Adolescent Medicine

Question 1

A sexually active 17-year-old female presents with:

Right upper quadrant abdominal pain
Vaginal discharge
Fever
She started her menses today.

What is the most likely diagnosis?

Answer 1

Perihepatitis (Fitz-Hugh–Curtis syndrome)
Explanation
Perihepatitis is due to Neisseria gonorrhoeae, Chlamydia trachomatis, and/or a mixed polymicrobial infection. It is characterized by right upper quadrant abdominal pain that worsens with deep breathing and is often referred to the right shoulder. Marked tenderness of the right upper quadrant is common on exam. It is a complication of pelvic inflammatory disease in ~ 10% of cases. During menses, the inflammatory process is thought to ascend from the fallopian (uterine) tubes along the paracolic gutters to the right upper quadrant. Aminotransferases are usually normal or only slightly elevated

Question 2

For adolescents, what body mass index (BMI) is considered to be obese?

Answer 2

≥ 95th percentile
Explanation
The Centers for Disease Control and Prevention (CDC) defines obesity as having a BMI ≥ 95th percentile for children and adolescents of the same age and sex. Overweight is defined as having a BMI between 85th and 95th percentile for children and adolescents of the same age and sex.

Question 3

A 15-year-old boy presents with:

A painless ulcer on his dorsal penis that is “punched out” with clean-appearing, sharp, firm, slightly elevated borders
Bilateral regional lymphadenopathy
What is the most likely diagnosis?

Answer 3

Answer
Primary syphilis
Explanation
This is a classic description of a chancre, or primary syphilis, a sexually transmitted disease caused by the spirochete Treponema pallidum. The lesion typically begins as a painless papule at the site of inoculation, which soon ulcerates to produce a 1- to 2-cm ulcer with a raised, firm, indurated (“punched out”) margin. The ulcer typically has a nonexudative base and is associated with mild to moderate (often bilateral) regional lymphadenopathy. Screen initially with a nontreponemal test (e.g., RPR); a reactive nontreponemal test is then confirmed with a treponemal test (e.g., FTA-ABS). Treat primary syphilis (chancre) with penicillin G benzathine, 2.4 million units IM × 1 dose; if patient is < 48 kg, dose with 50,000 units/kg IM.

Question 4

What organism is responsible for granuloma inguinale?

Answer 4

Answer
Klebsiella granulomatis
Explanation
Granuloma inguinale is a genital sexually transmitted infection caused by Klebsiella granulomatis, an intracellular gram-negative bacterium. It is rare in the U.S. and presents as a painless, friable, slowly progressive, beefy red, ulcerative lesion that is extremely vascular and bleeds easily on contact; regional lymphadenopathy is typically absent.

Question 5

A 15-year-old boy presents with a left-sided scrotal mass that feels like a “bag of worms.” The mass increases with Valsalva.

What is the most likely diagnosis?

Answer 5

Varicoceles
Explanation
Varicoceles are dilated scrotal veins. Patients usually present with complaint of a sensation of pressure, heaviness, or engorgement of the left hemiscrotum. They are classically described as having the appearance and feel of a “bag of worms,” which is best observed with the patient standing and when performing the Valsalva maneuver. Varicoceles are either primary or secondary. Unilateral right varicoceles are very rare and are often due to underlying pathology, such as inferior vena caval (IVC) obstruction from a clot or tumor. Surgery is necessary if the affected testicle is painful, fails to grow during puberty, or has become hypotrophic, so watch for loss of testicular volume (> 2 mL difference between the 2 testicles).

Question 6

What organism is responsible for chancroid?

Answer 6

Haemophilus ducreyi
Explanation
Haemophilus ducreyi, a small, fastidious, gram-negative rod, is the organism responsible for chancroid. The initial lesion is an erythematous papule that rapidly evolves into a pustule, which then erodes into a 1- to 2-cm painful ulcer with an erythematous base covered with a grayish-yellow purulent exudate. Borders are clearly demarcated and sometimes undermined. Inguinal lymphadenitis is common; involved nodes often undergo liquefaction, leading to the development of fluctuant, painful buboes, which sometimes rupture and discharge frank pus.

Question 7

A 15-year-old boy presents with a nontender, fluid-filled mass in his right testicle.

What is the most likely diagnosis?

