Secondary Amenorrhea - American Academy of Pediatrics

Report
2014 PEDIATRIC BOARD
REVIEW COURSE
ADOLESCENT MEDICINE
WARREN M. SEIGEL M.D., M.B.A., F.A.A.P., F.S.A.H.M.
Chairman, Department of Pediatrics
Director of Adolescent Medicine
Coney Island Hospital
Brooklyn, NY
Vice-Chair, American Academy of Pediatrics
District II – New York
CASE #1
Katherine is a 14 year old female who presents
for a routine examination for sports. She has no
complaints. Her past medical history and family
history are unremarkable.
On physical examination, you note that she
has Tanner 3 breasts and pubic hair.
Which of these would indicate sexual maturity
rating (Tanner) stage 3 development in a female?
1.
2.
3.
4.
5.
Fine hair on the upper lip
Acne
Darkly pigmented, slightly
curly pubic hair
Breast and papilla
elevated as a small mound
Menstruation
0%
1
0%
0%
2
3
0%
0%
4
5
6
PUBERTY




Physical changes associated with
development
Sequence of change is similar for all
adolescents
Variations in tempo and timing are common
Physical changes reflect underlying hormonal
changes
SEQUENCE OF PUBERTY

GIRLS
 Breast Buds
 Pubic Hair Appears
 Growth Spurt
 Axillary Hair
 Pubic Hair Matures
 Breasts Mature
 Menarche (First Period)
 Adult Height

BOYS








Testicular enlargement
Growth of penis/scrotum
Appearance of pubic hair
Axillary Hair
First ejaculations
Growth spurt
Facial hair
Adult Height
Features of Female Development





Onset:
Growth
spurt:
Height
Achieved:
Menarche:
Acne:
10 years (8-13)
Tanner 2 - 3
4 inches/year
12 years
common at
Tanner 3 - 4
A 13 year old boy is seen in your office because of breast
enlargement over the past 6 months. He denies pain,
galactorrhea and marijuana use. He is taking no
medications. Physical examination reveals sexual maturity
rating (Tanner) stage 2 genitalia and pubic hair growth and
asymmetric breast buds beneath each nipple, with the left
measuring 1 cm and the right 3 cm. Of the following, the
most appropriate INITIAL management for this boy is:
1. Head CT with contrast
2. MRI of the abdomen
3. Serum beta-human
chorionic gonadotropin level
4. Reassurance that this is a
normal occurrence
5. Ultrasonography of the
testes
0%
1
0%
0%
2
3
0%
0%
4
5
6
Features of Male Puberty

Onset:

Peak Height Velocity:
First Ejaculations:
Average Height Gained:
Strength Peak:



9-13 years
(average = 12)
Tanner 3 - 4
Tanner 3
5-7 inches/year
Tanner 4 – 5
Gynecomastia occurs in approximately 60%
CASE #1
(continued)
Later in the course of your history, you find
out that Katherine has tried tobacco, drinks
alcohol “on weekends with my friends” and
“smokes weed once in a blue”.
Adolescence is best described
as the period:
1. Immediately before, during,
and after puberty
2. Of physiologic adjustment to
maturity
3. Of psychosocial transition
from childhood to adulthood
4. Of maximal physical growth
5. Of maximal sexual
development
0%
1
0%
0%
2
3
0%
0%
4
5
6
FEATURES OF EARLY
ADOLESCENCE
(Am I Normal?)









Physical Changes and Concerns
Sense of Being “Center Stage”
Sense of Invulnerability
Wide Mood Swings
Rejection of Childhood Things
Beginnings of Emancipation
Non-Parent Adult Role Models
Same-Sex Friendships
Concrete Thinking
FEATURES OF MIDDLE
ADOLESCENCE
(Am I Liked?)







Puberty (Almost) Complete
Testing/Showing Off “New
Body”
Independence-Dependence
Conflicts
Strong Peer Attachments
Concern With Sexual Appeal
Experimentation/Risk-Taking
Abstract Thinking Begins
FEATURES OF LATE
ADOLESCENCE
(Am I Loved?)






