Vignette: Adolescent Medicine

1. PID:
a] Etiology: Most commonly: Neisseria gonorrhoeae and Chlamydia trachomatis are the commonest, but others too are implicated.

Hence: CDC says: "all women who are diagnosed with acute PID should be tested for N. gonorrhoeae and C. trachomatis and should be screened for HIV infection.

A word about GC testing: Nucleic acid ampilification test (NAAT) is the method of choice.
What sample to send for NAAT:
# When you have cervical discharges available, send that.
# Urine-based testing is indicated for young women in whom a gynecologic examination may be unnecessary (eg, for those who are asymptomatic). Urine-based testing can also be used to screen male partners
2. A usually healthy 16-year-old girl presents with left-side abdominal discomfort of 2 weeks' duration. Her last menstrual period was 3 weeks ago. Pelvic ultrasonography shows a fluid-filled cyst measuring 4.6 cm on the left ovary.
Next step is: Repeat US in 4- 6 weeks.
Ovarian Cysts:
a] Ovarian cysts, with or without associated pain, are a common finding during pelvic ultrasonography in postmenarchal adolescents.
These cysts usually are the result of persistent physiologic follicles (follicular cysts) or, less commonly, the corpus luteum that forms during the menstrual cycle.
- Small cysts (<4>80%);
- Fewer than 30% of 6- to 8-cm cysts are expected to regress spontaneously.

C/Fs:
- Many ovarian cysts are asymptomatic.
- Some patients may present with irregular menses, urinary frequency, constipation, pelvic heaviness, or significant pelvic pain. Corpus luteum cysts are associated more frequently with delayed menses and, due to their larger size, are more prone to complications, including ovarian torsion and hemoperitoneum.

b] Management: The management of an ovarian cyst in a postmenarchal adolescent is based on ultrasonographic appearance, size, and symptoms.

In general, a fluid-filled cyst (<6> that has no ultrasonographic evidence of increased echoes or debris, septation, or calcifications, such as the one found in the adolescent described in the vignette, is managed with follow-up examinations or ultrasonography. Most of these are follicular cysts that are expected to resolve in 4 to 8 weeks. However, a corpus luteum cyst, suggested by ultrasonographic appearance with a few internal echoes, may be slower to regress and, if asymptomatic, may be observed for up to 3 months. Therapy with combined Estrogen + Progesterone that suppresses the hypothalamic ovarian axis also may be offered to patients in an attempt to decrease the likelihood of future cyst formation. This is particularly important for those who have von Willebrand disease or are recipients of anticoagulation therapy because they are at increased risk for hemorrhage into a cyst.
NB: Combined estrogen and progestin contraceptive therapy does not hasten the resolution of existing ovarian cysts. New lower estrogen formulations may not be as effective in preventing future cysts compared with older generations of oral contraceptives.
Laparoscopic cyst aspiration or cystectomy and, less often, a laparotomy usually are reserved for cysts that are large (>6 to 8 cm), increasing in size, or causing significant symptoms.
Cyst aspirations have been associated with recurrences.

A cystectomy should preserve as much ovarian tissue as possible. The ultrasonographic finding of a fluid-filled cyst in a postmenarchal adolescent requires no additional imaging studies. Computed tomography and magnetic resonance imaging are useful in the further evaluation of a solid mass or cysts that have complex ultrasonographic features (that may suggest the presence of a tumor).

Depo-medroxyprogesterone acetate may reduce the risk of developing cysts, but the progestin may slow regression of follicular cysts. Therefore, it is not recommended for the patient in the vignette at the time of presentation.

3. Question 25/07
A 15-year-old postmenarcheal girl presents with persistent right lower quadrant discomfort of 6 weeks' duration and a feeling of abdominal fullness. Her last menstrual period was 3 weeks ago. Results of a urine pregnancy test are negative, and urinalysis results are normal. Ultrasonography reveals a well-defined right ovarian cyst filled with multiple echoes.

Right answer: measurement of serum tumor markers
Wrong answer: repeat USG in 4 to 8 weeks

Here the buzz word is: ovarian cyst with multiple echoes (on US). That is suspicious of malignancy.
Let us talk now:
i) Ovarian masses in adolescent girls may result from functional cysts and benign or malignant neoplasms. Ovarian cysts are very common in adolescents. Although many ovarian cysts are asymptomatic, some patients present with pain, irregular menses, urinary frequency, constipation, or pelvic heaviness.

In general, a simple, fluid-filled cyst less than 6 cm in size documented on ultrasonography may be managed with conservative observation that usually includes follow-up examinations or ultrasonography. Many of these cysts resolve in 4 to 8 weeks.

ii) However, solid masses and cysts that have USG findings suspicious for malignancy require further evaluation. Suspicious cysts have complex features, such as septations, are multiloculated, and have increased echoes or calcifications, as described for the cyst in the vignette.
Such cysts subsequently are imaged with CT or MRI to define more clearly the characteristics of a solid mass or suspicious cyst and identify liver or lung metastases. Surgical intervention is based on the radiologic images and the identification of tumor markers.

Tumor markers (eg, CA 125, alpha-fetoprotein, human chorionic gonadotropin, carcinoembryonic antigen, F9 embryoglycan) assist in the diagnosis of an ovarian neoplasm and reflect clinical response or recurrences. Accordingly, serum tumor markers should be measured in the patient in the vignette.

iii) Rx of simple cyst (not the one with malignant potential as in the vignette here):

In 4 to 8 weeks, most simple, fluid-filled ovarian cysts resolve or decrease in size, although corpus luteum cysts may be slower to regress, usually showing evidence of regression by 3 months.

