Common Teen Gynecology

Jesse Barondeau, MD FAAP

Division leader of Adolescent Medicine

Children’s Nebraska/UNMC

Outline

• Normal range of menarche and regularity
• Oligomenorrhea/PCOS
• Anatomical
• Endocrine
• Menorrhagia
• Normal anovulatory
• Infection
• Hormonal
• Infection
• Vaginitis
• STI
• Syphilis increase
• Gc/ct
• Birth control
• Pregnancy
• Where to get condoms or testing
• Spanish resources or resources to teach developmentally appropriate reproductive health

Old time videos

• https://youtu.be/8W14YssL_Cs?si=kmEdTQLmoYYwOcYm
• Real life video
• https://youtu.be/vG9o9m0LsbI?si=qLR2F617cMk7me5_
• Disney cartoon

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Ranges of female pubertal development

• Thelarche (8-14yo) classically
• Avg- 9.5-10.5 (race dependent) darker skin=earlier
• 6 months= adrenarche
• 2yrs= menarche or up to 4 yrs later is out of norm
• Regular cycles in 1-3yrs
• All done in around 4 yrs

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• Avg age of menarche= 12

Adolescent development- NORMAL RANGE�Physical- SMR or Tanner staging

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Adolescent development�What’s abnormal?

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• Precocious puberty (has changed)
• Complicated by ethnic and population differences, but
• <8 in females
• <9 in males
• Average age
• Menarche- ~12
• Boys Start ~12

Cognitive development

Cognitive Development

Eating Disorders

ADHD

ADHD

Anx/dep

Anx/dep

Anx/dep

Anx/dep

Eating Disorders

ODD/CD

ODD/CD

ODD/CD

Bipolar

Menstrual irregularities

Contraception

Contraception

Primary Amenorrhea

• No bleeding by age 14-15 without secondary sex characteristics
• No bleeding by age 16
• No bleeding 1 year after attaining

SMR 5

• No bleeding 4 years after breast development (usually 2-2.5 years)
• No bleeding with stigmata of Turners Syndrome

Primary Amenorrhea- Causes

• Pregnancy
• Anatomical: Imperforate hymen, transverse vaginal septum, abnormal cervix
• No uterus: androgen insensitivity (46XY), 5 alpha reductase def (46XY), Rokitansky Kuster Syndrome (46XX), Turner Syndrome (45XO)
• Ovarian failure- Post-chemotherapy
• Chromosome abnormality- Turner (45XO) or Noonan
• Autoimmune gonadal destruction
• FSH receptor deficiency
• Functional
• Eating disorder
• Chronic illness/stress
• Delayed puberty
• Pituitary disorder

Secondary Amenorrhea

• After previous menses, no subsequent menses for 6 months

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• OR a length of time equal to 3 previous cycles

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• 1^st year after menarche “doesn’t count”

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Secondary Amenorrhea- Causes

• Endocrine/hormone:
• PCOS- hyperandrogenism
• Prolactinoma- pituitary problem
• Hypothyroidism

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• Medications: anti-psychotics
• Eating disorders

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Oligomenorrhea

• Similar to secondary amenorrhea.

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• PCOS/hyperandrogenism is most likely cause
• Hypothyroidism
• Eating disorder
• Female athlete triad
1. Low energy
2. Weakened bones
3. Menstrual dysfunction

PCOS

• Oligo/amenorrhea
• Hyperandrogenic signs (lab or PE)
• US- polycystic ovaries (don’t have to do this)

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PCOS-causes

• Increased androgens: DHEAS (adrenal), testosterone (ovary)
• Hyperinsulinemia (happens in puberty for all)
• Elevated LH- stimulates theca cells – increased androgens
• IGF-1 and decreased IGFBP1- stims theca cells, insulin resistance,
• LH:FSH >3 (not always), FSH may be normal or low

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Sequelae/treatment

• Anovulation/oligomen- OCPs or just progesterone challenge every 6 wks
• Hirsutism- cosmetic, OCP, spironolactone
• Obesity- lifestyle…Metformin??
• Metabolic
• Insulin resistance- metabolic syndrome or DM2- metformin may help. Screen glucose maybe Q2yrs
• Hyperlipids- Screen at least once, may repeat Q2yrs
• Metformin- activates ovulation/fertility
• Watch out for pregnancy!!!

