Phenotypic Characterization of Polycystic Ovary Syndrome in Adolescents Based on Menstrual Irregularity

OBJECTIVE

Polycystic ovary syndrome (PCOS) in adolescents is associated with adverse metabolic outcomes. The association of menstrual irregularity with metabolic risk among adolescents with PCOS was assessed.

METHOD

A retrospective medical record review of 366 adolescents with PCOS aged 13-18 years was conducted, from which 265 girls newly diagnosed with PCOS were included and divided into those presenting with primary amenorrhea (PA), secondary amenorrhea (SA) and oligomenorrhea (OM). Androgen concentrations and markers of metabolic risk were compared among the groups.

RESULTS

Most subjects presented with OM (PA = 17, SA = 30 and OM = 218). Subjects with PA were younger than those with OM but not different from those with SA. Mean BMI was not different between groups. Total testosterone and insulin levels were higher in PA than SA and OM (p < 0.01 and 0.02, respectively). Fasting glucose was higher in PA than OM (p = 0.048) but not different from SA. Triglyceride levels were higher in PA than SA and OM (p < 0.001 each). More subjects with PA and SA had metabolic syndrome (52%) than those with OM (29.1%) (p = 0.027). The differences in triglycerides and glucose persisted despite BMI adjustment in multivariate regression models.

CONCLUSION

Adolescents with PCOS presenting with PA are at risk of metabolic disease beyond expected based on BMI.

Fasting Glucose Changes in Adolescents with Polycystic Ovary Syndrome Compared with Obese Controls: A Retrospective Cohort Study

STUDY OBJECTIVE

To compare changes in fasting glucose among adolescents with polycystic ovary syndrome (PCOS) with those in obese adolescents without PCOS.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study of 310 adolescents with PCOS and 250 obese adolescents (age range 13 to 18 years) seen at Mayo Clinic, Rochester, MN, from 1996 to 2012.

METHODS

Included for analysis were 98 adolescents with PCOS and 150 obese adolescents who had 2 or more fasting glucose measurements separated by at least 6 months. Adolescents with impaired fasting glucose (IFG) or diabetes were excluded. Multivariate models were used to assess predictors of change in fasting glucose.

RESULTS

At diagnosis, adolescents with PCOS had lower body mass index (BMI) (kg/m(2)) and older age than obese adolescents (P < .001). Adolescents with PCOS had shorter follow-up (P = .02). Baseline fasting glucose was not different between groups. Mean change in fasting glucose was 2.4 ± 9.4 mg/dL per year for PCOS and 2.2 ± 6.2 mg/dL per year for obese adolescents (P = .83). Significant predictors for change in fasting glucose were BMI and fasting glucose at diagnosis (P < .01). Within the PCOS cohort, BMI was a significant predictor for development of IFG (P = .003). Prevalence of hypertension increased in the PCOS cohort from baseline to follow-up (P = .02). PCOS and BMI were significantly associated with development of HTN in the entire cohort.

CONCLUSION

Adolescent girls with PCOS do not show a significant change in fasting glucose or an increased risk for the development of IFG compared with obese adolescents. BMI, not PCOS status, was the strongest predictor for changes in fasting glucose and development of IFG over time.

Intermediate and Long-term Outcomes of Giant Fibroadenoma Excision in Adolescent and Young Adult Patients

Giant fibroadenomas (5 cm or greater) are benign breast masses that often present in adolescence and require surgical excision. Long-term outcomes, recurrence rates, and the need for additional reconstructive surgery in this population are unknown. Patients aged 11-25 years whose pathology reports indicated the presence of a giant fibroadenoma were eligible for this study. Medical records were reviewed for presentation, treatment, and outcomes. A subset of patients completed an investigator-designed long-term outcome survey to measure additional outcomes and the desire or need for subsequent reconstructive surgery. Forty-six patients with at least one giant fibroadenoma (mean size 7.4 ± 2.8 cm) were identified. Most patients underwent excision with a periaroeolar incision (n = 31), and an enucleation technique (n = 41), and four patients underwent immediate breast reconstruction. Thirty-three patients had complete medical records with a mean follow-up time of 2.2 ± 4.1 years and no complaints of asymmetry, additional breast deformities, or reconstructive surgery procedures documented. In addition, nine patients completed the investigator-designed survey with a mean follow-up time of 10.1 ± 8.7 years (range 1.5-27.0). Three of these patients reported postoperative breast asymmetry and the desire to pursue reconstructive surgery. Aesthetic outcomes of giant fibroadenoma excision may be satisfactory for many patients without immediate reconstruction, but for others, the need for reconstructive surgery may arise during development. Providers should address this potential need prior to discussing treatment options and during postoperative follow-up. Caution should be exercised before recommending immediate reconstruction.