Definition of Adult Role in Society
Definition of Adult Role in Family
Mainly Independent Decisions, Actions
Established, Realistic, Self-Identity
Realization of Vulnerability, Limitations
Abstract Thinking Well Established
High Risk Behaviors

Alcohol


71% acknowledge use
Cocaine



Tobacco




45% acknowledge use
23% currently smoking
Inhalants

45% acknowledge use
18% currently smoking
Marijuana



7% acknowledge use
3% currently use
11% acknowledge use
Prescription Drugs

21% acknowledge use
CASE # 2
Jonathon is a 16 year old male who comes to
your office complaining of a clear urethral
discharge and burning on urination for the past
1 week. He admits to being sexually active, the
last time being 10 days ago.
The MOST prevalent sexually transmitted
infection (STI) among adolescents and young
adults in the US is:
3.
Chlamydia
Genital herpes
Gonorrhea
4.
HPV
5.
Syphilis
1.
2.
0%
1
0%
0%
2
3
0%
0%
4
5
6
CHLAMYDIA TRACHOMATIS
 MALES
 FEMALES
 Asymptomatic
 Asymptomatic
 Urethritis
 Cervicitis
 Epididymitis
CHLAMYDIA: SIGNS AND
SYMPTOMS

MALE:

FEMALE:
Burning, Urethral Discharge,
Pain in Epididymis
Vaginal/Cervical Discharge,
Pelvic Pain, Painful Intercourse,
Burning
MAY BE NO SYMPTOMS IN
MALE OR FEMALE.
CHLAMYDIA TRACHOMATIS

DIAGNOSIS
 Culture: “gold standard”
 Leukocyte esterase; urine dip in males
 Enzyme linked assay (EIA or ELISA)
 Direct Fluorescent Antibody (DFA)
 DNA probes
 Nucleic
Acid Amplification Tests
(NAATs)
CHLAMYDIA TRACHOMATIS



TREATMENT
 Azithromycin 1 gm single dose by mouth
 Doxycycline 100 mg by mouth twice daily for
7 days
PARTNER TREATMENT!!!
Follow-up “Test of Cure” recommended
An 18 year old girl complaining of heavy menstrual periods that last
8-10 days. Physical examination reveals a creamy, greenish vaginal
and cervical discharge that contains many leukocytes and Gram
negative diplococci in pairs. A pregnancy test is negative and
syphilis serology is pending. Of the following, the BEST antibiotic
therapy for this patient is:
1.
2.
3.
4.
5.
Amoxicillin
Amoxicillin and
Erythromycin
Ceftriaxone
Ceftriaxone and
Azithromycin
Spectinomycin and
Doxycycline
0%
1
0%
0%
2
3
0%
0%
4
5
6
GONORRHEA: SIGNS AND
SYMPTOMS

MALE:

FEMALE:
Yellow “Drip” from Penis,
Burning, Pain in Epididymis
Vaginal/Cervical discharge,
Heavy Menses, Painful
Intercourse, Burning, Frequency
MAY BE NO SYMPTOMS IN
MALE OR FEMALE
Neisseria Gonorrhea
 MALE
 Urethritis
 Epididymitis
 FEMALES
Asymptomatic
 Cervicitis
 Bartholin’s gland
abscess
 Pelvic
Inflammatory
Disease (PID)

NEISSERIA GONORRHEA

DIAGNOSIS
 Culture: “Gold Standard”
 Leukocyte esterase suggestive in males
 DNA probes, PCR, EIA are all available
 Nucleic Acid Amplification Tests
(NAATs)
NEISSERIA GONORRHEA

TREATMENT
 Ceftriaxone
 Cefixime
 Ofloxacin
 Ciprofloxacin
250 mg IM in single dose
400 mg PO in single dose
400 mg PO in single dose
500 mg PO in single dose
ADDITIONAL TREAMENT FOR
CHLAMYDIA TRACHOMATIS IS TYPICAL
SYPHILIS: SITE OF INFECTION

MALE:
FEMALE:

INFANT:

