Adolescent Flashcards
what is the average age of first intercourse?
16.5
what is the age of consent in Canada? what is the close age exception?
age of consent in Canada: 16
close age exception:
14-15: can consent to sex with someone up to 5 years older
12-13: can consent to sex with someone up to 2 years older
must not be in a position of authority (teacher, coach, clergy etc)
18 years for exploitative sex (pornography, prostitution)
what are the contraceptive methods failure rates? chance condoms combined pill depo provera LARCs
chance- 85% condoms- 18% combined pill- 9% depo provera -6% LARCs- 0.2% * percentage of teens pregnant after 1 year of using this method
The patch, vaginal ring and OCP are less if effective if weight is greater than?
90kg
what is the number one contraceptive method recommended in Canada now?
LARCs (long acting reversible contraception)
What are the 3 options for LARCs
Mirena- good for up to 5 years, progesterone only
Jaydess- good for 3 years
kyleena- good for 5 years (smallest)
How can you increase the efficacy of condoms? who do you not recommend this for?
increased efficacy if combined with spermicidal form or jelly
high failure rate therefore recommend a backup for pregnancy protection
avoid spermicide in high risk for HIV populations (street youth or trading sex for money)
what are the estrogen related side effects associated with oral contraception? serious side effect?**
breast tenderness breakthrough bleeding nausea headaches hypertension thromboembolism drug interactions (P450) slight increased risk of cervical dysplasia (>5years)
Serious:
thrombosis (risk increases with smoking and age and in girls with migraine with aura and migraine with focal neurologic symptoms)
what would you do with your OCP if there was frequent breakthrough? nausea? headache?
breakthrough- increase the estrogen dose
nausea- decrease the estrogen dose
headache- use a monophasic pill, Lower estrogen
what dose of estrogen do we usually start with for our combined OCP
30-35 mcg estrogen
what drugs do OCP interact with?
anticonvulsants
- many decrease the efficacy of OCP
- valproate is NOT affected
- could use higher dose estrogen pill (35) or IUD
what are some contraindications to IUD (8) **
pregnancy/suspected pregnancy PID (current or within the last 3 months) acute/purulent cervicitis pelvic TB undiagnosed vaginal bleeding (suspicious for serious condition) distorted uterine cavity malignancy of genital tract Wilson disease (copper IUD)
Is weight gain a side effect from combined birth control?
NO!!! This is a myth. May have some fluid retention that comes and goes through the month
what type of OCP can be used for back to back?
Monophasic OCP (21, 21, 21, 21 then 5 days off) Seasonale (12 weeks of pills then 7 off)
what are some side effects from Depot Provera? **
irregular bleeding for 3-12 months amenorrhea weight gain (4-15 pounds) reduced bone density - caution if steroids, eating disorder, chronic renal failure - consider BMD depression/mood changes delays return to fertility- average 10 months!
what should you prescribe with Depo Provera
Calcium and vitamin D
when should you consider Depo Provera
Good choice when you don’t want a LARC
- can’t reliably take pills
- estrogen is contraindicated
- want amenorrhea
when should you give emergency contraception?
within 72 hours but up to 5 days
what options are available for emergency contraception?
Ella
- 30mg taken once
- up to 120 hours after unprotected sex
- does not reduce efficacy over time
Plan B (progesterone only)
- give 1.5mg once
- nausea 23%
Copper IUD
up to 7 days
what are 2 contraindications to emergency contraception?
pregnancy
history of anaphylaxis to product
what else should you do when you give emergency contraception?
arrange follow up in 1 week (ensure they are not pregnant- should have bleed within 3 weeks)
give prescription for emergency contraception
encourage condom use/regular contraception
what is gender dysphoria
a strong desire to be of the other gender or in insistence that one is the other gender
the condition is associated with clinically significant distress or impairment
what are some medical treatment options for transgender youth?
LUPRON Continuous OCP Testosterone Estrogen Sprionolactone Cyproterone acetate
** surgery (top or bottom) is not approved in children
what is the criteria for anorexia nervosa
A. Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than that minimally expected.
B. Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes with weight gain, even though at a significantly low weight.
C. Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.
what is binge eating disorder?
No compensatory behaviour
occurs 1/week for 3 months
eating an excessive amount of food
sense of lack of control during binge episode
- Eating, in a discrete period of time (e.g., within any 2 hr period), an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances.
- A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
what is the criteria for bulimia nervosa?
Binge eating + compensatory behaviour!
A. Recurrent episodes of binge eating.
B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise.
C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for 3 mo.
D. Self-evaluation is unduly influenced by body shape and weight.
E. The disturbance does not occur exclusively during episodes of anorexia nervosa.
What is the criteria for ARFID?
A. An eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
- Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
- Significant nutritional deficiency.
- Dependence on enteral feeding or oral nutritional supplements.
- Marked interference with psychosocial functioning.
