CURRENT Diagnosis and Treatment Pediatrics, (Current Pediatric Diagnosis & Treatment) 22nd Edition

4. Adolescence

Amy E. Sass, MD, MPH

David W. Kaplan, MD, MPH

Adolescence is a period of rapid physical, emotional, cognitive, and social development. Generally, adolescence begins at age 11–12 years and ends between ages 18 and 21. Most teenagers complete puberty by age 16–18 years; in Western society, however, for educational and cultural reasons, the adolescent period is prolonged to allow for further psychosocial development before the individual assumes adult status. The developmental passage from childhood to adulthood includes the following steps: (1) completing puberty and somatic growth; (2) developing socially, emotionally, and cognitively, and moving from concrete to abstract thinking; (3) establishing an independent identity and separating from the family; and (4) preparing for a career or vocation.

In the United States in 2010, there were 22.0 million adolescents aged 15–19 years and 21.5 million aged 20–24 years. Adolescents and young adults (ages 15–24 years) constitute 14% of the US population. Between 1990 and 2006, the population 10–24 years of age increased from 40.1 to 63.3 million. In the next several decades, the proportion of racial and ethnic minority adolescents is expected to increase. It is projected that by 2040 the percentage of non-Hispanic whites will drop below 50% of the total adolescent population. Hispanics are becoming the second most populous racial and ethnic group of adolescents.

In 2010, there were 10,887 deaths among adolescents aged 15–19 years, representing a rate of 49.4 per 100,000. Cultural and environmental rather than organic factors pose the greatest threats to life. The three leading causes of death in adolescents aged 15–19 years were unintentional injury (41.7%), homicide (16.8%), and suicide (15.2%). The primary cause of unintentional injury death was motor vehicle crashes (63.8%), followed by poisoning (16.4%), which includes prescription drug overdoses and is the only unintentional injury mechanism to increase over the past decade. Homicide deaths were predominantly attributable to firearms (84.8%), while both firearms and suffocation were leading mechanisms of suicide death (40.3% and 45.3%, respectively). The mortality rate of adolescent males aged 15–19 was more than twice that of females (69.6 vs 28.1 per 100,000, respectively), largely due to higher rates of unintentional injury, homicide, and suicide death among males.

The rate of adolescent morality declined by 7.7% from the previous year and 26.4% from 2000. This decline may be largely attributable to decreases in unintentional injury. Motor vehicle crashes, the leading cause of death among teenagers in the United States, account for more than one-quarter of deaths in this age group. In 2010, approximately 2700 teenagers in the United States aged 16–19 were killed and almost 282,000 were treated and released from emergency departments (EDs) for injuries suffered in motor-vehicle crashes. Research suggests that the most comprehensive graduated drivers licensing (GDL) programs, designed to delay full licensure while allowing teenagers to get their initial driving experience under low-risk conditions, are associated with reductions of 38% and 40% in fatal and injury crashes, respectively, among 16-year-old drivers.

Demographic and economic changes in the American family have had a profound effect on children and adolescents. The percentage of children and adolescents living in two-parent households has decreased significantly, from 79% in 1980 to 66% in 2009 (range: 80% in Asians, 60% in Hispanics, 33% in blacks). In 2010, more than 16 million children younger than 18 years lived in households with incomes below 100% of the U.S. Census Bureau’s poverty threshold, representing 22.0% of all children in the United States and an increase from 20.7% in 2009. Poverty affects many aspects of a child’s life, including living conditions, nutrition, and access to health care, and significant racial/ethnic disparities exist. Nearly 40% of non-Hispanic black children lived in households with incomes below 100% of the poverty threshold, as did approximately 35% of non-Hispanic American Indian/Alaska Native children and Hispanic children, compared to 12.4% of non-Hispanic white children. Single-parent families are particularly vulnerable to poverty. In 2010, 46.9% of children living in a female-headed household experienced poverty, as did 28.1% of children living in a male-headed household, compared with 11.6% of children living in married-couple families.

The major causes of morbidity during adolescence are psychosocial and often correlate with poverty: unintended pregnancy, sexually transmitted infection (STI), substance abuse, smoking, dropping out of school, depression, running away from home, physical violence, and juvenile delinquency. High-risk behavior in one area is frequently associated with problems in another (Figure 4–1). For example, teenagers who live in a dysfunctional family (eg, drinking, physical, or sexual abuse) are much more likely than other teenagers to be depressed. A depressed teenager is at greater risk for drug and alcohol abuse, academic failure, inappropriate sexual activity, STIs, pregnancy, and suicide.

 Figure 4–1. Interrelation of high-risk adolescent behavior.

Early identification of the teenager at risk for these problems is important in preventing immediate complications and future associated morbidities. Early indicators for problems related to depression include

1. Decline in school performance

2. Excessive school absences or cutting class

3. Frequent or persistent psychosomatic complaints

4. Changes in sleeping or eating habits

5. Difficulty in concentrating or persistent boredom

6. Signs or symptoms of depression, extreme stress, or anxiety

7. Withdrawal from friends or family or change to a new group of friends

8. Severe violent or rebellious behavior or radical personality change

9. Conflict with parents

10. Sexual acting-out

11. Conflicts with the law

12. Suicidal thoughts or preoccupation with themes of death

13. Drug and alcohol abuse

14. Running away from home

Baker SP, Chen L, Li G: Nationwide Review of Graduated Driver Licensing. Washington, DC: AAA Foundation for Traffic Safety; 2007. http://www.aaafoundation.org/pdf/NationwideReviewOfGDL.pdf.

Centers for Disease Control and Prevention: Web-based Injury Statistics Query and Reporting System (WISQARS). Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2007. http://www.cdc.gov/injury/wisqars/index.html.

D’Angelo LJ, Halpern-Felsher BL et al: Adolescents and driving: a position paper of the Society for Adolescent Health and Medicine. J Adolesc Health 2010;47(2):212–214 [PMID: 20638018].

Mulye TP et al: Trends in adolescent and young adult health in the United States. J Adolesc Health 2009;45(1):8–24 [PMID: 19541245].

Teen Drivers: Fact Sheet: http://www.cdc.gov/motorvehiclesafety/teen_drivers/teendrivers_factsheet.html.

U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau: Child Health USA 2012. Rockville, MD: U.S. Department of Health and Human Services; 2013.

Youth Risk Behavior Surveillance System (YRBSS): http://www.cdc.gov/HealthyYouth/yrbs/index.htm.

How, where, why, and when adolescents seek health care depends on ability to pay, distance to healthcare facilities, availability of transportation, accessibility of services, time away from school, and privacy. Many common teenage health issues, such as unintended pregnancy, contraception, STI, substance abuse, depression, and other emotional problems have moral, ethical, and legal implications. Teenagers are often reluctant to confide in their parents for fear of punishment or disapproval. Recognizing this reality, healthcare providers have established specialized programs such as teenage family planning clinics, drop-in centers, STI clinics, hotlines, and adolescent clinics. Establishing a trusting and confidential relationship with adolescents is basic to meeting their healthcare needs. Patients who sense that the physician will inform their parents about a confidential problem may lie or fail to disclose information essential for proper diagnosis and treatment.

GUIDELINES FOR ADOLESCENT PREVENTIVE SERVICES

The American Medical Association guidelines for adolescent preventive services and the American Academy of Pediatrics’ Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents cover health screening and guidance, immunization, and healthcare delivery. The goals of these guidelines are (1) to deter adolescents from participating in behaviors that jeopardize health; (2) to detect physical, emotional, and behavioral problems early and intervene promptly; (3) to reinforce and encourage behaviors that promote healthful living; and (4) to provide immunization against infectious diseases. The guidelines recommend that adolescents between ages 11 and 21 years have annual routine health visits. Health services should be developmentally appropriate and culturally sensitive. Confidentiality between patient and physician should be ensured.

Adolescence is one of the physically healthiest periods in life. The challenge of caring for most adolescents lies not in managing complex organic disease, but in accommodating the cognitive, emotional, and psychosocial changes that influence health behavior. The physician’s initial approach to the adolescent may determine the success or failure of the visit. The physician should behave simply and honestly, without an authoritarian or excessively professional manner. Because the self-esteem of many young adolescents is fragile, the physician must be careful not to overpower and intimidate the patient. To establish a comfortable and trusting relationship, the physician should strive to present the image of an ordinary person who has special training and skills.

Because the onset and termination of puberty vary from child to child, chronologic age may be a poor indicator of physical, physiologic, and emotional maturity. In communicating with an adolescent, the physician must be sensitive to the adolescent’s developmental level, recognizing that outward appearance and chronologic age may not be an accurate reflection of cognitive development.

Working with teenagers can be emotionally draining. Adolescents have a unique ability to identify hidden emotional vulnerabilities. The physician who has a personal need to control patients or foster dependency may be disappointed in caring for teenagers. Because teenagers are consumed with their own emotional needs, they rarely provide the physician with ego rewards as do younger or older patients.

The physician should be sensitive to the issue of counter-transference—the emotional reaction elicited in the physician by the adolescent. How the physician relates to the adolescent patient often depends on the physician’s personal characteristics. This is especially true of physicians who treat families that are experiencing parent-adolescent conflicts. It is common for young physicians to overidentify with the teenage patient and for older physicians to see the conflict from the parents’ perspective.

Overidentification with parents is readily sensed by the teenager, who is likely to view the physician as just another authority figure who cannot understand the problems of being a teenager. Assuming a parental-authoritarian role may jeopardize the establishment of a working relationship with the patient. In the case of the young physician, overidentification with the teenager may cause the parents to become defensive about their parenting role and to discount the physician’s experience and ability.

Adolescents respond positively to settings and services that communicate sensitivity to their age. A pediatric waiting room with toddlers’ toys and infant-sized examination tables makes adolescent patients feel they have outgrown the practice. A waiting room filled with geriatric or pregnant patients can also make a teenager feel out of place.

It is not uncommon that a teenage patient is brought to the office against his or her wishes, especially for evaluations of drug and alcohol use, parent-child conflict, school failure, depression, or a suspected eating disorder. Even in cases of acute physical illness, the adolescent may feel anxiety about having a physical examination. If future visits are to be successful, the physician must spend time on the first visit to foster a sense of trust and comfort.

It is helpful at the beginning of the visit to talk with the adolescent and the parents about what to expect. The physician should address the issue of confidentiality, telling the parents that two meetings—one with the teenager alone and one with only the parents—will take place. Adequate time must be spent with both patient and parents or important information may be missed. At the beginning of the interview with the patient, it is useful to say, “I am likely to ask you some personal questions. This is not because I am trying to pry into your personal affairs, but because these questions may be important to your health. I want to assure you that what we talk about is confidential, just between the two of us. If there is something I feel we should discuss with your parents, I will ask your permission first unless I feel it is life-threatening.”

Caring for adolescents is time-intensive. In many adolescent practices, a 40%–50% no-show rate is not unusual. The stated chief complaint often conceals the patient’s real concern. For example, a 15-year-old girl may say she has a sore throat but actually may be worried about being pregnant.

By age 11 or 12 years, patients should be seen alone. This gives them an opportunity to ask questions they may be embarrassed to ask in front of a parent. Because of the physical changes that take place in early puberty, some adolescents are too self-conscious to undress in front of a parent. If an adolescent comes in willingly, for an acute illness or for a routine physical examination, it may be helpful to meet with the adolescent and parent together to obtain the history. For angry adolescents brought in against their will, it is useful to meet with the parents and patient for 3–5 minutes to allow the parents to describe the conflict and voice their concerns. The adolescent should then be seen alone. This approach conveys that the physician is primarily interested in the adolescent patient, yet gives the physician an opportunity to acknowledge parental concerns.

The Interview

The first few minutes may determine whether or not a trusting relationship can be established. A few minutes just getting to know the patient is time well spent. For example, immediately asking “Do you smoke marijuana?” when a teenager is brought in for suspected marijuana use confirms the adolescent’s negative preconceptions about the physician and the purpose of the visit. It is preferable to spend a few minutes asking nonthreatening questions, such as “Tell me a little bit about yourself so I can get to know you,” “What do you like to do most?” “Least?” and “What are your friends like?” Neutral questions help defuse some of the patient’s anger and anxiety. Toward the end of the interview, the physician can ask more directed questions about psychosocial concerns.

Medical history questionnaires for the patient and the parents are useful in collecting historical data (Figure 4–2). The history should include an assessment of progress with psychodevelopmental tasks and of behaviors potentially detrimental to health. The review of systems should include questions about the following:

1. Nutrition: Number and balance of meals; calcium, iron, fiber, and cholesterol intake; body image.

2. Sleep: Number of hours, problems with insomnia or frequent waking.

3. Seat belt or helmet: Regularity of use.

4. Self-care: Knowledge of testicular or breast self-examination, dental hygiene, and exercise.

5. Family relationships: Parents, siblings, relatives.

6. Peers: Best friend, involvement in group activities, gangs, boyfriends, girlfriends.

7. School: Attendance, grades, activities.

8. Educational and vocational interests: College, career, short-term and long-term vocational plans.

9. Tobacco: Use of cigarettes and chewing and smokeless tobacco.

10. Substance abuse: Frequency, extent, and history of alcohol and drug use.

11. Sexuality: Sexual activity, contraceptive use, pregnancies, history of STI, number of sexual partners, risk for human immunodeficiency virus (HIV) infection.

12. Emotional health: Signs of depression, anxiety, and excessive stress.

 Figure 4–2. Adolescent medical history questionnaire.

The physician’s personal attention and interest is likely to be a new experience for the teenager, who has probably received medical care only through a parent. The teenager should leave the visit with a sense of having a personal physician.

Physical Examination

During early adolescence, teenagers may be shy and modest, especially with a physician of the opposite sex. The examiner should address this concern directly, because it can be allayed by acknowledging the uneasiness verbally and by explaining the purpose of the examination. For example, “Many boys that I see who are your age are embarrassed to have their penis and testes examined. This is an important part of the examination for a couple of reasons. First, I want to make sure that there aren’t any physical problems, and second, it helps me determine if your development is proceeding normally.” This also introduces the subject of sexual development for discussion.

A pictorial chart of sexual development is useful for showing the patient how development is proceeding and what changes to expect. Figure 4–3 shows the relationship between height, penis and testes development, and pubic hair growth in the male, and Figure 4–4 shows the relationship between height, breast development, menstruation, and pubic hair growth in the female. Although teenagers may not admit that they are interested in this subject, they are usually attentive when it is raised. This discussion is particularly useful in counseling teenagers who lag behind their peers in physical development.

 Figure 4–3. Adolescent male sexual maturation and growth.

 Figure 4–4. Adolescent female sexual maturation and growth.

Because teenagers are sensitive about their changing bodies, it is useful to comment during the examination: “Your heart sounds fine. I feel a small lump under your right breast. This is very common during puberty in boys. It is called gynecomastia and should disappear in 6 months to a year.”

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. Elk Grove Village, IL: American Academy of Pediatrics; 2007.

Ford C, English A, Sigman G: Confidential health care for adolescents: position paper for the Society for Adolescent Medicine. J Adolesc Health 2004;35:160 [PMID: 15298005].