Penis, Anus, Mouth, Lips
Vulva, Vagina, Cervix, Anus,
Mouth, Lips
Acquired During Pregnancy,
Birth Defects, Death
Spread to entire body in male and female
including heart and brain!
SYPHILIS: SIGNS AND
SYMPTOMS

PRIMARY SYPHILIS
Chancre on sex organs
 Painless indurated ulcer with smooth border
 Incubation = 3 weeks, healing = 6 weeks


SECONDARY SYPHILIS


Fever, rashes, generalized illness
TERTIARY SYPHILIS

Infection of brain, blood vessels
SECONDARY SYPHILIS


CONSTITUTIONAL SYMPTOMS
 Fever, malaise, adenopathy, musculoskeletal
symptoms
SKIN AND MUCOUS MEMBRANE
FINDINGS
 Rash – begins on trunk
 Rash – involves palms and soles
 Condyloma lata – moist plaques
 Alopecia
SKIN LESIONS ARE HIGHLY
INFECTIOUS!
Diagnosis – Syphilis


Serologic – nontreponemal
 RPR, VDRL, ART
Serologic – treponemal
 FTA-ABS, MHATP,TPHA
Treatment – Syphilis


Less than 1 year duration –
 Benzathine Penicillin-G 2.4 million units IM
Greater than 1 year duration –
 Benzathine Penicillin-G 7.2 million units, 3
divided doses
A 16 year old girl has had dysuria and a vaginal discharge for 2
weeks. Findings on pelvic examination include a frothy
vaginal discharge and cervical petechiae. Microscopic
examination of the discharge reveals flagellated
organisms. Results of a urinalyis are normal.
Among the following, the BEST treatment for this
patient’s problem is:
1.
2.
3.
4.
5.
Azithromycin
Cefixime
Ciprofloxacin
Doxycycline
Metronidazole
0%
1
0%
0%
2
3
0%
4
0%
5
6
Trichomonas


Males
 Generally asymptomatic
Females
 Malodorous vaginal discharge
 Cervicitis
 Vulvitis with labial edema
Trichomonas


Diagnosis
 Observation of flagellate on saline wet mount
Treatment
 Metronidazole 2 gm po x 1 dose
Bacterial Vaginosis




Non-gonococcal
Non-chlamydial
Non-trichomonal
Non-candidal
Due to Gardnerella vaginalis
Bacterial Vaginosis



Symptoms
 Vaginal discharge- grey-white, thin , watery
 Pruritis and itching may accompany
 Worsens with intercourse
 Malodorous
Diagnosis
 Saline wet prep with “clue” cells
Treatment
 Metronidazole 500mg PO bid x 7 days
Genital Herpes: Site of Infection



Males: Blisters on Penis, Scrotum, Buttocks
Females: Blisters on Vulva, Vagina, Cervix,
Buttocks
Infants: Systemic
Genital Herpes:
Signs and Symptoms

Primary Infection:
Very Painful
Painful Urination
1-3 weeks

Repeat Infections:
Less Painful
1 Week or less
Herpes Simplex - HSV





Skin lesions appear at site within 2-14 days
Grouped papules on erythematous base
Ulceration Erosion
Very painful
Constitutional symptoms
Genital Herpes: Treatment




Treat Virus
Treat Symptoms
No sex until 1 week after blisters heal
Treat partner only if infected
Treatment:
Genital Herpes

Primary


Recurrent



A) ACV 400 mg PO BID
B) ACV 200 mg po 2-5 times/day
Severe disease


Acyclovir 400 mg oral bid
Suppressive Therapy


Acyclovir 400 mg oral tid X 5 days
Prophylaxis


Acyclovir 400 mg oral tid X 7-10 days
ACV 5 -10 mg/kg IV every 8 hours X 5-7 days
No role for topical ACV
Human Papilloma Virus




Most common STI
Increasing prevalence among teens
Associated with majority of Pap smear
abnormalities
Treatment
Podophyllin
 Cryotherapy with liquid nitrogen
 Podofilox (home treatment)

