Adolescent Medicine

1 Adolescent Medicine  Jane Peterson, M.D.
2  Adolescent Growth and Development

Physiology of Pubescence

Pubescence results from the decreased sensitivity of the axis to

negative feedback

GnRH stimulates production of LH and FSH, which stimulates the

ovaries and testes to make estrogen and testosterone

Bone age (skeletal maturity) may be disparate by as much as two

years from chronological age and still be normal

Pubescence is a dynamic process that can take 2.5 to 5 years to

complete

Individuals who begin growth spurt early are initially taller than peers,

but they will ultimately be relatively shorter than those who begin

their growth spurt later

Pubescence is a dynamic process that takes two and a half to five years

to complete. The word pubescence is used, instead of puberty, because

pubescence implies that it is an extended process. Puberty is a process.

Also, remember that individuals may start the growth spurt early. Two

young men, fourteen years of age, they have different growth patterns.

And the implications of that are terrific among the adolescents them

selves. The nice thing that we can do for smaller adolescent, is that we

can assure him that when he comes back for the 10 year reunion, that

he is probably going to be taller than the guy that started developing

early.



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Physical Development

The first sign of pubescence in males in usually testicular enlargement

(normal age of onset is 11.5 years with a range of 9-14 years)

The first sign of pubescence in females is usually breast bud formation

(normal age of onset has a range of 8-14 years)

As far as physical development, the first sign of pubescence in males is

usually testicular enlargement. It usually starts around 11½ years of age.

The first sign of pubescence in females is breast bud development with

the usual onset is somewhere between eight and 14 years of age.



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Secondary Sexual Characteristics

Males - testicular growth, pubarche, penile growth, peak height velocity

Females - breast budding, pubarche, peak height velocity, menarche

Menarche usually occurs around 2 years after thelarche (usually SMR 4)

The height of girls will rarely increase more than two inches after menar-

che

Another important concept from the growth and development standpoint

is the sequence of secondary sexual characteristics. In males, that

sequence is the following: testicular growth, pubarche, penile growth,

and finally peak height velocity. From the graph over here, you can see

that for females, peak height velocity occurs much earlier, about two

years earlier than males. Remember too, that menarche usually occurs

around two years after thelarche, or the onset of breast bud develop-

ment, and it usually is a sexual maturity rating of 4 for females. Girls

height rarely increases more than a couple of inches after menarche.



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Tanner Staging of Breasts

Stage 1 - no palpable glands

Stage 2 - breast bud develops directly below areola

Stage 3 - gland is larger than areola

Stage 4 - "mound on mound" configuration with glands in areolar region

elevated separately from the other glands

Stage 5 - mature breast with flat areola

Tanner staging. This is the breast staging with stage 1, the top two

pictures, lateral and AP being Tanner stage 1, which is really just child

like. No palpable glands. Tanner stage 2 with a breast lump right under

the breast bud directly below the areola. Tanner stage 3 being when the

breast extends beyond the areola and is palpable beyond the areola.

Stage 4 is when we get the typical mound on mound configuration. The

first mound is actually the gland of the breast itself and the second

mound is where the areola and the nipple form one complex that be-

comes the second mound on top of the first mound. And finally, stage 5,

or the mature breast of the female where the puffiness of the areola

goes away and the areola becomes contiguous with the skin of the rest

of the breast with a protuberant nipple.



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Gynecomastia

Gynecomastia occurs very commonly in pubertal males.

Pubertal gynecomastia can be asymmetric and not indicate pathology.

Gynecomastia can cause a change in dressing habits and physical

activity.

Usually resolves in 1 to 2 years, and it rarely needs plastic surgery for

correction.

Another common finding in most of your practices and certainly in the

adolescent medicine world is that we see a lot of gynecomastia in

males. It is very common. Some estimates say that at least 25% of

males have gynecomastia to some extent or another. And certainly it

can also be represented in the female population as simple breast

asymmetry and there will be a huge disparity between one breast and

the other, which from a psychological standpoint can be traumatizing to

the adolescent female. We may need to refer those girls either for

reduction or augmentation of one of the breasts.