A hemangioma of the cervix in childhood can be a harbinger of menorrhagia and infertility as an adult

Early diagnosis of uterine hemangiomas may direct management decisions improving long-term outcome in children, adolescents and adulthood.

Gynecomastia in adolescent males

Gynecomastia is defined as an enlargement of the male breast. It is often benign, and can be the source of significant embarrassment and psychological distress. A general medical history and careful physical examination are essential to distinguish normal developmental variants from pathological causes. Treatment is geared toward the specific etiology when identified. In the majority of cases of pubertal gynecomastia, observation and reassurance are the mainstays of therapy as the condition usually resolves naturally. Pharmacological treatment and surgery are recommended only in selected cases.

Breast carcinoma in young women

OBJECTIVE

To estimate the incidence of breast carcinoma and survival in patients younger than 25 years old, and to describe presenting clinical signs and symptoms of breast cancer in this age group.

METHODS

A population-based descriptive study and case review in Olmsted County, Minnesota, was conducted using the resources of the Rochester Epidemiology Project. Participants were Olmsted County girls and women younger than 25 years old with histopathologically confirmed breast carcinoma diagnosed between 1935 and 2005. Nonresidents who presented to a medical facility within Olmsted County during this time period were included in some portions of the analysis. Main outcome measures were age-adjusted incidence, 5-year survival, and clinical presentation of breast carcinoma in girls and women younger than 25 years of age.

RESULTS

With four breast carcinomas observed in Olmsted County residents over 1,201,539 person-years, the annual age-adjusted incidence of breast cancer in this population was 3.2 per million (95% confidence interval, 0.1-6.2). All four cancers occurred in the 20- to 24-year age group (age-specific incidence, 16.2 per million). Eight additional cases of breast carcinoma were identified in nonresidents. Delay in diagnosis was common. All had at least one feature worrisome for an aggressive neoplasm identified in their clinical history, on physical examination or by imaging.

CONCLUSION

Breast carcinoma in young women is very rare, associated with delayed diagnosis, and usually associated with concerning features requiring biopsy.

LEVEL OF EVIDENCE

III.

Mucinous cystadenoma of ovary in a patient with juvenile polyposis due to 10q23 microdeletion: expansion of phenotype

Juvenile polyposis syndrome (JPS) is a hereditary condition characterized by development of gastrointestinal polyps, and caused by mutations in SMAD4 or BMPR1A genes. Juvenile polyps can also be found in a related group of syndromes with multisystemic involvement including Cowden disease, Lhermitte-Duclos disease, Bannayan-Riley-Ruvalcaba syndrome, and Proteus-like syndrome, all grouped as PTEN hamartoma tumor syndromes (PHTS). In all these conditions including JPS, polyps manifest in older childhood or early adulthood. Infantile juvenile polyposis (JPI) is a rare entity, presenting in the first year of life with severe gastrointestinal symptoms. Many of these patients have associated macrocephaly, hypotonia, and congenital anomalies. It was recently recognized that patients with infantile polyposis have a 10q23 microdeletion, involving both BMPR1A and PTEN genes. There is a major risk for gastrointestinal malignancies in these patients, but the risk for development of other tumors is not known. We describe a patient with a history of infantile polyposis, macrocephaly, developmental delay, hypotonia, and a 10q23 microdeletion. At age 14 she presented with bilateral mucinous cystadenoma of the ovary. This type of tumor was not previously reported in association with JPS, 10q23 microdeletion syndrome, or infantile polyposis. We believe that ovarian cystadenomas may be another neoplastic complication of infantile polyposis, and that our report widens the spectrum of the 10q23 microdeletion phenotype.

