Correct Answer: A. Current recommendations include screening all nonpregnant women every 5 to 10 years, starting in adolescence, with HgB and/or HCT. Employ selective screening if the patient has at least one risk factor for anemia (e.g., diet low in iron-rich foods, history of iron deficiency anemia, excessive menstrual bleeding, poverty, and/or food insecurities). Answers B to E are recommended components of universal health screening during annual health supervision visits for adolescents per the American Academy of Pediatrics.

Correct Answer: C. The first dose of HPV vaccine is routinely recommended at age 11 years old. The vaccination can be started at age 9 years. Only two doses of HPV vaccine are needed if the first dose was given before the 15th birthday. In a two-dose schedule of HPV vaccine, the minimum interval is 5 months between the first and second dose. Children aged 9 to 14 years who receive two doses less than 5 months apart will require a third dose of HPV vaccine. In a three-dose schedule of HPV vaccine, the minimum intervals are 4 weeks between the first and second dose, 12 weeks between the second and third dose, and 5 months between the first and third dose. If the HPV vaccination schedule is interrupted, earlier vaccine doses do not need to be repeated. There is no maximum interval of time between doses—only a minimum time between doses for vaccine efficacy. Patients do need to complete the two-dose or three-dose series depending on whether the first dose was received before age 15 years for maximum protection from HPV. The nonvalent HPV vaccine protects against nine HPV types (6, 11, 16, 18, 31, 33, 45, 52, and 58). HPV vaccination can prevent over 90% of cancers caused by HPV, including cervical, vaginal, vulvar, and anal cancers and precancers.

Correct Answer: E. Assessing screen time (including social media use) and physical activity is part of the “A,” Activities category. The “H” in the HEADSS mnemonic is for Home, “E” is for Education/employment, and “SS” is for “Sexuality/relationships” and “Suicide/depression” categories.

Correct Answer: D. This is the correct answer because health care providers are mandated reporters when abuse is suspected or has occurred. Answer A is incorrect. This disclosure does not warrant disclosure to a parent/guardian. Answer B is incorrect. Minors are entitled to confidential care in all states for treatment of sexually transmitted infections. Answer C is incorrect. More than half the states and the District of Columbia have laws explicitly allowing all individuals to consent to contraceptive care or those at a certain age (e.g., 12 or 14) and older to consent to this care. Nineteen states allow only specific categories of minors to consent to contraceptive services. Four states have no explicit case law or policy. ( https://www.guttmacher.org/state-policy/explore/overview-minors-consent-law )

Correct Answer: C. To establish rapport, after introducing yourself, you can ask the patient to introduce themselves, and if they do not indicate, ask them their preferred pronouns. Answer A is incorrect. This would not be the first question asked. Generally, time should be made for teen and parent to be interviewed together, then teen alone. If the patient is 18 or older, explicit permission should be asked if a parent should be allowed in any part of the visit due to HIPAA privacy laws. Answer B is incorrect. This is important to obtain, but it would not be the first question asked to establish rapport with a patient. Answer D is incorrect. This would not be the first question asked of the teen.

Correct Answer: B. The verbal conversation the practitioner has with a patient can be kept confidential, unless there is disclosure by the patient of abuse or safety concerns (suicide, homicide). Answer A is incorrect. Unless a piece of the medical record is created that would not be visible to anyone who has access to the chart, this cannot be assured. Many systems have created this in the history section of the note (HEADSSS, SHADESS questions) but cannot ensure this in the assessment and plan. Answer C is incorrect. This is dependent on the parameters set up for the patient portal and who is the primary “owner” of the portal and who is the proxy. It is always important to clarify this with the patient. Most adolescents may not be aware that their parents are the primary owners, even in systems that make parent the proxy, not the owner. Whoever’s email is associated with the portal as a primary email would be the individual receiving the information. Answer D is incorrect. Explanation of benefits is generally sent to the owner of the insurance policy, who is the parent/guardian in most cases, even for patients who are over 18. Many young adults, until age 26 years, are insured under their parent/guardian’s health insurance. Only 14 states have safeguards protecting confidentiality for insured individuals. ( https://www.guttmacher.org/state-policy/explore/protecting-confidentiality-individuals-insured-dependents )

Correct Answer: D. Clinicians caring for TGD patients should help patients find inclusive mental health providers especially if they are desiring medical or surgical therapy. Answer A is incorrect. More adolescents than adults identify as gender diverse. Answer B is incorrect. Providers should encourage the staff to use a patient’s name and pronouns. Answer C is incorrect. Gynecologists can and should care for transfeminine individuals.

