Chapter 18 Adolescents with Health Concerns Ken Cheyne, Michael R. Lawless DYSMENORRHEA/MENSTRUAL CRAMPS ETIOLOGY What Causes Dysmenorrhea? Dysmenorrhea, or menstrual cramps, is the most common gynecologic problem experienced by adolescent women and is a leading cause of short-term school absenteeism. More than 60% of women have some degree of dysmenorrhea and most do not readily report it, so the healthcare provider must routinely inquire about this symptom in the review of systems. Primary dysmenorrhea refers to menstrual pain for which there is no underlying pelvic pathology as a cause. It accounts for over three-fourths of the cases occurring before 25 years of age. It is caused by myometrial contraction in response to prostaglandins produced by the endometrium. Because initial menstrual periods are often anovulatory, adolescents may not complain of dysmenorrhea until several months after menarche. Secondary dysmenorrhea is menstrual pain associated with underlying pelvic pathology. Common causes include infection, structural abnormality of the uterus or cervix, presence of a foreign body such as an intrauterine device, a complication of pregnancy, or endometriosis. EVALUAzTION What Characterizes Dysmenorrhea? Primary dysmenorrhea is characterized by cramping pain associated only with menses. No other gynecologic or systemic symptoms should be present. The adolescent who is not sexually active and who has a history consistent with primary dysmenorrhea may first be given a therapeutic trial of a prostaglandin inhibitor such as ibuprofen (see treatment section) without a pelvic examination. If primary dysmenorrhea does not respond to prostaglandin inhibitors, a pelvic examination will be needed. An adolescent who has dysmenorrhea and is sexually active or has other gynecologic symptoms must also have a pelvic examination. Other diagnostic steps in evaluating secondary dysmenorrhea include a thorough medical and psychosocial history, cultures for sexually transmitted infections (STIs), and a pregnancy test. In some cases, pelvic ultrasonography and occasionally laparoscopy are a necessary part of the diagnostic process for more complicated cases of secondary dysmenorrhea. TREATMENT How Do I Treat Dysmenorrhea? Primary dysmenorrhea is treated with a prostaglandin inhibitor. A nonsteroidal antiinflammatory drug (NSAID) such as ibuprofen (400 mg every 4 to 6 hours) or naproxen (500 mg to start, then 250 mg three times daily) is a common choice. To be maximally effective, it is important that the medication be taken at the first indication that the menstrual period is beginning and continued at proper dosage for 2 or 3 days. The patient with primary dysmenorrhea who does not respond to NSAIDs, or the sexually active patient, may respond to oral contraceptives. Treatment for secondary dysmenorrhea is directed at the underlying cause, such as antibiotic therapy for an STI or hormonal suppression for endometriosis. GYNECOMASTIA ETIOLOGY What Is Gynecomastia? Gynecomastia is excessive development of the male breast. It occurs in up to two-thirds of adolescent males as a physiologic process during normal pubertal development, typically at sexual maturity rating (SMR) II and III. Enlargement of the male breast outside this peak stage of pubertal hormones may be associated with endocrine or chromosomal disorders, exogenous estrogen or androgen administered systemically or applied topically, or as a side effect of medications, including various antibiotics, cardiovascular medications, psychoactive medications, and drugs of abuse such as alcohol, marijuana, and opiates. Of particular note, gynecomastia can occur at any age as a result of anabolic steroid abuse for the purpose of enhancing athletic performance. The term pseudo-gynecomastia is used for apparent breast enlargement because of excessive fat tissue in overweight males. EVALUATION How Do I Evaluate Gynecomastia? Physiologic gynecomastia usually has breast enlargement limited to subareolar tissue and is accompanied by mild tenderness. Often the enlargement affects only one breast, or if both breasts are affected there is some asymmetry. Noting that the affected male is in SMR II or III (see Figure 15-3) is further assurance of a physiologic basis. Development of gynecomastia in a later stage of puberty makes a pathologic cause more likely. Obtain a thorough history of medications and substances of abuse, and perform a careful physical examination looking for other evidence of abnormal hormone production or for conditions associated with gynecomastia. TREATMENT How Do I Treat Gynecomastia? For most adolescent males with physiologic gynecomastia, management consists of education and reassurance that breast enlargement is a normal pubertal occurrence that is likely to resolve within 6 to 24 months. Without correct information, many boys (and their parents) worry that breast enlargement is a sign of femininity or breast cancer. If breast enlargement persists beyond 2 years, surgical reduction may be considered. Surgical reduction is reserved for the most severe cases of gynecomastia in regard to both breast size and psychological stress. URETHRAL OR VAGINAL DISCHARGE ETIOLOGY What Causes Vaginal or Urethral Discharge? A vaginal or urethral discharge should immediately raise concern about the presence of STI. About 25% of sexually active adolescents will develop an STI. Asking about sexual activity in a confidential interview is essential, with the caveat that some sexually active adolescents deny being sexually active even when the inquiry is confidential. Chlamydia infection and gonorrhea are the two most common bacterial causes of STI in both males and females. Nongonococcal, nonchlamydial urethritis and vaginitis are associated with Ureaplasma urealyticum infection and Trichomonas.< div class='tao-gold-member'> Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Children with Special Needs Immunization Bleeding and Bruising Growth Stay updated, free articles. Join our Telegram channel Join Tags: Pediatric Clerkship Guide Jun 19, 2016 | Posted by admin in PEDIATRICS | Comments Off on Adolescents with Health Concerns Full access? Get Clinical Tree
