ADOLESCENT MEDICINE
From Clinical Pediatrics, presented February 14-17, 2008, by the American Academy of Pediatrics, California Chapter 2
Diane Tanaka, MD, Assistant Professor of Clinical Pediatrics, the Keck School of Medicine of the University of Southern
California, Los Angeles, and Division of Adolescent Medicine, Childrens Hospital of Los Angeles
Educational Objectives
| The goal of this program is to improve the care of adolescent patients with menstrual disorders or sexually transmitted
infections. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Identify patients with menstrual disorders that require further investigation.
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| 2. Formulate an approach for managing patients with menorrhagia, dysfunctional uterine bleeding, or amenorrhea.
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| 3. Recognize and diagnose common sexually transmitted infections (STIs).
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| 4. Describe the pathophysiology of STIs.
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| 5. Describe current treatment regimens for STIs.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning
committee reported nothing to disclose.
Acknowledgments
Dr. Tanaka was recorded at Clinical Pediatrics, presented February 14-17, 2008, in Palm Springs, CA, by The American
Academy of Pediatrics, California Chapter 2. The Audio-Digest Foundation thanks Dr. Tanaka and the AAP for
their cooperation in the production of this program.
| MENSTRUAL DISORDERS: WHEN TO WORRY
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| Case 1: 15-yr-old girl complains of prolonged menstrual bleeding; current menses 16 days long (patient still bleeding);
menarche occurred at age 13 yr and patient not sexually active; normally, patient’s menses lasts 10 days and she uses 10
sanitary napkins/day; patient reports dizziness when moving from sitting to standing
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| Case 2: 17-yr-old girl with chief complaint of no menarche; patient’s mother did not have her first menses until 16 yr of
age; on examination, patient’s sexual maturity rating (SMR) 4 for breasts and pubic hair
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| Case 3: 13-yr-old girl seen for annual school physical (no medical complaints); she reports that menarche occurred at 12
yr of age; menses irregular (range, every 40 days to every 21 days); when periods occur, patient bleeds 5 to 6 days; what
is normal?—currently, average age at menarche 12.7 yr in whites (≈6 mo earlier in blacks); normal onset ≈2 yr after
breast budding (3.3 yr after growth spurt); two-thirds of patients reach menarche by SMR of 4; normal cycle 21 to 40
days; normal duration of menses 2 to 8 days, with loss of 20 to 80 mL blood; case 3 diagnosis—menstrual pattern within
normal limits
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| Definitions: dysfunctional uterine bleeding (DUB)—diagnosis of exclusion; abnormal endometrial sloughing in absence
of structural pathology or anomaly, usually due to anovulation; menorrhagia—prolonged or heavy uterine bleeding that
occurs at regular intervals; metrorrhagia—uterine bleeding occurring at irregular intervals; menometrorrhagia—
prolonged or heavy uterine bleeding that occurs at irregular intervals; oligomenorrhea—uterine bleeding that occurs at
intervals >40 days, but flow, duration, and quantity normal; primary amenorrhea—red flags for further evaluation include
1) no uterine bleeding or secondary sexual characteristics by 14 yr of age, 2) secondary sexual characteristics, but
no uterine bleeding by 16 yr of age, 3) SMR of 5 achieved ≥1 yr ago or onset of breast budding ≥4 yr ago, but no uterine
bleeding; secondary amenorrhea—≥1 episode of menstruation, but no subsequent menses for 6 mo or 3 cycles (whichever
longer)
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| Evaluation of menstrual disorders: history—menstrual, sexual, endocrine, family; systemic illnesses; review of systems
to detect, eg, thyroid disorder; physical examination—vital signs; SMR stage; skin, hair, mucus; thyrotropin (TSH)
to detect thyroid disorder; breasts; lymph nodes; abdomen; pelvic examination (if patient young and not sexually active,
at least external examination); look for pubic hair and vaginal outlet obstruction (eg, transverse vaginal septum, imperforate
hymen); if patient sexually active, perform more thorough genital examination
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| Presentation cause for concern: further evaluation indicated
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| Differential diagnosis of menorrhagia: pregnancy-related causes (patient may be afraid to report sexual activity); bleeding
diathesis; vaginal or cervical trauma; infection; cervical or vaginal polyp; malignancy rare cause of menorrhagia in adolescent
age-group
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| Common causes of hormonally mediated DUB: gynecologic immaturity; defective corpus luteum; hormonal contraception,