Establishment of normative data for the amount of breast tissue present in healthy children up to two years of age

OBJECTIVE

To establish a set of normal values for breast size in children up to two years of age, and to assess the effects of gender, gestational age, and type of feeding and growth parameters on breast size.

DESIGN

Prospective cohort study over 20 months

SETTING

The Mayo Clinic Rochester, MN, neonatal nursery and Community Pediatrics Clinic.

PARTICIPANTS

Well term infants and children through two years of age.

INTERVENTIONS

Measurement of breast size based on previously described methods to yield a figure called the breast unit.

MAIN OUTCOME MEASURE

Transformation of breast unit size into percentiles according to age.

RESULTS

The 50(th) to 99(th) percentiles for 810 healthy term Caucasian infant visits were calculated. The 50th breast unit percentile was similar in males and females at birth and declined with age following a quadratic relationship for females and a cubic relationship for males. Breast tissue in female infants remained larger and persisted longer. Palpable breast tissue was still present in 45.2% of male and 61.6% of female visits after 10 months of age. At age 18 months, 5% of girls had a breast size unit greater than 2.88 cm(2) and 5% of boys had a breast size unit greater than 1.00 cm(2).

CONCLUSIONS

These data allow creation of normal standards of breast size for age, which could provide a future clinical tool to assist clinicians in the evaluation of early childhood breast enlargement in similar populations.

Occurrence of two rare malignant neoplasms (breast and ovarian) in an adolescent female

BACKGROUND

Phyllodes breast tumors, particularly malignant ones, are rare in adolescents. Tumor behavior does not correlate with histopathology. This case of an adolescent with a malignant phyllodes tumor, followed by the occurrence of a borderline ovarian tumor, also uncommon in adolescence, may shed light on our understanding of phyllodes and uncommon gynecologic malignancies in the young.

CASE

A-14 year-old Caucasian female underwent wide local excision of a 4-cm malignant phyllodes breast tumor. At 17 years of age she had excision of a serous borderline tumor of the ovary.

COMMENTS

The occurrence of two rare neoplasms in an adolescent female raises questions about a common underlying etiology, such as a genetic mutation. Genetic evaluation of minors is a sensitive and complex issue. Natural history studies regarding phyllodes tumors presenting in adolescence are needed to establish recommendations regarding best practice, including the role of genetic evaluation in this population.

Sexual activity and other risk-taking behaviors among Asian-American adolescents

STUDY OBJECTIVE

The purpose of this paper is to review the existing literature of sexual activity and risk-taking behaviors among Asian-American youth.

DESIGN

Literature review of sexual activity, alcohol, tobacco, and illicit drug use among Asian-American adolescents.

RESULTS

Asian-Americans are the fastest growing racial group in the United States. Asian-American adolescents report lower involvement with sexual activity than all other racial/ethnic peer groups. Once initiated, however, Asian-American adolescents have sexual behavior patterns comparable to other adolescent groups. In general, Asian-Americans have low rates of alcohol and tobacco usage and the males have higher use rates than the females. Degree of acculturation in the United States appears to be associated with risk-taking behavior. Asian-American adolescents also initiate smoking later than other groups. Although drug use among Asian-American adolescents is historically low, there appears to be variability on the level of illicit drug use among certain Asian-American adolescent subgroups.

CONCLUSION

Clinicians should focus prevention efforts and education on the Asian-American groups associated with higher risk-taking behaviors, particularly males and those who are more acculturated. Furthermore, to benefit Asian-American youth, anti-smoking education should continue through high school and early adulthood.

Adolescents' knowledge of and attitudes toward Minnesota laws concerning adolescent medical care

BACKGROUND

Healthcare delivery to adolescents involves consent to care, confidentiality, and reimbursement in attendance to patients' medical problems. State laws address the medical care of minors with respect to privacy and autonomy. This study was conducted to determine adolescents' knowledge and attitudes toward the laws in their state, Minnesota, that influence their medical care. This information may guide health care providers in their education of adolescent patients, as well as advise future legislation on the healthcare of minors.