Correct Answer: B. Erythrocytosis is one of the most important risks of testosterone use and is an independent risk factor to venous thromboembolism in transmasculine individuals. Hypertension, elevated prolactin and a fasting LDL of 101 are not inherint risks of testosterone in typical range dosing.

Correct Answer: D. Currently there is no contraindication to any contraceptive option based on gender identity.

Correct Answer: C. Restraining a patient to examine them should be avoided unless they are under 2 years of age if caregivers are agreeable. ⁷

Correct Answer B. A speculum exam in a prepubertal child, in the office setting, is NEVER appropriate. If you suspect an infection, then vaginal swabs or lavage can be performed to obtain a culture. If you are worried about a foreign body or lesion, then vaginoscopy either at the bedside or in the operating room should be performed. ⁹

Correct Answer: D. In North America, screening for cervical cancer is indicated only starting at age 21 to 25 years old depending on the province or state you live in. The reason being that the benefits of cervical cancer screening do not outweigh the harms in a younger age group. Also, in young women, most HPV (human papillomavirus) infections go away on their own. Screening people less than 21 years old often leads to unnecessary treatment, which can have side effects. ^{10 , 11}

Correct Answer: B. This 11-year-old patient is in SMR III based on breast examination and is in their growth spurt, which occurs before menarche. They are already experiencing physiologic leukorrhea, indicating rising levels of estrogen, and for most this precedes menarche by ∼6 to 12 months. Answer A is incorrect. This patient is not experiencing delayed puberty, and thelarche and skeletal growth seem appropriate in timeline and are occurring before menarche. Answer C is incorrect. Although maternal and sibling pubertal changes are a good estimate of pubertal timing, the patient in this case is showing other signs, indicating a possible earlier menarche than their mother. Answer D is incorrect. Height growth potential continues for 2 to 2.5 years after menarche.

Correct Answer: C. This 8-year-old has a completely normal prepubertal physical examination. There is no evidence of puberty. The light hairs on the mons may be categorized at SMR stage 2; however, pubarche significant of sexual development pubic hair is categorized more at SMR stage 3 with pigmentation and thickening of the hairs. Mons hair growth can occur before axillary hair, but there are cases when the axillary hair develops first and can be normal. Answers A, B, and D are incorrect. Neither laboratory workup, imaging, or medical intervention is needed in this case. Adrenarchal development at younger than 8 years of age would be concerning for premature adrenarche.

Correct Answer: A. Breasts at SMR stage 3 and 5 can appear similar in contour, and overall breast size is not always helpful, as it is not a marker of pubertal change. Based on normal pubertal steps, menarche would be most likely to have occurred already at SMR 5 (typically in SMR 4 breast stage) and would be helpful in differentiating an SMR 3 from SMR 5 breast examination. Answer B is incorrect. Although the growth spurt should be complete by the time of menarche, it may still be occurring during SMR 3 development. Answer C is incorrect. A patient’s report of pubic hair is wonderful but may lack the specificity on the distribution and texture that we rely on for pubic hair SMR staging. Answer D is incorrect. Breast tenderness is highly variable and not specific to any one SMR stage. It can occur at the time of breast budding (SMR 2), and may continue throughout later stages of puberty and adulthood, often in a cyclical nature related to menses.

Correct Answer: C. A girl with features of Turner syndrome who has ovarian insufficiency will have an elevated FSH if bone age is at least 10 years. Answers A and D are incorrect. A pubertal child with functioning ovaries can have an FSH of 9 IU/L and estradiol of 96 pg/mL. Answer B is incorrect. A prepubertal child will have an LH below the limits of assay detection.

Correct Answer: D. The child has had normal pubertal timing and development without any evidence of a syndrome, and her cyclic pelvic pain suggests she may be having menstrual sloughing without evacuation of vaginal blood. This strongly suggests imperforate hymen. Answer A is incorrect. A webbed neck is often seen in Turner syndrome, which in 90% of girls will not result in menarche. Answer B is incorrect. Delta-shaped ears can be seen in CHARGE syndrome, which is often accompanied by delayed puberty with late or no development of secondary sex characteristics. Answer C is incorrect. Children with Russell-Silver syndrome have a small mandible and triangular facies; they can experience central precocious puberty.

