Topic on Adolescent Medicine

Adolescent Development
Epidemiology of Health Problems
Delivery of Health Care to Adolescents
Violent Behavior
Substance Abuse
The Breast
Menstrual Problems
Contraception
Adolescent Pregnancy
Adolescent Rape
STI
Chronic Fatigue Syndrome

Breast
Breast development one of the first signs of
puberty in females
Distinguish normal development, variation in
progression and definable disorder
Visual examination of the breast should be
routinely done during PE of female
adolescents

 Described according to SMR/Tanner staging

Breast disorders
Female disorders: chapter 551 (included in the
gynecologic problem)
Male disorders: chapter 581
pubertal gynecomastia 60% of males transient
imbalance estrogen and androgen hormones;
onset 10-13yo; peaks SMR 3-4; regresses at 1824mos

Breast disorders
True gynecomastia charact by discreet disc of
palpable glandular tissue under the nipple-areolar
complex
Pseudogynecomastia charact by more diffuse
adiposity of the anterior chest wall

Management

Reassurance and continued observation

Surgery for severe and persistent cases
No approved medical therapies
Promising drug: anti-estrogenic (tamoxifen)

Menstrual disturbances

Delayed onset, irregularity, heavy flow or pain

75% of female adolescents
Varies in the presentation
Explanation and reassurance of reproductive
health may be needed

Normal menstruation
Menarche: first menses; typically occurs 2.5
years after the onset of breast budding
(thelarche)
Occurs during SMR/tanner stage 4
Initially irregular, becomes more regular after
3 years from menarche
The older the age of onset of menarche, the
longer it takes for consistent ovulatory cycle

Menstrual irregularities
Immaturity of the hypothalamic-pituitaryovarian axis that governs the menstrual
cyclicity
Abnormal uterine bleeding (AUB) abnormal
in regularity, volume, frequency and duration
A qualifying letter is added to indicate the
etiology of abnormal bleeding

Categories of menstrual irregularities

AUB-O/ovulatory dysfunction previously
dysfuctional uterine bleeding
AUB-C/Coagulopathy disorders
AUB-N not yet classified

Important in the history..

Chronic illness/medication use

Timing of pubertal milestones
Detailed menstrual history/menarche
Family history of gynecologic problems
Presence galactorrhea
Changes in the skin, hair or bowel movement
Changes in the diet, exercise, sports participation
Psychosocial and psychological problems

Important in the history..

Psychosocial and psychological problems
Nutritional status: weight, height, BMI, blood
pressure, etc..
PE : document SMR, signs of androgen excess
(hirsustism, acne), signs of eating disorder
Genital examination, sexual activity
Pelvic examination
Trans-abdominal pelvic ultrasound

AMENORRHEA
Absence of menstruation
2 types: requires general evaluation
Primary amenorrhea: no menses after 4 years
of the onset of puberty
Secondary amenorrhea: absent of menses for
the length of 3 previous cycle in a postmenarche patient

Caveats exist..
Lack of pubertal signs by the age of 13 years
should prompt evaluation for pubertal delay
Sexually active evaluation should be initiated
without waiting for 3 missed period

Evaluation of amenorrhea
Previous menstrual bleeding
Genetic factors
Anatomic conditions (imperforate hymen)

Approach to Amenorrhea

Treatment
Varies depending on the underlying cause
Referral to specialists: endocrinologist,
adolescent specialist, gynecologist or surgery
Nutritional and psychological management
PCOS: lifestyle modifications and suppresion
of ovarian androgens (COC)
Secondary amenorrhea: hormonal therapy

MENSTRUAL IRREGULARITIES
AUB (abnormal uterine bleeding)
IMB (Intermenstrual bleeding )
HMB (Heavy menstrual bleeding)

Treatment
Depends on the underlying problem
Mild cases: iron supplementation
NSAIDs (naproxen): heavy bleeding and
concurrent dysmenorrhea
COC: cycling of estrogen and progestins;
effective in active bleeding
Hospitalized: hemodynamically unstable;
hemoglobin <7-8 gm/dL

Treatment
Moderate anemia: hormonal regimens; 3-4
COCs
Severe anemia: hormones, blood transfusion
Intrauterine foley balloon placement: if the
bleeding cannot be controlled hormonally
Dilatation and curettage: more common in
adults than in adolescents