thyroid disorders, polycystic ovary syndrome (PCOS), late-onset congenital adrenal hyperplasia (CAH); excessive
exercise or severe stress
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| Case 2 revisited: patient presented with history of primary amenorrhea; cause for concern (initiate work-up)
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| Differential diagnosis of primary amenorrhea
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| Uterus present, no breast development: central cause (failure to produce luteinizing hormone [LH] and follicle-stimulating
hormone [FSH] because of pituitary problem) or hypothalamic etiology, resulting in lack of gonadotropin-releasing
hormone (GnRH); if midfacial defects present (lack of cranial nerve 1 with anosmia), consider possibility of
Kallmann syndrome; peripheral causes—streak gonads (Turner’s syndrome most common etiology); enzymatic defect
affecting steroidogenesis (lack of key enzyme necessary for production of estrogen [most commonly, 17-α-hydroxylase
deficiency])
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| Normal breasts, no uterus: androgen insensitivity syndrome (patient XY), or Mullerian agenesis (patient XX)
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| No breasts, no uterus: patients genetically male; condition most commonly due to 17,20 lyase deficiency or 17-α-hydroxylase
deficiency, or lack of testes
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| Normal breasts, normal uterus: consider possibility of hypothalamic etiology; pituitary causes—infarction or adenoma;
empty sella syndrome; primary ovarian failure; uterine causes—intrauterine scarring or synechiae (Asherman’s
syndrome) most common; pregnancy before first withdrawal bleeding
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| Secondary amenorrhea: more straightforward than primary amenorrhea; if patient sexually active, rule out pregnancy
and thyroid disorders; prolactin disorders; severe weight loss (consider possibility of eating disorder)
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| Laboratory tests: choice depends on symptomatology; complete blood cell count; LH and FSH to assess pituitary function;
if concerned about adrenal etiology, testosterone (total and free), dehydroepiandrosterone levels; for primary amenorrhea,
pelvic ultrasonography to confirm whether uterus present; thyroid function tests (TSH)
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| Treatment of DUB or menorrhagia: stable hemoglobin ≥12 g/dL and light-to-moderate flow—observation reasonable;
consider combination oral contraceptive pill (OCP) containing estrogen (≥30 µg) and progesterone (taper by number
of pills); reevaluate in 2 to 3 mo; patients iron-deficient (supplementation indicated); nonsteroidal anti-inflammatory
drugs; hemoglobin <10 g/dL and heavy flow—if patient hemodynamically stable, treat as outpatient (if not, hospitalize);
treat with OCP, conjugated estrogen intravenously (IV) to halt blood flow, and antiemetic (regimen effective within 24 hr)
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| Bleeding diathesis: outpatient treatment—OCP with taper (mechanism release of endogenous desmopressin
[DDAVP]); consider medroxyprogesterone (eg, Depo-Provera) to induce amenorrhea; or oral progesterone 10 mg once
daily for 5 to 10 days; for von Willebrand’s disease, DDAVP; leuprolide (eg, Lupron; consult endocrinologist); inpatient
treatment—determine whether transfusion indicated; consult hematologist; IV fluid resuscitation; OCP with taper; conjugated
estrogens; DDAVP
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| Treatment of bleeding secondary to hormonal contraception: if patient using OCP with low dose of estrogen
(ie, 20 µg), increase to 30 or 35 µg; if already at 30 to 35 µg, increase to 50 µg; or add conjugated estrogens (eg, Premarin);
if already using medroxyprogesterone, add conjugated estrogens for 1 wk, or combination OCP (once daily for 1
mo)
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| ABCS OF SEXUALLY TRANSMITTED INFECTIONS
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| Sexually transmitted diseases treatment guidelines (Centers for Disease Control and Prevention,
2006): available at cdc.gov/std/treatment/default.htm
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A for Abstinence
| Youth Risk Behavior Survey (2005): ≈50% of high school teens have had sexual intercourse (6% before 13 yr of
age); 14% reported having ≥4 partners; 34% had sexual intercourse with ≥1 person in previous 3 mo; increased condom
use seen
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B for Bumps
| Molluscum contagiosum: transmitted sexually or nonsexually; 1- to 5-mm smooth, rounded, shiny, firm, flesh-colored
to pearly white papules with umbilicated centers; most resolve spontaneously within 2 mo; treatment—curettage; cryotherapy