Gynecomastia in males can certainly change a lot of habits, including

whether they decide to dress a certain way. One of the common things

is that the guy wears a very tight T-shirt with lots of layers over to totally

disguise the prominence of the breast. The other thing we hear is that

physical activity changes. That they stop going swimming. If the P.E. at

school requires that they take a shower with everybody, they avoid P.E.

at all costs. Go to the showers as everyone else is getting dressed

which makes them late to class and therefore they're constantly tardy.

Gynecomastia in males will resolve within a year or two. Most of the time

you don't need to do anything but give a little reassurance. Rarely, we

will send someone over for plastic surgery. When they are Tanner stage

4 or sexual maturity rating of 4 and preferably even 5, but it depends

again upon how psychologically traumatizing the gynecomastia has

been.



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Stages of Pubic Hair Development

Stage 1 - no hair

Stage 2 - few straight hairs around base of penis or on labia majoris

Stage 3 - dense hair in circumscribed limits

Stage 4 - dense, curly hair in mons pubis area out to thighs

Stage 5 - hair extending laterally onto thighs or upwards toward umbili-

cus

Pubic area. Prepubertal or stage 1 is basically no hair. These are two

pictures of stage 2. I think if you look closely you can see a little bit of

hair here and a little more here. Stage 3 is when the dense hair is in very

circumscribed limits and moving on to 4, where basically the mons area

is filled out with dense, curly hair, and then 5 where the hair extends

onto the thighs or upwards toward the umbilicus.



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Stages of Testicular Development

Stage 1 - prepubescent, child-like, < 4 mL volume

Stage 2 - enlargement, usually first sign of pubescence, 4 to 6 mL

volume

Stage 3 - proliferation of seminiferous tubules, 8 to 10 mL volume

Stage 4 - 10 to 15 mL volume

Stage 5 - 15 to 25 mL volume

Testicles Development. Stage 1 is prepubescent or childlike, very small

volume in testicles. Stage 2 is where the testicles begin to enlarge and 3

a little larger, Tanner 4 a little larger and Tanner 5 a typical adult male.

The other thing I would like to point out on this slide is that it is an

uncircumcised adult male.



9

Psychosocial Development

Characteristics of Adolescent Psychosocial Development

Emancipation from parents and adults

Self identity based in reality

Psychosexual differentiation

Intellectual development with economic independence

Now for teenagers, many of us in the field say that it is basically like

going through the "terrible twos but this time around it is too tall , too

fat , too short , too little", too smart, too dumb". Whatever. But there

are jobs that are really expected to occur during adolescence and this is

how you know that you've arrived", so to speak, as an adult. Adoles

cence need to emancipate or to break off from parents and adults.

They try desperately to look different from adults. Hence, all of the

tattooing and piercing and shades of hair and braiding - they try to look

different. Psychosexual differentiation also occurs. Becoming a loving,

caring person responsible in a relationship, the intellectual development

also occurs, understanding the need to go out and support yourself and

get a job.

The family goes through struggles, too. It is the job of a pediatrician to

evaluate how that family is handling this process and many families

don't handle it very well.



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Psychosocial Stages

Rapid body changes affect self esteem.

Evaluation of family dynamics requires one to look for sources of stress

and also predominant modes of coping with stress.

Family influence influences early modeling health behaviors, such as

smoking, drinking, conflict resolution and violence.

Psychosocial stages of adolescence are divided into early, middle and

late. With early adolescence usually it is 11, 12, 13 and it goes up to 14

or 15 years of age. Certainly, adolescents that are in the early phases

are preoccupied with their body image. These are the guys that every

time they go by the mirror they stop and look or they have a comb in

their back pocket and just have to pause a little bit to make sure every

hair is in the right place. There are minor parental conflicts and rebellion

that commonly occurs. The peers are usually same sex and age. Peer

acceptance is what s paramount. The parent and the family are replaced

by the peer group as the most influential group in what they do. That

peer education or peer mentoring can work because of these principles.

