Adolescent Medicine and Gynecology Flashcards by Courtney Shockley

Name the components of SMR (Tanner stage) 1 for a male.

Absent pubic hair
Childlike phallus
Testicular volume <2.5mL

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Name the components of SMR (Tanner stage) 2 for a male.

Fine pubic hair
Childlike phallus
Increased size and volume of testicles
More textured scrotum

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Name the components of SMR (Tanner stage) 3 for a male.

Carse, curly and pigmented pubic hair
Increased Phallus size
Increased testicular size

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Name the components of SMR (Tanner stage) 4 for a male.

Denser and curled pubic hair, but less than an adult

Phallus closer to adult size

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Name the components of SMR (Tanner stage) 5 for a male.

Pubic hair extending to the inner thigh, adult like
Adult sized phallus
Adult sized testicles

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What is the normal age range for pubertal development for boys and girls?

9-13

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What is the maximum amount of time it should take to go from SMR 2-5?

5 years

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Name the components of SMR (Tanner stage) 1 for a female.

Absent pubic hair

No glandular breast tissue

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Name the components of SMR (Tanner stage) 2 for a female.

Pubic hair along labia

Small breast buds, with glandular tissue

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Name the components of SMR (Tanner stage) 3 for a female.

Coarse, curly and pigmented pubic hair

Breast tissue extending beyond the areola.

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Name the components of SMR (Tanner stage) 4 for a female.

Denser and curled pubic hair, less than adult

Enlarged areola and papilla for a secondary mound

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Name the components of SMR (Tanner stage) 5 for a female.

Pubic hair extending to the inner thigh, adult like

Breasts without a separate projection of the areola from the remainder of the breast

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At what age is no pubertal development considered “delayed” in males? In females?

Males-age 14

Females-age 13

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What is the first sign of puberty in males? In females?

2 “bumps” getting bigger
Males-testicular growth
Females-breast budding

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What lab values should increase during the growth spurt?

Alk Phos and hematocrit

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What is pre-pubertal height velocity? Peak velocity?

Pre-pubertal is 5-6 cm/yr

Peak is 9-10 cm/yr

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What is the sequence of male pubertal development?

Testicular growth > Pubarche > Penile growth > Peak height velocity

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Below what age is onset of puberty considered abnormal in a male? In a female?

Males-age 9

Females-age 8

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Does early puberty result in taller or shorter adult height?

Shorter

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What is the most common cause for delayed puberty in boys?

Constitutional delay

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How does bone age correlate with chronological age in constitutional delay?

Bone age lags behind initially, then catches up later

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At what age does puberty typically occur in males?

Age 10-11

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After which SMR stage does peak height velocity occur in males? in females?

Males-Stage 4

Females-Stage 3-4

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After which SMR stage does axillary hair develop in males?

Stage 5

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In relationship to testicular growth, when does pubarche typically occur?

About 1 year after

What does it indicate if a male develops pubic hair and penile enlargement in the absence of testicular enlargement?

Extragonadal androgen stimulation

In what scenarios is pubertal male gynecomastia considered abnormal?

Hx of ketoconazole exposure Bilateral gynecomastia Galactorrea (in marijuana users)

Is unilateral gynecomastia in males and asymmetric breast development in females considered normal?

Yes

What is the sequence of female pubertal development?

Breast budding > Pubarche > Peak height velocity > Menarche

What is the average age at thelarche?

Age 11

In relationship to thelarche, when does pubarche typically occur in females?

1-2 years later

At what age is it considered abnormal for no breast development to have occurred?

Age 13

Which hormone is responsible for breast development? Pubic and axillary hair development?

Breast-estrogen | Hair-Androgen

Which hormonal abnormality is associated with thelarche without pubarche?

Androgen insensitivity

Which hormonal abnormalities are associated with pubarche without thelarche?

Excessive androgens or Low estrogen

In relationship to thelarche, when should menarche occur? At what age?

~2 years later, age 12-13

In relationship to menarche, when does peak height velocity occur in females?

Before

How many days is considered a normal menstruation?