(liquid nitrogen); caustic chemicals (trichloroacetic acid [TCA], podophyllin); follow up at 1 mo to detect recurrence
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| Herpes simplex virus (HSV) infection
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| Diagnosis: single or grouped vesicles may rupture (painful); initial infection lasts ≈12 days (recurrent infections ≈4 days);
multinucleated giant cells characteristic; monoclonal antibody detection useful, but culture gold standard for definitive
diagnosis
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| Treatment: first episode—acyclovir standard; or valacyclovir bid; recurrent infections—same medications, shorter
courses; suppressive therapy—does not eliminate viral shedding; oral acyclovir 400 mg bid or valacyclovir
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| Human papillomavirus (HPV) infection: causes genital warts (condyloma acuminata); HPV is nonenveloped double-stranded
DNA virus; >40 types infect epithelial lining of anogenital tract and other mucosal areas; most infections
transient and asymptomatic; risk for cervical cancer—90% of infections involve low-risk types (eg, HPV-6 and -11) and
most associated with external lesions; HPV-16 and -18 high-risk types; treatment—debulking of lesions does not eliminate
virus from body; patient-administered treatments include podofilox and imiquimod; speaker prefers cryotherapy
with liquid nitrogen; consider podophyllin (use petroleum jelly [Vaseline] or surgical lubricating jelly [Surgilube] around
lesion to protect surrounding skin from caustic effects); consider TCA; other options include electrodesiccation and electrocautery;
HPV vaccine—quadrivalent vaccine (Gardasil) targets HPV-6, -11, -16, and -18; immunogenic, safe, and
highly effective; Gardasil approved for use in girls and women 9 to 26 yr of age; vaccine given as intramuscular (IM) injection
at 0, 2, and 6 mo
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| Chancroid: pathogen Haemophilus ducreyi (gram-negative bacillus); painful ulcer surrounded by red halo (may be necrotic
or erosive with serpiginous borders); accompanied by unilateral adenopathy; characteristic bubo occurs in ≤60% of
cases; usually diagnosed clinically (definitive diagnosis made by culture); treatment—azithromycin (1 dose); IM injection
of ceftriaxone; ciprofloxacin 500 mg bid orally for 3 days; erythromycin (beware gastrointestinal [GI] upset); sexual
partners who had contact ≤10 days before onset of symptoms should be examined and treated
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| Lymphogranuloma venereum (LGV): pathogen Chlamydia trachomatis; may present initially with small painless
vesicle or nonindurated ulcer at site of inoculation (adenopathy in groin area 1 wk to 1 mo later); stiffness and aching in
groin just before adenopathy erupts; adenopathy may resolve spontaneously or progress to abscesses that rupture and produce
draining sinuses or fistulae; diagnosed by complement fixation test (titers 1:64 or higher positive); start empiric
treatment before confirmation by laboratory; treatment—doxycycline or erythromycin for 3 wk; dissemination possible,
with involvement of kidneys, liver, or vascular system; most common severe morbidity results from rectal involvement
(perianal abscess and rectovaginal or other fistulae); as late sequelae, rectal strictures may develop 1 to 10 yr after infection;
persons who have had sexual contact with the patient ≤ 60 days before onset of symptoms should be examined and
treated
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C for Chancre
| Primary syphilis: chancre painless indurated ulcer located at site of exposure (usually external genitalia); other primary
sites include cervix, mouth, anus, lips, face, breast, and fingers; accompanied by tender inguinal lymphadenopathy;
incubation period 9 to 90 days (average, 21 days); pathogen Treponema pallidum; may see “kissing” lesions;
chancre heals in 3 to 6 wk; treatment—benzathine penicillin first-line treatment (if patient penicillin-allergic, doxycycline);
tetracycline; if patient cannot tolerate doxycycline or tetracycline, refer for penicillin skin testing, or prescribe
erythromycin (less effective) or daily ceftriaxone injection for 10 days (careful follow-up mandatory); repeat serologic
tests at 3 and 6 mo; initial screen nontreponemal specific test (confirm with fluorescent treponemal antibody absorption
[FTA-ABS] test); organism can cross blood-brain barrier (look for 4-fold decrease in nontreponemal antibody titers by 6
mo; if absent, evaluate cerebrospinal fluid [CSF]); by 3 to 12 mo, most patients seronegative
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D for Discharge
| Trichomonas vaginitis: Trichomonas vaginalis motile flagellated parasite; discharge yellow, white or green and frothy
(can be malodorous); symptoms include itching (differential diagnosis yeast infection) and dysuria; diagnosed via culture,