Early adolescents are very concrete thinkers- they take thing literally.



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Characteristics of Early Adolescence

11-13 through 14-15 years of age

Preoccupation with body changes in search for identity

Minor parental conflicts and rebellion common

Peers are usually same sex and age, peer acceptance paramount

Concrete cognition

Beginning to seek independence

Limited dating

Limited ability to imagine the consequences of risky behavior

Limited ability to link cause and effect in regard to health behavior (eg,

smoking, reckless driving, overeating)

Attachment to non-parental adults is common

Early adolescents are beginning to seek independence. Therefore, you

frequently see them alone and in their rooms trying to block out the rest

of the world, particularly parents and what you are trying to tell them.

Very limited dating occurs. It is usually the pack or the group mentality

where there are several guys and several girls and they may pair up, or

go over and say, Did you know that Sally likes you and she'd really like

to hold your hand and go out with you?"

There is this limited ability to imagine the consequences of risky behav

ior. If they haven't experienced it, since they are concrete thinkers, they

can't carry through on prevention. Because as a concrete thinker, you

have to have done it before you can really process it. There is also a

limited ability to link the cause and effect in regard to health behaviors.

We can tell them that smoking is bad for them, but if you want to be cool

and you want to fit the image, then the image wins out.

What also happens here is that oftentimes the parent role is replaced by

another caring adult, and this should not be downplayed in the commu

nities.



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Characteristics of Middle Adolescence

14-15 through 16-17 years of age

Peer group remains very important for social and behavioral norms

Dating a major activity

Conflicts with parents, emancipation issues become dominant themes

Beginning of abstract cognition

Feelings of omnipotence and invincibility

Pubescence almost complete

Risk-taking behaviors, rebellion, and impulsiveness are necessary as

part of achieving independence

Rejection of authority and risk-taking tendencies may include rejection of

medical advice and treatment previously accepted

Middle adolescence is really when peer pressure mounts up. They really

look to the peers for the social norm. This is paramount in this group.

Dating becomes a major activity. Conflicts with parents and emancipa-

tion issues.

There is also the beginning of abstract thinking during middle adoles

cence. There are also feelings of omnipotence and invincibility. This is

what drives them to do the weird things they do. Driving 120 miles per

hour down the road, popping pills. They have to feel like they can take

on the world because that is what we are asking them to do. Leave the

home, go establish yourself somewhere else, find a job, support yourself

and raise a family.

Pubescence is almost complete now. There are lots of risk taking

behaviors which sometimes are a little more severe than others. There

is also a rejection of authority. This may take on that they used to listen

to your medical advice and they've had asthma for years and now they

are beginning to reject that authority also.



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Late Adolescence

17-21 years of age (or older)

Emancipation complete, parent-child relationship is adult to adult

Peer group superseded by strong individual relationships

Intimacy with commitment rather than exploration

Planning for the future

Self-identity established

Understands consequences of actions and risk-taking behavior

Consistent abstract thinker

Age does not equate to stage

Finally they start becoming human again and move into late adoles

cence which is 17-21 years of age, where they really do have that

emancipation complete. The parent-child relationship goes back to more

of an adult to adult kind of thing. The peer group is superseded by the

need for strong individual relationships and there is intimacy with com

mitment rather than exploration. There is lots of planning for the future.

The self identity is established. They understand the consequences and

at this point are pretty consistent abstract thinkers.



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Chronic Illness or Disease in Adolescents

Consequences of Chronic Illness or Disease

May cause pubertal delay

May cause decreased self-esteem or depression

Efforts to be "normal" may be detrimental to therapy

Social isolation

Emancipation from parents becomes more difficult

Certainly, chronic disease and illness gets in the way of adolescent

growth and development. When they have chronic diseases, it can

interrupt not only the physical stuff, but certainly can cause the social

isolation that occurs and causes a real problem for emancipation.



