Adolescent and Gyne Flashcards
T or F: parental conflict peaks in mid-adolescence.
True
Also: abstract thinking.
When does menstruation occur?
Tanner Stage 4
What occurs in Tanner Stage 4?
M:
- *- max penile growth
- axillary hair, voice change
F:
- *- double breast contour
- *- menarche
- coarse, curly hair
What occurs in Tanner Stage 2?
M:
- *- testicular enlargement
- pubic at base
F:
- *- breast bud
- hair on labia
What occurs in Tanner Stage 3?
M:
- *- penile growth
- voice break
F:
- breast + areola enlarged; no sep contour
- *- peak ht velocity
- acne
- dark hair start too curl
14 y.o. M 3cm unilateral tender breast.
- US
- F/U 6 mo
- Karyotype
- CT scan
F/U in 6 month
Pubertal Gynecomastia
When does preoccupation with body image occur?
Early adolescence
3 reasons to breach confidentiality:
- harm to self or others
- harm to other children
- communicable dx (reportable diseases)
- impaired driving ability (report any >16 y.o. suffering condition that make it diff to drive)
- gun shot wounds
5 things to help transition teen to adult care:
- see teen w/out parent for part of apt
- give increasingly level of responsibility or info
- peer support meetings
- provide transition letter
- collaborate w/ adult care provider
Which is more commonly seen in bulimia nervosa compared to anorexia nervosa:
- cachexia
- hypothermia
- low BP
- enlarge salivary glands
- extremely dry skin
Enlarged salivary glands
Kids with AN becomes osteopenia because:
Estrogen deficiency
+ high cortisol, low IGF-1, low lean body mass, low wt, nutritional, amenorrhea
Is lanugo or alopecia seen in anorexia nervosa?
Lanugo
AN= full thinning scalp hair. Other AN signs - orthostatic change - low temp - thinning hair - draw skin, lanugo - delayed pubertal - atrophic breast - cold limb - orange skin (carotenemia) - edema of limbs
List criteria for Anorexia Nervosa?
- Fear of gaining wt
- Disturbance in wt/shape
- Restricted intake for requirements (leading to low wt for age, sex, developmental trajectory)
List criteria for Bulimia Nervosa?
- Self-evaluation influenced by shape + wt
- Binge eating (eat excessive amount + lack of control during episode)
- Compensatory behaviour (vomit, laxative, diuretic, med, fasting)
- 1X/ wk x 3 month
Note: Binge Eating Dix is just the binge without compensatory behaviour.
What comorbidities do you see with Bulimia?
P/E findings?
- Depression
- Anxiety
- Substance use
- Cluster B/ borderline PD
P/E:
- Older
- large parotid
- oral ulcer
- dental enamel erosion
- russell sign (callus on knuckle)
What is ARFID?
Eating disturbance=
- Result in wt loss or nutritional deficiency or depend on enteral feed or interfere w/ f’n
- No body image disturbance
- Not due to other medical illness
List 3 DDX of eating disorders:
GI: IBD, Celiac, Infectious Gastro, HIV
Endo: Thyroid, DM, addison’s
Psychiatric: OCD, Substance use
Other: CNS lesion, SMA syndrome, CA
T or F: growth, atrophy, bone density issue are irreversible issues with eating disorder.
True
What is the tx target avg body weight for kids with ED?
90% of average body wt for sex, ht, age
Goal: nutritional rehab by parents -> then switch of responsibility to teen (wt already restored) -> focus on teen development
Reasons to admit for eating disorder:
Physical:
- *- T < 36.1
- *- HR < 50 bpm awake (< 45 asleep)
- *- BP < 80/50
- *- orthostatic BP
- dehydration, syncope
- *- rhythm/ long QT
- < 75-80% body wt
- body fat < 10%
Psych:
- *- SI (intent + plant)
- poor motivation to recover
- coexisting psych d/o
Lab:
- low K, Phos, BG, Cl
- liver, cardiac, renal compromise
Other:
- *- failed outpatient tx
- *- refusal to eat/ intractable vomiting
What are common comorbidities with anorexia nervosa?
- Anxiety
- Depression
Which is most worrisome in anorexic pt?