GROWTH & DEVELOPMENT

Pubertal growth and physical development are a result of activation of the hypothalamic-pituitary-gonadal axis in late childhood. Before puberty, pituitary and gonadal hormone levels are low. At onset of puberty, the inhibition of gonadotropin-releasing hormone in the hypothalamus is removed, allowing pulsatile production and release of the gonadotropins, luteinizing hormone (LH), and follicle-stimulating hormone (FSH). In early to middle adolescence, pulse frequency and amplitude of LH and FSH secretion increase, stimulating the gonads to produce estrogen or testosterone. In females, FSH stimulates ovarian maturation, granulosa cell function, and estradiol secretion. LH is important in ovulation and also is involved in corpus luteum formation and progesterone secretion. Initially, estradiol inhibits the release of LH and FSH. Eventually, estradiol becomes stimulatory, and the secretion of LH and FSH becomes cyclic. Estradiol levels progressively increase, resulting in maturation of the female genital tract and breast development.

In males, LH stimulates the interstitial cells of the testes to produce testosterone. FSH stimulates the production of spermatocytes in the presence of testosterone. The testes also produce inhibin, a Sertoli cell protein that inhibits the secretion of FSH. During puberty, circulating testosterone levels increase more than 20-fold. Levels of testosterone correlate with the physical stages of puberty and the degree of skeletal maturation.

A teenager’s weight almost doubles in adolescence, and height increases by 15%–20%. During puberty, major organs double in size, except for lymphoid tissue, which decreases in mass. Before puberty, there is little difference in the muscular strength of boys and girls. The muscle mass and muscle strength both increase during puberty, with maximal strength lagging behind the increase in mass by many months. Boys attain greater strength and mass, and strength continues to increase into late puberty. Although motor coordination lags behind growth in stature and musculature, it continues to improve as strength increases.

The pubertal growth spurt begins nearly 2 years earlier in girls than in boys. Girls reach peak height velocity between ages 11½ and 12 years, and boys between ages 13½ and 14 years. Linear growth at peak velocity is 9.5 cm/y ± 1.5 cm in boys and 8.3 cm/y ± 1.2 cm in girls. Pubertal growth lasts about 2–4 years and continues longer in boys than in girls. By age 11 years in girls and age 12 years in boys, 83%–89% of ultimate height is attained. An additional 18–23 cm in females and 25–30 cm in males is achieved during late pubertal growth. Following menarche, height rarely increases more than 5–7.5 cm.

In boys, the lean body mass increases from 80% to 85% to approximately 90% at maturity. Muscle mass doubles between 10 and 17 years. By contrast, in girls, the lean body mass decreases from approximately 80% of body weight in early puberty to approximately 75% at maturity.

Sexual maturity rating (SMR) is useful for categorizing genital development. SMR staging includes age ranges of normal development and specific descriptions for each stage of pubic hair growth, penis, and testis development in boys, and breast maturation in girls. Figures 4–3 and 4–4 show this chronologic development. SMR 1 is prepuberty and SMR 5 is adult maturity. In SMR 2 the pubic hair is sparse, fine, nonpigmented, and downy; in SMR 3, the hair becomes pigmented and curly and increases in amount; and in SMR 4, the hair is adult in texture but limited in area. The appearance of pubic hair precedes axillary hair by more than 1 year. Male genital development begins with SMR 2 during which the testes become larger and the scrotal skin reddens and coarsens. In SMR 3, the penis lengthens; and in SMR 4, the penis enlarges in overall size and the scrotal skin becomes pigmented.

Female breast development follows a predictable sequence. Small, raised breast buds appear in SMR 2. In SMR 3, the breast and areolar tissue generally enlarge and become elevated. The areola and nipple form a separate mound from the breast in SMR 4, and in SMR 5 the areola assumes the same contour as the breast.

There is great variability in the timing and onset of puberty and growth, and psychosocial development does not always parallel physical changes. Chronologic age, therefore, may be a poor indicator of physiologic and psychosocial development. Skeletal maturation correlates well with growth and pubertal development.

Teenagers began entering puberty earlier in the last century because of better nutrition and socioeconomic conditions. In the United States, the average age at menarche is 12.53 years, but varies by race and ethnicity; 12.57 for non-Hispanic whites; 12.09 years in non-Hispanic blacks, and 12.09 for Mexican American girls. Among girls reaching menarche, the average weight is 48 kg, and the average height is 158.5 cm. Menarche may be delayed until age 16 years or may begin as early as age 10. Although the first measurable sign of puberty in girls is the beginning of the height spurt, the first conspicuous sign is usually the development of breast buds between 8 and 11 years. Although breast development usually precedes the growth of pubic hair, the sequence may be reversed. A common concern for girls at this time is whether the breasts will be of the right size and shape, especially because initial breast growth is often asymmetrical. The growth spurt starts at about age 9 years in girls and peaks at age 11½ years, usually at SMR 3–4 breast development and SMR 3 pubic hair development. The spurt usually ends by age 14 years. Girls who mature early will reach peak height velocity sooner and attain their final height earlier. Girls who mature late will attain a greater final height because of the longer period of growth before the growth spurt ends. Final height is related to skeletal age at onset of puberty as well as genetic factors. The height spurt correlates more closely with breast developmental stages than with pubic hair stages.

The first sign of puberty in the male, usually between ages 10 and 12 years, is scrotal and testicular growth. Pubic hair usually appears early in puberty but may do so any time between ages 10 and 15 years. The penis begins to grow significantly a year or so after the onset of testicular and pubic hair development, usually between ages 10 and 13½ years. The first ejaculation usually occurs about 1 year after initiation of testicular growth, but its timing is highly variable. About 90% of boys have this experience between ages 11 and 15 years. Gynecomastia, a hard nodule under the nipple, occurs in a majority of boys, with a peak incidence between ages 14 and 15 years. Gynecomastia usually disappears within 6 months to 2 years. The height spurt begins at age 11 years but increases rapidly between ages 12 and 13 years, with the peak height velocity reached at age 13½ years. The period of pubertal development lasts much longer in boys and may not be completed until age 18 years. The height velocity is higher in males (8–11 cm/y) than in females (6.5–9.5 cm/y). The development of axillary hair, deepening of the voice, and the development of chest hair in boys usually occur in mid-puberty, about 2 years after onset of growth of pubic hair. Facial and body hair begin to increase at age 16–17 years.

Herman-Giddens ME, Steffes J, Harris D et al: Secondary sexual characteristics in boys: data from the Pediatric Research in Office Settings Network. Pediatrics 2012;130(5):e1058-e1068 [PMID: 23085608].

Lee JM, Kaciroti N, Appugliese D et al: Body mass index and timing of pubertal initiation in boys. Arch Pediatr Adolesc Med 2010;164:139 [PMID: 20124142].

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Rosenfield RL, Lipton RB, Drum ML: Thelarche, pubarche, and menarche attainment in children with normal and elevated body mass index. Pediatrics 2009;123:84 [PMID: 19117864].

Susman EJ et al: Longitudinal development of secondary sexual characteristics in girls and boys between ages 9½ and 15½ years. Arch Pediatr Adolesc Med 2010;164(2):166–173 [PMID: 20124146].

Adolescence is a period of progressive individuation and separation from the family. Adolescents must learn who they are, decide what they want to do, and identify their personal strengths and weaknesses. Because of the rapidity of physical, emotional, cognitive, and social growth during adolescence, it is useful to divide it into three phases. Early adolescence is roughly from 10 to 13 years of age; middle adolescence is from 14 to 16 years; and late adolescence is from 17 years and later.

Early Adolescence

Early adolescence is characterized by rapid growth and development of secondary sex characteristics. Body image, self-concept, and self-esteem fluctuate dramatically. Concerns about how personal growth and development deviate from that of peers may be great, especially in boys with short stature or girls with delayed breast development or delayed menarche. Although there is a certain curiosity about sexuality, young adolescents generally feel more comfortable with members of the same sex. Peer relationships become increasingly important. Young teenagers still think concretely and cannot easily conceptualize about the future. They may have vague and unrealistic professional goals, such as becoming a movie star or a lead singer in a rock group.

Middle Adolescence

During middle adolescence, as rapid pubertal development subsides, teenagers become more comfortable with their new bodies. Intense emotions and wide swings in mood are typical. Although some teenagers go through this experience relatively peacefully, others struggle. Cognitively, the middle adolescent moves from concrete thinking to formal operations and abstract thinking. With this new mental power comes a sense of omnipotence and a belief that the world can be changed by merely thinking about it. Sexually active teenagers may believe they do not need to worry about using contraception because they can’t get pregnant (“it won’t happen to me”). Sixteen-year-old drivers believe they are the best drivers in the world and think the insurance industry is conspiring against them by charging high rates for automobile insurance. With the onset of abstract thinking, teenagers begin to see themselves as others see them and may become extremely self-centered. Because they are establishing their own identities, relationships with peers and others are narcissistic. Experimenting with different self-images is common. As sexuality increases in importance, adolescents may begin dating and experimenting with sex. Relationships tend to be one-sided and narcissistic. Peers determine the standards for identification, behavior, activities, and clothing and provide emotional support, intimacy, empathy, and the sharing of guilt and anxiety during the struggle for autonomy. The struggle for independence and autonomy is often a stressful period for both teenagers and parents.

Late Adolescence

During late adolescence, the young person generally becomes less self-centered and more caring of others. Social relationships shift from the peer group to the individual. Dating becomes much more intimate. By 10th grade, 40.9% of adolescents (41.9% of males and 39.6% of females) have had sexual intercourse, and by 12th grade, this has increased to 62.3% (59.6% of males and 65% of females). Abstract thinking allows older adolescents to think more realistically about their plans for the future. This is a period of idealism; older adolescents have rigid concepts of what is right or wrong.

Sexual Orientation

Sexual orientation develops during early childhood. Gender identity is established by age 2 years, and a sense of masculinity or femininity usually solidifies by age 5 or 6 years. Homosexual adults describe homosexual feelings during late childhood and early adolescence, years before engaging in overt homosexual acts.

Although only 5%–10% of American young people acknowledge having had homosexual experiences and only 5% feel that they are or could be gay, homosexual experimentation is common, especially during early and middle adolescence. Experimentation may include mutual masturbation and fondling the genitals and does not by itself cause or lead to adult homosexuality. Theories about the causes of homosexuality include genetic, hormonal, environmental, and psychological models.

The development of homosexual identity in adolescence commonly progresses through two stages. The adolescent feels different and develops a crush on a person of the same sex without clear self-awareness of a gay identity and then goes through a coming-out phase in which the homosexual identity is defined for the individual and revealed to others. The coming-out phase may be a difficult period for the young person and the family. The young adolescent is afraid of societal bias and seeks to reject homosexual feelings. The struggle with identity may include episodes of both homosexual and heterosexual promiscuity, STI, depression, substance abuse, attempted suicide, school avoidance and failure, running away from home, and other crises.

In a clinical setting, the issue of homosexual identity most often surfaces when the teenager is seen for an STI, family conflict, school problem, attempted suicide, or substance abuse rather than as a result of a consultation about sexual orientation. Pediatricians should be aware of the psychosocial and medical implications of homosexual identity and be sensitive to the possibility of these problems in gay adolescents. Successful management depends on the physician’s ability to gain the trust of the gay adolescent and on the physician’s knowledge of the wide range of medical and psychological problems for which gay adolescents are at risk. Pediatricians must be nonjudgmental in posing sexual questions if they are to be effective in encouraging the teenager to share concerns. Physicians who for religious or other personal reasons cannot be objective must refer the homosexual patient to another professional for treatment and counseling.

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BEHAVIOR & PSYCHOLOGICAL HEALTH

It is not unusual for adolescents to seek medical attention for apparently minor complaints. In early adolescence, teenagers may worry about normal developmental changes such as gynecomastia. They may present with vague symptoms, but have a hidden agenda of concerns about pregnancy or an STI. Adolescents with emotional disorders often present with somatic symptoms—abdominal pain, headaches, dizziness, syncope, fatigue, sleep problems, and chest pain—which appear to have no biologic cause. The emotional basis of such complaints may be varied: somatoform disorder, depression, or stress and anxiety.

The most common somatoform disorder of adolescence is conversion disorder or conversion reaction. A conversion reaction is a psychophysiologic process in which unpleasant feelings, especially anxiety, depression, and guilt, are communicated through a physical symptom. Psychophysiologic symptoms result when anxiety activates the autonomic nervous system, causing symptoms such as tachycardia, hyperventilation, and vasoconstriction. The emotional feeling may be threatening or unacceptable to the individual who expresses it as a physical symptom rather than verbally. The process is unconscious, and the anxiety or unpleasant feeling is dissipated by the somatic symptom. The degree to which the conversion symptom lessens anxiety, depression, or the unpleasant feeling is referred to as primary gain. Conversion symptoms not only diminish unpleasant feelings but also release the adolescent from conflict or an uncomfortable situation. This is called secondary gain. Secondary gain may intensify the symptoms, especially with increased attention from concerned parents and friends. Adolescents with conversion symptoms tend to have overprotective parents and become increasingly dependent on their parents as the symptom becomes a major focus of concern in the family.

 Clinical Findings

Symptoms may appear at times of stress. Nervous, gastrointestinal, and cardiovascular symptoms are common and include paresthesias, anesthesia, paralysis, dizziness, syncope, hyperventilation, abdominal pain, nausea, and vomiting. Specific symptoms may reflect existing or previous illness (eg, pseudoseizures in adolescents with epilepsy) or modeling of a close relative’s symptom (eg, chest pain in a boy whose grandfather died of a heart attack). Conversion symptoms are more common in girls than in boys. Although they occur in patients from all socioeconomic levels, the complexity of the symptom may vary with the sophistication and cognitive level of the patient.

History and physical findings are usually inconsistent with a physical cause of symptoms. Conversion symptoms occur most frequently during stress and in the presence of individuals meaningful to the patient. The common personality traits of these patients include egocentricity, emotional lability, and dramatic, attention-seeking behaviors.

 Differential Diagnosis

Conversion reactions must be differentiated from hypochondriasis, which is a preoccupation with developing or having a serious illness despite medical reassurance that there is no evidence of disease. Over time, the fear of one disease may give way to concern about another. In contrast to patients with conversion symptoms, who seem relieved if an organic cause is considered, patients with hypochondriasis become more anxious when such a cause is considered.

Malingering is uncommon during adolescence. The malingering patient consciously and intentionally fabricates or exaggerates physical or psychological symptoms. Such patients are motivated by external incentives such as avoiding work, evading criminal prosecution, obtaining drugs, or obtaining financial compensation. These patients may be hostile and aloof. Parents of patients with conversion disorders and malingering have a similar reaction to illness. They have an unconscious psychological need to have sick children and reinforce their child’s behavior.

Somatic delusions are physical symptoms, often bizarre, that accompany other signs of mental illness. Examples are visual or auditory hallucinations, delusions, incoherence or loosening of associations, rapid shifts of affect, and confusion.

 Treatment

The physician must emphasize from the outset that both physical and emotional causes of the symptom will be considered. The relationship between physical causes of emotional pain and emotional causes of physical pain should be described to the family, using examples such as stress causing an ulcer or making a severe headache worse. The patient should be encouraged to understand that the symptom may persist and that at least a short-term goal is to continue normal daily activities. Medication is rarely helpful. If the family will accept it, psychological referral is often a good initial step toward psychotherapy. If the family resists psychiatric or psychological referral, the pediatrician may need to begin to deal with some of the emotional factors responsible for the symptom while building rapport with the patient and family. Regular appointments should be scheduled. During visits, the teenager should be seen first and encouraged to talk about school, friends, the relationship with the parents, and the stresses of life. Discussion of the symptom itself should be minimized; however, the physician should be supportive and must never suggest that the pain is not real. As parents gain insight into the cause of the symptom, they will become less indulgent and facilitate resumption of normal activities. If management is successful, the adolescent will gain coping skills and become more independent, while decreasing secondary gain.