Chapter 18 Adolescents with Health Concerns Ken Cheyne, Michael R. Lawless DYSMENORRHEA/MENSTRUAL CRAMPS ETIOLOGY What Causes Dysmenorrhea? Dysmenorrhea, or menstrual cramps, is the most common gynecologic problem experienced by adolescent women and is a leading cause of short-term school absenteeism. More than 60% of women have some degree of dysmenorrhea and most do not readily report it, so the healthcare provider must routinely inquire about this symptom in the review of systems. Primary dysmenorrhea refers to menstrual pain for which there is no underlying pelvic pathology as a cause. It accounts for over three-fourths of the cases occurring before 25 years of age. It is caused by myometrial contraction in response to prostaglandins produced by the endometrium. Because initial menstrual periods are often anovulatory, adolescents may not complain of dysmenorrhea until several months after menarche. Secondary dysmenorrhea is menstrual pain associated with underlying pelvic pathology. Common causes include infection, structural abnormality of the uterus or cervix, presence of a foreign body such as an intrauterine device, a complication of pregnancy, or endometriosis. EVALUAzTION What Characterizes Dysmenorrhea? Primary dysmenorrhea is characterized by cramping pain associated only with menses. No other gynecologic or systemic symptoms should be present. The adolescent who is not sexually active and who has a history consistent with primary dysmenorrhea may first be given a therapeutic trial of a prostaglandin inhibitor such as ibuprofen (see treatment section) without a pelvic examination. If primary dysmenorrhea does not respond to prostaglandin inhibitors, a pelvic examination will be needed. An adolescent who has dysmenorrhea and is sexually active or has other gynecologic symptoms must also have a pelvic examination. Other diagnostic steps in evaluating secondary dysmenorrhea include a thorough medical and psychosocial history, cultures for sexually transmitted infections (STIs), and a pregnancy test. In some cases, pelvic ultrasonography and occasionally laparoscopy are a necessary part of the diagnostic process for more complicated cases of secondary dysmenorrhea. TREATMENT How Do I Treat Dysmenorrhea? Primary dysmenorrhea is treated with a prostaglandin inhibitor. A nonsteroidal antiinflammatory drug (NSAID) such as ibuprofen (400 mg every 4 to 6 hours) or naproxen (500 mg to start, then 250 mg three times daily) is a common choice. To be maximally effective, it is important that the medication be taken at the first indication that the menstrual period is beginning and continued at proper dosage for 2 or 3 days. The patient with primary dysmenorrhea who does not respond to NSAIDs, or the sexually active patient, may respond to oral contraceptives. Treatment for secondary dysmenorrhea is directed at the underlying cause, such as antibiotic therapy for an STI or hormonal suppression for endometriosis. GYNECOMASTIA ETIOLOGY What Is Gynecomastia? Gynecomastia is excessive development of the male breast. It occurs in up to two-thirds of adolescent males as a physiologic process during normal pubertal development, typically at sexual maturity rating (SMR) II and III. Enlargement of the male breast outside this peak stage of pubertal hormones may be associated with endocrine or chromosomal disorders, exogenous estrogen or androgen administered systemically or applied topically, or as a side effect of medications, including various antibiotics, cardiovascular medications, psychoactive medications, and drugs of abuse such as alcohol, marijuana, and opiates. Of particular note, gynecomastia can occur at any age as a result of anabolic steroid abuse for the purpose of enhancing athletic performance. The term pseudo-gynecomastia is used for apparent breast enlargement because of excessive fat tissue in overweight males. EVALUATION How Do I Evaluate Gynecomastia? Physiologic gynecomastia usually has breast enlargement limited to subareolar tissue and is accompanied by mild tenderness. Often the enlargement affects only one breast, or if both breasts are affected there is some asymmetry. Noting that the affected male is in SMR II or III (see Figure 15-3) is further assurance of a physiologic basis. Development of gynecomastia in a later stage of puberty makes a pathologic cause more likely. Obtain a thorough history of medications and substances of abuse, and perform a careful physical examination looking for other evidence of abnormal hormone production or for conditions associated with gynecomastia. TREATMENT How Do I Treat Gynecomastia? For most adolescent males with physiologic gynecomastia, management consists of education and reassurance that breast enlargement is a normal pubertal occurrence that is likely to resolve within 6 to 24 months. Without correct information, many boys (and their parents) worry that breast enlargement is a sign of femininity or breast cancer. If breast enlargement persists beyond 2 years, surgical reduction may be considered. Surgical reduction is reserved for the most severe cases of gynecomastia in regard to both breast size and psychological stress. URETHRAL OR VAGINAL DISCHARGE ETIOLOGY What Causes Vaginal or Urethral Discharge? A vaginal or urethral discharge should immediately raise concern about the presence of STI. About 25% of sexually active adolescents will develop an STI. Asking about sexual activity in a confidential interview is essential, with the caveat that some sexually active adolescents deny being sexually active even when the inquiry is confidential. Chlamydia infection and gonorrhea are the two most common bacterial causes of STI in both males and females. Nongonococcal, nonchlamydial urethritis and vaginitis are associated with Ureaplasma urealyticum infection and Trichomonas.< div class='tao-gold-member'> Only gold members can continue reading. Log In or Register to continue Share this:Click to share on Twitter (Opens in new window)Click to share on Facebook (Opens in new window) Related Related posts: Children with Special Needs Immunization Bleeding and Bruising Growth Stay updated, free articles. Join our Telegram channel Join Tags: Pediatric Clerkship Guide Jun 19, 2016 | Posted by admin in PEDIATRICS | Comments Off on Adolescents with Health Concerns Full access? Get Clinical Tree