METHODS

Written questionnaires were administered to 636 9(th) through 12(th) grade students in required classes at the three public high schools in Rochester, MN, providing a representative sample of approximately fifty participants from each of the four grades. Results from the sixteen-question, anonymous survey were compiled to calculate an overall median knowledge score. Median scores were also reported by individual question, policy category, gender, grade, and socioeconomic status. Adolescent opinion was scored on a system in which +1 signified a "good law," 0 "neither a good nor bad law," and -1 a "bad law." These opinion scores were used to determine adolescents' attitudes by category as well as an overall positive, negative, or neutral opinion toward the laws.

RESULTS

594(93.4%) students returned surveys. Adolescents obtained a median score of 31.3% (range, 0-100%) correct on a knowledge test. Opinion score was positive, with a median of + 0.38. 81.1% of adolescents reported that the laws in the survey had no effect on their lives.

CONCLUSIONS

These results indicate that adolescents are not knowledgeable of Minnesota laws regarding their medical care. Overall opinion of the existing laws is positive, particularly of those laws that protect minor consent. Most adolescents feel that these laws have not affected their lives. Low knowledge and a lack of a sense of impact from these laws indicate a need for clinicians to educate patients and their families about the legal aspects of adolescent medical care. These results are particularly relevant at a time when changes to current minor health care legislation are under consideration.

Physician knowledge and attitudes of Minnesota laws concerning adolescent health care

STUDY OBJECTIVE

To determine physicians' knowledge and attitudes of medico-legal issues affecting adolescent health care.

DESIGN, SETTING, PARTICIPANTS

A cross-sectional, mailed survey was distributed to 900 randomly selected primary care physicians in Minnesota, and all eligible physicians in Olmsted County.

INTERVENTIONS

Physicians were mailed a survey with questions concerning Minnesota consent and confidentiality laws.

MAIN OUTCOME MEASURES

Physician knowledge and attitudes of consent and confidentiality laws.

RESULTS

A total of 317 (26%) surveys were returned. Olmsted county physicians achieved a median score of 37.5% and non-Olmsted physicians achieved a median score of 50% correct on a test of knowledge. Using a scoring scale where -1 signified "a bad law," 0 signified "neither a good nor bad law," and +1 signified "a good law," attitude regarding the laws was a median of +0.5 for both groups. In all, 41.1% of Olmsted physicians and 51.7% of non-Olmsted physicians felt that the laws had affected them or their practice. Olmsted physicians were compared to a cohort of Olmsted parents previously reported, with statistically significant differences noted.

CONCLUSIONS

Results suggest that primary care physicians are not knowledgeable of Minnesota laws affecting adolescent health care. Opinion of these laws was positive, with notable exceptions. Physicians lack a sense of impact of laws affecting adolescent health care. Physicians were more knowledgeable and felt more positively about the laws than did parents of adolescents. Lack of knowledge and the presence of certain attitudes identify areas where physicians could benefit from greater understanding.

Breast disorders in adolescent females

This article reviews the recent medical literature on breast disorders in female adolescents. Most of the articles are reviews or case reports, because there is a paucity of primary research, particularly controlled prospective studies, in this area. The papers reviewed are clinically relevant, particularly in the evaluation of an adolescent with a breast mass. The information on early life factors (genetic and acquired) on subsequent risk for breast cancer later in life should be useful in our provision of anticipatory guidance to our adolescent patients regarding their breast cancer risk. The emerging literature on ethical issues raised by BRCA genetic screening is particularly important as we consider testing for our young patients.

Legal issues in reproductive health care for adolescents

Adolescents need reproductive and sexuality-related health care. State and federal laws affect consent, confidentiality, and payment for services. State minor consent laws allow minors to consent based on the minor's status or the services sought. State and federal laws affect confidentiality of health information generally as well as programs for specific services, such as family planning or drug and alcohol abuse treatment. Medicaid, the new State Children's Health Insurance Program, and categorical funding programs are important funding sources. Adolescents' ability to use these sources for confidential reproductive and sexuality-related services is evolving. However, possible changes in federal law and the transition to managed care in both public and private insurance present significant challenges they may face in the future.