Menorrhagia & metrorrhagia

Too much and for too long

• Infection
• Pregnancy-miscarriage
• Anovulatory- immature hypopit-gonad axis
• Coagulopathy

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Case - Abnormal Uterine Bleeding

• A 15 y/o comes in complaining of a period that has been going on for 6 weeks
• Menarche at age 13
• Menses have been irregular with intervals of 2-3 months
• What else do you want to know?
• Vitals and exam normal

What went wrong?

1. No progestin withdrawal
2. Anovulation still the most likely cause
3. With no progestin withdrawal, lining grows until it can’t support itself
4. Incomplete AB?

This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute.

Case

• Evaluation the same as if they are having no bleeding (secondary amenorrhea causes)
• Pregnancy not likely, but painful bleeding needs evaluation for ectopic
• Consider sexually transmitted infections (STI)

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This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute.

Case

• What labs?
• (Pregnancy test)
• LH / FSH
• Thyroid function tests
• Prolactin
• ADD a CBC
• Don’t forget hyperandrogenism / obesity labs
• Consider pelvic exam
• Consider STI labs

This presentation is the intellectual property of the author/presenter. Contact them for permission to reprint and/or distribute.

Case

• Treatment:
• If she is not anemic you have many options
• Give enough estrogen to stabilize the overgrown endometrial lining to stop the bleeding, then have a normal progestin withdrawal bleed
• Any monophasic 30-35 mcg OCP ( I like Lo-Ovral)
• BID until bleeding stops, then one a day until the pack is gone
• Will have withdrawal bleed when she reaches placebo week
• Then can wait and see what happens, or continue with new pack of OCP’s if appropriate or she desires (not Lo-Ovral)

Case

• If she cannot take an estrogen containing medication, then could just treat with “Progestin challenge” dose of progestin
• Will continue to bleed while taking pills, then should have a withdrawal bleed, but then should stop – obviously a delayed fix in a population not known for their patience

Case

• In the case of a patient with signs or symptoms of anemia or hypovolemia (shock) you may need to get the bleeding under control more quickly
• Dose 4 times per day (with antiemetic)
• Generally requires admission to manage side effects of high dose estrogens
• Definitely requires admission for signs of shock or Hgb less than 9

Case

• High dose OCP – 50mcg estrogen (Ovral)
• QID with antiemetic
• If bleeding not slowing after two pills switch to IV conjugated estrogens – 25mg q 4-6 hours until bleeding stops
• If not stopping after 24 hours consider GYN consultation for possible D&C

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Case

• In a patient admitted for bleeding problems, consider:
• Coagulopathy
• Anatomic problems
• Pursue the appropriate evaluation in consultation with GYN or Heme/Onc

Sexually transmitted infections

• Chlamydia
• Gonorrhea
• Syphillis
• HIV
• Herpes Simplex Virus
• HPV
• Unusual ones

• A 16yo F comes into the clinic for a sore throat. She describes typical URI symptoms (rhinorrhea, congestion, cough). During HEADSS questioning she admits to having sex in the past with 1 partner. You ask “Did you use condoms everytime?”. She replies “Yes!”

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• How often were condoms used?
• What would you like to screen her for?

• A 16yo F comes into the clinic for vaginal discharge and dysuria. She had unprotected sex 3 days ago and her partner later told her she should get tested.

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• What would you like to screen her for?

• A 16yo F comes into the clinic for vaginal discharge and dysuria. She had unprotected sex 3 days ago and her partner later told her she should get tested.

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• CT is positive only- what to treat with?
• GC only- what to treat with?

Chlamydia

• Most common ‘nongonococcal urethritis’
• Others: Ureaplasma urealyticum, Mycoplasma genitalium, Trichomonas vaginalis
• All treated the same but not + on Gc/CT
• Also causes LYMPHOGRANULOMA VENEREUM
• Painless vesicles leading to unilateral inguinal lymphadenopathy and may rupture.

Gonorrhea

• CLAP
• Think about pharyngitis!
• Can disseminate- arthritis, dermatitis, meningitis, endocarditis
• Azithromycin can add to ceftriaxone efficacy

• A 16yo F comes into the clinic for vaginal discharge and pelvic pain. She had unprotected sex 10 days ago and her partner later told her she should get tested. She has mucopurulent discharge on exam and CMT.

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• What does she have and how would you treat?
• What are criteria?