CASE # 3
Over the past 6 months, Marianne, a 15
year old girl in your practice, has missed 8
days of school because of severe, episodic
lower abdominal pain that coincides with
menses. Menarche was at age 13 and menses
are regular. She states that she is not sexually
active. Findings on physical exam are
normal.
Of the following, the BEST treatment for this
girl’s abdominal pain is:
1.
2.
3.
4.
5.
Abdominal exercises
Acetaminophen
Hydrochlorothiazide
Low-salt diet
Naproxen
0%
1
0%
0%
2
3
0%
0%
4
5
6
Normal Menstruation

Normal menstruation is an indication that
the hypothalamic--pituitary--ovarian-uterine axis is intact and responsive.
Physiology of Menses


FSH - stimulates the maturation of
ovarian follicles
- directs the conversion of
androgens in the granulosa
cells of the ovary to estrogens
LH - stimulates theca cells of the
ovary to produce androgens
- midcycle LH surge stimulates
ovulation
Physiology of Menses


Estrogens- stimulate the proliferation of
endometrial epithelial and stromal cells.
Stimulate glandular formation.
Progesterone- produced by corpus
luteum, causes the endometrium to
function in a secretory manner, leading
to increased blood vessel growth and
tortuosity.
Normal Menstrual Cycles
Follicular Phase
Ovulatory Phase
Luteal Phase
Follicular Phase




Endometrial proliferation under estrogen
influence
Endometrial stroma becomes compact
Estrogen triggers midcycle LH surge
Cervical mucus is watery
Ovulatory Phase
Following ovulation, corpus luteum
produces both Estrogen and
Progesterone.
 Progesterone exerts suppressive
effect on Estrogen resulting in the
conversion of the endometrium to a
secretory state.

Ovulatory Phase
Vaginal secretions and Cervical
mucus are copious and clear.
 Secretions placed on glass slide
will demonstrate “ferning” pattern
when allowed to dry. (know this !)

Case # 3
(continued)
Upon further questioning, Marianne admits
that her last menstrual period was approximately
8 weeks ago. She is sexually active with a single
male partner and does not use condoms
consistently.
Menstrual Abnormalities
Primary Amenorrhea
 Secondary Amenorrhea
 Dysmenorrhea
 Dysfunctional Uterine Bleeding
 Polycystic Ovary Disease

Amenorrhea

Definition: Amenorrhea is the
absence of menses.
Amenorrhea

 Secondary Amenorrhea:
Primary Amenorrhea:
 The lack of menses
 Absence of menses
by age 14 with the
for a period of at least
absence of
3 cycle lengths or for
secondary sexual
a period of 6 months
characteristics.
 The lack of menses
by age 16 regardless
of the status of
secondary sexual
characteristics.
Primary Amenorrhea

Differential Diagnosis
 Hypothalamus
 Pituitary
 Ovary
 Uterus & Outflow Tract
Primary Amenorrhea

Hypothalamic Causes
Physiologic delay – often familial
 Systemic disease – often chronic
 Stress
 Athletics
 Eating Disorders
 Obesity
 Drugs

Cytoxin, Phenothiazines,
Isotretinoin, Amphetamines
 Steroids, Opiates

Primary Amenorrhea

Pituitary Causes
 Idiopathic Hypopituitarism
 Tumor
 Hemochromatosis
Primary Amenorrhea

Thyroid and Adrenal Gland Causes
 Hypothyroidism
 Hyperthyroidism
 Congenital Adrenal Hyperplasia
 Tumor
Primary Amenorrhea

Gonadal Causes
 Turner Syndrome and Mosaicism
 Pure Gonadal Dysgenesis
 Testicular Feminization Syndrome
 Hermaphroditism
 Ovarian Failure
Primary Amenorrhea