Parental knowledge and attitudes of Minnesota laws concerning adolescent medical care

OBJECTIVE

To determine parents' knowledge and attitudes of medicolegal issues affecting adolescent medical care.

DESIGN

An anonymous, mailed survey with 16 questions concerning Minnesota consent and confidentiality laws that affect adolescents' medical care.

SETTING

A community of >70 000 in rural, southeastern Minnesota.

PARTICIPANTS

Parents of 600 randomly selected 7th- through 12th-grade public school students.

RESULTS

Two hundred eighty-eight (48%) parents returned the surveys. Parents achieved a median score of 18.8% (range, 0%-93.8%) correct on a test of knowledge. Opinion was a median of +0.3 on a scale where -1 signified "a bad law," 0 signified "neither a good nor bad law," and +1 signified "a good law." Four questions, however, generated a more intense response. Seventy-seven percent of parents reported that, as a whole, the laws in the survey had no effect on them and/or their children.

CONCLUSIONS

These results suggest that parents are not knowledgeable of Minnesota laws that affect adolescent medical care. Overall opinion of these laws was mildly positive, with notable exceptions. Parents also lack a sense of impact of laws affecting adolescent medical care. Lack of knowledge and the presence of certain attitudes allow for identification of issues that clinicians should address by incorporating medicolegal education into the care of adolescents and their families. These results are especially timely in light of the Parental Rights and Responsibilities Act under consideration in Congress, which would provide parents greater authority over their children's medical care.

Levonorgestrel contraceptive implants in female patients 14 to 21 years old

OBJECTIVE

To determine which factors are associated with duration of use of a levonorgestrel implant (Norplant) for contraception in adolescents and young adults.

DESIGN

We retrospectively studied 144 young women (14 to 21 years of age) who chose a levonorgestrel contraceptive implant at Mayo Clinic Rochester between April 1990 and December 1993.

MATERIAL AND METHODS

The following information was obtained at the time of insertion of the implant and from any follow-up visits: demographics, prior contraceptive experiences, frequency and management of complications, complications noted at removal of the implant, and subsequent contraceptive choice. The duration of use was examined.

RESULTS

Of the 144 young women who underwent insertion of a Norplant system, 75 telephoned or made a medical appointment because of implant-related side effects. During the follow-up period, 64 patients had the Norplant system removed. The Kaplan-Meier estimate of the probability of the Norplant system remaining in place for at least 12 months was 83 % and for at least 24 months was 63 %. Duration of Norplant use was not found to differ with respect to age, prior contraceptive use, or timing of insertion, but it was significantly shorter among those with a prior pregnancy than in those who had never been pregnant.

CONCLUSION

These findings suggest that a group of young women who are likely to continue use of a contraceptive implant (with or without treatment for side effects) are those who have never been pregnant.

Young Moms' Clinic: a multidisciplinary approach to pregnancy education in teens and in young single women

STUDY OBJECTIVE

To study outcome of pregnant adolescents and single young women who attended and those who chose not to attend a nonurban, developmentally appropriate, pilot antenatal clinic called the "Young Moms' Clinic." To study "perceived" outcome among the Young Moms' Clinic participants.

METHODS

A multidisciplinary clinic was established to provide education about pregnancy, childbirth, infant care, contraception, and healthy lifestyles to young mothers with similar backgrounds. Over a 2-year period, all adolescents and single young mothers aged 13-23 years were invited to attend the Young Moms' Clinic after the first trimester. The Clinic group consisted of the first 101 young women who were invited and chose to attend. The nonclinic group consisted of the first 95 young women who were invited but declined to attend. Both groups had the same obstetric care givers, had a similar number of prenatal visits (median number, 12), and delivered in the same hospital. Univariate and multivariate analyses were performed to determine whether participation in the clinic was an independent factor in outcome.