Therapy with combined estrogen and progestin OCPs that suppress the hypothalamic ovarian axis has been offered to patients who have simple, fluid-filled ovarian cysts, particularly those who have von Willebrand disease or who are recipients of anticoagulation therapy. Such therapy is an attempt to decrease the likelihood of future cyst formation and the risk of hemorrhage.
4. A premenarcheal 11-year-old girl presents with a sticky, whitish vaginal discharge. On physical examination, her breasts and pubic hair are at sexual maturity rating 2. While obtaining a sample of the vaginal secretions, you note thickening of a crescent-shaped hymen. Microscopic examination of a saline preparation of the discharge reveals many epithelial cells. The vaginal pH is less than 4.5.

= Physiological leucorrhea

In most cases, physiologic leukorrhea can be diagnosed based on history, physical examination, and microscopic examination of the vaginal discharge. The discharge usually is asymptomatic; there is no associated pruritus, malodor, or dysuria. Physical examination reveals other effects of estrogen, such as early breast development or thickening of the hymen, as reported for the girl in the vignette.

5. Less Estrogen is a risk factor for osteoporosis.
Remember: E makes a (female) body. Hence role in making bones strong.
Hence: Increased risk of osteoporosis is seen in:
i) Ovarian failure : Turner syndrome, ovarian damage due to radiation or cytotoxic drugs, autoimmune oophoritis, galactosemia, and trisomy 21.
ii) Hypoestrogenic states: anorexia nervosa, the female athlete triad (disordered eating, osteoporosis, and amenorrhea), and medication-induced causes (eg, depo-medroxyprogesterone).
NB: Patients who have müllerian aplasia (Mayer-von Rokitansky-Küster-Hausser syndrome), characterized by vaginal agenesis (dimple or small pouch) and absence or hypoplasia of the upper genital structures, have normal labia and ovaries. These patients have an otherwise normal female phenotype and normal female karyotype. Although renal and skeletal anomalies are associated with müllerian aplasia, osteoporosis is not.

6. Now let us talk about Osteopenia also.
Question 34/07
A 16-year-old Caucasian girl from the NE parts of USA: presents for a health supervision visit. She drinks three to four diet sodas a day and describes herself as "couch potato." She has a h/o asthma and had been hospitalized for administration of IV methylprednisolone twice in the past year. P/E: Physical examination findings are normal. She is at SMR 4 and has had normal menses for 3 years. A year ago, she fell while walking and fractured her ulna. You are considering therapy for suspected osteopenia.

Of the following, the MOST appropriate therapy for this patient at this time is:

= oral calcium and vitamin D supplement
NOT: oral calcium and vitamin D supplement; intranasal calcitonin

i) The adolescent described in the vignette has risk factors for osteopenia (low bone density).
These include:
- living in the northeastern United States,
- not being active,
- drinking diet soda (which contains phosphoric acid),
- having received intravenous steroids,
- and already having had one fracture.

ii) The initial evaluation of a teen in whom osteopenia is suspected :
Serum calcium, phosphorus, 25-hydroxyvitamin D, and PTH
And bone mineral density.

iii) Rx: If osteopenia or hypovitaminosis D is demonstrated:

a] The initial therapy involves a calcium supplement (600 to 1,200 mg/d) and vitamin D replacement (usually 800 units of vitamin D).

Other therapies, such as alendronate, calcitonin, estrogen, and phosphorus, usually are not necessary in otherwise healthy adolescent girls.
7. Question 160/2006
After falling with all his weight onto his left shoulder, a 16-year-old soccer player complains of pain in the upper chest near his shoulder. P/E: tenderness and a slight bulge over the middle third of his left clavicle.
Radiography : a nondisplaced fracture of the middle third of the clavicle with 20 degrees of angulation.
Will you just provide a sling OR reduce it under conscious sedation?
Answer: Just sling

The pt has a nondisplaced midshaft fracture of the clavicle . Send him home in a sling or figure-of-eight dressing for 3 weeks; casting is not indicated.
i) The clavicle is the most commonly fractured bone in children. Most are greenstick fractures.
ii) Fractures of the medial clavicle in children may involve injury to the physis, with resulting anterior or posterior displacement. Computed tomography often is required to evaluate this injury fully. Particularly with posterior displacement, the trachea or mediastinal vessels may be compressed. Evidence for either should prompt immediate orthopedic consultation.

iii) Lateral fractures of the clavicle also may involve the physis, but the inferior periosteum and ligamentous structures usually remain intact, and uneventful healing is the rule.

8. Question 57/07
A 16-year-old girl: RUQ pain, right shoulder pain, and nausea. Afebrile. She has been taking combined OCPs for 6 months. USG of the gallbladder performed after an emergency department visit 2 days ago are normal.
Of the following, the most appropriate NEXT step in the evaluation of this patient's pain is:

= pelvic examination

False Answers: computed tomography scan of the liver; US abd; hepatobiliary scintography; H breath test
Think of Fitz- Hugh-Curtis syndrome here! Thus pelvic exam.
i) Fitz-Hugh-Curtis syndrome, a perihepatitis, is a complication of PID associated with chlamydial or, less commonly, gonococcal infections.
The perihepatitis involves the liver capsule and surrounding peritoneum and presents as right upper quadrant pain, as described for the girl in the vignette.
The diagnosis of Fitz-Hugh-Curtis syndrome initially may be overlooked because of the absence of associated lower abdominal symptoms.

Right upper quadrant pain coupled with a high index of suspicion, evidence of PID, and lack of evidence for hepatitis, gallbladder disease, or pancreatitis form the basis for diagnosing Fitz-Hugh-Curtis syndrome.

NB: A hydrogen breath test is particularly useful for the evaluation of lactose intolerance in adolescents who have recurrent abdominal pain.