2-10 days

How do you advise/work up a a female within 2 years post-menarche who is having infrequent or longer than 28 days between menstrual cycles?

Provide reassurance and follow up

Describe physiologic leukorrhea. When does this occur in relationship to menarche?

White, odorless, mucoid dishcarge | Usually precedes menarche by 3-6 months and can continue for several years after

What has to be considered in a pre-menarche female with bloody vaginal discharge?

Foreign body Straddle injury Abuse

How much is a post-menarche female expected to grow?

~4cm

Define premature thelarche.

The development of breast tissue without the appropriate appearance of pubic hair

How do you advise a parent with concern of breast buds in a 3 y/o female?

Reassurance. This is normal in females <4.

Define precocious puberty in males. In females.

The appearance of secondary sexual characteristics (thelarche and pubarche or pubarche and genital development) before the age of 9 in males or 8 in females.

Define premature pubarche.

Presence of pubic hair without breast tissue. (Premature Adrenarche)

Define true precocious puberty.

Normal sequence of puberty, just early.

Define pseudo precocious puberty.

Puberty out of sequence. (menarche without pubarche or development of secondary sexual characteristics without testicular enlargement.

What are the underlying causes of pseudo precocious puberty?

Over production of sex steroid hormones by ovaries or testes (Germ cell tumors) Over production of sex steroid hormones by adrenals (CAH) Exogenous sex hormones (OCPs or anabolic steroids)

Which hormone class is responsible for axillary hair and acne development?

Androgens

How do you advise a parent whose child has axillary hair, but not other evidence of adrenalization?

Quarterly f/u and growth velocity monitoring

Precocious puberty in combination with each of the following leads to which cause: 1. Optic fundus abnormality 2. Acne 3. Visual field defects 4. Change in vaginal color 5. Facial or axillary hair 6. Prominence of the labia minora 7. Muscle bulk

1. CNS lesion 2. Androgenic (testicular or adrenal) 3. CNS lesion 4. Estrogenic (ovarian) 5. Androgenic (testicular or adrenal) 6. Estrogenic (ovarian) 7. Androgenic (testicular or adrenal)

In precocious puberty, what types of abnormalities are likely to be diagnosed by US?

Adrenal or ovarian masses

What lab testing is helpful in differentiating causes of precocious puberty?

LH, FSH, adrenal steroids

What imaging modality is best to dx central precocious puberty?