If the symptom continues to interfere with daily activities and if the patient and parents feel that no progress is being made, psychological referral is indicated. A psychotherapist experienced in treating adolescents with conversion reactions is in the best position to establish a strong therapeutic relationship with the patient and family. After referral is made, the pediatrician should continue to follow the patient to ensure compliance with psychotherapy.

American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision. Washington, DC: American Psychiatric Press; 2000.

Kreipe RE: The biopsychosocial approach to adolescents with somatoform disorders. Adolesc Med Clin 2006;17:1 [PMID: 16473291].

Silber TJ: Somatization disorders: diagnosis, treatment, and prognosis. Pediatr Rev 2011;32(2):56–63 [PMID: 21285301].

Symptoms of clinical depression (lethargy, loss of interest, sleep disturbances, decreased energy, feelings of worthlessness, and difficulty concentrating) are common during adolescence. The intensity of feelings during adolescence, often in response to seemingly trivial events such as a poor grade on an examination or not being invited to a party, makes it difficult to differentiate severe depression from normal sadness or dejection. In less severe depression, sadness or unhappiness associated with problems of everyday life is generally short-lived. The symptoms usually result in only minor impairment in school performance, social activities, and relationships. Symptoms respond to support and reassurance.

 Clinical Findings

The presentation of serious depression in adolescence may be similar to that in adults, with vegetative signs—depressed mood, crying spells, inability to cry, discouragement, irritability, a sense of emptiness and futility, negative expectations of oneself and the environment, low self-esteem, isolation, helplessness, diminished interest or pleasure in activities, weight loss or weight gain, insomnia or hypersomnia, fatigue or loss of energy, feelings of worthlessness, and diminished ability to think or concentrate. In adolescents, it is not unusual for a serious depression to be masked because the teenager cannot tolerate the severe feelings of sadness. Such a teenager may present with recurrent or persistent psychosomatic complaints, such as abdominal pain, chest pain, headache, lethargy, weight loss, dizziness, syncope, or other nonspecific symptoms. Other behavioral manifestations of masked depression include truancy, running away from home, defiance of authorities, self-destructive behavior, vandalism, drug and alcohol abuse, sexual acting-out, and delinquency.

 Differential Diagnosis

A complete history and physical examination and review of the past medical and psychosocial history should be performed. The family history should be explored for psychiatric problems. Early onset depression and bipolar illness are more likely to occur in families with a multigenerational history of early onset and chronic depression. The lifetime risk of depressive illness in first-degree relatives of adult depressed patients is between 18% and 30%.

The teenager should be questioned about the symptoms of depression and, specifically, about suicidal ideation or preoccupation with thoughts of death. The history should include an assessment of school performance, looking for signs of academic deterioration, excessive absence, cutting class, changes in work or other outside activities, and changes in the family (eg, separation, divorce, serious illness, loss of employment by a parent, recent move to a new school, increasing quarrels or fights with parents, or death of a close relative). The teenager may have withdrawn from friends or family or switched allegiance to a new group of friends. The physician should inquire about possible physical and sexual abuse, drug and alcohol abuse, conflicts with the police, sexual acting-out, running away from home, unusually violent or rebellious behavior, or radical personality changes. Patients with vague somatic complaints or concerns about having a fatal illness may have an underlying affective disorder.

Adolescents with symptoms of depression require a thorough medical evaluation to rule out contributing or underlying medical illness. Among the medical conditions associated with affective disorders are eating disorders, organic central nervous system disorders (tumors, vascular lesions, closed head trauma, and subdural hematomas), metabolic and endocrinologic disorders (hypothyroidism, hyperthyroidism, hyperparathyroidism, Cushing syndrome, Addison disease, or premenstrual syndrome), Wilson disease, systemic lupus erythematosus, infections (infectious mononucleosis or syphilis), and mitral valve prolapse. Marijuana use, phencyclidine abuse, amphetamine withdrawal, and excessive caffeine intake can cause symptoms of depression. Common medications, including birth control pills, anticonvulsants, and β-blockers, may cause depressive symptoms.

Some screening laboratory studies for organic disease are indicated, including complete blood count and erythrocyte sedimentation rate, urinalysis, serum electrolytes, blood urea nitrogen, serum calcium, thyroxine and thyroid-stimulating hormone (TSH), Venereal Disease Research Laboratory testing or rapid plasma reagin, and liver enzymes. Although metabolic markers such as abnormal secretion of cortisol, growth hormone, and thyrotropin-releasing hormone have been useful in confirming major depression in adults, these neurobiologic markers are less reliable in adolescents.

 Treatment

The primary care physician may be able to counsel adolescents and parents if depression is mild or situational and the patient is not contemplating suicide or other life-threatening behaviors. If there is evidence of a long-standing depressive disorder, suicidal thoughts, or psychotic thinking, or if the physician does not feel prepared to counsel the patient, psychological referral should be made.

Counseling involves establishing and maintaining a positive supportive relationship; following the patient at least weekly; remaining accessible to the patient at all times; encouraging the patient to express emotions openly, defining the problem, and clarifying negative feelings, thoughts, and expectations; setting realistic goals; helping to negotiate interpersonal crises; teaching assertiveness and social skills; reassessing the depression as it is expressed; and staying alert to the possibility of suicide.

Patients with bipolar disease or those with depression that is unresponsive to supportive counseling should be referred to a psychiatrist for evaluation and antidepressant medication. The Food and Drug Administration (FDA) has issued a “black box warning” alerting providers that using antidepressants in children and adolescents may increase the risk of suicidal thoughts and behavior. Adolescents taking these medications should be monitored closely.

Birmaher B et al: Four-year longitudinal course of children and adolescents with bipolar spectrum disorders: the Course and Outcome of Bipolar Youth (COBY) study. Am J Psychiatry 2009;166:795 [PMID: 19448190].

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2010). Available from www.cdc.gov/injury/wisqars.

March JS, Vitiello B: Clinical messages from the Treatment for Adolescents With Depression Study (TADS). Am J Psychiatry 2009;166(10):1118–1123 [PMID: 19723786].

Simon GE: The antidepressant quandary—considering suicide risk when treating adolescent depression. N Engl J Med 2006; 355:2722 [PMID: 17192536].

Wilkinson P et al: Treated depression in adolescents: predictors of outcome at 28 weeks. Br J Psychiatry 2009;194(4):334–341 [PMID: 19336785].

Zuckerbrot RA et al: Guidelines for Adolescent Depression in Primary Care (GLAD-PC): I. Identification, assessment, and initial management. Pediatrics 2007;120:e1299 [PMID: 17974723].

In 2010, suicide was the third leading cause of death among persons aged 15–24 years, resulting in 4600 deaths, at a rate of 10.5 deaths per 100,000 population. The most common methods used in suicides of adolescents and young adults included firearms (44%), suffocation (40%) and poisoning (8%). Among young adults ages 15 to 24 years old, there are approximately 100–200 attempts for every completed suicide.

In 2011, data from the Youth Risk Behavior Surveillance System showed that 15.8% of high school students had seriously considered attempting suicide during the 12 months prior to the survey. Overall, 7.8% of high school students reported having attempted suicide one or more times in the past 12 months, reflecting a significant increase since 2009 (6.3%). Female students were more likely than males to have considered suicide, and females (9.8%) were more likely to report at least one suicide attempt than males (5.8%). The incidence of unsuccessful suicide attempts is three times higher in females than in males. Firearms account for approximately 50% of suicide deaths in both males and females.

Mood swings are common in adolescence. Short periods of depression are common and may be accompanied by thoughts of suicide. Normal adolescent mood swings rarely interfere with sleeping, eating, or normal activities. Acute depressive reactions (transient grief responses) to the loss of a family member or friend may cause depression lasting for weeks or even months. An adolescent who is unable to work through this grief can become increasingly depressed. A teenager who is unable to keep up with schoolwork, does not participate in normal social activities, withdraws socially, has sleep and appetite disturbances, and has feelings of hopelessness and helplessness should be considered at increased risk for suicide.

Angry teenagers attempting to influence others by their actions may be suicidal. They may be only mildly depressed and may not have any long-standing wish to die. Teenagers in this group, usually females, may attempt suicide or make an impulsive suicidal gesture as a way of getting back at someone or gaining attention by frightening another person. Adolescents with serious psychiatric disease such as acute schizophrenia or psychotic depressive disorder are also at risk for suicide.

 Risk Assessment

The physician must determine the extent of the teenager’s depression and the risk that he or she might inflict self-injury. Evaluation should include interviews with both the teenager and the family. The history should include the medical, social, emotional, and academic background. The Patient Health Questionnaire-9 (PHQ-9) is a nine-item standardized depression questionnaire that is incorporated in the Adolescent Health Questionnaire in the section labeled “Health Concerns” (see Figure 4–2.).

 Treatment

The primary care physician is often in a unique position to identify an adolescent at risk for suicide because many teenagers who attempt suicide seek medical attention in the weeks preceding the attempt. These visits are often for vague somatic complaints. If the patient shows evidence of depression, the physician must assess the severity of the depression and suicidal risk. The pediatrician should always seek emergency psychological consultation for any teenager who is severely depressed, psychotic, or acutely suicidal. It is the responsibility of the psychologist or psychiatrist to assess the seriousness of suicidal ideation and decide whether hospitalization or outpatient treatment is most appropriate. Adolescents with mild depression and low risk for suicide should be followed closely, and the extent of the depression should be assessed on an ongoing basis. If it appears that the patient is worsening or is not responding to supportive counseling, referral should be made.

Brent DA et al: The Treatment of Adolescent Suicide Attempters study (TASA): predictors of suicidal events in an open treatment trial. J Am Acad Child Adolesc Psychiatry 2009;48(10):987–996 [PMID: 19730274].

Centers for Disease Control and Prevention: Suicide trends among youths and young adults aged 10–24 years—United States, 1990–2004. MMWR Morb Mortal Wkly Rep 2007;56(35): 905–908 [PMID: 17805220].

Connor J, Rueter M: Predicting adolescent suicidality: comparing multiple informants and assessment techniques. J Adolesc 2009;32(3):619–631 [PMID: 18708245].

Kroenke K, Spitzer RL: The PHQ-9: a new depression and diagnostic severity measure. Psychiatr Ann 2002;32:509–521.

Prager LM: Depression and suicide in children and adolescents. Pediatr Rev 2009;30(6):199–205 [PMID: 19487428].

Richardson LP et al: Evaluation of the patient health questionnaire-9 item for detecting major depression among adolescents. Pediatrics 2010;126(6):1117–1123 [PMID: 21041282].

Shain BN, American Academy of Pediatrics Committee on Adolescence: Suicide and suicide attempts in adolescents. Pediatrics 2007;120:669 [PMID: 17766542].

Wilkinson P et al: Clinical and psychosocial predictors of suicide attempts and nonsuicidal self-injury in the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). Am J Psychiatry 2011;168(5):495–501 [PMID: 21285141].

Williams SB et al: Screening for child and adolescent depression in primary care settings: a systematic evidence review for the U.S. Preventive Services Task Force. Pediatrics 2009;123(4): e716–e735 [PMID: 19336361].

Substance abuse is a complex problem for adolescents and the broader society. See Chapter 5 for an in-depth look at this issue.

 Background

The prevalence of obesity (body mass index [BMI] > 95th percentile for age and gender) among adolescents 12–19 years has increased from 5% to 17% in the past 25 years, with higher rates in black and Hispanic youth. Furthermore, an adolescent who is overweight (BMI between 85th and 95th percentiles) has a 70% chance of becoming an obese adult. Figure 4–5 illustrates the multiple morbidities related to overweight and obesity during adolescence and the risk of the additional comorbidities associated with obesity in adulthood. Perhaps the most common short-term morbidities for overweight and obese adolescents are psychosocial, including social marginalization, poor self-esteem, depression, and poor quality of life. Like physical comorbidities, these psychosocial complications can extend into adulthood. Recent data on adolescent dietary and physical activity behaviors that potentiate overweight and obesity indicate that almost 80% of teens have deficient fiber intake, 63% have less than the recommended level of physical activity (60 minutes per day, 5 days per week), 33% watch 3 or more hours of television per average school day, and 25% participate in nonacademic computer activities for more than 3 hours per average school day.

 Figure 4–5. Complications of obesity. DVT, Deep venous thrombosis; PE, pulmonary embolism. (Adapted and reproduced, with permission, from Xanthakos SA, Daniels SR, Inge TH: Bariatric surgery in adolescents: an update. Adolesc Med Clinics 2006;17(3):589–612 [PMID: 17030281].)

 Evaluation

Regular screening for overweight and obesity by measuring BMI during routine visits and providing anticipatory guidance for the adolescent and family regarding healthy nutrition and physical activity are essential for early identification and prevention of overweight and related comorbidities. A family history of obesity, diabetes mellitus, hypertension, hyperlipidemia, and coronary heart disease places the overweight young person at even higher risk of developing these comorbidities. Details of individual and family dietary behaviors, assessment of physical activity and time spent with sedentary activities, previous efforts to lose weight, and current readiness to change can identify areas for modifiable lifestyle behaviors to promote weight loss. The review of systems should include questions about symptoms associated with comorbid conditions including insulin resistance and diabetes, gallbladder disease or steatohepatitis, sleep dysfunction, and menstrual irregularities (female patients). If an overweight adolescent is otherwise healthy and has no delay in growth or sexual maturation, an underlying endocrinologic, neurologic, or genetic cause of overweight is unlikely. BMI percentile and the presence of risk factors for morbidities can serve as guides for laboratory evaluations of overweight adolescents in the primary care setting (Table 4–1).

 Treatment

Comprehensive interventions that include both behavioral therapy and modifications in diet and physical activity seem to be the most successful approaches to obesity and its comorbidities, but clinical trials testing these interventions are limited. Several studies of childhood obesity treatment have confirmed the critical importance of parental participation in weight control programs. The greater independence of adolescents means that providers must discuss health behaviors directly with them while involving parents in the discussions and encouraging the whole family to make the home environment and family lifestyle a healthy one.

The most current evidence on obesity treatment in the pediatric population recommends a four-stage approach that includes (1) prevention plus (Table 4–2); (2) structured weight management; (3) comprehensive multidisciplinary intervention; and (4) tertiary care intervention. The appropriate weight management stage for each patient is based on age, BMI percentile, comorbid disease, and past obesity treatment.

Providers caring for overweight and obese adolescents should identify comorbidities and treat them as indicated. For example, an overweight teen with daytime somnolence and disruptive snoring may need a sleep study to evaluate for obstructive sleep apnea. A nonpregnant overweight young woman with acanthosis nigricans and oligomenorrhea should be evaluated for polycystic ovary syndrome (PCOS). There are few guidelines regarding pharmacotherapy for obesity in the adolescent. Medication options include sibutramine, a selective serotonin reuptake inhibitor (SSRI) that is approved for patients age 16 and older, and orlistat, a lipase inhibitor approved for patients age 12 and older. In general, obese adolescents who might benefit from medication should be referred to a multidisciplinary weight loss program, as medication should only be used as part of a comprehensive program which includes diet, physical activity, and behavioral modifications. Bariatric surgery is reserved for severely obese adolescents who are physically mature, who have a BMI of 50 kg/m² or more (or ≥ 40 kg/m² with significant comorbidities), who have failed a structured 6-month weight loss program, and who are deemed by psychological assessment to be capable of adhering to the long-term lifestyle changes required after surgery.