PID criteria

• CMT, adnexal tenderness, or uterine tenderness are all you need for dx.
• Enhance suspicion or support dx.
• Fever >101
• Mucopurulent discharge
• Abundant WBC on microscopy
• High ESR
• High CRP
• GC/CT + testing

• A 17yo F comes for f/u after finding a positive GC/CT test on a screening test and being treated appropriately. He was treated and is now fine
• What about HSV??
• If symptomatic- culture of sores or serology
• If partner has known infection.
• Asymptomatic- maybe if multiple partners
• Serology and cultures are poorly sensitive
• False positives are more common
• Teens have low incidence of HSV

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Syphillis

• Remember
• Primary- painless chancre w/ tender inguinal nodes
• Secondary- maculopapular skin rash and condylomata lata
• Latent- no signs
• Tertiary- cardiac, neuro, ophtho, gummas
• RPR or VDRL then treponemal tests (TP-PA or fluorescent treponemal Ab test)

Insert <1 hour before sex.

Topics

• Indications
• Contraindications
• Options and brief description
• Drug interactions
• Oops- pregnancy

Indications

• Acne
• Dysmenorrhea
• Abnormal Uterine Bleeding or irregular menses
• PCOS
• Not want to get pregnant….duh!!

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Contraindications- WHO (Estrogen)

• H/O DVT/PE
• Known thrombogenic mutation (Factor V, Protein S/C)
• Migraine w/ aura
• Breast-feeding <6wks
• Stage 2 HTN
• Major surgery planned
• Heart disease
• Stroke
• Breast Cancer
• Liver Disease

How it works

• Estrogen- Controls menses (Not pregnancy)
• “normal” dose: 30-35ug… w/o side effects, good to start on
• “low” dose: 20-25ug… for estrogen related side effects
• High dose: 50 ug…use with other meds inducing hepatic enzymes
• Progestin- Prevents Pregnancy
• Androgen side effects except drosperinone (Yasmin)
• Increased clotting potential? Slightly
• 2-3/10,000 vs 4/10,0000

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Efficacy

• <1% in trials. 8% for typical use.
• One trial: compared patient diaries with computer chip monitoring
• 1^st cycle- 60% reported perfect use….Computer said 33% had perfect use
• 3^rd cycle- computer reported >50% missing more than 2 pills.

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Efficacy

• Body wt: Some studies show connections btw weight and failure rates.
• Some show connections with lower-dose formulations.
• Heavier women are at increased risk for thrombosis, especially with higher-dose estrogen
• At this point, something is safer and better than nothing, but should probably discuss this with pts.
• Other options: abstinence and losing weight.

Drug Interactions

• Depends on action of hepatic enzymes- increases clearance of hormones
• Anticonvulsants: (Also teratogenic)
• Barbituates, phenytoin, carbamazepine, felbamate, topiramate, and vigabatrin
• IUD or progestin injection may be better
• May try 35ug EE w condoms and assess breakthrough bleeding– increase to 50ug (not proven)

Drug Interactions

• Antibiotics
• Rifampin and griseofulvin: only 2 agents that affect levels
• Isoniazid can increase transaminases and mask an estrogen-induced hepatoma.
• -cyclines, -cillins, quinalones, metronidazole…do nothing
• St John’s Wort: Increased spotting, large follicles, and ovulation detected
• Tobacco- increases metabolism

Copyrights apply

Pill Initiation

• Conventional:
• Start on 1^st day of menses.
• Problematic if irregular or oligomenorrhea or adolescent
• Sunday:
• Start Sunday after next menses
• Up to 25% of teens never start OCP when told to use these methods.
• 2002 study: Quick start vs conventional
• 3 months later: 72% vs 56%

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Quick Start- DO THIS!!!

• Start now.
• Keep it simple
• HCG prior is a good idea
• Not because of teratogenic fears
• Only other question is whether or not to provide EC also.

Mono vs multiphasic

• Mono phasics- same dose every time

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• Tri phasics- changes dose every week.
• Can’t do extended cycling with these.
• No real significant advantage.

Extended Cycling

• Only do placebo once every 3 months!!
• Any hormonal option.

Options

• OCP- Easy to forget. Most commonly known.
• Many brands
• My 1^st is Ortho-Cyclen/Sprintec
• Yasmin for PCOS or overweight: Clotting concern
• If patient is uncomfortable with clotting concern than Ortho-Cyclen

What if you forget a pill?