15

Compliance Issues in Adolescence

Barriers to Compliance

time and financial costs

inconvenience

pain

embarrassment or the acknowledgment of personal vulnerability

Most difficult part of achieving compliance may be to change estab-

lished behaviors (eg, stop smoking, reduce fat intake, exercise).

Psychosocial screening tool, HEADS. It takes just a few minutes to get

an enormous amount of information from the adolescent about the home

environment, the education environment, all the different things. Like E

is originally for "education". A is for "activities , finding out what they do

in their spare time and particularly what their friends do. What is going

on in the drug, alcohol, tobacco world with them, and finally sexuality

and what is going on with that. So, remember HEADS. And it describes

and guides you with certain questions you can use in your practice to try

to get that done.



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Methods of Improving Compliance

Allow the adolescent to help formulate treatment plan

Make the regimen simple and inconspicuous

Choose the battles that are important and ignoring the insignificant

problems

Use motivation and positive consequences, not fear or negative conse-

quences

Encourage praise and acceptance by family



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Clinical Assessment of Psychosocial Functional

Status

Home Situation

Who lives with the patient?

What are relationships like at home?

What do caretakers do for a living?

Recent changes in the family?

Divorce or separation?



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Education, employment, eating

School/grade performance?

Favorite subjects?

Career aspirations?

Employment history?

Weight and diet history?



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Activities, affect

Activities with peers?

Interests?

Abuse/rape/acquaintance rape?

Extracurricular activities?

Use of automobile/seatbelts?

Sleep problems?

Feeling sad, crying for no reason?

History of suicidal thoughts?



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Drugs

Use of substances by peers?

Use of substances by family?

Alcohol - frequency, amount?

Tobacco - frequency, amount?



21

Sexuality

History of sexual behaviors, frequency, number and sex of partners?

History of pregnancy/abortion?

Sexually transmitted diseases?

Contraception - attitudes, use?



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Behavioral Health Issues

Leading cause of death among adolescents is motor vehicle accidents,

followed by firearm deaths.

Adolescents feel a tremendous amount of stress and pressure which

may come from school (expectations or teachers), peers, relationships,

parents, siblings or others.



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Delinquency

Risks for adolescent delinquency include poverty, parental addiction and

psychiatric disorders and school failure.

Most common medical problems of incarcerated youth include trauma,

affective disorders, substance use and acute primary care problems.



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Consent and Confidentiality

Minors can give consent for medical treatment under the following legal

circumstances:

After they are married

After they have become a parent

Military service

Living on one's own

Supporting one's self

A minor is allowed to seek diagnosis and treatment for the following

conditions without parental consent:

Sexually transmitted diseases

Pregnancy

Contraception

Substance abuse

Consent and confidentiality is usually defined by a state's definition.

Nationally there is a Supreme Court decision that takes priority over

state law that grants us the privilege to give teenagers contraception.

Many states describe those circumstances in detail where minors can

consent for medical treatment without parental consent, and this often

involve things like marriage, parenthood, military service, living on your

own and supporting yourself. Another one that is not listed is legal

emancipation by court. Usually adolescents are given the ability to seek

diagnosis and treatment for sexually transmitted diseases, pregnancy,

contraception and substance abuse by state statutes.



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Eating Disorders

Classic anorexia nervosa characteristics

Majority of patients are female

These patients are usually very neat and particular about grooming

and dress

They are very careful that their rooms are extremely tidy

They usually display good academic performance, and they may

rewrite homework until perceived to be perfectly done

Enmeshment of the family is common

Parents are usually overprotective, and involvement of the child in

parental conflict is common

Patients may be controlling and manipulative

Concrete operational thought processes are typical

Anorexia nervosa is common among gymnasts and dancers

Vomiting is unusual. The main focus of their attention is restriction

Eating disorders. First is the classic anorexia nervosa. Females are

constantly bombarded with the message that this is what you are ex

pected to look like. Certainly just looking at pictures of pretty girls

doesn't make you become anorexic. There are lots of complexities.