RESULTS

Maternal weight gain and infant birth weight were significantly higher in the Clinic group. Pregnancy complications (preterm labor, intrauterine growth retardation, anemia) were significantly higher in the nonclinic group. Participants in the nonclinic group were almost three times as likely to have cesarean section delivery as those in the Clinic group. Neonatal intensive care unit transfer occurred only in infants of the control group.

CONCLUSIONS

Participation of pregnant adolescent and young adult women from a nonurban community in a developmentally targeted pilot, prenatal program resulted in fewer pregnancy complications and improved outcome in comparison with those who chose not to participate in the program. The results may be subject to bias because of self-selection among participants.

Surgically treated adnexal masses in infancy, childhood, and adolescence

OBJECTIVE

We retrospectively evaluated the clinical presentation and histopathologic findings of benign and malignant adnexal masses in infants, children, and adolescents.

STUDY DESIGN

Between 1955 and 1992, 486 patients (aged 7 days through 20 years) with adnexal masses were surgically evaluated.

RESULTS

Of 521 adnexal masses, 92% were benign, including 335 nonneoplastic and 144 of 186 (77%) neoplastic lesions. The frequency of ovarian malignancies correlated inversely with patient age. Germ cell, stromal, and epithelial malignancies accounted for 40%, 21%, and 33%, respectively, of the 42 cancers. Nonconcordance between preoperative and postoperative diagnoses was noted in 94 cases. The most common preoperative diagnosis necessitating reassignment was acute appendicitis. During the last decade of this study, ultrasonography and computed tomography missed no malignancies.

CONCLUSION

Physicians who care for young girls must be familiar with the differential diagnosis of adnexal masses to advise conservative management when appropriate and surgical intervention when necessary.

Urinary oxalate and glycolate excretion patterns in the first year of life: a longitudinal study

To determine the range of normal values, we studied urinary excretion of oxalate and glycolate prospectively and longitudinally in a cohort of 30 healthy term infants. Random urine samples were obtained at 2 days, 2 weeks, and 2, 4, 6, and 9 months of age. The results had a log-normal distribution. The mean oxalate/creatinine ratio, as determined by the oxalate oxidase method, was 0.08 (in milligrams of oxalate to milligrams of creatinine) with a normalized range of 0.02 to 0.31. The mean ratio when oxalates were measured by using the Olthuis assay was 0.13 (range 0.03 to 0.53). The mean glycolate/creatinine ratio was 0.07 (range 0.02 to 0.26). These values did not correlate with increasing age. The oxalate/creatinine ratios were higher in formula-fed infants than in those who were fed human milk (0.14 +/- 0.16 vs 0.08 +/- 0.04; p < 0.01).

Episodic central neurogenic hyperventilation in an awake child with systemic histiocytosis

A 3 year old boy with systemic histiocytosis, diabetes insipidus and a lytic parietal bone lesion experienced episodes of central neurogenic hyperventilation 3 weeks after radiation to the head but was conscious and alert at presentation. At admission, the PaO2 was 133 mmHg, PaCO2 was 8 mmHg and pH 7.65. Magnetic resonance imaging revealed a pontomedullary lesion that resolved during the ensuring year. Central neurogenic hyperventilation has not been described previously as a complication of systemic histiocytosis.

Nyctohemeral changes in bone turnover assessed by serum bone Gla-protein concentration and urinary deoxypyridinoline excretion: effects of growth and ageing