DYSMENORRHEA
Painful uterine cramps that precede and
accompany menses
Occurs 93% of adolescent females
Severe enough that it interferes school and
other activities

Classification of dysmenorrhea
Primary dysmenorrhea: absence of any
specific pelvic pathologic condition; 90% of
cases; typically presents after 12 months after
menarche
Reason after ovulation, withdrawal of progesterone
results in the synthesis of prostaglandins by
endometrium which stimulate vasoconstriction, uterine
ischemia and pain smooth muscle contraction

Classification of dysmenorrhea
Secondary dysmenorrhea: anatomic
pathology or infection such PID
Most common cause: endometriosis, implants of
endometrial tissue found outside the uterus near
fallopian tubes and ovaries

 mittelschmerz: brief severe pain with

ovulation, occurs at midcycle and noncyclic
pelvic pain

Premenstrual dysphoric
disorder/PMDD
PMDD depressive disorder
- manifestations: anxiety or depressed mood in
the luteal phase of menstrual cycle (ie second
half, after ovulation)
- occurs 2-6% of adolescent females worldwide

Premenstrual syndrome/PMS
PMS: precipitated by ovulation; symptoms
recur in the luteal phase and disappear at the
end of menstruation
Manifestations:
Breast fullness and tenderness
Bloating, fatigue, headache, increase appetite
Irritability and mood swings, depression
Inability to concentrate
Tearfulness and violent tendencies

Treatment
PMS: education and stress management
technique including exercise
PMDD: supportive, selective serotonin
reuptake inhibitors/SSRI (fluoxetine), calcium
(treat both mood and pain symptoms)

Contraceptive use
Most common: condom withdrawal pill
Advantages: decreases pregnancy, if it is use
consistently and correctly
Counselling: offers opportunities to identify
and reinforce sexual behaviours

Goals of contraceptive counselling

1. To understand adolescent perceptions and
misperceptions about pregnancy and use of
OCs
2. Help adolescent put unprotected intercourse
risk in a personal perspective
3. Educate the adolescent regarding the true
and benefits for the various methods
available
4. Help them choose a safe and effective
method

LONG-ACTING REVERSIBLE
CONTRACEPTION (LARC)
Levonorgestrel IUD (copper IUD and
etonogestrel subdermal implant)
Considered as forgettable contraception (does
not require frequent visits and do not depend on
user compliance for effectiveness)

Action: thickening of the cervical

mucus and inhibiting sperm
survival; effective 3-5years

How can we choose as to the type of

contraception?

IMPLANTS
Progestin-only etonogestrel: single rod that
releases 60ug/day of etonogestrel
Action: cause atrophic endometrium and
thickening of the cervical mucus
Complication: related localized infection and
side effects of implantation

INJECTABLE PROGESTIN-ONLY
Medroxyprogesterone (Depo-provera, DMPA)
Route: deep IM (150 mg) or subcutaneous
injection
Action: inhibits ovulation
Re-administered every 3 months (13wk)
Indicated: difficulty in compliance, intellectual
or physically impaired

PROGESTIN-ONLY PILLS
mini pills
Less reliable in inhibiting ovulation
Effective after 2 days of initiation in thickening
the cervical mucus and the effects short-lived
If the pill is taken > 3hours late from schedule,
an untended pregnancy can occur

COMBINED HORMONAL
CONTRACEPTION (CHC)
Mechanism of action: to prevent surge of LH,
as a result inhibits ovulation; thickened the
cervical mucus
The effectiveness is dependent on the
compliance

Rules for missed pills

OTHER COMBINATION METHODS

Transdermal patch
Vaginal contraceptive rings (NuvaRing)

ENERGENCY CONTRACEPTION
Unprotected mid-cycle intercourse: 20-30%
risk of pregnancy

DUAL PROTECTION
Protection for STIs/HIV and effective
contraception
CONDOMS: no major side effects, low price,
available without prescription
Female condom

OTHER METHODS

Spermicide
Withdrawal
Fertility awareness
LAM (lactation amenorrhea method)
highly effective if criteria are met:
a. no return of menses
b. infant <6 months old
c. exclusive breastfeeding