Barlow SE: Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120 (Suppl 4):S164–S192 [PMID: 18055651].

Daniels SR, Greer FR: Committee on Nutrition: lipid screening and cardiovascular health in childhood. Pediatrics 2008;122(1): 198–208 [PMID: 18596007].

Davis MM et al: Recommendation for prevention of childhood obesity. Pediatrics 2007;120(Suppl 4):S229–S253 [PMID: 18055653].

Eaton DK et al: Youth risk behavior surveillance—United States, 2009. MMWR Surveill Summ 2010;59(5):1–142 [PMID 20520591]. http://www.cdc.gov/mmwr/pdf/ss/ss5905.pdf.

Krebs NF et al: Assessment of child and adolescent overweight and obesity. Pediatrics 2007;120(Suppl 4):S193–S228 [PMID: 18055652].

Skelton JA et al: Prevalence and trends of severe obesity among US children and adolescents. Acad Pediatr 2009;9:322–329 [PMID: 19560993].

Spear BA et al: Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics 2007;120(Suppl 4): S254–S288 [PMID: 18055654].

Xanthakos SA, Daniels SR, Inge TH: Bariatric surgery in adolescents: an update. Adolesc Med Clin 2006;17(3):589–612 [PMID: 17030281].

Growth charts are available at the Centers for Disease Control and Prevention web site, http://www.cdc.gov/growthcharts.

A teenager who has missed more than 1 week of school for a physical illness or symptom and whose clinical picture is inconsistent with serious illness should be suspected of having primary or secondary emotional factors that contribute to the absence. Investigation of absences may show a pattern, such as missing morning classes or missing the same days at the beginning or end of the week.

School avoidance should be suspected in children who are consistently absent in spite of parental and professional attempts to encourage attendance. Adolescents with school avoidance often have a history of excessive school absences or separation difficulties as younger children. They may have a record of recurrent somatic complaints. Parents often feel helpless to compel their adolescent to attend school, may lack the sophistication to distinguish malingering from illness, or may have an underlying need to keep the teenager at home.

A complete history and physical examination should include a review of the patient’s medical, educational, and psychiatric history. Any symptoms of emotional problems should be explored. After obtaining permission from the patient and parents, the physician may find it helpful to speak directly with school officials and some key teachers. The adolescent may be having problems with particular teachers or subjects or experiencing adversity at school (eg, bullying or an intimidating instructor). Some students get so far behind academically that they see no way of catching up and feel overwhelmed. Separation anxiety, sometimes of long duration, may be manifested in subconscious worries that something may happen to the mother while the teenager is at school.

The school nurse may have useful information on the frequency of nurse visits in past school years. It is important to determine the parent’s typical responses to absences and somatic complaints. The parent(s) may be making subconscious attempts to keep the adolescent at home, which may in turn produce secondary gains for the patient that perpetuate the complaint.

 Treatment

Returning to school quickly after a period of avoidance is key to recovery. The pediatrician should facilitate this process by offering to speak with school officials to excuse missed examinations, homework, and papers. The pediatrician should speak directly with teachers who are punitive with the objective of making the transition back to school as easy as possible. The longer adolescents stay out of school, the more anxious they may become about returning. If an illness or symptom becomes so severe that an adolescent cannot go to school, the patient and the parents must be informed that a visit to a medical office is necessary. The physician focuses visits on the parents as much as on the adolescent to alleviate parental guilt about sending the child to school. If the adolescent cannot stay in school, hospitalization should be recommended for in-depth medical and psychiatric evaluation. Parents should be cautioned about the possibility of relapse after school holidays, summer vacation, or an acute illness.

Hanna GL et al: Separation anxiety disorder and school refusal in children and adolescents. Pediatr Rev 2006;27:56 [PMID: 16452275].

Suveg C et al: Separation anxiety disorder, panic disorder, and school refusal. Child Adolesc Psychiatr Clin N Am 2005;14:773 [PMID: 16171702].

The amount and complexity of course work increase significantly in middle school at the same time as the rapid physical, social, and emotional changes of puberty. To perform well academically, young adolescents must have the necessary cognitive capacity, study habits, concentration, motivation, interest, and emotional focus. Academic failure presenting at adolescence has a broad differential:

1. Limited intellectual ability

2. Learning disabilities

3. Depression or emotional problems

4. Visual or hearing problems; other physical disability

5. Excessive school absenteeism secondary to chronic disease such as asthma or neurologic dysfunction

6. Inability to concentrate

7. Attention-deficit/hyperactivity disorder

8. Lack of motivation

9. Drug and alcohol use/abuse

Each of these causes must be explored. Evaluation requires a careful history, physical examination, appropriate laboratory tests, and standardized educational and psychological testing.

 Treatment

Management must be individualized to fit the specific needs and foster the specific strengths of the patient. For children with learning disabilities, an individual prescription for special education courses, teachers, and extracurricular activities is important. Counseling helps these adolescents gain coping skills, raise self-esteem, and develop socialization skills. If the patient has hyperactivity or attention-deficit disorder causing poor ability to concentrate, a trial of stimulant medication (eg, methylphenidate or dextroamphetamine) may be useful. If the teenager is depressed or if other serious emotional problems are uncovered, psychological evaluation should be recommended.

Wilens TE et al: Attention-deficit/hyperactivity disorder in adults. JAMA 2004;292:619 [PMID: 15292088].

Wolraich ML et al: Attention-deficit/hyperactivity disorder among adolescents: a review of the diagnosis, treatment, and clinical implications. Pediatrics 2005;115:1734 [PMID: 15930238].

BREAST DISORDERS

The breast examination should be part of the routine physical examination in girls as soon as breast budding occurs. The preadolescent will thus accept breast examination as a routine part of health care, and the procedure can serve as an opportunity to offer reassurance and education. The breast examination begins with inspection of the breasts for symmetry and SMR stage. Asymmetrical breast development is common in young adolescents, and is generally transient, although 25% of women may continue to have asymmetry as adults. Organic causes of breast asymmetry include unilateral breast hypoplasia, amastia, absence of the pectoralis major muscle, and unilateral juvenile hypertrophy, in which there is rapid overgrowth of breast tissue usually immediately after thelarche.

The breast examination is performed with the patient supine and the ipsilateral arm placed behind the head. Using flat finger pads, the examiner palpates the breast tissue in concentric circles starting at the outer borders of the breast tissue along the sternum, clavicle, and axilla and then moving in toward the areola. The areola should be compressed gently to check for nipple discharge. Supraclavicular and infraclavicular and axillary regions should be palpated for lymph nodes.

Teaching adolescents to perform breast self-examinations is controversial. In the past, experts have recommended adolescent self-examination as a means of helping them develop comfort with their changing bodies and for future cancer detection. More recently, however, experts have questioned whether self-examination might in fact result in anxiety, increased physician visits, and unnecessary invasive procedures since the vast majority of breast masses in adolescents are benign. The U.S. Preventive Services Task Force found little evidence that teaching or performing routine breast self-examination in adolescents reduces breast cancer mortality. Despite the lack of data for or against teaching or performing breast self-examinations during adolescence, there is some consensus that young women at increased risk of breast cancer—adolescents with a history of malignancy, adolescents who are at least 10 years postradiation therapy to the chest, and adolescents 18–21 years of age whose mothers carry the BRCA 1 or BRCA 2 gene—should perform monthly breast self-examinations after each menstrual period.

The majority of breast masses in adolescents are benign (Table 4–3). The incidence of primary and secondary breast cancers in girls aged 15–19 years during 2000–2009 was 0.15 per 100,000. Rare malignancies of adolescent girls include juvenile secretory carcinoma, intraductal carcinoma, rhabdomyosarcoma, malignant cystosarcoma phylloides, and metastatic tumor. Retrospective studies indicate that biopsies of breast masses in adolescents most commonly show fibroadenoma (67%), fibrocystic change (15%), and abscess or mastitis (3%).

Common

Fibroadenoma

Fibrocystic changes

Breast cysts (including subareolar cysts)

Breast abscess or mastitis

Fat necrosis (after trauma)

Less common (benign)

Lymphangioma

Hemangioma

Intraductal papilloma

Juvenile papillomatosis

Giant fibroadenoma

Neurofibromatosis

Nipple adenoma or keratoma

Mammary duct ectasia

Intramammary lymph node

Lipoma

Hematoma

Hamartoma

Galactocele

Rare (malignant or malignant potential)

Juvenile secretory carcinoma

Intraductal carcinoma

Cystosarcoma phylloides

Sarcomas (fibrosarcoma, malignant fibrous histiocytoma, rhabdomyosarcoma)

Metastatic cancer (hepatocellular carcinoma, lymphoma, neuroblastoma, rhabdomyosarcoma)

1. Fibroadenoma

Fibroadenomas are the most common breast masses of adolescent girls. These and other breast lesions are listed in Tables 4–3 and 4–4. Fibroadenomas are composed of glandular and fibrous tissue. A fibroadenoma is typically nontender and diagnosed clinically with examination findings of a rubbery, smooth, well-circumscribed, mobile mass most often in the upper outer quadrant of the breast, although fibroadenomas can be found in any quadrant. Ten to twenty-five percent of girls will have multiple or bilateral lesions. Fibroadenomas are typically slow growing with average size 2–3 cm. They may remain static in size for months to years with 10%–40% completely resolving during adolescence. The dense fibroglandular tissue of the adolescent breast may cause false-positive results on standard mammograms. Thus, ultrasonography is the best imaging modality with which to evaluate a breast mass in an adolescent if further evaluation beyond the clinical examination is necessary. Fibroadenomas less than 5 cm can be monitored for growth or regression over 3–4 months. Further evaluation will be dictated by the patient’s course with semiannual clinical examinations for a few years followed by annual examinations for a mass that is regressing. Patients with concerning breast masses including fibroadenomas that are larger than 5 cm, undiagnosed breast masses that are enlarging or have overlying skin changes, and any suspicious breast mass in a patient with a history of previous malignancy should be referred to a breast care specialist.

2. Fibrocystic Breast Changes

Fibrocystic breast changes are much more common in adults than adolescents. Symptoms include mild swelling and palpable nodularity most commonly in the upper outer quadrants. Mastalgia is typically cyclic, usually occurring just before menstruation. Reassuring the young woman about the benign nature of the process may be all that is needed. Nonsteroidal anti-inflammatory medications such as ibuprofen or naproxen sodium help alleviate symptoms. Oral contraceptive pills are also beneficial. Supportive bras may provide symptomatic relief. Studies have shown no association between methylxanthine and fibrocystic breasts; however, some women report reduced symptoms when they discontinue caffeine.

3. Breast Abscess

Although breast feeding is the most common cause of mastitis, shaving or plucking periareolar hair, nipple piercing, and trauma occurring during sexual activity are predisposing factors in teenagers. The most common causative organisms are normal skin flora. The female with a breast abscess usually complains of unilateral breast pain, and examination reveals overlying inflammatory changes. The examination may be misleading in that the infection may extend deeper into the breast than suspected. Staphylococcus aureus is the most common pathogen. β-Hemolytic streptococci, Escherichia coli, and Pseudomonas aeruginosa have also been implicated. Fluctuant abscesses should be incised and drained and fluid cultured. Antimicrobial coverage for S aureus (including methicillin-resistant strains) should be given initially (generally orally, unless infection is severe) and the patient should be monitored closely for response to therapy until culture and sensitivity results are available.

Healing time after nipple piercing is 3–6 months. Health risks associated with nipple piercing, in addition to breast abscess, include allergic reactions to the jewelry, keloid scar formation, and increased risk of hepatitis B and C and HIV. Complications associated with abscess formation secondary to nipple piercing include endocarditis, cardiac valve injury, cardiac prosthesis infection, metal foreign body reaction in the breast tissue, and recurrent infection.

Ductal ectasia is a common cause of nipple discharge in the developing breast and is associated with dilation of the mammary ducts, periductal fibrosis, and inflammation. It can present with bloody, brown, or sticky multicolored nipple discharge and/or a cystic breast mass, which is usually in the subareolar region. Blocked ducts and fluid collections usually resolve spontaneously but can become infected, producing mastitis. Patients should look for erythema, warmth, and tenderness indicating mastitis. Oral antibiotics covering skin flora should be initiated if infection is suspected. Serous or serosanguinous nipple discharge is common and can be associated with fibrocystic breast changes. Montgomery tubercles are small glands located at the outer aspect of the areola that can drain clear or brownish fluid through an ectopic opening on the areola and may be associated with a small subareolar mass. These lesions and discharge typically resolve spontaneously. Intraductal papillomas arising from proliferation of ductal cells projecting into the duct lumen are a rare cause of bloody or serosanguineous nipple discharge and can also present with a subareolar or peripheral mass. These lesions are associated with increased risk of malignancy in adults.

Galactorrhea is distinguishable from other causes of nipple discharge by its milky character and tendency to involve both breasts. It is usually benign. The most common causes include chronic stimulation or irritation of the nipple, medications and illicit drugs (drugs causing galactorrhea are listed in Table 4–5), pregnancy, childbirth, or abortion. Prolactin-secreting tumors (prolactinomas) and hypothyroidism are common pathologic causes of galactorrhea during adolescence. Less common causes of hyperprolactinemia and galactorrhea include diseases in or near the hypothalamus or pituitary that interfere with the secretion of dopamine or its delivery to the hypothalamus. Included are tumors of the hypothalamus and/or pituitary, both benign (eg, craniopharyngiomas) and malignant (eg, metastatic disease), infiltrative diseases of the hypothalamus (eg, sarcoidosis), and pituitary stalk damage (eg, section due to head trauma or surgery or compression). Stimulation of the intercostal nerves (eg, chest wall surgery or herpes zoster infection), renal failure (decreased prolactin clearance), polycystic ovarian syndrome, and emotional or physical stress can also cause hyperprolactinemia, which can induce galactorrhea.

Anticonvulsants (valproic acid)

Antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants)

Anxiolytics (alprazolam)

Antihypertensives (atenolol, methyldopa, reserpine, verapamil)

Antipsychotics

Typical (haloperidol, phenothiazine, pimozide)

Atypical (risperidone, olanzapine, molindone)

Antiemetics (prochlorperazine)

Herbs (anise, blessed thistle, fennel, fenugreek seed, nettle)

Hormonal contraceptives

Isoniazid

Illicit drugs (amphetamines, cannabis, opiates)

Motility agents (metoclopramide)

Muscle relaxants (cyclobenzaprine)

 Clinical Findings

Breast ultrasonography can be helpful in determining the cause of nipple discharge and breast masses. Depending upon additional findings from the history and examination, evaluation of galactorrhea may include a pregnancy test, prolactin level, and thyroid function studies. If there is a question as to whether the discharge is true galactorrhea, fat staining of the discharge can be confirmatory. Elevated TSH confirms the diagnosis of hypothyroidism. Elevated prolactin and normal TSH, often accompanied by amenorrhea, in the absence of medication known to cause hyperprolactinemia suggests a hypothalamic or pituitary tumor. In such cases, magnetic resonance imaging (MRI) of the brain and consultation with a pediatric endocrinologist are indicated.