Answer 7

Hydrocele
Explanation
Hydroceles are nontender, soft, fluctuant masses formed by a collection of fluid between the parietal and visceral layers of the tunica vaginalis. A new-onset hydrocele can be associated with a hernia or testicular mass and requires evaluation by ultrasound. Transillumination is also useful. Generally, no treatment is necessary unless it becomes painful, large, or associated with a hernia/mass.

Question 8

For which sexually transmitted infections (STIs) should sexually active adolescent females be screened annually?

Answer 8

Chlamydia trachomatis and Neisseria gonorrhoeae
Explanation
Annual screening for both Chlamydia and gonorrhea is recommended in sexually active women 24 years of age and younger. Most chlamydial and gonococcal infections are asymptomatic or minimally symptomatic in women; left untreated, serious complications—including pelvic inflammatory disease, infertility, pregnancy complications, and chronic pelvic pain—may occur. The data is insufficient to make strong recommendations in HIV-uninfected heterosexual men unless they have a history of STI, are seeking STI evaluation, or are seeking care in a setting of high prevalence (e.g., adolescent clinics, correctional facilities).

Question 9

What is the most common reason for hospitalization of all adolescents?

Answer 9

Pregnancy
Explanation
The primary cause of hospitalization for all adolescents is pregnancy-related conditions, even with males included in the “all adolescents” category. The 2nd most common reason for hospitalization of adolescents is mental disorders.

Question 10

A 14-year-old girl presents with:

Anxiety about the way her body looks
Intense fear of becoming obese
BMI < 5th percentile
What is the most likely diagnosis?

Answer 10

Answer
Anorexia nervosa (AN)
Explanation
This patient meets all three DSM-5 diagnostic criteria for AN. AN is the deadliest of all psychiatric conditions, with severe AN having a mortality rate 10–12 times higher than that of the general population. AN occurs in 1/200 girls; girls outnumber boys 10:1.

Question 11

A 9-year-old girl is evaluated after she was sexually abused by her cousin.

Is the HPV vaccine indicated in this patient, and if so, what is the recommended schedule for vaccine administration?

Answer 11

Yes; administer the 2-dose vaccine series—1st dose at this visit and 2nd dose in 6–12 months.
Explanation
Because this patient is at an increased risk of HPV due to her history of sexual abuse, the HPV vaccine series should be started now. Routinely, the vaccine series is recommended for females and males at 11–12 years of age. It may be started as early as 9 years of age, even in the absence of high risk. The number of doses is dependent on age at vaccine initiation.
Age 9–14 years at initiation: 2-dose series at 0 and 6–12 months
Age ≥ 15 years at initiation: 3-dose series at 0, 1–2, and 6 months
Immunocompromised patients (including HIV) aged 9–26 years at initiation: 3-dose series at 0, 1–2, and 6 months

Question 12

A 14-year-old boy presents with asymmetric left breast tenderness and swelling. The swelling is about 3 cm. He is on no medications.

What is the appropriate management?

Answer 12

Answer
Reassurance and observation
Explanation
Benign pubertal gynecomastia, defined by an increase in glandular breast tissue in a pubertal male, occurs in up to 65% of boys. Mean age of onset is 13 years and 2 months, reaching peak prevalence at 14 years of age, occurring during SMR Stage 2, 3, or 4. It is uncommon after age 17. It is due to a decreased ratio of androgen to estrogen and a change in the sensitivity of breast tissue receptors. The area of enlargement is typically tender, often asymmetric, and measures < 4 cm. Most benign pubertal gynecomastia resolves spontaneously over 6–24 months and only requires reassurance.

Question 13

An 18-year-old college freshman presents with painless swelling of his left testicle that he noticed while washing himself. You feel an irregularly shaped, firm mass that does not transilluminate.

What is the best treatment?

Answer 13

Answer
Complete orchiectomy
Explanation
Testicular neoplasms are the most common solid tumors in males 15–35 years of age. Complete orchiectomy, potentially coupled with peritoneal lymph node dissection, radiation, and chemotherapy, is the treatment most often indicated for testicular cancer. Prior to orchiectomy, workup includes measuring β-hCG (elevated in choriocarcinoma and mixed germ cell tumors), α-fetoprotein (elevated in yolk sac tumors and embryonal carcinoma), and LDH; performing testicular ultrasound or MRI; and CT scan of chest and abdomen. Note: Most seminomas do not produce any markers!