Uterus and Outflow Tract Causes
 Synechiae
 Pregnancy
 Agenesis
 Imperforate Hymen
A 15 year old girl has reached Tanner Stage 4. She has had
periodic abdominal discomfort but has never
menstruated. Physical examination reveals a midline
abdominal mass. Pregnancy test is negative.
On genital examination, you are MOST likely to see:
1.
A bluish, bulging
hymen
2.
A hymenal opening of
about 1 cm
An annular hymenal
membrane
Labial adhesions
obscuring the hymen
Vaginal discharge and
labial irritation
3.
4.
5.
0%
1
0%
0%
2
3
0%
0%
4
5
6
Evaluation of Primary
Amenorrhea






History
Physical Examination
Pelvic Examination
 Ultrasound if needed to define anatomy
FSH, LH, Prolactin, Testosterone
Bone Age
Karyotype
Secondary Amenorrhea

Think
 Pregnancy
 Pregnancy
 Pregnancy
Secondary Amenorrhea

Hypothalamic Causes
 Stress
 Athletics
 Eating Disorders
 Obesity
 Drugs
Cytoxin, Phenothiazines, Isotretinoin, Amphetamines
 Steroids, Opiates

 Systemic
Enteritis, colitis
 Diabetes
 CF, renal disease

Secondary Amenorrhea

Pituitary Causes
 Hyperprolactinemia
 Pituitary Adenoma
 Post-Oral Contraception
Secondary Amenorrhea

Thyroid Causes
 Hyperthyroidism
 Hypothyroidism
Secondary Amenorrhea

Adrenal Causes
 Congenital Adrenal Hyperplasia
 Adrenal Tumor
Secondary Amenorrhea

Gonadal Causes
 Polycystic Ovary Syndrome
 Gonadal Dysgenesis
 Ovarian Failure
Secondary Amenorrhea

Uterus and Outflow Tract Causes
 Asherman Syndrome
 scarring from D&C
 Tumor
Evaluation of Secondary
Amenorrhea



Complete History & Physical Exam
Pelvic Examination
Pregnancy Test
Evaluation of Secondary
Amenorrhea

Pregnancy Test NEGATIVE:


Provera, 10 mg BID X 5 days
Withdrawal bleed indicates:

Ovaries produce adequate estrogen to
stimulate endometrial proliferation in the
uterus. Also indicates that the outflow tract
is intact and functioning normally.
Evaluation of Secondary
Amenorrhea

Lab Evaluation:
CBC with diff, ESR
 UA
 FSH, LH, prolactin


Radiologic Evaluation:

pelvic ultrasound
Dysmenorrhea



Definition – pain associated with menses
Etiology:
 Prostaglandin PGE2 and PGF2 implicated
 Endometriosis
Onset within 6-12 months following Menarche
Dysmenorrhea

Lower abdominal to back/thigh pain reported
 Polyps, benign tumors
 Infection
Dysmenorrhea

Differential Diagnosis
 Endometriosis
 Pelvic Inflammatory Disease
 Benign Tumor
 Anatomic abnormality
Workup for Dysmenorrhea




Complete physical examination including
pelvic exam
CBC with differential, ESR/CRP
GC/chlamydia screen
Wet mount of discharge if present
Management of Dysmenorrhea

Primary Dysmenorrhea (no abnormality on
evaluation)
Non-steroidal anti-inflammatory agent
 Reassurance
 If no improvement with NSAIDS,
estrogen/progesterone combination contraceptive


Secondary Dysmenorrhea
Infection – treat
 Endometriosis – refer to GYN

CASE #4
Adrienne is a 14 year old female who complains of
vaginal bleeding for the past month. She states that she
has been using approximately 6 – 8 pads per day and
that her bleeding has been heavier than usual.
Menarche was at 13 years. She denies sexual activity.
Which of the following statements is true regarding
Dysfunctional Uterine Bleeding (DUB) in the adolescent?
1.
It is diagnosed by excluding
bleeding of organic cause.
2.
If exsanguinating and
unresponsive to all other
measures, it is better treated by
hysterectomy than by irradiation.
It can usually be controlled by
administration of estrogens and
progestigens.
It is frequently associated with
dysmenorrhea.
It occurs as a normal part of
adolescent growth and
development.
3.
4.
5.
0%
1
0%
0%
2
3
0%
0%
4
5
6
Dysfunctional Uterine Bleeding