Complexities with the family, with yourself, with your self image, control,

manipulation, etc.



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Anorexia Nervosa -- DSM IV Criteria

Refusal to maintain body weight at or above a minimally normal weight

for age and height (e.g., maintenance of body weight <85% of that

expected)

Intense fear of gaining weight or becoming fat, even though underweight

Disturbance in the way which one's body weight or shape is experi-

enced, undue influence of body weight or shape on self-evaluation or

denial of the seriousness of the current low body weight

Amenorrhea (absence of at least three consecutive menstrual cycles or

requirement of hormone therapy after three missed cycles)

The girls who do have anorexia nervosa are usually very neat and

particular about their dress. Everything around them is in order. They

have neat and tidy rooms for instance and usually are very good stu-

dents. Actually, most of them are straight A students. They repeat their

homework assignments for instance until things are absolutely perfect. If

there is a smudge on the paper, they will rewrite the paper so it is

perfect. Over and over. Obsessive-compulsive disorders are sometimes

a co-morbid diagnosis that is given to the anorectic patient. It is also a

fair amount of enmeshment of the family. Once those kinds of things

start coming out, you can see how difficult it is to be an individual and to

have that normal developmental milestone of separation that is sup-

posed to occur.



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Differential Diagnosis of Anorexia Nervosa

Gastrointestinal Disorders

Crohn's disease

Ulcerative colitis

Pancreatitis

Malabsorption syndromes

Achalasia

Neurologic Disorders

CNS tumor or lesion, especially midline

Seizure disorder

Psychiatric Disorders

Schizophrenia

Paranoid disorders

Affective disorders

Obsessive-compulsive disorder

Endocrine Disorders

Diabetes mellitus or insipidus

Hypo- or hyperthyroidism

Addison syndrome

Gonadal dysfunction

Pregnancy

Panhypopituitarism

We also see sometimes overprotective parents and, in particular,

involvement in parental conflict by the anorectic patient themselves.

These patients are extremely controlling and manipulative. Often times

the staff is pitted against each other, and pretty soon people are begin-

ning to get unhappy with each other on the team and saying, You told

her that blah, blah, blah and you told her she didn't have to have two

bites of food. What is driving all that is that they are accomplishing what

they want to and that is to create chaos and confusion which then puts

them more and more in control. These patients also usually have con-

crete operational thought processes. They are very commonly involved

in certain sports, gymnasts or dancers. In the anorectic patient, vomit

ing is unusual. These are the restricters. They just don't eat. Exercise is

a major portion of the disease.

The patients also get very secretive and controlling about their food

intake to the point that one of the patients what we were caring for was

hiding her food in the suspended ceiling in her room.

DSM IV criteria. It is basically a refusal to maintain body weight at least

less than 85% of expected body weight or ideal body weight. There is

also an intense fear of gaining weight or becoming fat even though they

are very thin. This is truly inner self and deep inner sole kind of intense

fear that if they eat those three or four peas on the plate, they are just

going to blossom into this obese person. Males who only comprise

about 5-10% of the anorectic population, males don't see as much as

this kind of media presentation about the male body that the females do.

There definitely is, with the DSM IV criteria, a disturbance in the way that

they look at their body and the shape. There have been lots of study of

the perception of the body image by the anorectic and it is always much

bigger than the actual body is. In one picture, that is just a severely

emaciated patient, they still feel like they are just grossly obese and will

continue to get bigger. Also, in menstruating females if amenorrhea is

present, which is defined as an absence of three cycles in a row and

that also includes if they must receive hormonal therapy in order to have

periods. That counts as amenorrhea.

Certainly with anorexia, before the diagnosis sticks, we need to make

sure there's not something else causing this patient to be very thin.

There are lots and lots of things we have to exclude before we treat

them with strictly a psychiatric approach.