1. To investigate whether there is a nyctohemeral rhythm in bone turnover, we measured serum bone Gla-protein (osteocalcin, an index of osteoblast activity) concentration every 2h and urinary deoxypyridinoline (a marker of bone collagen resorption) excretion for 8h periods in 10 pubertal girls (aged 10-14 years), 15 premenopausal women (aged 20-49 years) and 17 postmenopausal women (aged 50-75 years). 2. The serum concentration of bone Gla-protein and the urinary excretion of deoxypyridinoline were five times higher in the pubertal girls than in the premenopausal women. The urinary excretion of deoxypyridinoline in the postmenopausal women was twice that in the premenopausal women. 3. There was a nyctohemeral pattern in all age groups with mean night-time increases of 28% (P < 0.001) in the urinary excretion of deoxypyridinoline and of 5% (P < 0.001) in the serum bone Gla-protein concentration. 4. There also were nyctohemeral patterns in the urinary excretion of calcium (P < 0.02), sodium (P < 0.001) and potassium (P < 0.001), with decreases at night. There was a negative correlation between the night-time changes in the urinary excretion of deoxypyridinoline and calcium, especially in adult women (P < 0.01). 5. The serum level of parathyroid hormone increased with age, but this effect was only observed at night (01.00 to 07.00 hours). There was a nyctohemeral rhythm of the serum intact parathyroid hormone level at all ages, with a peak in the afternoon and night. 6. Thus, at night, there is a large increase in bone resorption and a small increase in osteoblastic activity, representing a nyctohemeral rhythm of bone turnover.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnostic considerations in breast disorders of children and adolescents

A review of the medical literature on breast disorders in children and adolescents leads to a number of conclusions. Though females may develop breast masses early in life, the risk of malignancy is extremely low. Therefore, most breast masses in the young can be managed conservatively without surgery. Breast masses in young girls may represent thelarche or tumors of adjacent structures, but are unlikely to be malignant. The most common form of bilateral breast enlargement in prepubertal girls is premature thelarche, a benign, transient, and incomplete form of precocious puberty. Fibroadenoma is the most common cause of breast mass in female adolescents. In the rare case in which a breast mass in this population is malignant, it is more likely to be a noncarcinomatous or metastatic cancer. Because of the low risk of malignancy and the relatively different composition of the adolescent as compared to the adult breast, mammography is not recommended for routine screening or routine imaging of breast masses in adolescents. The role of breast self-examination should be further studied.

A proposal for obstetric and pediatric management of adolescent pregnancy

Of the 1 million pregnancies among adolescents in the United States each year, approximately 500,000 result in live births. These pregnancies are at high risk but are amenable to obstetric and pediatric intervention. Medical, social, and economic risks for both the adolescent mother and her infant are substantially decreased by early and comprehensive prenatal care. A combined obstetric and pediatric protocol for the management of adolescent pregnancy can improve both the perinatal and the long-term outcome.

Survey of genitourinary organisms in a population of sexually active adolescent males admitted to a chemical dependency unit

Sixty-two males consecutively admitted to an adolescent chemical dependency unit for treatment over a one-year period were studied. When interviewed, all denied having urogenital symptoms. Forty-eight reported having had sexual intercourse. Of these 48, 34 were screened (urethral swab) for Neisseria gonorrhoeae, Chylamydia trachomatis, Ureaplasma urealyticum, and Gardnerella vaginalis. Eighteen of the 34 males who had complete screening were found to harbor one or more organisms: 3 had Chlamydia, 13 had Ureaplasma, and 11 had Gardnerella. In addition, 61 of the original 62 subjects were tested for serum antibodies to Treponema pallidum and for pyuria. No subjects were found to have syphilis. Pyuria was present in all subjects with Chlamydia but in only two with Ureaplasma or Gardnerella.

Office pediatric gynecology

The frequency and variety of gynecologic problems that can afflict young girls make the gynecologic examination an important part of every routine general medical evaluation of the child. Conversely, gynecologic problems necessitate a complete general evaluation to determine an underlying etiology and possibly associated findings elsewhere. This article will address the approach to the examination of the genitalia of the young child and the approach to diagnosis and management of the most common gynecologic conditions presenting in childhood.

Common gynecologic problems in adolescents

Gynecologic problems are the most common reason adolescent girls see physicians. Therefore, physicians who see teenagers need to be prepared to deal with common gynecologic problems in this population, such as amenorrhea, dysmenorrhea, abnormal vaginal bleeding, contraception, and sexually transmitted disease. This article will provide the primary care physician with information on these issues and advice on performing the gynecologic evaluation of the adolescent patient.