Polymenorrhea – bleeding which occurs at
regular intervals of less than 21 days
Menorrhagia – prolonged or excessive bleeding
at regular intervals of 21-35 days
Metrorrhagia – irregular interval bleeding
Dysfunctional Uterine Bleeding

Etiology – anovulatory bleeding secondary to
immature hypothalamic-pituitaryovarian axis
Dysfunctional Uterine Bleeding

Differential Diagnosis
Anovulatory Bleeding
 Pregnancy complications


Ectopic, spontaneous abortion
Endometritis
 Malignancy
 Iatrogenic
 Ovarian

Dysfunctional Uterine Bleeding
Evaluation







Complete History and Physical Exam
Menstrual and Sexual History
Pregnancy Test
CBC with differential
Platelet Count
PT/PTT
Von Willebrand Factor Antigen/Panel, Ristocetin
Cofactor
Management of Dysfunctional Uterine
Bleeding

If Hemoglobin is stable
 Observation and reassurance
 Begin Iron Therapy
 Combination estrogen/progestin
contraceptive pills
Management of Dysfunctional Uterine
Bleeding

If bleeding is severe, Hemoglobin unstable
 Estrogen every 4-6 hours until bleeding is
stopped
 Then begin Estrogen and Progesterone
containing pills as maintenance daily
Polycystic Ovary Disease


Anovulatory cycles with irregular bleeding
Suspect in the mid adolescent with menstrual
irregularity
Polycystic Ovary Disease




Etiology: Defect in gonadotropin secretion
leading to elevated LH. FSH is
normal/borderline low.
Acyclic estrogen/progesterone secretion
Elevated Androgen secretion
Anovulation
Polycystic Ovary Disease

Presentation
Amenorrhea
 Hirsuitism
 Obesity
 Infertility

Polycystic Ovary Disease

Differential Diagnosis
 Familial Hirsuitism
 Cushing’s Syndrome
 Androgen excess
 Late onset CAH (21-hydroxylase
deficiency)
 Androgen producing tumor
 Anabolic steroid use
Polycystic Ovary Disease

Evaluation
 History including
PMH
 Medication History
 Menstrual History
 Sexual History
including pregnancy,
infection, abortion

Physical Exam
 Obesity
 Hirsuitism
 Clitoromegaly
Polycystic Ovary Disease



Pelvic Examination
 Size of ovaries
Ultrasound
 Size of Ovaries
Laboratory Evaluation
 LH/FSH, E2, DHEAS, Testosterone,
17-OH Progesterone
Polycystic Ovary Disease

Treatment
 Normalization of Menses

Estrogen Dominant Oral Contraceptive Pill
 Hirsuitism
Weight Loss
 Cosmetics

 Fertility
Clomid
 Metformin

CASE #5
Mark is a 15 year old boy who comes to your office
for a routine physical examination. His mother asks to
meet with you alone and says that a few weeks ago she
found a plastic baggy with marijuana under his bed.
She requests that you perform a drug test without
telling her son.
QUESTIONS



Will you perform the drug test without telling
Mark?
If not, what will you tell Mark as an alternative?
What will you tell Mark about drug testing?
The most commonly abused substance by
adolescents is:
1.
2.
3.
4.
5.
Marijuana
Tobacco
Cocaine
Alcohol
Ecstasy
0%
1
0%
0%
2
3
0%
0%
4
5
6
Substance Abuse

Definition:
 The persistent use of illicit substances despite
experiencing negative consequences from
their use.
 Substance abuse is a multi-dimensional
disorder with a complex biopsychosocial
etiology.
Multiple Drug Use
Adolescents rarely report a
“drug of choice” but rather use
multiple substances.
Age at First Use
The age of first use for US teens is
11-12 years of age.
Case #5
(continued)
Mark’s grades have been falling and he quit the
football team recently. He has a new group of friends
that he never brings home. Mark tells you that he
occasionally smokes marijuana but he denies using any
other drugs. He admits to being sexually active and
drinking beer with his friends on weekends.
His parents are concerned because they recently smelled
alcohol on his breath when he returned from a party.
Of the following behaviors, which would be MOST
suggestive of a serious problem with substance abuse?
1.
2.
3.
4.
5.
Associating with teenagers
who use drugs
Dropping his grades from
A’s to B’s
Quitting the football team
Sleeping more than 12
hours per night
Smoking cigarettes
0%
1
0%
0%
2
3
0%
4
0%
5
6
Risk Factors for Illicit Drug Use



