bleeding time/amount abnormal: nl: 3-7 days, 30-40ml
abn: >8-10days, >80ml
average time to normalcy in cycles from menarche: 1-1.5yrs
Secondary amenorrhea: absence of 3 cycles or 6 months. Only applicable in someone who has established regular cycles.
Amenorrhea with delayed puberty: Dx: Ovary problem: high FSH due to no neg feedback from ovary (no estrogens). Turner S. is most common

Hyp-Pit problem: most common stress, intense athletic training, inadequate nutrition., panhypopit, hypothyroid, prader willi.
Amenorrhea with normal puberty: PREGNANT.
the pit-hypothalm problems causing delayed puberty can also cause this.
Depo, Norplant.
Asherman S: uterine stranding post abortion
Sheehan S. Pit infarction from bleed/hypotension during labor.
Amenorrhea with genital tract abnormalities: imperforate hymen: blueish hymen, midline abd mass, cyclic abd pain.
vaginal agenesis: Mayer-Rokitansky-Kuster-Hauser S., and testicular feminization. (norm breasts, no pubic hair)
Polycystic ovary Syndrome: Bad term. no ovulation, too much androgen (testosterone), hirsut, acne, obese, associated with insulin resistance, glucose intolerance, hi lipids.
Primary dysmenorrhea vs Secondary: Primary: prostaglandins
Secondary: pelvic pathology (endometriosis)
most prevalent STD in teens: HPV, almost 50% of young women
most common bacterial STD in teens: Chlamydia
vaginitis treatments: Chlamydia = azithromycin
gonorrhea = cefixime
candida = clotrimazole
trichomonas = metronidazole.
gynecomastea, abnormal: older male (tanner 5)
lasting longer than 2 yrs.
liver and adrenal tumor, testicular neoplasm, thyroid, Klinefelter.
malodrous vaginal discharge: Trich, BV, candida, cervicitis (gonorrhea, Chlamydia, HSV)
cervicitis, dx, rx: friable cervix ith purulent dx: endocervicitis.
GC/Chlamyd
Azithromycin, Cefixime
Short stature and bone age, number of years off and still normal: up to 2 yrs delayed bone age from chrono is within normal
familial short stature: bone age = chrono
constitutional delay of growth: bone age and tanner stage is delayd
bone age corresponds to height-age.
"late bloomers"
FHx of delayed puberty.
slow growth in first 2-3yrs, hug 5th% then sprout late.
Bacterial vaginosis: more common if sexually active.
Fishy odor, + whiff test
clue cells
Why measure androgen levels for amenorrhea: obese teen with signs of virilization. polycystic ovary syndrome.
why measure gonadotropin levels in amenorrhea: abnormal pubertal development suggestive of hypothalamic-pituitary-ovary axis problems.
Signs of Trichomoniasis in men and women: F: yellow-green frothy, malodorous discharge, bad itch.
M: usually asx. can have scant clear urethral discharge.
electrolytes in bolemia: vomiting: hypochloremic, hypokalemic, metabolic alkalosis (same as pyloric stenosis)
laxitives: acidosis
rape trauma syndrome: a form of PTSD, intense fear, re-experiencing trama, increased arousal,
absolute contrindications for oral contraceptives: thromboembolic disease, CVA, uterine cancer, CAD, pregnancy.
risk of thromboembolic phenom from the pill: increases risk 2-4 times. CVA, PE, DVT
Drugs that decrease efficacy of the pill: antiepileptics (phenytoin, carbamazepine, barbis)
rifampin
Reasons teen choose not to use contraception: 1. don't ming or want to become pregnant.
2. peer pressure.
3. weight gain concerns.
4. privacy.
leading causes of death in teens: accident (car and drowning), homicide (most common for black teens), suicide.
boys twice as likely to die in car than girls.
pubarche: pubic hair devleopment
a couple months after thelarche.
stage 5 breasts, tanner 1-2 pubic hair: androgen insensitivity (testicular fem)
tanner 5 pubic hair, no thelarche: androgen excess, no estrogen, or congenial absence of breast tissue.
wet mount: trichomonads, bacteria.
vaginal pH: prepuberty: 6.5-7.5
during and after: <4.5 (acidic)
Poland S.: absence of pectoralis, breast and ipsi limb problems.
no signs of puberty at what age warrants investigation: F: 13
M: 14
increased risk to develop atopic disease if you already got one: three times greater than general public.
When does peak height velocity happe in boys: after tanner 4. 80% have it with tanner 5
testicular volume: tanner 1, <4ml
tanner 3, 8-10
tanner 4, 13
alkaline phosphatase in puberty: varies greatly during rapid grosth. 105-420
usually rises with bile duct obstruction, GGt shouled also be up
If not then think of small intestine, kidney, bone (rickets, osteomalacia, fx)
Hb by age: rise after 12yrs. to adult levels:
M: 14-18
F: 12-16
black: 0.5 less on average.
cutoff for calling it precocious puberty: breat developmentbefor 6 in caucasian
before 5 in african american
acanthosis nigricans significance in teens: insulin resistancebut not specific
obese swith AN: increased risk for
dyslipidemia, type 2 DM, HTN
Abnormal tests with polycystic ovary syndrome: testosterone and other androgens elevated.
treatment for dysmenorrhea: prostaglandin inhibitors (NSAIDS)
exercise, tylenol, diet, rest don't work.
PID dx, rx: vaginal discharge, irregular bleeding, RUQ pain (Fitz-Hugh-Curtis) perihepatitis. dishcarge, cervical motionand adnexal tenderness.
early therapy is important. Hospitalization is not needed always, but warranted if febrile, vomiting. inpatient for teens compliance
PID complications: tubo-ovarian abscess, infertility, EP.chronic pelvic pain.
routine testing for sexually active under 18yrs: perhaps no pap. Urine PCR for GC/Chlamyd is best generic screen.
Bulimia dx: recurrent binge eating twice a week for 3 months. lack f control over eating during the binge.
normal BP vs hypertension: <90% for gender, height, age
90-95% borderline
>95% HTN if on repeated measures
Delayed puberty defined as: F; 13 and tanner 1
M: 14 and tanner 1
constitutional delay in puberty: 14-15yr old boy with fam hx of late bloomers. Can be superimposed on consitutional short stature (hard to tease apart).
Diff dx delayed puberty: constitutional delay
chronic illness
Pit (panhypopit, kallman)
hypothyroid
hyperprolactinemia
Turner, Klinefelter
hypogonadism: primary: testes don't work/absent, GnRH, LH, FSH hi, testosterone low (Noonan, Klinefleter)

secondary: hypo-pit doesn't work Low FSH, LH- Kallman S. (no smell, no GnRH)

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