Question 14

A 16-year-old girl presents with:

Homogeneous, white vaginal discharge
Epithelial cells that appear granular and stippled with ragged borders on saline wet-prep microscopy
Vaginal fluid with pH > 4.5
A fishy odor when 10% potassium hydroxide (KOH) is placed on the vaginal discharge smear
What is the most likely diagnosis?

Answer 14

Bacterial vaginosis (BV)
Explanation
The microscopic findings described are clue cells, which are the single most reliable predictor of BV. BV is a clinical syndrome due to the replacement of the normal vaginal flora (Lactobacillus) with anaerobes (Prevotella and Mobiluncus), Gardnerella vaginalis, and Mycoplasma hominis. Although not a true vaginitis (in that it is not characterized by an inflammatory response of the vaginal mucosa), it is the most common cause of abnormal vaginal discharge. Amsel criteria for diagnosis of BV (at least 3 criteria must be present) include: homogeneous, thin, grayish-white discharge coating the vaginal walls; vaginal pH > 4.5; presence of a fishy odor when a drop of 10% KOH is added to a sample of vaginal discharge (“whiff test”); at least 20% of epithelial cells are clue cells on wet mount.

Question 15

A 16-year-old girl presents with:

Diffuse, frothy, malodorous, yellowish-green vaginal discharge
Dysuria
Pruritus
Vulvular irritation
A “strawberry cervix” noted on PE
What is the most likely diagnosis?

Answer 15

Trichomoniasis
Explanation
Trichomoniasis, due to Trichomonas vaginalis, is classically asymptomatic in men but more commonly symptomatic in women. Common signs and symptoms may include a purulent, malodorous, frothy, thin discharge associated with burning, pruritus, dysuria, urinary frequency, lower abdominal pain, or dyspareunia. Punctate hemorrhages may be visible on the vagina and cervix (“strawberry cervix”). Treatment for women is metronidazole 500 mg PO 2×/day for 7 days or tinidazole 2 g × 1 dose. Treat women at any stage of pregnancy with metronidazole 500 mg PO 2x/day for 7 days. Treat sexual partners.

Question 16

A 15-year-old boy presents with gradual pain at the upper pole of the left testis. On exam, you feel a tender, pea-sized swelling at the upper pole of the testis; a bluish hue is visible through the scrotum.

What is the most likely diagnosis?

Answer 16

Torsion of the testicular appendage
Explanation
Torsion of the testicular appendage affects the appendix testis or appendix epididymis. It is a benign condition but must be differentiated from testicular torsion, which is a true emergency. Pain can be sudden or gradual. The blue hue visible through the scrotum is called the “blue dot” sign. Color Doppler ultrasound and radionuclide scans are normal. Treat with analgesics. Spontaneous resolution of symptoms occurs within 2–12 days without surgery.

Question 17

A pregnant patient presents with signs, symptoms, and lab confirmation of secondary syphilis. She has anaphylaxis to penicillin.

What is the most appropriate therapy?

Answer 17

Answer
Desensitization followed by penicillin therapy
Explanation
For pregnant women with syphilis and a history of an immediate-type allergic reaction (anaphylaxis) to penicillin, the only appropriate treatment is desensitization followed by penicillin therapy in appropriate doses depending on the stage of syphilis. Alternative treatment options are either not safe for the mother or fetus (e.g., doxycycline) or not effective for prevention of congenital infection.

Question 18

What is the mean age for menarche?

Answer 18

Answer
12.8 years of age
Explanation
The mean age for menarche is 12.8 years (normal range is 9–16 years of age), with White girls experiencing menarche an average of 6 months later than Hispanic girls and Black girls. Menarche commonly occurs at sexual maturity rating (a.k.a. Tanner) Stages 3–4, or ~ 2 years after onset of breast budding. It usually occurs just after peak height velocity

Question 19

A teen with anorexia nervosa is admitted and is placed on observed meals.

Besides potassium and magnesium, what other electrolyte abnormality are you most concerned with while refeeding her?

Answer 19

Answer
Hypophosphatemia
Explanation
Hypophosphatemia is a classic manifestation of refeeding syndrome. The body has been so energy depleted that refeeding overwhelms conversion of ADP to ATP and results in severe hypophosphatemia as phosphorus stores are depleted. Refeeding drives phosphorus intracellularly. Hypophosphatemia typically occurs within 1–2 weeks of refeeding and may cause hemolytic anemia, arrhythmias, heart failure, mental status changes, coma, and sudden death. Hypokalemia and hypomagnesemia are other manifestations. Thankfully, refeeding syndrome is rare, but always monitor for it.