 Treatment

Observation with serial examination is recommended for nipple discharge associated with breast mass unless a papilloma is suspected by the presence of bloody or serosanguineous nipple discharge with or without a subareolar or peripheral mass. This entity requires further evaluation and excision by a breast surgeon. Treating the underlying cause of galactorrhea is usually effective. Galactorrhea due to hypothyroidism should be treated with thyroid hormone replacement. An alternative medication can be prescribed in cases of medication-induced galactorrhea. Adolescents with galactorrhea without a breast mass who have normal prolactin and TSH levels can be followed clinically and counseled about supportive measures such as avoidance of nipple stimulation, stress reduction, and keeping a menstrual calendar to monitor for oligomenorrhea, which might indicate a systemic hormonal problem such as hyperprolactinemia or thyroid disease. In many cases, symptoms resolve spontaneously and no underlying diagnosis is made. Medical management of prolactinomas with dopamine agonists such as bromocriptine is the favored approach.

Gynecomastia, benign subareolar glandular breast enlargement, affects up to 65% of adolescent males. It typically appears at least 6 months after the onset of secondary sex characteristics with peak incidence during SMR stages 3 and 4. Breast tissue enlargement usually regresses within 1–3 years, and persistence beyond age 17 years is uncommon. Approximately half of young men with gynecomastia have a positive family history of gynecomastia. The pathogenesis of pubertal gynecomastia has long been attributed to a transient imbalance between estrogens that stimulate proliferation of breast tissue and androgens which antagonize this effect. Leptin has recently been implicated in the development of gynecomastia as levels are higher in healthy nonobese adolescent males with gynecomastia when compared to controls. There are several proposed mechanisms in which leptin acts biochemically to alter the estrogen-androgen ratio.

 Clinical Findings

Palpation of the breasts is necessary to distinguish adipose tissue (pseudogynecomastia) from the glandular tissue found in true gynecomastia, which is palpable as a fibroglandular mass located concentrically beneath the nipple-areolar complex. Gynecomastia is bilateral in almost two-thirds of patients. Findings that indicate more serious disease include hard or firm breast tissue, unilateral breast growth, eccentric masses outside of the nipple-areolar complex, and overlying skin changes. A genitourinary examination is needed to evaluate pubertal SMR, testicular volume and masses, or irregularities of the testes.

In the absence of abnormalities on history or physical examination, clinical monitoring of male gynecomastia for 12–18 months is sufficient. Laboratory evaluation is warranted if the patient with gynecomastia is prepubertal, appears undervirilized, has an eccentric breast mass, has a rapid progression of breast enlargement, has a testicular mass, or has persistence of gynecomastia beyond the usual observation period. The initial laboratory evaluation includes thyroid function tests, testosterone, estradiol, human chorionic gonadotropin (hCG), and luteinizing hormone (LH). Additional studies depending on preliminary findings include karyotype, liver and renal function studies, dehydroepiandrosterone sulfate, and prolactin. Any patient with a testicular mass or laboratory results suggesting possible tumor, such as high serum testosterone, hCG, or estradiol, should have a testicular ultrasound. Further evaluation includes adrenal or brain imaging if a prolactin-secreting pituitary tumor or adrenal tumor is suspected.

 Differential Diagnosis

Gynecomastia may be drug-induced (Table 4–6). Testicular, adrenal, or pituitary tumors, Klinefelter syndrome, secondary hypogonadism, partial or complete androgen insensitivity syndrome, hyperthyroidism, or chronic diseases (eg, cystic fibrosis, ulcerative colitis, liver disease, renal failure, and acquired immunodeficiency syndrome) leading to malnutrition may be associated with gynecomastia. Breast cancer in the adolescent male is extraordinarily rare.

 Treatment

If gynecomastia is idiopathic, reassurance about the common and benign nature of the process can be given. Resolution may take up to 2 years. Surgery is reserved for those with persistent severe breast enlargement and/or significant psychological trauma. In cases of drug-induced gynecomastia, the inciting agent should be discontinued if possible. The patient should be referred to an endocrinologist or oncologist if other pathologic etiologies are diagnosed.

ACOG Committee Opinion: Breast concerns in the adolescent. Obstet Gynecol 2006;108(5):1329–1336 [PMID: 17077268].

De Silva NK: Breast disorders in the female adolescent. Adolesc Med State Art Rev 2012;23(1):34–52 [PMID: 22764554].

Hagan JF, Shaw JS, Duncan PM : Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics; 2008.

Howlader N et al (eds): SEER Cancer Statistics Review, 1975-2009 (Vintage 2009 Populations). Bethesda, MD: National Cancer Institute; 2012. http://seer.cancer.gov/csr/1975_2009_pops09/. (Based on November 2011 SEER data submission, posted to the SEER web site, 2012).

Jayasinghe Y, Simmons PS: Fibroadenomas in adolescence. Curr Opin Obstet Gynecol 2009;21(5):402–406 [PMID: 19606032].

DiVasta A, Weldon C, Labow BI: The breast: examination and lesions. In: Emans SJ, Laufer MR, Goldstein DP, eds. Pediatric and Adolescent Gynecology, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:587–610.

Nordt CA, DiVasta AD: Gynecomastia in adolescents. Curr Opin Pediatr 2008;20(4):375–382 [PMID: 18622190].

GYNECOLOGIC DISORDERS IN ADOLESCENCE

The ovulatory menstrual cycle is divided into three consecutive phases: follicular (days 1–14), ovulatory (midcycle), and luteal (days 16–28). During the follicular phase, pulsatile gonadotropin-releasing hormone from the hypothalamus stimulates anterior pituitary secretion of follicle stimulating hormone (FSH) and LH. Under the influence of FSH and LH, a dominant ovarian follicle emerges by day 5–7 of the menstrual cycle, and the other follicles become atretic. Rising estradiol levels produced by the maturing follicle cause proliferation of the endometrium. By the midfollicular phase, FSH begins to decline secondary to estradiol-mediated negative feedback, while LH continues to rise as a result of estradiol-mediated positive feedback.

Rising LH initiates progesterone secretion and luteinization of the granulosa cells of the follicle. Progesterone in turn further stimulates LH and FSH. This leads to the LH surge, which causes the follicle to rupture and expel the oocyte. During the luteal phase, LH and FSH gradually decline. The corpus luteum secretes progesterone. The endometrium enters the secretory phase in response to rising levels of estrogen and progesterone, with maturation 8–9 days after ovulation. If pregnancy and placental hCG release do not occur, luteolysis begins; estrogen and progesterone levels decline and the endometrial lining is shed as menstrual flow approximately 14 days after ovulation. In the first 2 years after menarche, the majority of cycles (50%–80%) are anovulatory. Between 10% and 20% of cycles are anovulatory for up to 5 years after menarche.

Indications for a pelvic examination in an adolescent include abdominal or pelvic pain, intra-abdominal or pelvic mass, abnormal vaginal bleeding or other menstrual disorders, pathologic vaginal discharge, or need for cervical cytology screening. The American College of Obstetricians and Gynecologists advocates starting Papanicolaou (Pap) screening at age 21 years for both sexually experienced and sexually inexperienced women. This is based on the low incidence of cervical cancer in younger women and the potential for adverse effects associated with follow-up of young women with abnormal cytology screening results, regardless of type of test used. Pregnancy during adolescence does not alter screening guidelines. Recommendations for special populations, including sexually active adolescents newly diagnosed with HIV, include performing a Pap test twice in the first year after diagnosis and annually thereafter. In addition, adolescents who have been sexually active and are immunocompromised (eg, organ transplant recipient, long-term steroid use) should have Pap screening after the onset of sexual activity even if younger than 21 years of age. This screening should include Pap tests at 6 month intervals during the first year of screening and then annual Pap tests thereafter. Algorithms for managing abnormal cytology can be found at the American Society for Colposcopy and Cervical Pathology website, http://www.asccp.org/ConsensusGuidelines/tabid/7436/Default.aspx. Guidelines for management of abnormal cytology in HIV positive women can be obtained through the Centers for Disease Control (CDC) at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5804a1.htm.

The adolescent may be apprehensive about the first pelvic examination. Sensitive counseling and age-appropriate education about the purpose of the examination, pelvic anatomy, and the components of the examination should occur in an unhurried manner. The use of diagrams and models may facilitate discussion. Time should be allotted for the adolescent to ask questions. Ideally, the examination should occur in a controlled and comfortable setting. The adolescent may request to have her mother or family member present during the examination for reassurance; however, in many instances an adolescent will request that the examination occur confidentially. Having another female staff present to support the adolescent in this setting may be helpful. A female staff chaperone should be present with male examiners.

The pelvic examination begins by placing the patient in the dorsal lithotomy position after equipment and supplies are ready (Table 4–7). Patients with orthopedic or other physical disabilities require accommodation for proper positioning and comfort. The examiner inspects the external genitalia, noting sexually maturity rating, estrogenization of the vaginal mucosa (moist, pink, and more elastic mucosa), shape of the hymen, the size of the clitoris (2–5 mm wide is normal), any unusual rashes or lesions on the vulva such as folliculitis from shaving, warts or other skin lesions, and genital piercing or body art. It can be helpful to ask an adolescent if she has any questions about her body during the inspection as she might have concerns that she was too shy to ask (eg, normalcy of labial hypertrophy). In cases of alleged sexual abuse or assault, the presence of any lesions, including lacerations, bruises, scarring, or synechiae about the hymen, vulva, or anus, should be noted.

The patient should be prepared for insertion of the speculum to help her remain relaxed. The speculum should be inserted into the vagina posteriorly with a downward direction to avoid the urethra. A medium Pedersen speculum is most often used in sexually experienced patients; a narrow Huffman is used for virginal patients. In a virginal female prior to the speculum examination, a one-finger examination in the vagina can help the provider identify the position of the cervix and can give the patient an appreciation for the sensation she can expect with placement of the speculum. Warming the speculum with tap water prior to insertion can be more comfortable for the patient and also provide lubrication. Simultaneously touching the inner aspect of the patient’s thigh or applying gentle pressure to the perineum away from the introitus while inserting the speculum helps distract attention from the placement of the speculum. The vaginal walls and cervix are inspected for anatomical abnormalities, inflammation, and lesions and the quantity and quality of discharge adherent to the vaginal walls and pooled in the vagina are noted. The presence of a cervical ectropion is commonly observed in adolescents as erythema surrounding the cervical os. The ectropion is the extension of the endocervical columnar epithelium outside the cervical os onto the face of the cervix.

Specimens are obtained in the following order: vaginal pH, saline and KOH wet preparations, cervical cytology (Pap) screening if indicated, and endocervical swabs for gonorrhea and Chlamydia (Table 4–8). Sexually transmitted infections are discussed in further detail in Chapter 44. The speculum is then removed, and bimanual examination is performed with one or two fingers in the vagina and the other hand on the abdomen to palpate the uterus and adnexa for size, position, and tenderness.

1. Amenorrhea

Primary amenorrhea is defined as having no menstrual periods or secondary sex characteristics by age 13 years or no menses in the presence of secondary sex characteristics by age 15 years. In the adolescent who has achieved menarche, secondary amenorrhea is defined as the absence of menses for three consecutive cycles or for 6 months in a patient with irregular cycles.

A. Evaluation of Primary and Secondary Amenorrhea

In evaluating amenorrhea, it is helpful to consider anatomical levels of possible abnormalities from the hypothalamus to the genital tract (Table 4–9).

Hypothalamic-pituitary axis

Hypothalamic suppression

Chronic disease

Stress

Malnutrition

Strenuous athletics

Drugs (haloperidol, phenothiazines, atypical antipsychotics)

Central nervous system lesion

Pituitary lesion: adenoma, prolactinoma

Craniopharyngioma, brainstem, or parasellar tumors

Head injury with hypothalamic contusion

Infiltrative process (sarcoidosis)

Vascular disease (hypothalamic vasculitis)

Congenital conditionsa

Kallmann syndrome (anosmia)

Ovaries

Gonadal dysgenesisa

Turner syndrome (XO)

Mosaic (XX/XO)

Injury to ovary

Autoimmune disease (oophoritis)

Infection (mumps)

Toxins (alkylating chemotherapeutic agents)

Irradiation

Trauma, torsion (rare)

Polycystic ovary syndrome

Ovarian failure

Uterovaginal outflow tract

Müllerian dysgenesisa

Congenital deformity or absence of uterus, uterine tubes, or vagina

Imperforate hymen, transverse vaginal septum, vaginal agenesis, agenesis of the cervixa

Androgen insensitivity syndrome (absent uterus)a

Uterine lining defect

Asherman syndrome (intrauterine synechiae postcurettage or endometritis)

Tuberculosis, brucellosis

Defect in hormone synthesis or action (virilization may be present)

Adrenal hyperplasiaa

Cushing disease

Adrenal tumor

Ovarian tumor (rare)

Drugs (steroids, ACTH)

ACTH, adrenocorticotropic hormone.
^aIndicates condition that usually presents as primary amenorrhea.

A stepwise approach, using clinical history, growth charts, physical examination, and appropriate laboratory studies will allow providers to determine the etiology of amenorrhea in most adolescents. Evaluation begins with a thorough developmental and sexual history. Establishing a pubertal timeline including age at thelarche, adrenarche, growth spurt, and menarche is helpful in evaluating pubertal development. Although there can be variations in the onset, degree, and timing of these stages, the progression of stages is predictable. Adrenal androgens are largely responsible for axillary and pubic hair. Estrogen is responsible for breast development; maturation of the external genitalia, vagina, and uterus; and menstruation. Lack of development suggests pituitary or ovarian failure or gonadal dysgenesis. Determining the patient’s gynecologic age (time in years and months since menarche) is helpful in assessing the maturity of the hypothalamic-pituitary-ovarian axis. A menstrual history includes date of last menstrual period (LMP), frequency and duration of periods, amount of bleeding, and premenstrual symptoms. Irregular menstrual cycles are common in the first 1–2 years after menarche. Two-thirds of adolescents with a gynecologic age more than 2 years have regular menstrual cycles.

Relevant components of the past medical and surgical histories include the neonatal history, treatment for malignancies, presence of autoimmune disorders or endocrinopathies, and current medications (prescribed and over-the-counter). Family history includes age at menarche of maternal relatives, familial gynecologic or fertility problems, autoimmune diseases, or endocrinopathies. A review of systems should focus on symptoms of hypothalamic-pituitary disease such as weight change, headache, visual disturbance, galactorrhea, polyuria, and/or polydipsia. A history of cyclic abdominal and/or pelvic pain in a mature adolescent with amenorrhea may indicate an anatomic abnormality such as an imperforate hymen. Acne and hirsutism are clinical markers of androgen excess. Both hypo- and hyperthyroidism can cause menstrual irregularities. Changes in weight, quality of skin and hair, and stooling pattern may indicate a thyroid problem. A confidential social history should include sexual activity, contraceptive use, the possibility of pregnancy, and use of tobacco, drugs, or alcohol. The patient should also be questioned about major stressors, symptoms of depression and anxiety, dietary habits including any disordered eating or weight-loss behaviors, and athletic participation.

A thorough physical examination should include the components listed in Table 4–10. If a patient cannot tolerate a pelvic or bimanual examination, the presence of the uterus can be assessed by rectoabdominal examination or ultrasonography. Ultrasound provides evaluation of pelvic anatomy and possible genital tract obstruction, measurement of the endometrial stripe as an indicator of estrogen stimulation, and identification of ovarian cysts or masses.