Correct answer: B. A child with a hypothalamic hamartoma can have central precocious puberty, which can be suppressed until additional physical and emotional growth occur. Suppression is best accomplished using an Gonadotropin releasing hormone (GnRH) analogue that stops pulsatile LH and FSH release. Answer A is incorrect. Hormone replacement with transdermal estrogen and oral progesterone would continue menses and bone age advancement and compromise final adult height. Answer C is incorrect. An aromatase inhibitor is sometimes used for children with McCune-Albright syndrome, a cause of peripheral sexual precocity, to lower estrogen levels but does not have a mechanism of action to prevent LH and FSH stimulation of the ovaries. Answer D is incorrect. Intramuscular depot progesterone injections would not prevent bone age maturation, so final height would be compromised, and unpredictable menstrual bleeding might still occur.

Correct Answer: C. Constipation is often associated with urethral prolapse. Answer A is incorrect. Urethral prolapse occurs in states of hypoestrogen and is not associated with precocious puberty. Answer B is incorrect. Chronic pulmonary conditions with sustained increased intra-abdominal pressure may be associated with urethral prolapse, not allergic rhinitis. Answer D is incorrect. Uterine prolapse is rare and not associated with urethral prolapse.

Correct Answer: D. Although usually sporadic, risk factors for infantile hemangiomas include prematurity, advanced maternal age, placental abnormalities, female gender, and low birth weight.

Correct Answer: A. The treatment of CPP includes long-acting GnRH analogue therapy until the normal age of pubertal onset. Answer B is incorrect. Cystectomy is reserved for an adrenal or ovarian tumor. Answers C and D are incorrect. Aromatase inhibitors and selective estrogen receptor modulators are considered in the treatment of McCune-Albright syndrome.

Correct Answer: B. This is the correct answer because menstrual periods lasting longer than 7 days in duration may be an indicator of an underlying bleeding disorder or other concern, and therefore those patients require investigation. Answer A is incorrect. Individuals who have not started menses by 13 years of age do not require further investigation unless there is a lack of breast development/pubertal development. Individuals with breast development who have not started their menses by age 15 may also require more investigation. Answer C is incorrect. This individual is 2 years post menarche, and the average cycle length intervals can vary between 21 and 45 days. Most menstrual cycles become more regular in time, and those who are older at age of menarche may have anovulatory cycles for longer than those with earlier menarche. Answer D is incorrect. It is a red flag if menstrual periods occur only every 3 months or less.

Correct Answer: C. This is the correct answer because the majority of dysmenorrhea in adolescents and young adults is primary and is associated with a normal ovulatory cycle and no pelvic pathology. Answer A is incorrect. Primary dysmenorrhea is mitigated by prostaglandin release and prostaglandin-mediated uterine contractions. Answer B is incorrect. Any individual with period complaints needs to be supported and appropriate treatment offered (even if menstrual symptoms reported are considered “normal” or nonpathologic). Periods need not interfere in someone’s functioning. Answer D is incorrect. Dysmenorrhea is common in adolescents and tends to get less common as people age.

Correct Answer: D. This is correct because studies have shown that Black adolescents begin puberty and menstruation earlier than their White peers, whereas Latinx youth have menarche between the two. It is important to note that the effects of structural racism on pubertal onset have not been adequately researched. Answer A is incorrect. The age of menarche varies globally, with the onset of both puberty and menarche appearing to occur later in lower-income countries (LICs), likely secondary to suboptimal nutritional status. Answer B is incorrect. Many variables have been identified as potential contributors to timing of menarche; for example, higher weight/BMI, more robust nutritional status, and higher socioeconomic status have all been linked with earlier onset of menarche around the world. Physical activity, sleep quality, and emotional stressors may also be important contributors to pubertal timing. Answer C is incorrect. The median age of menarche across well-nourished individuals in HICs has been relatively stable for several decades, at 12.4 years of age.

Correct Answer: B. An immature hypothalamic-pituitary-ovarian axis is the single most common cause of AUB in an adolescent. Answers A, C, and D are incorrect as they are not common in this age group

Correct Answer: B. Adolescents with HMB should undergo a workup for bleeding disorder. Eight days of bleeding is considered prolonged, and the patient has additional risk factors of frequent pad changes and nosebleeds. Answers A, C, and D are incorrect because they do not qualify as heavy menstrual bleeding

Correct Answer: D. All options may decrease bleeding over time, but norethindrone acetate is the only option used in the acute setting.

Correct Answer: A. Functional impairment dysmenorrhea leads to a major impact on a person’s work and/or school. It is a leading cause of recurrent short-term school absenteeism for adolescent girls in addition to having a negative impact on sleep, per the American College of Obstetricians and Gynecologists (ACOG). Practice Bulletin “Dysmenorrhea and Endometriosis in the Adolescent.” ⁵ Answers B, C, and D are incorrect. Primary dysmenorrhea does not have an impact on fertility, nor does endometrial cancer. Endometriosis can negatively affect fertility rates; however, it does not affect endometrial cancer risk.