Family Tolerance
Peer Influences- The most positive predictor of
drug and alcohol use among teens, is a positive
history of use among peers.
Other Factors
 Early Academic Failure
 Isolation
 Criminal Activity
Recognizing Substance Abuse
Problems





Behavioral Change
Unexpected Decline in School Performance
School Problems & Behavioral Concerns
Isolation from peers
Outbursts of anger or abusive behavior
without remorse
Obtaining the History



With the teen separated from parent/s
With assurance that the substance use history is
part of a routine interview
(it should be!)
With appropriate lead in questions...
Many teens your age go to parties where alcohol is
available…do you?
 Have you ever consumed a drink containing alcohol?
 Have you ever been drunk?

The “C.R.A.F.F.T.”






C -- Have you ever ridden in a CAR driven by
someone (including yourself) who was "high" or had
been using alcohol or drugs?
R -- Do you ever use alcohol or drugs to RELAX,
feel better about yourself, or fit in?
A -- Do you ever use alcohol or drugs while you are
by yourself, ALONE?
F -- Do you ever FORGET things you did while
using alcohol or drugs?
F -- Do your family or FRIENDS ever tell you that
you should cut down on your drinking or drug use?
T -- Have you gotten into TROUBLE while you
were using alcohol or drugs
Drug Screening

Ethical Issues- screening without the
knowledge and consent will likely have a
negative effect on the doctor-patient
relationship.

The AAP does not endorse such
“non-informed” screening.
In the habitual user, which of the following substances is
MOST likely to be detected by a urine screening test up
to 1 month after last use?
1.
2.
3.
4.
5.
Alcohol
Barbiturate
Cocaine
Marijuana
Phencyclidine
0%
1
0%
0%
2
3
0%
0%
4
5
6
Drug Screening...

Obtain the appropriate sample
Either urine or serum are adequate for general
screening.
 The use of hair for screening is more sophisticated
than generally necessary for routine screening.

Drug Screening...

How long will drug screening remain positive ?
 Ethanol
2-14 hours
 Amphetamines
< 48 hours
 Opiates
2 days
 Barbiturates
3-4 days
 Cocaine
2-4 days maximum
 Cannabinoids
10 - 20 days maximum
FIVE STAGES OF
SUBSTANCE ABUSE

STAGE 1
STAGE 2
STAGE 3
STAGE 4

STAGE 5



CURIOSITY
EXPERIMENTATION
REGULAR USE
PSYCHOLOGIC OR
CHEMICAL DEPENDENCY
USING DRUGS TO
FEEL “NORMAL”
CASE #6
Adrienne is a 13 year old female who is
brought to you by her mother for a physical
examination. She has no complaints and her
past medical history is unremarkable. The
mother requests that you examine her daughter
“to see if she’s a virgin” and if not, the mother
requests that you start her on some form of
contraception.
Adolescent Sexual Behavior



80% of Males and 70% of Females have
intercourse before age 20
Average age of first intercourse is 16
Often a series of single partners
Considerations in Contraceptive
Choice for Adolescents








Frequency of intercourse
Number of partners
Acceptability
Motivation and self-discipline
Access to medical care
Effectiveness
Safety vs. Risk
Cost
Which of the following is a
RELATIVE CONTRAINDICATION to
prescribing hormonal contraceptives that
contain both estrogen and progestin?
1.
2.
3.
4.
5.
Diabetes mellitus
Fibrocystic breast disease
Ovarian cyst
Pelvic inflammatory disease
Rheumatoid arthritis
0%
1
0%
0%
2
3
0%
0%
4
5
6
Prevention