- low K
- WBC < 1000
- Met alkalosis
- low protein
Low K
BW AbN:
- usually low WBC, low Hb, low K, if ++ vomit then low Cl- and met alkalosis in severe vomiting, elevated liver enzyme, long QTc
How do you prevent osteoporosis in an anorexic?
- Ca
- Vit D
- Estrogen
- Gain wt to min. 10% ideal wt
Calcium
** always Ca+ and vit D supplement for risk of low bone mineral density.
White early teen F with above avg intelligence and is avoidant perfectionist struggling with mood or anxiety. Anorexia Nervosa or Bulimia Nervosa?
Anorexia Nervosa
List some effects of starvation:
Brain: hypothalamic, depression, irritable
Cardiac: sinus brady, long QTc, MV prolapse
Refeeding: risk low Phos, K, Na, Mg etc.
GI: delayed gastric emptying, constipation, SMA syndrome
Gonads: amenorrhea, erectile dysfunction
Bones/ Osteopenia
Growth failure
List bulimia BW
- Low Na (can be hi/N)
- Low K
- Low Cl
- Metabolic Alkalosis
- Co2 up (compensation)
What is the most f cause of school absence of teen F:
- h/a
- dysmenorrhea
- asthma
- sore throat
Dysmenorrhea
AAP 1980 - “dysmenorrhea is leading cause of recurrent short term school absenteeism among teen F”
List a ddx for dysmenorrhea?
- Primary dysmenorrhea
- if pain between menses= NOT primary!
- Secondary > Endometriosis >Pelvic inflammatory dx >Preg complication > Mullerian anomalies w/ partial outflow tract obstruction > Abuse
Best for PCOS: increased LH/FSH, HTN or increased testosterone.
Testosterone ++
Just menarche. Pre and Post White vag d/c intermittent. Occasional irritation or itch. Likely dx?
Physiologic leukorrhea
Menometrorrhagia x 6 months. Bleed x 3 month.
- LOW E
- HIGH progesterone
- vWF deficiency
- LOW progesterone
=LOW progesterone.
(Remember E makes the grass and P is the lawn mower)
Menometrorrhagia= prolonged bleed irregular or more f than usual.
Irregular means not VWF
12 y.o. with T21. Menses hard to manage. Best option?
- depo
- IUD
- Continuous OCP x 84 days
- LHRH agonist
Continuous OCP x 84 weeks.
AAP 2016: OCP still most commonly used.
What excludes PID?
- neg. preg test
- neg. screen GC
- neg. screen Chlam
- no WBC on cervical d/c
Absence of WBC in cervical d/c
What is pelvic inflammatory dx?
Infection of F upper genital tract.
Etiology: polymicrobial.
- STI (chlamydia, gonorrhoea, HSV)
- mycoplasma, ureaplasma
- anaerobic
- other: E coli, gardnerella vaginalis, haemophils influenzae
CC: abdo pain + fever
- abdo + pelvic exam
Pelvic inflammatory disorder dx criteria:
Clinical dx: Lower abdo Pain + 1= = adnexal tender = cervical motion tenderness = Uterine tenderness
To add specificity:
- mucopurulent d/c or WBC on saline prep
- fever
- high ESR, CRP
- document of infection
Definitive dx if endometrial bx, US show fluid filled tubes, or Laparoscopy show abnormalities w/ PID
Treat of pelvic inflammatory disease:
+/- Hospitalization
Cefotixin IV + doxy IV
then Doxy x 14d
Otherwise IV= PO
i.e. ceftriaxone x 1 and doxy x14d +/- flagyll
T or F: early dx and tx of PID key to maintain fertility.
True
What are PID complications:
CAFE PID
- chronic pelvic pain
- abscess
- fitz-hugh-curtis syn
- peritonitis
- infertility
- disseminated infection
Define precocious puberty
M < 9 (9-14 Norm)
F < 8 (8-13 Norm)
T or F: premature thelarche only if < 5.
False.
Only if < 2.
+ no ht acceleration, no adv bone age, no other sign.
If > 3= ensure no central cause.
T or F: premature menarche can be normal.
False!
Must always look for a cause!
Dysmenorrhea. 3 causes? What two meds you can offer? How does it work?