Figure 4–6 illustrates an approach to the laboratory and radiologic evaluation of primary or secondary amenorrhea. Initial studies should include a urine pregnancy test, complete blood count, TSH, prolactin, and FSH. If there is evidence of hyperandrogenemia (acne, hirsutism) and PCOS is suspected, total and free testosterone and dehydroepiandrosterone sulfate (DHEAS) should be obtained. If systemic illness is suspected, a urinalysis and a chemistry panel (including renal and liver function tests) and erythrocyte sedimentation rate should be obtained. If short stature and delayed puberty are present, a bone age and karyotype should be done.

If pelvic examination or ultrasonography reveals normal female external genitalia and pelvic organs and the patient is not pregnant, the patient should be given a challenge of oral medroxyprogesterone, 10 mg daily for 10 days. Positive response to the progestin challenge with withdrawal bleeding is suggestive of the presence of a normal, estrogen-primed uterus.

Elevated serum prolactin indicates a possible prolactin secreting tumor. Prolactin testing is sensitive and can be elevated with stress, eating, or sexual intercourse. A mildly elevated test should be repeated prior to MRI of the brain for a prolactinoma. Elevated FSH indicates ovarian insufficiency or gonadal dysgenesis and a karyotype for Turner syndrome or Turner mosaic should be obtained. Autoimmune oophoritis should be assessed by antiovarian antibodies if the chromosome analysis is normal. Normal or low serum gonadotropins indicate hypothalamic suppression and functional amenorrhea if the patient’s weight is normal and there is a reasonable explanation such as vigorous exercise. Functional amenorrhea, although relatively common, is a diagnosis of exclusion. Low serum gonadotropin concentration can also be caused by malnutrition as in anorexia nervosa, endocrinopathies, and chronic diseases or by a central nervous system tumor.

 Figure 4–6. Evaluation of primary amenorrhea and secondary amenorrhea. CNS, central nervous system; DHEAS, dehydroepiandrosterone sulfate; FSH, follicle-stimulating hormone; TSH, thyroid-stimulating hormone; UA, urine analysis.

If the physical examination or ultrasound reveals an absent uterus, chromosomal analysis and serum testosterone should be obtained to differentiate between Mullerian dysgenesis and androgen insensitivity. Mullerian dysgenesis or Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is the congenital absence of the vagina with variable uterine development. These women have normal serum testosterone levels. Pelvic MRI is helpful to clarify the nature of the vaginal agenesis and to differentiate it from low-lying transverse vaginal septum, agenesis of the uterus and vagina, and imperforate hymen. Individuals with androgen insensitivity are phenotypically female but have an absent upper vagina, uterus, and fallopian tubes; a male karyotype; and an elevated serum testosterone (normal range for males).

The management of primary or secondary amenorrhea depends on the underlying pathology. Hormonal treatment is used in patients with hypothalamic, pituitary, and ovarian causes. Surgical repair may be required in patients with outflow tract anomalies.

B. Polycystic Ovary Syndrome

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder of reproductive-aged women. It occurs in up to 6% of adolescents and 12% of adult women. PCOS is characterized by ovarian dysfunction, disordered gonadotropin secretion, and hyperandrogenism, which cause amenorrhea, hirsutism, and acne. Many adolescents with PCOS are overweight and the association of PCOS with insulin resistance is well established. Adolescents with PCOS are at increased risk for obesity-related morbidities including type 2 diabetes mellitus, dyslipidemia, and cardiovascular disease; low self-esteem; and adult reproductive health problems including infertility and endometrial cancer.

The adolescent with PCOS usually presents with overweight, oligomenorrhea or secondary amenorrhea, acne, and hirsutism. The most recent set of diagnostic criteria for PCOS from the Androgen Excess and Polycystic Ovary Syndrome Society include: (1) presence of hyperandrogenism (hirsutism and/or biochemical hyperandrogenemia), (2) ovarian dysfunction (oligo-anovulation and/or presence of polycystic ovaries by ultrasound), and (3) the exclusion of other androgen excess or related disorders.

Table 4–11 outlines a standard laboratory evaluation for PCOS. If other etiologies of virilization such as late-onset congenital adrenal hyperplasia (history of premature pubarche, high DHEAS, clitoromegaly) are suspected, a first morning 17-hydroxyprogesterone should be collected to look for 21-hydroxylase deficiency. Urine cortisol or a dexamethasone suppression test is performed if Cushing syndrome is suspected. If the patient is overweight and/or has acanthosis nigricans, a fasting insulin, lipid panel, and 2-hour oral glucose challenge test are recommended. A simple fasting glucose is not sufficient, as women with PCOS can have normal fasting glucose but impaired postprandial tests. Consultation with a pediatric endocrinologist can assist in further evaluation and management of significantly elevated androgens and endocrinopathies.

Encouraging lifestyle changes that will promote weight loss is a primary goal of therapy for PCOS in adolescence. Weight loss is associated with improved menstrual regulation and decreased symptoms of hyperandrogenemia, obesity-related comorbidities, and infertility. Combination of estrogen/progesterone oral contraceptives may improve menstrual regularity, decrease ovarian and adrenal androgen production, and increase sex hormone-binding globulin (SHBG). There are no current guidelines for the use of insulin-sensitizing medications such as metformin to treat PCOS in adolescents.

2. Dysmenorrhea

Dysmenorrhea, or pain with menstrual periods is the most common gynecologic complaint of adolescent girls, with up to 90% of adolescent girls reporting some symptoms. Fifteen percent of adolescent women describe their symptoms as severe. The prevalence of dysmenorrhea increases with gynecologic age due to its association with ovulatory cycles. Dysmenorrhea can be designated as primary or secondary depending upon the absence or presence of underlying pelvic pathology (Table 4–12). Potent prostaglandins are the mediators of dysmenorrhea, producing uterine contractions, tissue ischemia, and hypersensitivity of pain fibers in the uterus.

In addition to taking a gynecologic and sexual history, an accurate characterization of the pain (timing with menses, intensity, duration, use of pain medications) is important in determining functional impairment. The pelvic examination can usually be deferred in nonsexually active adolescents with probable primary dysmenorrhea. Adolescents should be encouraged to keep track of their menstrual cycles using a calendar to predict when a period is imminent, thereby allowing for more proactive use of nonsteroidal anti-inflammatory drugs (NSAIDs) 1–2 days before the start of the anticipated period or with the first indication of discomfort. NSAIDs are typically continued for an additional 2–3 days after onset of pain. Recommended medications are ibuprofen 400–600 mg every 6 hours, or naproxen 500 mg twice a day. If the patient does not respond to NSAIDs, suppression of ovulation with oral contraceptive pills or other combined hormonal contraceptives such as the transdermal patch or intravaginal ring can be effective. These products can also be used continuously by skipping placebo pills or the fourth week off with the patch or ring when the menstrual period is expected to decrease the frequency of menstrual periods. Progestin-only medications such as depot medroxyprogesterone acetate (DMPA) are also options. If patients do not respond to these products and NSAIDs, further evaluation for secondary dysmenorrhea is indicated. A pelvic examination, pelvic imaging with ultrasonography or MRI, and diagnostic laparoscopy may be necessary for diagnosis. Secondary dysmenorrhea is more likely to be associated with chronic pelvic pain, midcycle pain, dyspareunia, and metrorrhagia.

3. Dysfunctional Uterine Bleeding

Dysfunctional uterine bleeding (DUB) results from irregular endometrial sloughing accompanying anovulatory cycles. It may be characterized by menorrhagia (prolonged bleeding that occurs at regular intervals) or menometrorrhagia (heavy prolonged bleeding that occurs irregularly and more frequently than normal). The differential diagnosis of common and less common etiologies in adolescences are listed in Table 4–13.

 Evaluation

In addition to a menstrual and sexual history, the bleeding pattern should be characterized by cycle length, duration, and quantity of bleeding (eg, number of soaked pads or tampons in 24 hours, number of menstrual accidents). Bleeding for more than 10 days is usually considered abnormal. The patient should be assessed for symptoms of anemia including fatigue, lightheadedness, syncope, tachycardia, and for other abnormal bleeding (gingivae, stool, easy bruising). The physical examination includes an assessment of hemodynamic stability with orthostatic heart rate and blood pressure measurements. Mucous membranes and skin should be evaluated for pallor; the heart for tachycardia and murmur; the abdomen for organomegaly; and the external genitalia for signs of trauma or congenital anomalies. If the patient has never been sexually active, a pelvic examination is usually unnecessary. In a sexually experienced female, a pelvic and bimanual examination to examine the vagina, cervix, and adnexa may be helpful to elucidate the diagnosis. Laboratory studies should include a complete blood cell count, pregnancy test, reticulocyte count, prothrombin time, partial thromboplastin time, TSH, and iron studies. A von Willebrand panel and a platelet function analysis should be considered with a history of heavy menstrual bleeding from menarche and/or bleeding from other sources. For patients suspected of having PCOS, total and free testosterone and dehydroepiandrosterone sulfate should be obtained. For sexually experienced females, cervical or urine-based testing for Chlamydia and gonorrhea should be obtained.

 Treatment

The severity of DUB is determined by hemodynamic status and degree of anemia and classified as mild, moderate, or severe (Table 4–14). The goals of treatment include (1) establishment and/or maintenance of hemodynamic stability, (2) correction of acute or chronic anemia, (3) resumption of normal menstrual cycles, (4) prevention of recurrence, and (5) prevention of long-term consequences of anovulation. Management depends on the severity of the problem and its specific etiology (see Table 4–14). Monophasic oral contraceptive pills containing a potent progestin such as norgestrel 0.3 mg with ethinyl estradiol 30 μg or levonorgestrel 0.15 mg with ethinyl estradiol 30 μg are frequently used for patients without medical contraindications to exogenous estrogens. The active pills in monophasic formulations contain the same concentration of progestins and estrogen and are preferred over multiphasic formulations which contain variable concentrations of estrogen which could potentially increase the risk of breakthrough bleeding. It is important to remind adolescents and their families that compliance with medications to control bleeding and treat anemia is imperative. Adolescents should be treated until the anemia is resolved and often for an additional 6 months or longer if there is an underlying problem such as platelet function abnormality or von Willebrand disease.

4. Mittelschmerz

Mittelschmerz is midcycle discomfort resulting from ovulation. The cause of the pain is unknown but irritation of the peritoneum due to spillage of fluid from the ruptured follicular cyst at the time of ovulation has been suggested. The patient presents with a history of midcycle, unilateral dull or aching abdominal pain lasting a few minutes to as long as 8 hours. Rarely, the pain mimics that of acute appendicitis, torsion or rupture of an ovarian cyst, or ectopic pregnancy. The patient should be reassured and treated symptomatically.

5. Premenstrual Syndrome & Premenstrual Dysphoric Disorder

It is estimated that 51%–86% of adolescent women experience some premenstrual symptoms. Premenstrual syndrome (PMS) is a cluster of physical and psychological symptoms that occur during the luteal phase of the menstrual cycle and resolve with menstruation. Physical symptoms include bloating, breast tenderness, fatigue, headache, myalgia, increased appetite, and food craving. Premenstrual emotional symptoms may include fatigue, mood lability, anxiety, depression, irritability, hostility, sleep dysfunction, and impaired social function. PMS can be diagnosed when at least one disabling physical or psychological symptom is documented prospectively for at least two consecutive menstrual cycles, is restricted to the luteal phase of the menstrual cycle, resolves by the end of menses, results in functional impairment, and is not an exacerbation of another underlying disorder. Severe PMS with functional impairment affects 3%–5% of women of reproductive age and is classified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision as premenstrual dysphoric disorder (PMDD). The clinical diagnosis of PMDD requires five physical symptoms with at least one affective symptom occurring in the majority of cycles during the preceding year.

The pathophysiology of PMS is not well understood; however, there is some evidence of dysregulation of serotonergic activity and/or of GABAergic receptor functioning during the luteal phase of the menstrual cycle with heightened sensitivity to circulating progesterone metabolites. PMS and PMDD are highly associated with unipolar depressive disorder and anxiety disorders, such as obsessive-compulsive disorder, panic disorder, and generalized anxiety disorder. During adolescence, it may be difficult to determine if the affective symptoms represent a mood or anxiety disorder, a premenstrual exacerbation of a psychiatric disorder, or simple PMS.

Current treatment for PMS in adolescence is based on findings from adult studies and includes lifestyle recommendations and pharmacologic agents that suppress the rise and fall of ovarian steroids or augment serotonin. SSRIs are increasingly used as first-line therapy for PMS and PMDD in adults, and a recent Cochrane review of SSRIs in severe adult PMS determined that SSRIs administered continuously or during the luteal phase were effective in reducing premenstrual symptoms. Once a diagnosis is made, proven effective interventions including education about pathophysiology, lifestyle changes (eg, increasing physical activity and smoking cessation), stress reduction, cognitive behavioral therapy, and nutritional counseling to improve calcium intake and/or calcium supplementation should be attempted. If contraception or cycle control is important, a combined hormonal contraceptive pill may be beneficial. The pill containing 20 μg ethinyl estradiol and 3 mg drospirenone with a 24/4 formulation has been shown to be therapeutic in studies of adult women with PMDD. If these interventions do not adequately control symptoms, luteal phase or continuous administration of SSRIs can be considered. Case reports indicate that adolescents with PMDD respond well to luteal phase dosing of fluoxetine at the standard adult dosage of 20 mg/d. SSRIs are not formally approved by the FDA for treatment of PMS or PMDD in adolescents.

6. Ovarian Cysts

Functional cysts account for the majority of benign ovarian tumors in postpubertal adolescents and are a result of the normal process of ovulation. They may be asymptomatic or may cause menstrual irregularities or pelvic pain. Large cysts can cause constipation or urinary frequency. Follicular cysts are the most common functional cysts. They are usually unilateral, less than 3 cm in diameter, and resolve spontaneously in 1–2 months. Cyst pain occurs as the diameter of the cyst increases, stretching the overlying ovarian cortex and capsule. If the patient’s discomfort is tolerable, she can be reexamined monthly and observed for resolution. Hormonal contraceptive products that suppress ovulation can be started to prevent additional cysts from forming. Patients with cysts should be counseled about the signs and symptoms of ovarian and/or tubal torsion, which are serious complications. Adnexal torsion presents with the sudden onset of pain, nausea, and vomiting. Low-grade fever, leukocytosis, and the development of peritoneal signs with rebound and guarding can be found. Torsion is a surgical emergency due to the risk of ischemia and death of the ovary. Patients should be referred to a gynecologist for potential laparoscopy if the cyst has a solid component and measures more than 6 cm by ultrasonography, if there are symptoms or signs of hemorrhage or torsion, or if the cyst fails to regress within 2 months. Corpus luteum cysts occur less commonly and may be large, 5–10 cm in diameter. The patient may have associated amenorrhea, or as the cyst becomes atretic, heavy vaginal bleeding. There may be bleeding into the cyst or rupture with intraperitoneal hemorrhage. To determine whether the bleeding is self-limited, serial hematocrit measurements and ultrasounds can be used. If the patient is stable, hormonal contraception that suppresses ovulation can be started to prevent additional cyst formation and the patient may be monitored for 3 months for resolution. Laparoscopy may be indicated if the cyst is larger than 6 cm or if there is severe pain or hemorrhage.

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CONTRACEPTION

According to the CDC 2011 Youth Risk Behavior Survey, almost half of high school students (47%) reported having had sexual experience and 34% reported being currently sexually active. Sixty percent reported using a condom at their latest intercourse. Most young people have sex for the first time at about the age of 17, but do not marry until their middle or late twenties. This means that young adults are at risk of unwanted pregnancy and STIs for nearly a decade. A sexually active female who does not use contraceptives has almost a 90% chance of becoming pregnant within a year.