Certainly gastrointestinal problems including Crohn's are things that we

have seen at our center. Under the neurologic category, we have to look

for CNS tumors and about every four to five years in our center we again

have someone referred in for evaluation of an eating disorder that ends

up with a brain tumor that has caused her problems to begin with,

especially the midline tumors. Other brain abnormalities which may

present as a seizure disorder include vasculitis and other autoimmune

disorders. Psychiatric disorders, including schizophrenia and especially

affective disorders with severe depression may cause lack of appetite..



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Treatment of Anorexia Nervosa

Rapid diagnosis and aggressive treatment of both psychiatric and

medical symptomatology

Initial phase concentrates on restoration of physiologic and psychologi-

cal functioning

Long-term phase focuses on change of individual and family pathology

and maintenance of healthy eating behavior

Endocrine differential diagnosis, thyroid problems with exophthalmos

and the fullness. But again I am just trying to make the point certainly

don't just jump on it that every 14-year-old that shows up in your practice

that wants to lose weight and watches all of her fat grams, has anorexia

if she is a little too thin. Keep looking for new diagnoses even in the

treatment of anorexia nervosa patients, because there can exist other

co-morbid physical diagnoses also.

Anorexia treatment principles. The first thing that we have to do is to

attack them basically from the psychiatric and a medical aspect. The

team usually consists of a medical person, a psychiatric person or

psychologist, a nutritionist, specialized nurses and certainly family

therapy is vital to the success of the treatment. In the initial phase, we

have to work on the life threatening kinds of things and work on the

physiologic and psychological emergencies, to get the patient function-

ing to the highest degree that you can. The long term phase is what is

really the tough part. That is where we try to get the family as well as the

patient functioning to the best of their ability and to maintain that healthy

lifestyle or healthy attitude towards eating behaviors and to address the

communication issues in the dysfunctional situations in other ways

besides controlling food.



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Indications for Hospitalization

Severe malnutrition, with weight <75% of ideal body weight

Acute medical complications

Dehydration and electrolyte imbalances

ECG abnormalities

Acute psychiatric emergencies

Failure of outpatient treatment

Comorbid diagnosis that interferes with therapy



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Characteristics of Bulimia Nervosa

These patients are usually of normal weight

Food consumption is often described as an addiction

Binge eating is not a response to hunger

Binge eating may occur in groups or cliques

Binge eating may be related to anxiety caused by a stressor

The disorder is often complicated by depression, feelings of inadequacy,

lack of control and strained relationship with parents

Preoccupation with control over eating is common

Mood swings are frequent

Half of patients have a relative who is alcoholic

Beware of substance abuse in these patients

Bulimia. These girls are often normal weight or even perhaps a little

overweight that have the same kind of control issues of food consump-

tion or food eating behavior described almost like an addiction. Binge

eating is definitely not a response to hunger. It may occur in groups or

cliques. It seems to be bimodal as far as age distribution, with young

middle school students and then again freshmen in college. It is proba-

bly related to anxiety. The transition from one peer group to another,

with the change from middle school to high school, and high school to

college, may contribute. Often depression is present and lots of feelings

of inadequacy and low self-esteem. Lack of control and very strained

relationships.

With bulimic patients, I think that we also need to look out for substance

abuse. Over half of the patients have an alcoholic somewhere in their

family. Substance abuse is also very common among the bulimic

patients, so this may complicate the treatment. Once you get the bulimia

under control, you may still have chronic substance abuse that contin-

ues for years and years to come unless it is arrested from the beginning.