3 Causes:
- primary/ idiopathic
- endometriosis
- uterine polyps
- ovarian cyst
- PID
- FB
Treatment:
- Exercise
- Well balanced Diet
- Topical heat
Two med Classes:
- NSAID (take as soon as you know menses coming) (prostaglandin synthetase inhibitor)
- OCP
Started menarche but irregular. No dysmenorrhea. Likely cause and 2 Tx?
Likely cause:
- anovulatory cycle due to immaturity of HPO axis
Tx:
- Reassurance
- Consider oral iron supplementation
- Consider OCP if troublesome
4 things on dx of vaginal bleeding in 8 y.o.
- FB (toilet paper)
- *- Sexual Abuse
- ** Trauma
- Central (Tumour affecting HPO axis)
- *- Hypothyroidism
Other
- Vulvovaginitis
- McCune Albright Syn
- genital tract malignancy
- estrogen exposure
- hemangioma
Absolute contraindication to OCP
*Migraine w/ aura
*Severe cirrhosis
*Uncontrolled HTN
*DM w/ neuropathy, nephropathy, retinopathy
*Acute DVT or PE
Known thrombophilia
*Hx of Stroke
Valvular Heart Dx
*SLE w/ antiphospholipid antibodies
Current breast CA
Note: smoking RELATIVE and really if ++ older
T or F: IUD cause infertility.
False.
T or F: you must do urine beta HCG before taking morning after pill.
False.
Not necessary.
What are absolute contraindication to morning after pill?
- Known pregnancy
* can give without preg test as even if (+) won’t cause therapeutic abortion. - Known allergy (anaphylaxis to product)
Chlamydia urethritis teen. Before can have sex again:
- must complete 7d of tx
- after partner tx
- after 6d
- until retested and found negative.
Can resume sex activity ONCE HE completes 7d of TX
- 1x azithro OR 7d course doxy
- sexual partners should be treated if contact within 60d of symptom onset
- most recent partner always treated
- no sex until 7d after single dose or after complete 7d regiment
T or F: most teenage pregnancies end in abortion
True
- just over 50%
T or F: most pubertal teen with chlamydia are asymptomatic.
True
Best tx of gonorrhoea?
Tx: Ceftriaxone (or cefixime) x1 and Azithro x 1 (*always tx presumptive chlamydia)
Other:
- Gram neg. diplococcus
- most F asymptomatic and most men symp.
- NAAT
T or F: you can immediately give contraception after an abortion. Versus 2 wk later.
True - give immediately!
When do menses return after emergency contraception
Return within 7d within expected date
- if next period more than 1 wk late = do pregnancy test
Sexually active teen. Pruritic genital lesions. Red macule and papule and blue-grey. Dx? Tx?
Dx: Pubic Lice
Key: pruritus, bites (blue-grey; look like bruises)
Dx: ID egg (nits), nymphs, lice with make eye
Tx: 1% Permethrin Cream rinse
Eyelid: petrolatum ointment x 8-10d
Prevention:
- machine wash + dryer everything hot
- vacuum everything
- avoid sex until tx
- tell all sex partners in last month
Most common bug of urethritis:
- N. gonorrhea most likely
Other: ureaplasma urealyticum, mycoplasma genitalium, trichomonas
Teen comes in for morning after pill. Latest after intercourse it is effective? Two things in management after?
*Maximum 72-120h
Subsequent:
- counsel for pill failure
- if period doesn’t return within 1 wk of usual timing then need preg testing
- if becomes pregnant discuss options
- counsel safe sex (does not protect against STI)
- encourage barrier protection
T or F: liver CA is one potential long-term sequelae of anabolic steroid use.
True
Other listed AE:
- aggression, anxiety, depression + others
- HTN
- low glucose tolerance
- hepatic transaminitis
- poor sperm count and testicular atrophy
- menstrual irregularities
Most important reason to be concerned about teen alcohol abuse:
- risk taking behav while drinking
- assoc. depression
- liver dx
- poor school performace
Risk taking behaviour while drinking.