Abstinence & Decision Making

Talking with teenagers about sexual intercourse and its implications can help teens make informed decisions regarding engaging in sexual activity. The American Academy of Pediatrics endorses a comprehensive approach to sexuality education that incorporates encouraging abstinence while providing appropriate risk reduction counseling regarding sexual behaviors. Counseling should include discussions about STI prevention and contraceptive methods including emergency contraception (Table 4–15). Encouraging adolescents to use contraception when they do engage in sexual intercourse does not lead to higher rates of sexual activity. Adolescents often delay seeing a clinician for contraceptive services after initiating sexual activity. Concern about lack of confidentiality is an important reason for this delay.

 Methods Counseling

The goals of counseling adolescents about contraception include promoting safe and responsible sexual behavior through delaying the initiation of sexual activity, reinforcing consistent condom use for those who are sexually active, and discussing other contraceptive options to provide protection from unwanted pregnancy. Providers should familiarize themselves with their state policies regarding the ability of minors to consent for sexual and reproductive healthcare services. These data are accessible on the Internet from the Guttmacher Institute (http://www.guttmacher.org) and the Center for Adolescent Health and the Law (http://www.cahl.org).

Providers should consider the adolescent’s lifestyle, potential challenges to compliance, the patient’s need for confidentiality around the use of contraception, previous experiences with contraception and reasons for discontinuation, and any misconceptions regarding contraceptive options. Barriers to healthcare access including transportation and financial limitations should be identified. Prescribing contraception for other medical reasons (eg, management of dysmenorrhea) can create opportunities for providers and adolescent patients to make parents aware of the use of the medication while maintaining confidentiality around the sexual behaviors.

 Mechanism of Action

The primary mechanism of action for combined hormonal contraceptives containing estrogen and progestin (oral contraceptive pills [OCPs], transdermal patch, intravaginal ring) and the progestin-only methods (pills, DMPA, and the etonogestrel implant) is inhibition of ovulation. Thickening of the cervical mucus also makes sperm penetration more difficult, and atrophy of the endometrium diminishes the chance of implantation. (The mechanisms of action for intrauterine systems and devices are discussed later in this chapter in the section “Intrauterine Systems & Devices”.)

Starting all birth control methods during the menstrual period (either first day of bleeding or first Sunday of bleeding) produces the most reliable suppression of ovulation. Conventional OCPs, transdermal patches, and intravaginal rings typically require that the adolescent wait for her next period to begin before starting. Data show that many women who receive prescriptions or even samples of medication never begin the prescribed method. Furthermore, these women could become pregnant while waiting to start. “Quick start” is an alternative approach to starting contraception that allows the patient to begin contraception on the day of the appointment regardless of menstrual cycle day, following a negative pregnancy test. This approach has been studied in adolescent women and increases adherence with the method of choice. Unfortunately, these studies also highlight the generally poor long-term compliance with contraceptive treatment in this age group.

 Medical Considerations

Evaluation of an adolescent female requesting contraception should include a review of current and past medical conditions, current medications and allergies, menstrual history, confidential social history including sexual history, and family medical history. Important components of a sexual history include age at first intercourse, number of partners in lifetime, history of STIs and pelvic inflammatory disease (PID), condom use, current and past use of other contraceptives and reasons for discontinuation, and pregnancy history and outcomes. It is helpful to have a baseline weight, height, BMI, and blood pressure. A pelvic examination is not necessary before initiating contraception. However, if the woman is sexually active and has missed menstrual periods or has symptoms of pregnancy, a pregnancy test is warranted. Screening for STIs should be offered if a sexually experienced woman is asymptomatic and testing for STIs is indicated if she is symptomatic.

The World Health Organization’s publication, Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use is an evidence-based guide providing criteria for initiating and continuing contraceptive methods based on a risk assessment of an individual’s characteristics or known preexisting medical condition. Table 4–16 lists absolute (a condition which represents an unacceptable health risk if the contraceptive method is used) and relative (a condition where the theoretical or proven risks usually outweigh the advantages of using the method) contraindications to using combined hormonal birth control pills. These contraindications can be extended to other combined hormonal products that contain estrogen and progestins including the transdermal patch and intravaginal ring. The CDC has also published the US Medical Eligibility Criteria for Contraceptive Use which was adapted from the WHO publication and allows the consideration of use of combined hormonal contraceptive products for women who are currently receiving anticoagulation therapy.

Absolute contraindications

Pregnancy

Breast feeding (within 6 wk of childbirth)

Hypertension SBP > 160 mm Hg or DBP > 100 mm Hg

History of thrombophlebitis; current thromboembolic disorder, cerebrovascular disease, or ischemic heart disease

Known thrombogenic mutations (factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)

Systemic lupus erythematosus

Complicated valvular heart disease (with pulmonary hypertension; atrial fibrillation; history of bacterial endocarditis)

Diabetes with nephropathy; retinopathy; neuropathy

Liver disease: active viral hepatitis; severe cirrhosis; tumor (hepatocellular adenoma or hepatoma)

Breast cancer (current)

Migraine headaches with aura

Major surgery with prolonged immobilization

Relative contraindications

Postpartum (first 3 wk)

Breastfeeding (6 wk–6 mo following childbirth)

Hypertension (adequately controlled HTN; any history of HTN where BP cannot be evaluated; SBP 140–159 mm Hg or DPB 90–99 mm Hg)

Migraine headache without aura (for continuation of COC)

Breast cancer history with remission for 5 y

Active gallbladder disease or history of COC-induced cholestasis

Use of drugs that affect liver enzymes (rifampin, phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine, lamotrigine, ritonavir-boosted protease inhibitors)

BP, blood pressure; DBP, diastolic blood pressure; HTN, hypertension; SBP, systolic blood pressure.

It is important to assess patients for possible risk factors for venous thromboembolic events (VTE) prior to initiating any contraceptive product containing estrogen. The risk of VTE for reproductive-aged women is extremely low (4 per 100,000 women per year for nonpregnant women not using contraceptive product containing estrogen). The use of estrogen increases the risk of VTE for nonpregnant women (10–30 per 100,000 women per year); however, pregnancy itself markedly increases the risk of VTE (60 per 100,000 women per year). In light of the low population risk of VTE, it is not cost-effective to screen all reproductive-aged women for inherited thrombophilia (factor V Leiden, prothrombin mutation, protein S, protein C, and antithrombin deficiencies). Table 4–17 shows helpful screening questions for personal and family history of VTE. If a close relative had a VTE, determine whether testing for inherited thrombophilia was conducted. If a specific defect was identified, testing the patient for that defect prior to initiating a product containing estrogen is warranted. If testing is unknown but the family history is highly suggested of inherited thrombophilia, testing for all of the inherited thrombophilic disorders prior to initiating estrogen should be considered. Additionally, if testing is indicated but not possible, providers should consider alternative contraceptive products that do not contain estrogen.

 Tips for Prescribing & Monitoring Contraceptive Use

It is important to thoroughly review the advantages, disadvantages, potential side effects, and instructions for use of contraceptive methods in a concise and age-appropriate manner with adolescent patients. Written instructions that are clear and at an appropriate educational level can also be helpful (www.youngwomenshealth.org is a useful source for instructions). Some offices utilize consent forms to further ensure that the adolescent has a full understanding of the chosen contraceptive method. Teens need to be reminded that hormonal contraception will not protect them from STI transmission (including HIV infection) and condoms need to be used consistently. Encouraging teens to be creative about personal reminders such as setting a cell phone alarm to take a pill can help with compliance. Teens often discontinue birth control for nonmedical reasons or minor side effects and should be encouraged to contact their providers if any questions or concerns about the chosen method arise to avoid unintentional pregnancy. Frequent follow-up visits every few months with a provider may also improve adherence. These visits also provide opportunities for further reproductive health education and STI screening.

Barrier Methods

Male condoms have been used more widely in the last several decades as a result of educational and marketing efforts driven by the AIDS epidemic. All sexually active adolescents should be counseled to use condoms correctly and consistently with all intimate behaviors (oral, vaginal, and anal intercourse). Condoms offer protection against STIs by providing a mechanical barrier. Polyurethane condoms can be used by adolescents with an allergy to latex. Spermicides containing nonoxynol-9 are no longer recommended, as exposure to spermicide can cause genital irritation which may facilitate the acquisition of STIs including HIV. Patients should be counseled to use water-based lubricants with condoms.

Vaginal barrier methods include the female condom, diaphragm, and cervical cap. The female condom is a polyurethane vaginal pouch that can be used as an alternative to the male condom. Female condoms have lower efficacy in preventing pregnancy and STIs and are more expensive than male condoms. Diaphragms and cervical caps may not be feasible for adolescents as they require prescription, professional fitting, and skill with insertion.

Combined Hormonal Methods

 Oral Contraceptive Pills, Transdermal Patch, & Intravaginal Ring

Combined oral contraceptive pills (COCs) are the most commonly used contraceptive method in the adolescent age group. COCs are also utilized for noncontraceptive indications (Table 4–18). All COCs contain estrogen (ethinyl estradiol or EE). “Low-dose” COCs contain 20–35 mcg of ethinyl estradiol per pill. There are a variety of progestins used in COCs, most made from testosterone with differing androgenic profiles. Drospirenone is a newer progestin derived from spironolactone that possesses antiandrogenic and antimineralocorticoid activity. This formulation has appeal for use with patients who have PCOS but should not be prescribed for patients with risk of hyperkalemia (those who have renal, hepatic, or adrenal insufficiency or taking certain medications including angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists). Extended cycle regimens are available which allow women to decrease menstrual frequency from four menstrual cycles per year to formulations that provide hormonal pills daily for the whole year, eliminating menstrual periods altogether. New formulations with fewer placebo pills (4 vs the standard 7) decrease the duration of the menstrual period. There is also a chewable COC for those who cannot swallow pills.

Protection against life-threatening conditions

Ovarian cancer

Endometrial cancer

Pelvic inflammatory disease

Ectopic pregnancy

Morbidity and mortality due to unintended pregnancies

Alleviate conditions affecting quality of life

Iron-deficiency anemia

Benign breast disease

Dysmenorrhea

Irregular menstrual cycles

Functional ovarian cysts

Premenstrual syndrome

Acne

In general, contraceptive side effects are mild and improve or lessen during the first 3 months of use. Table 4–19 shows the more common estrogenic, progestogenic, and combined (estrogenic and progestogenic) effects of COCs. In general, these symptoms can also be extended to the other combined hormonal methods. If a patient taking contraceptive pills has persistent minor side effects for more than 3 months, a different type of COC can be tried to achieve the hormonal effects desired (eg, decreasing the estrogen content or changing progestin). Breakthrough bleeding is a common side effect in the first few months of COC use and generally resolves without intervention. If breakthrough bleeding is persistent, the provider should rule out other possible etiologies such as missed pills, pregnancy, infection, or interaction with other medications. For women who have spotting or bleeding before completing the active hormonal pills, increasing the progestin content will provide more endometrial support. For those with continued spotting or bleeding after the period, increasing the estrogen content will provide more endometrial support.

 Transdermal Patch

The transdermal patch, Ortho Evra, releases 20 mcg of ethinyl estradiol and 150 mcg of norelgestromin daily. One patch is worn for 7 days and changed weekly for 3 consecutive weeks. The patch is an attractive alternative to COCs for adolescents who have difficulty remembering to take a pill every day; however, the higher bioavailability of estrogens delivered transdermally (60% higher than with 35 mcg COCs) has raised concern that the patch might increase the risk of VTE over other estrogen-containing contraceptive products. Studies evaluating this risk have shown conflicting results. The FDA updated the safety labeling for Ortho Evra in September 2009 to include its interpretation of these studies showing a zero to twofold increase in the risk of thromboembolic events. The FDA maintains that Ortho Evra is a well-tolerated and effective contraceptive for women with low-risk profile for VTE. As with other estrogen-containing contraceptive products, patients should be advised to avoid smoking and consider planned discontinuation of these methods around major surgery and prolonged immobilization. In clinical trials, the most common side effects included breast disorders (pain and swelling), headache, nausea, and skin irritation. The patch may be less effective in women weighing more than 90 kg and those with skin conditions preventing absorption.

 Intravaginal Ring

The NuvaRing is a vaginal ring that releases 15 mcg of ethinyl estradiol and 120 mcg of etonogestrel per day. The patient places the ring inside the vagina for 3 weeks, and removes it the first day of the fourth week to allow for withdrawal bleeding. A new ring is inserted each month. In clinical trials, the most common side effects included vaginitis and vaginal discharge, headache, weight gain, and nausea.

Progestin-Only Methods

 Oral Contraceptive Pills

Progestin-only pills (POPs) do not contain estrogen. They are used in women with contraindications to estrogen-containing products such as the presence of inherited risk factors for thrombophilia or unacceptable estrogen-related side effects with COCs. The efficacy of POPs in preventing pregnancy is slightly less than COCs. They require strict compliance and regular dosing schedule due to the shorter half-life of the progestin. A patient must take POPs daily at the same time (within 3 hours). The primary mechanisms by which pregnancy is prevented includes thickening cervical mucous and thinning the endometrial lining. Ovulation is inhibited in approximately 50% of women. The main side effect of POPs is unpredictable menstrual patterns. The need for strict compliance and the possibility of breakthrough bleeding may make POPs a less desirable method for teens.

 Injectable Hormonal Contraception

Depot medroxyprogesterone acetate (DMPA), or DepoProvera, is a long-acting injectable progestin contraceptive. It is injected into the gluteal or deltoid muscle every 12 weeks at a dose of 150 mg. The first injection should be given during the first 5 days of the menstrual cycle to ensure immediate contraceptive protection. The quick-start method may also be used with DMPA following a negative pregnancy test. Adolescents who have been sexually active within the previous 2 weeks of administration of DMPA using the quick-start method should be informed of the chance of pregnancy and instructed to return for a repeat pregnancy test 2 weeks after receiving DMPA. With a failure rate of less than 0.3%, long-acting nature reducing compliance issues, reversibility, and lack of estrogen-related side effects, it is an attractive contraceptive option for many adolescents. The hypoestrogenic state that results from DMPA suppression of the hypothalamic-pituitary-ovarian axis reduces the normal effect of estrogen to inhibit bone resorption. The FDA issued a black box warning in 2004 that long-term (> 2 years) use of DMPA was a cause of decreased bone density. This factor is of particular concern as adolescence is the critical time of peak bone accretion. Current recommendations are that long-term use of DMPA should be limited to situations where other contraceptive methods are inadequate. Although DMPA use is associated with decreased bone density, there are studies showing that bone mineral density recovers after stopping DMPA. There are no studies to date that can answer the question of whether decreased bone density from adolescent DMPA use increases the risk of osteoporosis and fractures in adulthood. The consensus of experts in the field at this time is that the advantages of using DMPA generally outweigh the theoretical risks of fractures later in life. As with every other contraceptive method, providers need to help their patients weigh the pros and cons of initiating and continuing with this method of contraception. Adolescents using DMPA should be counseled to take adequate dietary calcium (1300 mg/d) and vitamin D (400 IU/d), to avoid tobacco smoking and to have regular weight-bearing physical activity for overall bone health. Other adverse effects of DMPA include unpredictable menstrual patterns, weight gain (typically 5 lb per year for the first 2 years of use), and mood changes.