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DSM IV Criteria for Bulimia Nervosa

Recurrent episodes of binge eating. An episode of binge eating is

characterized by both of the following:

eating, in a discrete period of time (e.g. within any 2 hr period), an

amount of food that is definitely larger than most people would eat

during a similar period of time and under similar circumstances

a sense of lack of control over eating during the episode (e.g. a

feeling that one cannot stop eating or control what or how much one

is eating)

Recurrent inappropriate compensatory behavior in order to prevent

weight gain such as: self-induced vomiting; misuse of laxative, diuretics,

enemas or other medications; fasting; or excessive exercise

The binge eating and inappropriate compensatory behaviors both occur,

on average, at least twice a week for three months

Self evaluation is unduly influenced hy body shape and weight

The disturbance does not occur exclusively during episodes of Anorexia

Nervosa

DSM IV criteria basically is recurrent binge eating. It is characterized by

eating, in a discrete period of time, more than the usual person would

eat. They eat two gallons of ice cream, an entire large bag of potato

chips within an hour and a half and then purge and binge in another hour

or two. Again, not a response to hunger. They also describe it as out of

control behavior. That they can't stop the eating. They just go on and on.

There is this recurrent inappropriate behavior to keep from gaining

weight which may include diuretics, laxatives, purging, extreme fasting,

lots of exercise. The binge eating has to occur twice a week for three

months to really meet the DSM criteria. The bulimic patients, again

mostly girls, also have this really undue response to their body shape

and their weight. It is just overwhelming how much they think about body

image and weight. The other criteria is that it can't be anorexia nervosa.

It is really a continuum of eating disorders and you can have any combi

nation in between these two.

The treatment for bulimia is basically that for anorexia, with handling the

emergencies to begin with, although they are less common, and then

working on the long term phase which is again the hard part. Trying to

heal the family.



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Diagnosis of Obesity

Identification

>85 percentile of body mass index (BMI) which is weight (in kilo-

grams) divided by the height squared (in meters) or kg/m2

>85 percentile of triceps skinfold thickness

Obesity. Obesity is one of those really frustrating ones for me personally

because it seems like there is not a lot that you can really do unless the

patient decides that they want something done.. With obesity, the family

does not see it as a major threat to health or a major problem, com

monly because they are obese themselves. Diagnosis consists of

greater than the 85 percentile for body mass index (BMI) or greater than

the 85 percentile for triceps skinfold thickness.



33

Treatment of Obesity

Effective Interventions

Motivated adolescent

Peer group process and support

Positive role models within the family

Change in exercise and eating behaviors

Ineffective Interventions

Unmotivated or apathetic adolescent

Crash diets

Obesity treatment. The effective interventions are when the adolescents

themselves want treatment to occur. It usually needs to be a

multidisciplinary approach. Support groups are helpful. Crash diets don't

work. The newest thing on the scene for adolescent obesity is the Phen-

Fen diets. The question is however that they need to be on it for the rest

of their lives and there are some serious cardiac side effects. This is

used a lot more in internal medicine and family practice people with

older adults who have seemed to have tried everything and can't lose

weight and get put on this Phen-Fen diet and it does work. They are not

prescribed routinely for adolescents.



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Adolescent Pregnancy

Close association exists between school failure or dropout and adoles-

cent pregnancy. When a girl gets pregnant and decides to parent, she is

often already two years behind in grade level

Youth itself may not be the risk factor

Racial vs. socioeconomic status

Resiliency factors

Environmental factors

Primary amenorrhea. This is defined as the absence of menarche by the

age of 16 with otherwise normal growth or by the age of 14 with no

secondary sexual characteristics present or no menses two years after

completed sexual maturity. Imperforate hymen can be a cause of an

apparent primary amenorrhea. History and physical is really important in

figuring out where to start with amenorrhea. This system is based on the

fact that if you have breasts absent and uterus present, here are the

things you need to worry about. Then if breasts and uterus are both

present, then the breakout is either cyclical or non cyclical. Pregnancy is

by far and away the most important thing for a woman to worry about

with secondary amenorrhea. The differential diagnosis includes preg-

nancy, pregnancy, pregnancy when you are dealing with secondary

amenorrhea.