List fives things that would increase concern for substance abuse in patient:
- type of drug
- circumstance (alone vs. group)
- f and timing
- premorbid mental health dx
- general functioning
CRAFT Mnemonic: screen fo substance use in primary care. In last 12 months…
- CAR- ridden in car who was high or using
- RELAX- used to fit in
- ALONE- use
- FORGET- thing while using
- FAMILY + FRIENDS- tell you to cut down
- TROUBLE- while using
4 clinical manifestations of cocaine use?
- euphoria
- psychosis
- motor agitation
- decreased fatiguability
- mental alertness
- sympathomimetic: all UP (pupils dilated, tachy, HTN, high T, high RR)
T or F: antidepressants can cause sexual dysfunction in teens.
True- SSRI
Other: GI symptom, h/a, insomnia, appetite change, anxiety, increased SI thoughts
Why are testes small if anabolic steroids used?
Exogenous steroid = suppress HPA = less FSH + LH = less T and spermatogenesis = less size of testes
T or F: parenting classes do not affect rate of child abuse.
False.
HELP REDUCE RISK.
Risk of depression recurrence within first year of d/c SSRI tx?
40%
Child on fluoxetine and risperidone. High DTR + tremor + ataxia.
Which drug is the problem:
fluoxetine?
Risperidone?
** Serotonin= d/c +/- cyproheptadine
Serotonin Syndrome: HARMED - hyperthermia (all VS up) - agitation - reflexes ++, rigid - myoclonus - encephalopathy - diaphoresis
Risperidone: - EPS (dystonia, restless, tremor, tardive dyskinesia) - long QT - metabolic syn - wt gain -DM - high lipid - high prolactin - hepatotoxicity - low WBC, neut (= agranulocytosis) - sz - NMS = FEVER (slow onset with more generalized rigidity) - fever, encephalopathy, VS unstable, high CK, rigid (lead pie) muscles
Suicide RF for teens. List what you remember.
- M
- Low SES
- homosexual
- mental health dx
- substance abuse
- impulsivity
- low self-esteem
- perfectionism
- hopelessness
- parental divorce or death
- adverse childhood exerpeince
- hx of abuse
- bullying
- parent mental health
- fhx (+) suicide
T or F: tourettes is min. 2 motor + 1 vocal x 6 month.
False.
x1 year
<18 y.o.
Co-morbid: ADHD, OCD, LD
if interfere w/ life= Tx= Clonidine
T or F: oral sex is more common than sexual intercourse?
True
T or F: 1/3 of grade 10 F and M have had sex.
True.
How can you remember Age of Consent in Canada?
16 unless authority or exploitative.
Close age exception:
“2 and 2; 5 and 5”
12-13= consent with someone up to 2yr older
14-15= can consent up to 5yr older
T or F: pregnancy rates among Canadian teens are rising.
False; declining.
T or F: > 1/3 of teen who deliver will have another preg within 2yr.
True.
T or F: post partum depression risk in teens > older mom.
False.
Post partum depression rate similar to non-teen mom.
List the failure rate of the following contraceptive methods:
- chance
- withdrawal
- condom
- combined pill
- depo
- LARC
Chance= 85% Withdrawal= 22% Condom=18% Combined= 9% Depo= 6% LARC= 0.2 %
Note: if < 90kg combined pill even less effective.
T or F: LARC fertility takes 6 month once its removed.
False.
1-2 cycles.
T or F: there is a increase risk of STI or PID post LARC insertion.
True
BUT only for first 21d
List IUD AE:
Increasing spotting
Amenorrhea
List OCP Pro and Con:
Pro:
- easy to use
- shorter, less dysmenorrhea
- less acne and hirsutism
Con:
- breast tender
- nausea
- h/a
- breakthrough bleed (resolves)
Serious AE:
- thrombosis (2X VTE or stroke risk but still very minimal. Increased if migraine w/ aura. Either= less than if got pregnant)
Troubleshooting: if frequent breakthrough= E up, too much nausea= E down; headache then lower E
What are OCP drug interaction?
- Anti-Sz = decrease efficacy of OCP i.e. carbamazepine, clobazam, fosphenytoin - Rifampin - St John's Wart
FINE:
- VPA FINE
- Abx FINE
T or F: it is safe to do “Extended cycling” with the OCP.
True.
= 21-21-21-21- then no pills for 5 d
OR 12 week pill and 7 days off.