NO evidence of body image disturbance!!
what are indications for hospitalizations for eating disorder?
severe malnutrition:
weight <75-80% average body weight for age, sex and height
arrested growth and development
fluid and electrolyte abnormalities
- dehydration
- hypokalemia, hyponatremia, hypophosphatemia
cardiac abnormalities
- arrhythmia
- bradycardia <50bpm anytime, <45bpm at night
- hypotension (<80/50 mmHg)
- hypothermia (body temp <35.5)
- orthostatic changes in HR (>20bpm) or BP (>10mm Hg)
Behavioral
- acute food refusal
- uncontrollable binging ad purging
- acute psychiatric emergencies (suicidal ideation)
- comorbid diagnosis
Do the majority of teens with gonorrhoea or chlamydia have symptoms?
NO, most are asymptomatic!!!
what are some symptoms of chlamydia?
asymptomatic dysuria vaginal discharge abdominal pain vaginal spotting (especially after sex)
what is the most common STI?
HPV then chalmydia (most common bacterial STI)
what is the treatment for Chlamydia?
Azithromycin 1g PO x1 dose *** treatment of choice for teens
other options: doxycycline, erythromycin, tetracycline
what is the treatment for Gonorrhea?
Ceftriaxone or Cefixime
AND
Azithromycin or Doxycycline
when do we start screening with PAPs?
21 then every 3 years if sexually active
what are some complications of untreated PID?
ectopic pregnancy chronic pelvic pain infertility (tubal factor infertility) peri-hepatitis (may present with RUQ pain as first symptom) tubo-ovarian abscess
what is required for the diagnosis of PID?
lower abdominal pain plus either:
adnexal tenderness
cervical motion tenderness
uterine tenderness
what is the treatment for PID? (as outpatient)
Ceftriaxone 250mg IM in a single dose PLUS doxycycline 100mg PO BID x 14 days consider adding metronidazole close F/U!! * make sure you treat the partner!!
what are the indications for hospitalization for PID?
concerns regarding adherence pregnancy failure to respond to oral treatment severe illness, vomiting or high fever tubo-ovarian abscess HIV infection
what is inpatient treatment of PID?
Cefoxitin 2g IV every 6 hours PLUS
doxycycline 100mg IV or PO every 12 hours
what is the most common breast mass in teens?
fibroadenomas
2nd- fibrocystic disease (bilateral)
what are the 3 most common drugs used by teens?
alcohol
energy drinks
cannabis
regular use of cannabis in teens is linked to what?
psychosis
mood disorders
Lower lifetime achievement
cannabis use disorder
what are 2 short term risks associated with cannabis?
MVA
psychosis
how can we improve adherence?
simplify
once daily dosing
long acting meds
no treatments during school day
take into account sleeping in on weekend and sleepovers with friends
meds should not be associated with eating or not eating
minimize side effects
patient physician relationship- the single most important modifiable predictor of adherence!!
- continuity of care
- friendly clinic space and staff
- time spent with their MD
- direct conversations about adherence
- be on time
- after school appointments
- their MD takes a personal interest in them
what EKG finding is associated with AN
prolonged QT
what are the tasks of adolescence?
achieving independence from their parents
adopting peer codes and lifestyles
assigning increased importance to body image and acceptance of ones body image
establishing sexual, vocational and moral identities
what are the stages of psychosocial development
Early: 12-14 y
Middle: 15-16 y
Late: 17-18 y
Early
- body image issues begin
- start to separate from parents
Middle
- experimentation
- sense of immortality
Late
- abstract thinking
- less egocentric
what is the diagnostic criteria for PCOS
abnormal uterine bleeding pattern (<19d or >90d always abnormal) evidence of hyperandrogenism - elevated testosterone - hirsutism - mod-severe inflammatory acne
what is the management of PCOS
1st line- combined oral contraceptive pill
- normalize endometrial cycling
- inhibit ovarian function (normalize serum androgens)
alternative:
1) progestin mono therapy (regulates periods only!)
2) insulin lowering therapy- either weight reduction or medication such as Metformin- have 50% probability of improving menstrual cyclicity
what is the mechanism of action of OCP?
- thickens cervical mucous
- blocks sperm penetration
- progestin
- inhibits ovulation by inhibiting LH surge
what are some benefits of OCP
decreases dysmenorrhea decreases menorrhagia reduces anemia improvement in acne, hirsutism reduces risk of ovarian, endometrial cancers may help with ovarian cysts decrease benign breast disease
how does the copper IUD work
“functional spermicide”
copper ions interfere with sperm motility, transport, capacitation, cause sperm head-tail disconnection
foreign body inflammatory reaction
what contraception help reduce the risk of acute sickle cell crisis?