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Causes of Adolescent Pregnancy

Sexual promiscuity

Denial

"Myth-information"

Magical thinking

Poor planning/foresight

Trying to make alternate situation

Fail to take responsibility

Wrong information sources

Low self-esteem

Absent fathers

Poor communications skills

Poor insight

Peer pressure

Easily pressured



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Maternal Complications of Teenage Pregnancy

Anemia

Hypertension and preeclampsia

Fewer years of education

Poorer socioeconomic status

Social isolation, depression, stress

High risk for repeat pregnancy

Prenatal care received less often than older women



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Neonatal Complications of Teenage Pregnancy

Prematurity

Sudden Infant Death Syndrome

Poor school performance

Behavior problems

Developmental delay

Neglect

Low birth weight



38

Diagnosis Primary Amenorrhea

Defined as absence of menarche by age 16 with otherwise normal

growth and development or no menses 2 years after completed sexual

maturity

Imperforate hymen can cause primary amenorrhea



39

Differential Diagnosis of Amenorrhea with

Breasts and Uterus Present

Hypogonadotropic hypogonadism

CNS lesion

Kallman syndrome

Pituitary gonadotropic deficiencies (e.g. chronic disease, anorexia

nervosa)

Hypergonadotropic hypogonadism (Gonadal dysgenesis)

Turner syndrome (45 XO or mosaic)

Radiation or chemotherapy leading to functional oophorectomy



40

Breast Absent Uterus Absent

Gonadal enzyme deficiency (17-alpha-hydroxylase deficiency)

Agonadism

Breasts Present Uterus Absent

Mullerian agenesis (Meyer-Rokitansky-Kuster-Hauser syndrome) XX

karyotype

Androgen insensitivity (testicular feminization) XY karyotype



41

Breasts Present Uterus Present

If cyclical pain present, rule out vaginal outlet obstruction (eg, imperfo-

rate hymen, transverse vaginal septum, rarely pregnancy)

If cyclical pain not present, hypothalamic-pituitary ovarian axis distur-

bance (evaluate as secondary amenorrhea)



42

Secondary Amenorrhea

Defined as cessation of menses after menarche

Irregular bleeding is normal during the first 2 years post-menarche.

Sporadic periods with absence of menses for several months is normal.

After regular cyclical pattern established, missing three cycles in a row is

considered secondary amenorrhea



43

Differential Diagnosis of Secondary Amenorrhea

Pregnancy is the most common cause, and it must always be excluded.

Hypothalamic disruption

Stress

Systemic disease (e.g. anorexia nervosa, inflammatory bowel dis-

ease, diabetes mellitus, thyroid disease, pituitary adenoma or infarc-

tion)

Exercise-induced amenorrhea

Uterine adhesions/Asherman syndrome

If hirsutism is present consider:

Congenital adrenal hyperplasia (C21-hydroxylase deficiency)

Polycystic ovary syndrome/chronic anovulation

1. Virilization with ache, hirsutism (be sure to ask about hair re-

moval cream use)

2. LH/FSH ratio >2.5:1

3. Sonogram evidence of multicystic ovaries is not necessary for

diagnosis

Cushing syndrome



44

References

1. American Psychiatric Association. Diagnostic and Statistical Manual,

4th Edition. Washington, DC, American Psychiatric Association, 1994.

2. Brookman RR. "When Your Teenage Patient is Pregnant," Pediatric

Management, June 1992, pp. 29-36.

3. Dietz WH, Robinson TN. "Assessment and Treatment of Childhood

Obesity," Pediatrics In Review, 1993; 14(9): 337-343.

4. Elster AB, Lamb ME, Travarre J, et al. "The Medical and Psychosocial

Impact of Comprehensive Care on Adolescent Pregnancy and Parent-

hood". JAMA, 1987, 258:1187-1192.

5. English A. "Treating Adolescents: Legal and Ethical Considerations,"

Medical Clinics of North America, 1990; 74(5): 1097-1109.

6. Goldenring JM, Cohen E. "Getting Into Adolescent Heads", Contempo-

rary Pediatrics, July 1988, pp. 75-92.