Birth control myths

• Weight gain
• Causes Infertility
• Causes abortion or harm fetus

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ORTHO-EVRA�THE PATCH

General information

• Left in place for 7 days and replaced weekly for 3 weeks, no patch during 4^th week
• Efficacy comparable to OCPs
• Compliance is better than with OCPs
• Women who weigh >200 lbs had increased risk of pregnancy
• Small percentage discontinue due to local skin irritation

NUVARING�THE RING

General information

• Introduced in 2001
• Ethinyl estradiol and etonogestrel
• Etonogestrel is the biologically active metabolite of desogestrel
• Left in place for 3 weeks
• Removed during 4^th week
• Efficacy is similar to OCPs
• Compliance better than OCPs
• Small number report leukorrhea and vaginal irritation

Annovera

General

• First injection should be during menses
• Only contraindication is pregnancy
• Most common adverse effect is menstrual changes
• Amenorrhea is common
• 40% during first 3 months
• 60% by 12 months
• Average weight gain 4.4 lbs (increased caloric intake, NOT THE SHOT)

DMPA and bone density (2004 black box warning)

• May decrease bone density
• 60% of bone mass acquired during adolescence
• May increase risk of osteopenia and osteoporosis later in life
• Studies showed 1.5% decrease in BMD after 1 year & 3.1% decrease over 2 years (this was in contrast to increase in BMD in controls)
• BMD increases after discontinuation
• Probably should not be used in patients at risk for osteoporosis such as chronic renal disease and anorexia nervosa

Professional Society Recommendations

• ACOG guidelines- advantages outweigh the theoretical concerns
• SAM position paper- benefits outweigh the potential risks, continue without any restrictions on duration of use
• WHO recommendations- no restriction on use or duration of use, benefits outweigh theoretical concerns

Monthly injectable hormonal contraception

• Lunelle
• 5 mg estradiol cypionate & 25 mg medroxyprogesterone acetate
• Adverse effects and contraindications are similar to those of OCPs
• BMD not affected and menses are regular because it contains estrogen
• Not popular among adolescents since these are monthly shots

IMPLANON-NEXPLANON�IMPLANTABLE CONTRACEPTION

General information

• Implanon-
• Contains etonogestrel- active metabolite of desogestrel
• Available in U.S. in 2005 but around in Europe since 1998
• Highly effective
• Remain in place for 3 years 🡪 5 years!
• Associated with irregular bleeding during first year
• Great for those who cannot remember a pill daily
• Headache is another common side effect
• No bone mineral density problems

Mode of action

• Inhibits ovulation
• Thickens cervical mucus
• Alters lining of the uterus
• Ovulation and fertility return within 3 months

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IUD

IUD

• Paragard- 10yrs 🡪 12
• Mirena- 7🡪 8
• Liletta (generic)- 7🡪 8
• Kyleena- 5🡪 6
• Skyla- 3

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General information

• Failure rate is 0.3%
• Old news/myth: Questionable whether to use in adolescents due to increased rate of infection, possible future infertility
• STI risk increased for about a month.
• Contains levonorgestrel which gradually releases over 5 years
• Useful for adolescents with severe menorrhagia & dysmenorrhea

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Mode of action

• Prevent sperm from fertilizing the ova or prevent implantation
• Ovulation frequently occurs
• Prevention of endometrial growth
• Thickening of cervical mucus
• Inhibition of sperm mobility & function
• Fertility rapidly returns after removal

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Copper IUD

• Releases small amounts of copper that kills or immobilizes sperm before fertilization of egg
• Can be removed at any time
• Should be replaced after 12 years

Emergency Contraception

• Yuzpe: 2 doses of 100ug EE and 0.5 mg levonorgestrel, 12 hrs apart
• Plan B: 1.5 mg of levonorgestrel; OTC!
• 0.75 mg of levonorgestrel Q12H x2 or 1.5 mg x1
• Ella: Progestin receptor…not OTC
• ulipristal 30mg; most effective oral EC
• More consistent for higher weight individuals
• Copper IUD
• Rare use

Timing

Yuzpe(Reduction in Preg Rate)

• <24 hrs: 77%
• 25-48hr: 36%
• 49-72hr: 31%

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• 72-120 hrs: may be no difference btw groups.

Levonorgestrel

• 95%
• 85%
• 58%

Pregnant

• Keep child
• Adoption
• Abortion

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• Don’t tell over phone
• Prenatals
• High Risk OB

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Good resources

• https://www.teenhealth101.org/
• https://amaze.org/

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• https://youngwomenshealth.org/

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• https://youngmenshealthsite.org/

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• https://www.girlshealth.gov/

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Old time videos

• https://youtu.be/8W14YssL_Cs?si=kmEdTQLmoYYwOcYm
• Real life video
• https://youtu.be/vG9o9m0LsbI?si=qLR2F617cMk7me5_
• Disney cartoon

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My contact info

• Office phone – 402-955-4140
• Cell phone- 253-273-8248
• Email: jbarondeau@childrensnebraska.org

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