Drugs of abuse Alcohol Amphetamines Heroin Marijuana
Psychoactive agents (e.g., diazepam, phenothiazines, tricyclics) symptoms of pruritus or odor, it is most likely physiologic leukorrhea, due to ovarian estrogen stimulation of the uterus and vagina. A physical examination should reveal evidence of an estrogenized vulva and hymen without erythema or excoriation. The physician should always be alert for signs of abuse. If there are symptoms, cultures should be obtained. In these circumstances, vaginal cultures can be obtained without a speculum because sexually transmitted infections are vaginal until menarche, when cervical infections are the rule. Inspection of physiologic leukorrhea shows few white blood cells, estrogen maturation of vaginal epithelial cells, and no pathogens on a culture.
Menarche typically occurs approximately 2 years afterthelarche, at the average age of 12.6 years. The initial menses are anovulatory and tend to be irregular in duration. Thisirregularity may persist for 2 to 5 years, so reassurance may berequired. During this phase, estrogen feedback on the hypothalamus decreases gonadotropin secretion, which reducesestrogen production and induces an estrogen withdrawalbleed that can be prolonged and heavy. Anovulatory bleedingis usually painless. As the hypothalamic-pituitary-gonadalaxis matures, the cycle becomes ovulatory, and menses aresecondary to progesterone withdrawal. When ovulation isestablished, the average cycle length is 21 to 45 days. Someadolescents ovulate with their first cycle, as indicated by pregnancy before menarche.
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Breast enlargement in boys is usually a benign, self-limited condition. Gynecomastia is noted in 50% to 60% of boys during early adolescence. It is often idiopathic, but it may be noted in various conditions (Table 68-3). Typical findings include the appearance of a 1to 3-cm, round, freely mobile, often tender, and firm mass immediately beneath the areola during sexual maturity rating stage III. Large, hard, or fixed enlargements and masses associated with any nipple discharge warrant further investigation. Reassurance is usually the only treatment required. If the condition worsens and is associated with psychological morbidity, it may be treated with bromocriptine. Surgical treatment with reduction mammoplasty can be helpful with massive hypertrophy.
Irregular menses is the most common complaint of early adolescent girls. As regular, ovulatory cycles become established, pain with menstruation (dysmenorrhea) is a frequent complaint.
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Primary amenorrhea is the complete absence of menstruation by 16 years of age in the presence of breast development or by 14 years of age in the absence of breast development. However 98% of adolescents have onset of menarche by age 15; therefore, investigations should begin at that age in young women without menses. Secondary amenorrhea refers to the cessation of menses for more than 3 consecutive months, any time after menarche.
Primary amenorrhea may be a result of functional or anatomic abnormalities of the hypothalamus, pituitary gland, ovaries, uterus, or vagina. Physiologic immaturity, stress, excessive exercise, and abnormal dietary patterns (anorexia/bulimia) are the most common causes of amenorrhea. Pregnancy should be considered in all cases of secondary amenorrhea, even if the patient denies sexual activity.