Question 20

A 16-year-old female is diagnosed with pelvic inflammatory disease (PID) and requires inpatient therapy. She has a history of anaphylaxis to cephalosporins.

What are two options for the 2-antibiotic regimen recommended for her therapy?

Answer 20

Ampicillin-sulbactam plus doxycycline or clindamycin plus gentamicin
Explanation
Initial therapy for PID should provide antimicrobial coverage against C. trachomatis, N. gonorrhoeae, streptococci, gram-negative enteric bacilli, and anaerobic organisms. The choices for parenteral therapy in hospitalized cephalosporin-allergic patients are ampicillin-sulbactam 3 g IV every 6 hours plus doxycycline 100mg PO or IV every 12 hours or clindamycin 900 mg IV every 8 hours plus a gentamicin loading dose of 2 mg/kg IV/IM, which is followed by a maintenance dose of 1.5 mg/kg every 8 hours. Patients can usually be transitioned from parenteral to oral therapy after 24–48 hours of sustained clinical improvement.

Question 21

What is the most common organism to cause mastitis in an adolescent girl?

Answer 21

Staphylococcus aureus
Explanation
Acute mastitis is a localized breast infection more common in newborns and lactating females (puerperal mastitis) and is only occasionally seen in a nonpregnant adolescent. Patients present with an indurated, fluctuant, red, tender, and swollen area on the breast. The most common causative organism is Staphylococcus aureus. Treat with an antistaphylococcal antibiotic, heat, and analgesia

Question 22

A 15-year-old boy presents with:

Acute onset of severe pain and swelling of his left testicle and inguinal area
Nausea/vomiting
Exam shows a diffusely swollen and tender left testicle and an absent cremasteric reflex.

What is the likely diagnosis?

Answer 22

Testicular torsion (a.k.a. torsion of the spermatic cord)
Explanation
Testicular torsion is a surgical emergency! Urologic evaluation should be immediate. Survival of the testicle is directly related to how many hours have passed since the onset of the torsion. A radionucleotide scan or color Doppler ultrasound demonstrates decreased perfusion on the affected side. Testicular torsion requires immediate surgical detorsion of the affected testicle with surgical fixation of both testicles (bilateral orchiopexy); salvage of the affected testicle is the rule if surgery takes place within 6 hours of onset of symptoms. The testicle remains viable in 60% of cases if surgery is performed within 6–12 hours.

Question 23

A pregnant teen presents in active labor. You note that she has active genital warts. She and her baby have no other issues.

Which type of delivery should she have?

Answer 23

Vaginal delivery
Explanation
Do not get genital warts confused with genital herpes. Mothers with active genital herpes lesions at the time of delivery require C-section. Genital warts at the time of delivery do not require C-section unless their size and/or number obstruct the birth canal. You still must worry about possible complications in the newborn (e.g., laryngeal papillomatosis).

Question 24

What is the #1 cause of adolescent mortality?

Answer 24

Unintentional injuries
Explanation
Unintentional injuries (e.g., motor vehicle accidents, discharge of a firearm, drowning, poisoning) account for about 40% of all deaths during adolescence. Consistently, males face more than twice the risk of females from death due to unintentional injury. Suicides and homicides are the next most common causes of adolescent deaths.

Question 25

What is the most common solid breast mass in an adolescent girl?

Answer 25

Answer
Fibroadenoma
Explanation
Fibroadenomas represent a benign mix of stromal elements, ducts, and acini. The masses are firm, painless, rubbery in character, and distinct from the rest of the breast. They are typically asymptomatic but can cause discomfort for a few days prior to onset of menses; however, they do not usually regress or change with hormonal fluctuations. They tend to be in the upper outer quadrant of the breast, and most range in size from 2–3 cm. Simply observe asymptomatic solid breast masses that are < 3 cm. Perform excisional biopsy on persistent, larger, or suspicious lesions.