MRI

What is the DDx of central precocious puberty?

``` Hamartomas Hydrocephalus Arachnoid or ventricular cysts Meningitis Encephalitis Neoplasms CNS trauma ```

What is the most likely reason for not using contraception?

The desire to become pregnant

What percentage of pregnancies occur within the first 6 months after coitarche?

50%

What percentage of pregnancies occur within the first month after coitarche?

20%

What are the absolute contraindications to OCPs?

BC HELP Breast Cancer, Coronary artery disease and Cerebrovascular disease, Hepatic Disease, Elevated Lipids, Pregnancy

What are the relative contraindications to OCPs?

HTN, Depression, Migraines, Breast-feeding, Drugs that interfere with absorption (anti-convulsants)

Which is safer: Contraceptives or Pregnancy and delivery?

Contraception

What are the indications for Pap Smear in a sexually active female? Non-sexually active?

Sexually active: any age yearly | Non-sexually active: age 18 every 3 years

What are the causes of primary amenorrhea?

Polycystic ovary disease Androgen insensitivity Turner syndrome Anatomical Obstruction

What are the presenting symptoms of PCOS?

Amenorrhea Obesity (not always) Hirsutism Acne

What lab findings are to be expected in PCOS?

LH:FSH ratio >2.5 | Elevated Androgen levels

What is the treatment for PCOS?

Weight loss, OCPs and anti-androgen medication (spironolactone)

What are the presenting symptoms of androgen insensitivity?

Normal breast development, amenorrhea, no pubic hair

What are the presenting symptoms of Turner's Syndrome?

Amenorrhea, Breast budding without further development, No pubic hair

How is Turner's syndrome dx?

Karyotype

What is the DDx of secondary amenorrhea?

Pregnancy Exercise-induced Anorexia

What is the most common cause of secondary amenorrhea?

Pregnancy

Describe the classic pt dx with exercise-induced amenorrhea.

Female teenager, heavy athletic training, menstrual cycles gradually become shorter and lighter until they stop.

What lab abnormality is likely to be seen in exercise-induced amenorrhea?

Low serum estradiol (E2)

Pt's with exercise-induced amenorrhea have an increased risk for what?

Anorexia nervosa | Low Bone density and osteoporosis

Describe the management of exercise-induced amenorrhea.

1. Reduction in the intensity of exercise 2. Stop smoking as it increases the risk of stress fractures 3. Calcium supplementation 4. Increase caloric intake

Is hormone replacement useful in the treatment of exercise-induced amenorrhea?

What is proven to reduce the risk of bone demineralization in pt's with exercise-induced amenorrhea?

Resumption of menses

In addition to exercise-induced amenorrhea, what other process can cause low bone density in an otherwise healthy adolescent female?

Delayed puberty

Describe primary dysmenorrhea.

Crampy, lower abdominal pain and pelvic pain occurring with menses but not due to any other pelvic pathology.

What is the cause of primary dysmenorrhea?

Prostaglandins produced during the ovulatory cycle

How is primary dysmenorrhea treated?

Prostaglandin inhibitors (NSAIDs)

In true primary dysmenorrhea, is treatment with exercise, healthy diet, tylenol, and rest effective?

Describe secondary dysmenorrhea.

Pain occurring at all times in the menstrual cycle due to pelvic pathology such as endometriosis

What are the si/sx of PTSD?

Recurrent nightmares Fears of being alone Diminished interest in school Decreased appetite

What are the leading causes of morbidity and mortality of of adolescents?

Accidents (MVA) Homicide Suicide

What are the 4 diagnostic criteria for anorexia nervosa?

1. Distorted body perception 2. Weight 15% below expected 3. Intense fear of gaining weight 4. Absence of 3 consecutive menstrual cycles

``` Of the following, which is the most important criterion for making the diagnosis of anorexia nervosa? Excessive exercise Thinking he/she is despite normal weight Using diuretics Depression Dieting over several months ```

Thinking he/she is fat despite having normal weight

What is the hallmark of bulimia nervosa?

Binge eating and induced vomiting

Name 3 physical exam findings associated with bulimia.

Salivary gland enlargement, dental enamel erosion, bruises or calluses over the knuckles

Name 3 lab findings associated with bulimia.

Hypokalemia Hypochloremia Metabolic alkalosis

What are the indications for hospital admissions with bulimia?

``` Failure of outpatient treatment Dehydration EKG abnormalities Mallory Weiss tear Suicidal ideation ```

What is an eating disorder patient at risk for during treatment?

Hypophosphatemia from refeeding syndrome

Which is the most prevalent STI among adolescents?

HPV

Which is the most common bacterial STI?

Chlamydia

True or False: Genital Warts are often asymptomatic in males.

True

What is the primary organism associated with Bacterial vaginosis?

Gardnerella vaginalis

What is the "Whiff test" looking for to diagnose BV?

the presence of amines after the addition of potassium hydroxide

What is the diagnostic microscopic finding for BV?

Clue cells

True or False: Trichomonas Vaginalis causes significant symptoms in males.

False

Symptoms of Trichomonas in a female include:

Vaginal burning/itching, Abnormal vaginal odor, Dyspareunia

Physical exam findings of Trichomonas in a female include:

Frothy yellow discharge and strawberry cervix

What is the diagnostic microscopic finding of trichomonas?

Flagellated organisms on slides

What is the treatment of choice for trichomonas?

2 gram single dose of flagyl for patient and partner

True or False: Gonorrhea is most commonly assymptomatic.

True

How does Gonorrhea present in males? In females?

Males: dysuria and discharge. Can get epididymitis with unilateral scrotal pain and swelling Females: dysuria and malodorous discharge. Urethritis and Cervicitis

What are some complications of Gonorrhea infection in a female?

PID and Fitz-Hugh-Curtis Syndrome