List Depo-Provera AE:
Pro:
- good if E contraindicated
- amenorrhea
Con:
- irregular bleed
- wt gain (5-15 lb)
- reduced bone density (**take with Vitamin D and Ca)
T or F: in most children, gender dysphoria will persistent into adolescence.
False.
If (+) as child -> most don’t
If (+) in teen -> most do.
T or F: highest risk of suicidal behaviour in transgender youth is while awaiting consult.
True.
What is gender dysphoria?
Marked incongruence between experienced gender + assigned.
x 6 month.
min. 6 of:
- strong desire to be other gender
- cross-dressing
- cross-gender role in play
- presence toward stereotypical toys
- preference for playmate of other gender
- rejection of stereotypical toy of same sex
- dislike for sexual anomy
- desire for pubertal traits
+ significant distress or impairment in social, school or other
For fun: options for transgender youth
Pubertal suppression
- Lupron
Menstrual suppression
- Continuous OCP
Masculinizing hormone= T
Feminizing hormone= Estrogen, sprinolactone
Sx: top- Sx as teen (can’t do bottom Sx till adult)
T or F: you must always treat for chlamydia if Gonorrhea (+).
yes!
Ceftriaxone IM x1
+ Azithro x 1
OR cefixime PO + azithro.
What is the most common STI?
HPV!
What is the current recommendation for PAPs?
Start at age 21
Every 3 yr
If sexually active.
When do you consider hospitalization for PID?
- pregnancy
- failed PO tx
- adherence concern
- severe illness, vomit, high fever
- tuba-ovarian abscess
- HIV infection
16 y.o. with unilateral PAINLESS breast mass. Likely dx? - fibroadenoma - adenocarcinoma - fibrocystic change - met tumour - lipoma
Fibroadenoma
Most= BENIGN fibroadenoma!
Other: trauma , abscess, node.
Fibrocystic= Bilateral
< 1%= malignant
Breast Pain. Thoughts?
Common in puberty. OCP may better or worsen it. R/O mass, infection Avoid tight fitting bra during exercise NSAID + supportive.
What is the order of substance use prevalence for:
alcohol, high energy drinks, cannabis
Alcohol Prev > high energy drinks > Cannabis
Teen where symp get better w/ hot showers?
Hyperemesis Cannabinoid Syndrome.
Heavy menstrual bleeding typically caused by an ovulation. Most common reasons:
1= HPO axis maturation
Other causes of an ovulation:
- pregnancy
- thyroid dx
- chronic liver/renal dx
- Cushing
- PCOS, CAH
- wt loss/stres/ exercise
- premature ovarian failure
Heavy menstrual bleeding. Tx options?
- Contraception
- NSAID (start few days before helps with pain and lightens menses)
- Antifibrinolytic= Tranexamic Acid
What is primary versus secondary amenorrhea?
Primary= no menses ever!
> no puberty + no menses by 13
> secondary trait but no menses by 15
** most commonly gonadal dysgenesis and mullerian agenesis.
Secondary= 3 months of amenorrhea.
** most commonly stress, wt loss, disordered eating or preg!
List causes of amenorrhea:
Hypothal
> Chronic dx, familial delay, stress, ED, Kallmann, Tumour, Drugs
Pit
> Infarct, Sx, Radiation
Thyroid
Adrenal: CAH, cushing, tumour
Ovary: gonadal dysgenesis, AI failure, Fagile X, PCOS, irradiation
Uterus= pregnancy
And other gyne congenital anomalies (i.e. cervix genesis or transverse septum in vagina, imperforate hymen)
Amenorrhea W/U
beta-HCG CBC U/A TSH, FT4 FSH, LH Prolactin Pelvic US
+/- androgen panel if think (PCOS, late CAH, Cushings etc.)
If high FSH= gonadal dysgenesis, ovarian failure
Low FSH= hypothalamic if pituitary issue.
Note: Progestin challenge= withdrawal bleed. Confirm E made. If negative= E not made!
What should you do if you miss an OCP pill?
Take 1 pill ASAP and take daily until end of pack.
If missed 3 pills = back up contraception x 7d!
List common RF for vulvovaginitis
Tight clothes Overweight Bubble baths Urinating knee together Wipe back to front