Question 26

A 14-year-old female gymnast presents with primary amenorrhea. She is worried because all her friends have started their menstrual cycles. She has no past medical or surgical history and takes no medication. Breast development began at 12 years of age. Physical examination reveals the following:

BMI of 18.5
Sexual maturity rating 4 (SMR 4; a.k.a. Tanner stage 4) breasts and pubic hair
What is the diagnosis?

Answer 26

Normal pubertal development
Explanation
Primary amenorrhea is defined as the absence of menses:
by 15 years of age with the presence of normal secondary sexual development,
by 13 years of age with complete absence of secondary sexual characteristics, or
> 3 years after onset of thelarche.
This patient is only 14 years of age and therefore does not meet the criteria for primary amenorrhea. She is showing normal development and has a normal BMI.

Question 27

A 15-year-old girl presents with dysmenorrhea.

What is the likely cause of her pain?

Answer 27

Answer
Prostaglandin production
Explanation
Prostaglandin production causes vasoconstriction and muscular contractions. In addition to the antiinflammatory and analgesic properties of NSAIDs, they decrease menstrual cramping by inhibiting prostaglandin synthesis. Combined oral contraceptives—which inhibit ovulation, leading to an atrophic endometrium, decreased menstrual flow, and decreased prostaglandin release—are often effective in adolescents who do not improve with NSAIDs.

Question 28

What is the most common reason for secondary amenorrhea?

Answer 28

Pregnancy
Explanation
Secondary amenorrhea is the absence of menses for > 3 months in adolescents who previously had regular menstrual cycles or the absence of menses for 6 months in those who had irregular cycles. Pregnancy is the most common cause of secondary amenorrhea. Pregnancy can also be the cause of primary amenorrhea (no menses to 15 years of age), but this is rare.

Question 29

A 15-year-old boy presents with:

A nontender nodule above and posterior to the right testis
No change with Valsalva
The nodule transilluminates.

What is the most likely diagnosis?

Answer 29

Answer
Spermatocele
Explanation
A spermatocele is a retention cyst of the epididymis containing spermatozoa and located in the efferent ductal system. It presents as a smooth, cystic, mobile nodule above and posterior to the testis. Spermatoceles do not change in size with the Valsalva maneuver and sometimes transilluminate. Typically, they do not affect fertility or require therapy.

Question 30

What is the 1st sign of sexual development in boys?

Answer 30

Answer
Testicular enlargement
Explanation
Male sexual development generally begins at an average age of 11.6 years (range of 9.5–13.7 years of age), with the 1st physical sign of puberty being testicular enlargement. Onset of puberty occurs, on average, 6 months earlier for Black boys than for White boys and Hispanic boys. For boys, puberty usually lasts an average of 5 years (range 3–6 years).

Question 31

A 17-year-old girl presents with:

Bilateral painless parotid gland swelling
Loss of tooth enamel
Metabolic alkalosis
What is the most likely diagnosis?

Answer 31

Bulimia nervosa (BN)
Explanation
BN affects 2–3% females in the U.S. and < 1% of boys. Patients with BN have recurrent episodes of binge eating during which they feel that they “lack control” of their eating behavior. Due to persistent concern with their body shape/weight, they regularly resort to self-induced vomiting, diuretics and/or laxatives, fasting, and overexercising to prevent weight gain. Signs and symptoms of self-induced vomiting include bilateral painless parotid gland swelling, loss of tooth enamel, metabolic alkalosis, calluses and lacerations on the dorsum of the hands (Russell sign), and soft palate petechiae.

Question 32

In young boys, epididymitis can be caused by a urinary tract infection. In teen boys, what needs to be at the top of the differential diagnosis list as the cause of epididymitis?

Answer 32

Answer
Sexually transmitted infections such as chlamydia or gonorrhea
Explanation
In an adolescent, epididymitis is often caused by Chlamydia trachomatis or Neisseria gonorrhoeae or both. Infections of Escherichia coli and other bowel flora, contracted via unprotected anal intercourse, can also cause epididymitis. Patients present with subacute onset of pain in the hemiscrotum, increased urinary frequency, dysuria, urethral discharge, and fever. The epididymis is swollen and tender on physical examination. Unlike testicular torsion, in epididymitis, the cremasteric reflex is present, the testicle lies in the normal position, and pain is often relieved by elevation of the testis (Prehn sign). Urinalysis, Gram stain, urine NAATs, and cultures of urethral discharge are typically diagnostic. In contrast to testicular torsion, in epididymitis, a radionuclide scan and Doppler ultrasound demonstrate increased perfusion and flow. Treat the patient and partner(s) with the appropriate antibiotic(s).