Abstinence
 Effective
 No cost
 Applicable for all
 Requires willpower
for both partners

Withdrawal
 Effective 77-84%
 No cost
 Does not prevent
STIs
 Always available
 Choice of last resort
Prevention

Fertility Awareness
Recognition of fertile
and safe times in cycle
 Effectiveness 76-98%
 No major health
concerns
 No cost
 Difficult if irregular
cycles
 Requires discipline in
both partners
 Poor choice for
adolescents


Condoms
Prevent sperm from entering
vagina
 Must be in place prior to
contact and during
withdrawal
 Effectiveness 90-98%
 Over-the-counter
 Best protection against STIs
 Requires motivated couple
 Appropriate for casual sex
partner

Prevention

Diaphragm
 Barrier to cervix
 Must be in place prior
to sexual contact & 6
hrs after
 Effective 81-98%
 Requires physical exam
 Can be inconvenient
 Very motivated teen in
stable relationship

Intrauterine Device (IUD)
 Prevents implantation
 Device placed inside
uterus
 Effectiveness 95-98%
 Requires medical
surveillance
 May be appropriate for
adolescents who desire
long term contraception
Prevention

Sponge
 Disposable barrier to
cervix
 Moistened sponge used
similar to Diaphragm
 Effectiveness 80-91%
 Over-the-counter
 Some STI protection
 Expensive
 Appropriate for
motivated teen
 Good back-up method

Foam & Spermicides
 Chemical destruction
of sperm in vagina
 Must be in place prior
to intercourse
 Effectiveness 82-97%
 Over-the-Counter
 Some STI protection
 Requires motivated
couple
 Appropriate for
motivated adolescents
Prevention

Sterilization
 Permanent surgical
sterilization
 99% Effectiveness
 Medically
performed
 Not appropriate
for adolescents

Hormonal Contraceptives
 Prevents ovulation
 Effective 98-99%
 Multiple health benefits
 Medical complications
lowest in adolescents
 Must be taken daily
 Minor side effects
 Often method of choice
for adolescents
A 14 year old girl who has sickle cell disease wishes to use hormonal
contraception. She had a stroke 3 years ago associated with
persistent left-sided weakness and a seizure disorder. Menarche
occurred at age 12 and menses are irregular. She has been sexually
active for 2 years and has had 3 partners. Her current partner
occasionally uses condoms.
The most important CONTRAINDICATION to the use of
hormonal contraceptives in this patient is her history of
4.
Epilepsy
Inconsistent use of
condoms
Irregular menstrual
bleeding
Multiple sexual partners
5.
Stroke
1.
2.
3.
0%
1
0%
0%
2
3
0%
0%
4
5
6
Prevention

Injectable Hormones
 Suppresses hormone
cycle
 Injection every 1-3
month
 98-99% effective
 Long lasting, unrelated
to intercourse
 Requires more frequent
medical visits

Emergency Contraception
 Prevents implantation
 Taken post intercourse
 Effective 99%
 Emergency method for
Rape, Contraceptive
Failure
 Available Over-theCounter for those 17 years
of age and older
Prevention

Contraceptive Patch
 Delivers continuous
systemic doses of
hormones
 Change weekly x 3
weeks then patch-free
x 1 week
 Patch contains 6.00
mg norelgestromin
and 0.75 mg ethinyl
estradiol

Vaginal Ring
Progestin: Etonogestrel:
120 µg/day & Estrogen:
Ethinyl Estradiol: 15
µg/day
 Worn for three out of
four weeks
 Self insertion &
removal
Contraindications for
Hormonal Contraception

Absolute
 Past or current history of
thromboembolic disorder,
cerebrovascular disease,
Breast cancer or Estrogen
dependent neoplasia
 Prolonged immobilization
 Acute liver function
impairment
 Pregnancy

Relative
 Vascular or migraine
headaches
 Collagen vascular
diseases
 Severe hypertension
 Chronic heart disease
 Sickle cell disease
 Severe renal disease
 Diabetes mellitus

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