Correct Answer: E. Endometriosis has been found in all body parts listed. Most commonly found in the dependent portions of the abdominal cavity, lesions are also found along the surface of the bladder and ovary. Literature reviews include a compilation of pulmonary endometriosis, which can be diagnosed via biopsy and characterized by catamenial hemoptysis. Halban’s theory of lymphatic/vascular spread supports remote locations of endometriosis.

Correct Answer: C. According to a recent Cochrane Database Systematic Review, NSAIDs appear to be a very effective treatment for dysmenorrhea. Answer A is incorrect. Laparoscopy has a role in the diagnostic process in cases of pelvic pain/dysmenorrhea resistant to NSAIDs and various regimens of hormonal methods. This approach may be also used in cases where the patient and family want to have a definitive diagnosis with a histologic technique. Answer B is incorrect. GnRH antagonists are reserved for dysmenorrhea cases resistant to NSAIDs and hormonal regulation and, ideally, for cases with biopsy-proven endometriosis because of the significant side effect profile. Answer D is incorrect. Oral contraceptive pills may be prescribed as the next step if dysmenorrhea is not controlled with NSAIDs.

Correct Answer: C. The patient’s presentation, specifically her history of an eating disorder and low BMI, are most suggestive of functional hypothalamic amenorrhea, a common cause of secondary amenorrhea. Answers A, B, and D are incorrect. Her history is not consistent with the other listed etiologies.

Correct Answer: B. The most common cause of secondary amenorrhea is pregnancy, and this should be checked in every patient before considering other causes. Answers A, C, and D are incorrect. Although the other tests listed are indicated in further evaluation of secondary amenorrhea, the first step would be to rule out pregnancy, as it is the most common cause of secondary amenorrhea.

Correct Answer: D. This is the correct answer because it is important to perform a karyotype test in patients presenting with primary amenorrhea to determine whether a Y chromosome is present. This will further help determine the etiology of the patient’s complaints and may have further implications for treatment. Answer A is incorrect. Although a serum FSH is indicated, a karyotype is more helpful in determining an etiology of the patient’s presentation. Answers B and C are incorrect. Abnormal serum prolactin and TSH are less likely to cause a primary amenorrhea with absent müllerian structures.

Correct Answer: D. This is the correct answer because the patient described has polycystic ovary syndrome (PCOS). All of the choices have been implicated in the pathogenesis of PCOS. In this disease process, insulin resistance is hypothesized to alter normal hypothalamic hormonal feedback, causing an elevation in LH and FSH, increased androgens (e.g., testosterone) from theca interna cells, and a decreased rate of follicular maturation, resulting in unruptured follicles (cysts) and anovulation.

Correct Answer: D. Menarche typically occurs 2 to 2.5 years after breast development begins. We do not start medications for suppression until after this occurs. Answers A to C are incorrect. In addition to not wanting to put patients on medications before they need it (potentially for years), it is possible that the patient may have very light periods that do not bother her. We always discuss waiting until menarche to assess whether medication is necessary.

Correct Answer: B. Recommend progestin-only pills. Answers A and D are incorrect. As this patient has a history of a deep venous thrombosis, she should not take the estrogen component of a combined hormonal option. This includes a combined pill and the vaginal ring. Answer C is incorrect. It is also important to remember that even with medical comorbidities, patients can still be sexually active.

Correct Answer: D. All answers are correct. It is important to remember that in addition to addressing a patient’s chief concern, one should offer education as part of a reproductive health visit. In addition to addressing safety, healthy relationships, and sex and sexuality, this should include topics such as physiologic changes of puberty, safe online practices, consent, and sexual abuse.

Correct Answer: C. Energy remaining for bodily functions and physiologic processes after energy for exercise has been used. Answers A, B, and D are incorrect. RED-S is based on a mismatch between energy taken in through diet and calories expended through exercise. Energy availability is what remains after subtracting exercise energy expenditure from energy intake, based on fat-free mass. This remaining energy is what is left to support daily physiologic bodily functioning. Low energy availability and relative deficiency can have negative effects on the human body in a variety of domains: menstrual disorders, impaired bone health, gastrointestinal conditions, hematologic findings, immune function, cardiovascular health, endocrinologic abnormalities, impaired athletic performance, injury, and psychological stress.

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