Question 33

What is the 1st sign of sexual development for girls?

Answer 33

Onset of breast budding
Explanation
In most females, the onset of breast budding (thelarche) is the 1st physical sign of puberty. In the U.S., puberty begins at a mean age of 10 years in White girls and 6 months earlier in Hispanic girls and Black girls. Generally, Asian girls have the latest onset of puberty. Puberty for girls generally lasts an average of 4 years (range of 1.5–8 years).

Question 34

A sexually active 16-year-old boy presents with:

Urethral discharge
5 WBC/HPF with no organisms seen on Gram stain of urethral exudate
What is the most likely diagnosis?

Answer 34

Urethritis—most likely due to Chlamydia trachomatis
Explanation
Neisseria gonorrhoeae and Chlamydia trachomatis are the most common causes of urethritis. On Gram stain of the urethral discharge, the presence of ≥ 2 WBCs without any organisms is consistent with nongonococcal urethritis—most likely due to Chlamydia trachomatis. Gonococcal urethritis is diagnosed by the presence of gram-negative intracellular or extracellular diplococci in the urethral exudate. Treatment for urethritis due to Chlamydia trachomatis is doxycycline 100 mg orally 2×/day for 7 days; azithromycin 1 g orally in a single dose is an alternative treatment, keeping in mind that microbiologic treatment failure among men is higher for azithromycin than for doxycycline.

Question 35

A pregnant teen presents in active labor. You note that she has active genital herpes infection.

Which type of delivery should she have?

Answer 35

Answer
C-section
Explanation
In adolescents with genital HSV lesions or prodromal HSV symptoms at the time of labor, cesarean delivery is recommended. The major complication of maternal HSV infection during delivery is transmission to the newborn. Neonatal infection can result in serious morbidity and mortality; the risk of transmitting HSV from a mother with primary genital infection to her baby at or near delivery is very high (40–45%). Therefore, women presenting with lesions at the time of delivery should have a C-section. Women without prodromal or clinical signs and symptoms of herpes at delivery can deliver vaginally.

Question 36

A 16-year-old girl presents for well care. While her mother is out of the room, she discloses to you that she has had vaginal intercourse twice in the past year.

Along with counseling and testing for STIs, which birth control method do you tell her is recommended as 1st line by the AAP?

Answer 36

Answer
Long-acting reversible contraception (LARC)
Explanation
LARC, which includes subdermal progesterone implants and IUDs, is recommended by the AAP as 1st line contraception in sexually active adolescent females. It is the most effective form of birth control at over 99%. Worry about the risk of introducing or causing pelvic inflammatory disease (PID) with an IUD has been shown to be unfounded, with equal rates of PID in females with and without IUDs in place. Male condoms are the most effective method besides abstinence for preventing STIs; recommend them to adolescents even if they are using other forms of birth control.

Question 37

A 16-year-old girl presents with:

Low-grade fever
Inguinal lymphadenopathy
Vesicular lesions on her labia majora that are painful and itchy
Cervical motion tenderness
Thin, white vaginal discharge
What is the most likely diagnosis?

Answer 37

Herpes simplex
Explanation
Do not be dissuaded by the presence of lymphadenopathy, cervical motion tenderness, and vaginal discharge—all 3 of these are common with herpes infection, especially the initial herpes infection. The key here is the vesicular lesions that are painful and itchy, which makes syphilis unlikely. Obviously, she can be coinfected with Chlamydia or other STIs, but the vesicles are specific for herpes simplex infection.

Question 38

A 17-year-old girl presents with:

Amenorrhea
Galactorrhea
Pregnancy test is negative.

What is the most likely diagnosis?

Answer 38

Pituitary adenoma
Explanation
A pituitary lactotroph adenoma (i.e., prolactinoma or prolactin-secreting adenoma) may cause amenorrhea and is often associated with galactorrhea. By definition, a pituitary microadenoma measures < 10 mm; a macroadenoma measures > 10 mm. Most microadenomas do not increase in size, whereas macroadenomas have a significant potential for growth, resulting in visual field defects, headaches, and loss of anterior pituitary function. Bromocriptine, a dopamine agonist, often restores menses and decreases prolactin levels to normal in patients with a microadenoma.