 Contraceptive Implants

Adolescents most commonly use short-acting hormonal contraceptive methods described previously. Unfortunately, these methods have relatively high typical use failure rates (see Table 4–15) and low continuation rates. Higher failure rates combined with poor continuation rates decrease the efficacy of short-acting contraceptive methods in adolescents. Long acting reversible contraceptives (LARCs), which include contraceptive implants and intrauterine systems and devices, have lower rates of failure and discontinuation. In one study comparing 1-year continuation rates for short-acting contraceptives versus LARCs, the continuation rate for short-acting methods was 55% versus 86% for LARCs. The pregnancy rate associated with use of short-acting contraceptives was 22 times higher than the rate of unintended pregnancy associated with the use of LARCs. Adolescents should be encouraged to consider LARCs as the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion.

Implanon and Nexplanon are single-rod implant LARCs that contain the progestin etonogestrel, a metabolite of desogestrel. Nexplanon also contains barium sulfate which makes it radiopaque. Etonogestrel implants are placed subdermally and provide highly effective contraception for 3 years, with failure rates less than 1%. Implanon and Nexplanon suppress ovulation and thicken cervical mucous like DMPA, but do not suppress ovarian estradiol production or induce a hypoestrogenic state. The risk of decreased bone density is less than that associated with DMPA. Placement should occur during the first 5 days of the menstrual period or at any time if a woman is correctly using a different hormonal contraceptive method. Proper timing minimizes the likelihood that the implant is placed during an early pregnancy or in a nonpregnant woman too late to inhibit ovulation in the first cycle of use. Irregular menstrual bleeding is the single most common reason for stopping use in clinical trials. On average the volume of bleeding is similar to the woman’s typical menstrual periods but the schedule of bleeding is irregular and unpredictable. Other side effects include headache, weight gain, acne, breast pain, and emotional lability. Return to fertility is rapid following removal. Implanon and Nexplanon have not been tested in woman with a BMI greater than 130% ideal and could have decreased efficacy in these women. Etonogestrel implants are not recommended for women who chronically take medications that are potent hepatic enzyme inducers because etonogestrel levels may be substantially reduced in these women.

Intrauterine Systems & Devices

Intrauterine systems (IUS) and devices (IUD) are LARCs approved for use in nulliparous as well as parous teens and have high efficacy with failure rates < 1%. There are two forms of IUS that release the progestin levonorgestrel: Mirena, which releases 20 mcg of levonorgestrel per day and is approved for contraception for up to 5 years; and Skyla, which releases an average of 6 mcg per day and is approved for contraception for up to 3 years. The levonorgestrel IUSs have many contraceptive actions including thickening of cervical mucous, inhibiting sperm capacitation and survival, suppressing the endometrium, and suppression of ovulation in some women. Given that the contraceptive effect of levonorgestrel in the IUS devices is mainly due to its local effect versus systemic absorption, ovulation is not always suppressed and cysts related to normal ovulation can occur. Irregular bleeding is common in the first few months following insertion because endometrial suppression takes several months to evolve. Bleeding is then markedly decreased and secondary amenorrhea can occur. Other side effects include abdominal and/or pelvic pain, acne, ovarian cysts, and headache. In addition to pregnancy prevention, women with the IUS report reduced symptoms of dysmenorrhea and reduced pain from endometriosis. Cramping is common during insertion and spontaneous expulsion can occur. Uterine perforation during insertion is an uncommon risk.

The copper T 380A IUD, ParaGard, does not contain hormones and can provide contraception for up to 10 years. Its contraceptive actions include the release of copper ions which inhibit sperm migration and development of a sterile inflammatory reaction which is toxic to sperm and ova and prevents implantation. Menstrual pain and heavy bleeding are the most common reasons for discontinuation.

A common misconception about IUS and IUD use is that they increase the risk of PID. Current research shows that the risk of PID is increased above baseline only for the first 20 days after insertion. IUS and IUD have also not been shown to increase the risk of tubal infertility or ectopic pregnancy. Contraindications for placement of IUS/IUD include pregnancy, PID, or postabortion sepsis within the past 3 months, current STI, purulent cervicitis, undiagnosed abnormal vaginal bleeding, malignancy of the genital tract, uterine anomalies, or leiomyomata distorting the uterine cavity making insertion incompatible. Allergy to any component of the IUS/IUD is a contraindication. Patients with disorders of copper metabolism (Wilson disease) should not use the copper-containing IUD. Adolescents should be screened for STIs prior to insertion of an IUS or IUD.

Emergency Contraception

Emergency contraception (EC) is the only contraceptive method designed to prevent pregnancy after unprotected or underprotected intercourse (Table 4–20). Indications for EC include unprotected vaginal intercourse, failure of contraceptive methods (broken condoms, missing three or more active COC pills, detached contraceptive patch, removed vaginal ring, or late DMPA injection), and sexual assault. EC medications include products labeled and approved for use as EC by the FDA (levonorgestrel and ulipristal acetate) and the “off-label” use of COCs (the Yuzpe method).

Levonorgestrel EC, marketed as Plan B and Next Choice, consists of two pills containing 0.75 mg of levonorgestrel per pill. These products were originally prescribed with instructions to take one pill immediately after unprotected intercourse, followed by a second pill 12 hours later. Recent studies have shown that taking two pills simultaneously within 72 hours of unprotected intercourse has the same efficacy. Plan B One-Step is a one-pill regimen that contains 1.5 mg of levonorgestrel, taken immediately after unprotected intercourse. The exact mechanism of levonorgesterel EC is unknown but is thought to inhibit ovulation, disrupt follicular development, or interfere with the maturation of the corpus luteum. EC is not teratogenic and does not interrupt a pregnancy that has already implanted in the uterine lining. Therefore, pregnancy testing before use is not required. It is recommended that patients take these products within 72 hours of unprotected intercourse. EC has been studied up to 120 hours following unprotected intercourse; however, its efficacy diminishes with time from the event. EC is 90% effective if used within 24 hours, 75% effective if used within 72 hours, and approximately 60% effective if used within 120 hours. It is therefore important to counsel patients to take the medication as soon as possible following unprotected intercourse or contraception failure. EC could potentially prevent approximately 80% of unintended pregnancies and should be part of anticipatory guidance given to sexually active adolescents of both genders. Although these products have been available over the counter in recent years only for patients older than age 17 years (prompting consideration of advanced prescriptions for sexually active adolescents younger than age 17 years), regulations regarding the lower age limit for over-the-counter availability are in flux. A follow-up appointment should be conducted in 10–14 days after administration of EC for pregnancy testing, STI screening, and counseling regarding reproductive health and contraceptive use.

If an approved EC medication is not available, certain COCs containing levonorgestrel or norgestrel can also be used for EC in a two-dose regimen separated by 12 hours; this approach is known as the Yuzpe method (see Table 4–20). An antiemetic drug takes 30 minutes prior to pills containing estrogen may help control nausea. A pregnancy test is not required prior to prescription and administration of EC.

Ulipristal, marketed as ella, is a single pill containing 30 mg of ulipristal acetate that is available by prescription only and can be used within 120 hours after unprotected intercourse. Ulipristal binds to the human progesterone receptor and prevents binding of progesterone. Unlike levonorgestrel EC, a pregnancy test must be performed to exclude existing pregnancy before taking ulipristal because of the risk of fetal loss if used in the first trimester. Patients should also be counseled that a pregnancy test is indicated if their period is more than 7 days later than expected after taking ulipristal. Patients should be instructed to return for evaluation of the rare occurrence of ectopic pregnancy if severe abdominal pain occurs 3–5 weeks after use.

Providers should also be aware that insertion of ParaGard (copper IUD) within 5 days of unprotected intercourse is an additional method of emergency contraception available in the United States.

American College of Obstetricians and Gynecologists: Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group: ACOG Committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2012;120(4):983–988 [PMID: 22996129].

Committee on Adolescence: Contraception and adolescents. Pediatr 2007;120(5):1135–1148 [PMID: 17974753].

Committee on Adolescence: Emergency contraception. Pediatr 2012;130(6):1174–1182 [PMID: 23184108].

Duffy K, Gould MA: Adolescents and emergency contraception: update 2011. Curr opin Obstet Gynecol 2011;23(5):328–333 [PMID: 21836502].

Eaton DK et al: Centers for Disease Control and Prevention (CDC): youth risk behavior surveillance—United States, 2011. MMWR Surveill Summ 2012;61(4):1–166 [PMID: 22673000]. http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf.

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Martinez G, Copen CE, Abma JC: Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2006–2010. National Survey of Family Growth. National Center for Health Statistics. National Vital Health Stat 2011;23(31):1–44 [PMID: 22256688].

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In the United States, approximately 750,000 adolescents younger than age 19 become pregnant every year. The majority of teen pregnancies are unintended. Fifty-nine percent of adolescent pregnancies result in live births; 27% end in abortion; and 14% in miscarriage. The United States has the highest rate of teen pregnancy in the developed world. Pregnancy rates for female Hispanic and non-Hispanic black adolescents aged 15–19 years are much higher (107 and 117 per 1000, respectively) than their non-Hispanic white peers (43 per 1000). Lower socioeconomic status and lower maternal education are risk factors for teen pregnancy regardless of racial or ethnic group. The birth rate for adolescents in 2011—39.1 births per 1000 females aged 15–19 years—was the lowest it has ever been for all racial and ethnic groups since the historic high reached in 1957 (96.3).

Presentation

Pregnancy is the most common cause of secondary amenorrhea and should be considered as a cause of even one missed period. The level of denial about the possibility of pregnancy is high and adolescents with undiagnosed pregnancies may present with abdominal pain, nausea or vomiting, breast tenderness, urinary frequency, dizziness, or other nonspecific symptoms. In addition to denial, difficult social situations can delay diagnosis and contribute to delay in seeking prenatal care. Young newly pregnant adolescents may fear violence from their partner or abandonment by their family. Clinicians should have a low threshold for suspecting pregnancy and obtaining pregnancy tests.

Diagnosis

Pregnancies are dated from the first day of the LMP. The estimated due date can be calculated by adding 7 days to the LMP, subtracting 3 months and adding 1 year. Pregnancy dating calendars are widely available on the Internet. A speculum examination is not mandatory at the time of pregnancy diagnosis for an asymptomatic adolescent. If there is vaginal spotting or bleeding, unusual vaginal discharge, symptoms of STI, pelvic pain, or abdominal pain, a speculum examination is required. The differential diagnostic possibilities include infection, miscarriage, ectopic pregnancy, and other disorders of early pregnancy. An 8-week gestational age uterus is about the size of an orange and a 12-week uterus is about the size of a grapefruit on bimanual examination. The uterine fundus is just palpable at the symphysis pubis at 12 weeks’ gestational age, midway between the symphysis and umbilicus at 16 weeks and typically at the umbilicus at 20 weeks. If the uterus is smaller than expected for pregnancy dates, possible diagnoses include inaccurate dates, false-positive test, ectopic pregnancy, or incomplete or missed abortion. A uterus that is larger than expected may be caused by inaccurate dates, twin gestation, molar pregnancy, or a corpus luteum cyst of pregnancy. Enzyme-linked immunosorbent assay test kits specific for the β-hCG subunit and sensitive to less than 50 mIU/mL of serum hCG can be performed on urine (preferably the day’s first voided specimen, because it is more concentrated) in less than 5 minutes and are accurate by the expected date of the missed period in almost all patients. Serum radioimmunoassay, also specific for the β-hCG subunit, is accurate within 7 days after fertilization and is helpful in ruling out ectopic pregnancy or threatened abortion. Serum hCG doubles approximately every 2 days in the first 6–7 weeks of the pregnancy and a gestational sac is identifiable using transvaginal ultrasonography at hCG levels of 1000–2000 mIU/mL. In the absence of an accurate LMP, ultrasonography for confirmation of the presence of an intrauterine pregnancy and accurate dating can be obtained.

Management

A. Counseling at the Time of Pregnancy Testing

When an adolescent presents for pregnancy testing, it is helpful, before performing the test, to find out what she hopes the result will be and what she thinks she will do if the test is positive. The diagnosis of pregnancy may be met with shock, fear, anxiety, happiness, or most likely a combination of emotions. The clinician must discuss all pregnancy options with the patient including termination or continuing with the pregnancy and either placing the infant for adoption or raising the infant. Patients should be informed of the gestational age and time frames required for the different options. If providers are not comfortable discussing the option of termination, the adolescent should be referred to a provider who is comfortable with comprehensive options counseling. Many teenagers need help in telling and involving their parents. It is also important to ascertain the teen’s safety and make appropriate referral to social services if there are legitimate concerns. If the patient knows what she wants to do, she should be referred to the appropriate resources. If a teenager is ambivalent about her plans, it is helpful to follow up in 1 week to be certain that a decision has been made. Avoiding a decision reduces the adolescent’s options and may result in poor pregnancy outcomes. Providers can help ensure that the patient obtains prenatal care if she has chosen to continue the pregnancy. In addition, counseling about healthful diet; folic acid supplementation (400 mcg/d); and avoiding alcohol, tobacco, and other drugs is important.

B. Pregnancy Outcomes

Young maternal age, low maternal prepregnancy weight, poor weight gain, delay in prenatal care, maternal depression, exposure to domestic violence, and low socioeconomic status contribute to low birth weight and increased neonatal mortality. The poor nutritional status of some teenagers, substance abuse, and high incidence of STIs also play a role in poor outcomes. Teenagers are at greater risk than adults for preeclampsia, eclampsia, iron-deficiency anemia, cephalopelvic disproportion, prolonged labor, premature labor, and maternal death.

Good family support, early prenatal care, and good nutrition can make a difference with several of these problems. The psychosocial consequences for the teenage mother and her infant are listed in Table 4–21. Teenagers who are pregnant require additional support from their caregivers. Multidisciplinary clinics for young mothers, if available, may be the best providers for pregnant adolescents. Adolescent mothers tend to be more negative and authoritative when disciplining their children. They may have inadequate knowledge of normal behavior and development. Providers can help by educating the adolescent mother during routine visits regarding appropriate discipline and expectations of her child’s behavior.

Postpartum contraceptive counseling and follow-up may help prevent additional pregnancies. In untreated girls, the risk of a second unintended pregnancy within the next 2 years is approximately 30%. Combined hormonal contraceptive options can be started 6 weeks after delivery in non–breastfeeding adolescents; progestin-only methods can be started immediately postpartum, even in breast-feeding adolescents.

Ectopic Pregnancy

In the United States, approximately 1%–2% of pregnancies are ectopic. Adolescents have the highest mortality rate from ectopic pregnancy, most likely related to delayed diagnosis. Risk factors include history of PID or STIs. Repeat infections with Chlamydia increase risk for ectopic pregnancy, as does cigarette smoking. Conception while on progestin-only methods of contraception also increases the risk of ectopic pregnancy, because of the progestin-mediated decrease in tubal motility. The classic presentation is missed menstrual period, abdominal pain, and vaginal bleeding. A urine pregnancy test is usually positive by the time of presentation. The patient may have abdominal or pelvic tenderness, adnexal tenderness, and/or an adnexal mass on examination. The uterus is typically either normal sized or slightly enlarged. Diagnosis is based on serial serum quantitative hCG levels and transvaginal ultrasound. Patients should be referred urgently to an obstetrician gynecologist for management to avoid a ruptured ectopic pregnancy which is a surgical emergency. These patients often present in shock with an acute surgical abdomen.

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