Endocrine disorders of the pancreas and adrenal cortex in pediatric patients

Hyperinsulinemia, a common cause of persistent hypoglycemia in infants and children, can result in permanent damage to the central nervous system. Thus, early diagnosis and treatment are important. The typical clinical manifestation of hyperinsulinemic hypoglycemia is symptomatic hypoglycemia that responds poorly to medical therapy. Affected infants may have tremors, jitteriness, apnea, cyanosis, or seizures. If initial medical therapy (frequent feedings, large amounts of intravenously administered glucose, diazoxide, and glucocorticoids) fails to stabilize plasma glucose levels, subtotal pancreatectomy is indicated. This surgical intervention does not completely correct the hypoglycemia in all patients, but it effectively reduces the severity of the condition. Surgical treatment of pediatric patients with Cushing's syndrome or aldosteronoma has also been effective. In our experience, survival of patients with adrenocortical adenomas has been 100%, whereas only five of nine children with adrenocortical carcinomas survived, and four of the five were younger than 10 years of age.

Surgical management of hyperinsulinemic hypoglycemia in children

Nineteen children underwent subtotal pancreatectomy for hyperinsulinemic hypoglycemia. Of the four who were older than 10 years of age at onset of symptoms, three had islet adenomas, and one had endocrine cell dysplasia (ECD). The two patients with multiple adenomas had a family history of multiple endocrine neoplasia, type 1 (MEN 1). Of the 15 who were younger than 1 year of age at onset of symptoms, 12 had ECD alone, and three had ECD with adenomatosis. Four children required a second surgical procedure and near-total pancreatectomy because of persistent hypoglycemia. All 19 patients' conditions improved, with no postsurgical complications. After near-total pancreatectomy, all four patients were treated for fat malabsorption, but only two required insulin because of secondary diabetes mellitus. We concluded that subtotal pancreatectomy is a safe, effective adjunct to the treatment of children with hyperinsulinemic hypoglycemia.

Increased proteolysis. An effect of increases in plasma cortisol within the physiologic range

Prolonged exposure to glucocorticoids in pharmacologic amounts results in muscle wasting, but whether changes in plasma cortisol within the physiologic range affect amino acid and protein metabolism in man has not been determined. To determine whether a physiologic increase in plasma cortisol increases proteolysis and the de novo synthesis of alanine, seven normal subjects were studied on two occasions during an 8-h infusion of either hydrocortisone sodium succinate (2 micrograms/kg X min) or saline. The rate of appearance (Ra) of leucine and alanine were estimated using [2H3]leucine and [2H3]alanine. In addition, the Ra of leucine nitrogen and the rate of transfer of leucine nitrogen to alanine were estimated using [15N]leucine. Plasma cortisol increased (10 +/- 1 to 42 +/- 4 micrograms/dl) during cortisol infusion and decreased (14 +/- 2 to 10 +/- 2 micrograms/dl) during saline infusion. No change was observed in plasma insulin, C-peptide, or glucagon during either saline or cortisol infusion. Plasma leucine concentration increased more (P less than 0.05) during cortisol infusion (120 +/- 1 to 203 +/- 21 microM) than saline (118 +/- 8 to 154 +/- 4 microM) as a result of a greater (P less than 0.01) increase in its Ra during cortisol infusion (1.47 +/- 0.08 to 1.81 +/- 0.08 mumol/kg X min for cortisol vs. 1.50 +/- 0.08 to 1.57 +/- 0.09 mumol/kg X min). Leucine nitrogen Ra increased (P less than 0.01) from 2.35 +/- 0.12 to 3.46 +/- 0.24 mumol/kg X min, but less so (P less than 0.05) during saline infusion (2.43 +/- 0.17 to 2.84 +/- 0.15 mumol/kg X min, P less than 0.01). Alanine Ra increased (P less than 0.05) during cortisol infusion but remained constant during saline infusion. During cortisol, but not during saline infusion, the rate and percentage of leucine nitrogen going to alanine increased (P less than 0.05). Thus, an increase in plasma cortisol within the physiologic range increases proteolysis and the de novo synthesis of alanine, a potential gluconeogenic substrate. Therefore, physiologic changes in plasma cortisol play a role in the regulation of whole body protein and amino acid metabolism in man.