Depot provera reduces acute sickle cell crisis by 70%
what are some clinical signs suggestive of bulimia nervosa? (5)
- Russell’s sign (calluses on dorsum of hand)
- dental enamel erosion
- parotid gland enlargement
- edema
- fluctuating weight (healthy/overweight)
what are some medical complications of eating disorders (9)
temperature cardiac refeeding syndrome fluids/electrolytes osteopenia linear growth endocrine- amenorrhea, sick euthyroid, high cortisol GI Neurologic
what are some cardiac complications of eating disorders
electrocardiographic
- sinus bradycardia
- prolonged QTc (Corrects within 3 days of re-feeding)
orthostatic changes hypotension poor myocardial contractility mitral valve prolapse reduced LV thickness and mass silent pericardial effusion congestive failure (Aggressive fluid rehydration) cardiomyopathy- ipecac abuse
what electrolyte abnormalities are seen with refeeding syndrome
hypokalemia
hypomagnesemia
hypophosphatemia- shifts from extracellular to intracellular results in depleted ATP
what GI complications are seen with eating disorders
1) delayed gastric emptying
2) slowed GI motility
3) SMA syndrome- compression of the 3rd portion of the duodenum by abdominal aorta and overlying superior mesenteric artery (due to a lack of retroperitoneal fat)
4) constipation after stopping laxatives
5) with binging and purging
- gastric dilation and rupture
- rectal prolapse
- mallory-weiss tear
- GERD
- dental enamel erosion
what are some risk factors for osteopenia in eating disorders? what is the treatment?
LOW WEIGHT OR ABSENCE OF WEIGHT GAIN FOR PROLONGED PERIOD OF TIME
- early onset of amenorrhea
- long duration of amenorrhea
- low protein intake
- low calcium intake
- smoking
TX: WEIGHT RESTORATION TO A LEVEL WHERE MENSES RESUMES
- additional treatments include calcium 1300mg/day, vitamin d, do not use OCP
why do patients with eating disorders get amenorrhea
due to hypothalamic suppression
- weight at resumption of menses used as one marker of health **
what is the treatment for eating disorders
medical/nutrition management
- restoration of weight and healthy nutrition patterns
- avoidance/correction of medical complications
family based therapy NOT individual therapy
what is some parenting education that can be provided for eating disorders
- not their fault
- AN is a serious condition that probably would not improve without treatment
- be angry at the eating disorder but not at the child
- parent must take charge of child’s eating, exercise and weight gain
- supervise 3 meals, 2-3 snacks per day
- weight restoration first, thoughts/attitudes take longer
what are 4 complications of gonorrhoea in females?
PID infertility chronic pelvic pain ectopic pregnancy perihepatitis
males epididymo-orchitis reactive arthritis infertility (rare) disseminated gonococcal infection (DGI)
when should you do repeat testing for gonorrhoea or chlamydia?
repeat in 6 months as reinfection risk is high!!
what is the treatment for genital herpes?
1st episode:
acyclovir for 7-10, famicyclovir for 5d, or valacyclovir for 7-10 days
recurrence:
valacyclovir for 3 d
best if started within 12 hours of first lesion or during prodrome
what is the treatment for HPV (warts)?
imiquimod (aldera) cryotherapy podophyllin trichloroacetic acid laser
Ddx for genital lesions
herpes HPV molluscum primary syphilis (chancre)- painless chancroid- painful pearly papules
what are some additional criteria that increase specificity of PID?
fever >38.3 po
many wbc’s on saline microscopy of vaginal fluid
elevated ESR
elevated CRP
lab documentation of cervical infection with GC or CT
what does your treatment need to cover for PID
Chlamydica, gonorrhoea, bacterial vaginosis, anaerobes
what are markers of risk for substance abuse among youth (5)
street- involved concurrent mental health disorder gay, lesbian, bisexual, or transgendered family history of substance abuse family dysfunction
what is the CRAFFT screening questionnaire?
C: Have you ever ridden in a CAR driven by someone impaired
R- do you use drugs to RELAX or fit in
A- Do you use drugs ALONE
F- do you ever FORGET things you did while using drugs
F- Do your family or FRIENDS tell you to cut down
T- Have you gotten in TROUBLE while using drugs
what are some long term effects of inhalants
drastic and irreversible neurologic effects
- brainstem dysfunction
- motor, cognitive, sensory deficits
- signs may include irritability, tremor, ataxia, nystagmus, slurred speech, decreased visual acuity and deafness
cardiomyopathy distal RTA hepatitis dyspnea, emphysema bone marrow toxicity- leukaemia aplastic anemia teratogenic
what morbidity and mortality is associated with stimulants?
respiratory arrest from CNS depression
sudden sniffing death syndrome- likely to due primary cardiac arrhythmia
dangerous behaviour from disinhibition and feeling of invincibility
aspiration, suffocation
what are some ways you can detect inhalant use?
odour on breath
stain, paint, glitter on skin or clothing
personal dryness or pyoderma (huffer’s rash)
facial, oral, esophagopharyngeal freezing or burning
edema of lips, oropharynx, trachea
confusion, moodiness, irritability
pulmonary- wheezing, emphysema, dyspnea
what is the primary treatment for dysmenorrhea
NSAIDS
Adolescent female comes and asks you about the use of medical marijuana. What are 3 long-term negative consequences of recreational or medical marijuana?
Higher rates of other substance abuse (alcohol, ecstacy)
MVA accidents
Lower academic functioning and educational achievement
Risk of psychosis
More anxiety symptoms
Associated with Depression