Papanicolaou test, or wet mount; infects vagina, urethra, and Skene’s or Bartholin’s glands; can survive several hours in
urine and wet towels (however, most cases acquired through sex); incubation period 4 to 20 days (average, 7 days); strawberry
cervix may be detected on pelvic examination; laboratory studies include culture; often, bacterial vaginosis found
alongside Trichomonas vaginitis; treatment—single dose of metronidazole first-line treatment (patients should avoid alcohol
[emetic effect]); if discharge persists after single course, and reinfection not cause, treat with metronidazole 500 mg bid
orally for 7 days; metronidazole resistance emerging (if suspected, switch to 2 g metronidazole once daily for 5 days)
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| Chlamydia: most prevalent bacterial STI in United States; has predilection for columnar epithelium; incubation period ≤21
days; symptoms can include friable cervix, vaginal discharge, vaginal spotting, and dysuria; many patients asymptomatic;
laboratory studies—can collect specimens from urine or cervical os; for sexual abuse cases, culture vagina, nasopharynx,
and rectum; nucleic acid amplification tests (NAATs) highly sensitive and can be performed in boys or girls; other tests include
polymerase chain reaction, ligase chain reaction, and transcription-mediated amplification assay; treatment—single
dose of oral azithromycin (1 g), or doxycycline bid, or erythromycin (avoid if possible); other options ofloxacin and levofloxacin;
advise patient to abstain from intercourse with partner until both treated, or to use condoms; consider repeat testing
in 3 mo
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| Gonorrhea: pathogen Neisseria gonorrhoeae (gram-negative diplococci); preferentially infects columnar epithelial cells;
transmission through oral, anal, or genital contact; adolescent boys and men—more likely symptomatic; purulent profuse
discharge from urethra; infection can spread to prostate, epididymis; adolescent girls and women—more likely asymptomatic,
but symptoms include vaginal discharge; infection can spread to urethra and upper reproductive tract, causing
pelvic inflammatory disease
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| Laboratory studies: culture of anterior urethra; NAATs; can screen asymptomatic boys or men with leukocyte esterase test;
treatment—Chlamydia infections often coexist with gonorrhea (treat both empirically while awaiting culture results); because
of emerging antibiotic resistance, fluoroquinolones no longer recommended (use oral cefixime or ceftriaxone); disseminated
disease—ceftriaxone (hospitalization may be indicated)
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| Bacterial vaginosis: most frequent cause of abnormal vaginal discharge in postpubertal girls or women; causes fishy
odor; caused by Gardnerella vaginalis, anaerobic bacteria, or Mycoplasma hominis; autoinfection may play role; more
common in women who have sex with women; higher prevalence among black women; symptoms include vaginal discharge
and pruritus; classic clue cells on wet mount (epithelial cell with intraepithelial bacteria); vaginal ph >4.5; positive
whiff test when preparing potassium hydroxide slide; management—treat symptomatic women, and treat asymptomatic
women who are pregnant or about to undergo surgical procedures (eg, dilatation and curettage); metronidazole administered
intravaginally 500 mg bid for 7 days (avoid alcohol while on metronidazole to avoid emetic effect); consider clindamycin
(cream, gel, oral formulation, or ovules)
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Suggested Reading
Centers for Disease Control and Prevention, Workowski KA, Berma SM: MMWR Recomm Rep 55:1, 2006;
Eaton DK et al: Youth risk behavior surveillance: United States, 2005. MMWR Surveill Summ 55:1, 2006; Gottleib SL
et al: Prevalence of syphilis seroactivity in the United States: data from the National Health and Nutrition Examination Surveys
(NHANES) 2001-2004. Sex Transm Dis 35:507, 2008; Gray SH, Emans SJ: Abnormal vaginal bleeding in adolescents.
Pediatr Rev 28:175, 2007; Hwang LY et al: Sexual behaviors after universal screening of sexually transmitted
infections in healthy young women. Obstet Gynecol 109:105, 2007; Marazzo JM et al: Relationship of specific vaginal
bacteria and bacterial vaginosis treatment failure in women who have sex with women. Ann Intern Med 149:20, 2008;
Miller CA et al: Chlamydial screening in urgent care visits: adolescent-reported acceptability associated with adolescent
perception of clinical communication. Arch Pediatr Adolesc Med 161:777, 2007; Skov RE: Examining mandatory HPV
vaccination for all school-aged children. Food Drug Law J 62:805, 2007; Stampler KM et al: Vaginal wet mounts on asymptomatic
adolescent females: are they beneficial? J Pediatr Adolesc Gynecol 21:227, 2008; Wright TC Jr et al: Age
considerations when vaccinating against HPV. Gynecol Oncol 109:S40, 2008.
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