3 Adolescent Medicine

3.1 BCH Wards Tips

3.1.0.1 Primary diagnoses

Eating disorders
Anovulatory uterine bleeding
Some primary care patients admitted for Gen Peds issues

3.1.0.2 Format

Table rounds. Intern fills out and presents Eating Disorder worksheet (will be reviewed on the first day)
Do NOT write notes daily, but expected to examine patients daily, present thoughtful plans, and write an event note should something significant happen in a given 24hr period

3.2 Adolescent Clinic Tips

3.2.1 Overview

Goal skills
- Taking an effective social history
- Addressing confidentiality
- Discussing topics such as sex, contraception, substance use, and weight
- Performing respectful genital exams
- Strength-based approaches to management
Format
- Scheduled w/ same preceptor multiple times at BCH and BMC
- Try to schedule patients for return visits w/ you for continuity

3.2.2 BCH Adolescent Clinic Specifics

Population
- 11-25 yo
- Primarily from the Greater Boston Area and surrounding suburbs
- Primary and Subspecialty care for patients with eating disorders, reproductive endocrine concerns, and chronic fatigue
- Primary languages spoken: English and Spanish
Resources available:
- Mental health
- Psychopharm support
- Nutrition
- Resource specialist for social needs
- On-site sexual health counselling and STD testing (including HIV)

3.2.3 BMC Adolescent Clinic Specifics

Population
- 12-22 yo
- Primarily from Dorchester, Roxbury, Hyde Park, South Boston, and the South End
- Primary care, first point of medical contact for adolescents new to the United States, and subspecialty care for teen parents, adolescents with substance use disorders, gender diversity, individuals s/p sexual assault, and menstrual disorders
- Primary languages spoken: English, Haitian Creole, Spanish, and Cape Verdean Creole
Subspecialty programs & Resources available
- CATALYST (for adolescents and young adults w/ substance use)
- Teen and Tot programs (to serve young parents and their children)
- CATCH (providing gender affirming care to youth of all ages)
- Sexual assault follow-up clinic
- Menstrual Disorders Clinic
- Integrated behavioral health social workers, patient navigators, and a family planner

3.3 HEEADSSS Assessment¹

Parents, family members, or other involved adults should NOT be present during the HEEADSSS interview. Addressing this and the need for confidentiality at the beginning of the visit is important. Before asking adults to leave the room, always ask whether they have any concerns to express or questions to ask and assure them of further interaction once the confidential interview is over. Sometimes having a confidential moment with the adult can also be very informative to the patient’s care.

Consider starting your HEEADSSS assessment by asking about the patient’s strengths. A simple question such as “What are your greatest strengths” can go a long way in rapport building and eliciting motivations to engage in healthy behavior change.

Bold (green) = essential questions
Italics (blue) = as time permits
Plain text (red) = optional or when the situation requires

3.3.1 Home

Where do you live? Who lives w/ you?
What are your relationships like at home? Who can you talk to at home?
Is there anyone new at home? Has someone left recently?
Have you moved recently?
Have you ever had to live away from home? (Why?)
Have you ever run away? (Why?)

3.3.2 Education and/or Employment

Do you go to school? Do you work? Or both?
What are your favorite subjects at school? Your least favorite subjects?
How are your grades? Any recent changes? Any dramatic changes in the past?
What are your future education/employment plans/goals?
Are you working? Where? How many hours per week?
Tell me about your friends at school.
Have you ever had to repeat a class? Have you ever had to repeat a grade?
Have you changed schools in the past few years?
Have you ever been suspended? Expelled? Have you ever considered dropping out?
How well do you get along w/ the people at school? Work?
Do you feel connected to your school? Do you feel as if you belong?
Are there adults at school you feel you could talk to about something important? (Who?)

3.3.3 Eating

Do you have any concerns about your body shape, weight, or size?
Have you ever done anything to try to change your weight or body shape such as dieting, vomiting or taking diet pills/laxatives/supplements?
Have there been any recent changes in your weight?
How many meals/snacks do you eat each day?
What do you think would be a healthy diet? How does that compare to your current eating patterns?
Do you eat in front of the TV? Computer?
Does it ever seem as though your eating is out of control?

3.3.4 Activities

What do you and your friends do for fun? (w/ whom, where, and when?)
What do you and your family do for fun? (w/ whom, where, and when?)
Do you participate in any sports or other physical activities that are heart healthy?
How much time do you spend looking at a screen each day (other than doing your homework)?

3.3.5 Drugs

In the past year, how often have you smoked tobacco or MJ, vaped, or had alcohol?
- If any use disclosed, ask about other substances and do CRAFFT screen
- If no use disclosed, ask the following questions:
  - Do any of your friends drink, smoke, vape, or use drugs? Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs?
Is there any history of alcohol or drug problems in your family? Does anyone smoke at home?
Do you ever drink or use drugs when you’re alone?
(Assess frequency, intensity, patterns of use or abuse, and how youth obtains or pays for drugs, alcohol, or tobacco)

3.3.6 Sexuality

Do you see yourself as a boy, a girl, something different, or you’re not sure?
Are you attracted to other people? If so: boys, girls, both?
Have you ever had sex with anyone? If so, what kinds of sex? How many people have you had sex with?
Unfortunately some young people are forced to have sex. Has anyone ever forced you to have sex?
What are you doing to prevent pregnancy?
What are you doing to protect yourself from STDs and HIV?
Have you or your partners ever had an STD?
How many sexual partners have you had altogether?
Females: Have you ever been pregnant or worried that you may be pregnant? Males: Have you ever gotten someone pregnant or worried that that might have happened?
What percentage of the time do you use condoms during intercourse?
Does anything ever get in the way of always using a condom?
When you and your partner get into fights, what sort of things happen?

3.3.7 Suicide & Depression/Mood

PHQ2: Over the past two weeks have you felt down, depressed, or hopeless? Over the past two weeks have you had little interest or pleasure in doing things?
Have you thought about hurting or killing yourself or someone else?
IF ANY OF THE ABOVE ARE POSITIVE, perform full PHQ9
Do you have problems with anxiety?
Some young people have had bad things happen to them, and then they have nightmares, flashbacks or feel on-edge/ hyper-alert. Do you have these symptoms?

3.3.8 Safety

Do you feel safe at home? At school? In your community? With your friends? In your relationships?
Have you ever been bullied? Have you ever bullied someone else?
Have you ever been seriously injured? (How?) How about anyone else you know?
What percent of the time do you wear a seatbelt in the car?
Do you use safety equipment for sports and or other physical activities (for example, helmets for biking or skateboarding)?
Has anyone ever forced you to have sex with them, or hit, punched, kicked, slapped, or physically or sexually hurt you in any other way?
Is there a gun in your home/ do you have access to a gun?
Have you ever been in a car or motorcycle accident? If so, what happened?
Have you gotten into physical fights in school or your neighborhood? Are you still getting into fights?
Have you ever felt that you had to carry a knife, gun, or other weapon to protect yourself? Do you still feel that way?

3.4 Adolescent Screening Tools

	Screeners	When to use
Depression	PHQ-2, PHQ-A = PHQ-9 modified for adolescents, PSC-17 (up to age 15)	- Routine Child Health Maintenance visits - Visits for mood follow-up - When you’re concerned about depression and/or suicidality in your patient
Anxiety	PSC-17 (up to age 15), GAD-7, SCARED	- Routine Child Health Maintenance visits - Visits for mood follow-up - When you’re concerned that anxiety is a problem for your patient
Substance Use	S2BI, CRAFFT, BSTAD	- Routine Child Health Maintenance visits - F/u after visits in the ED for acute intoxication - When you’re concerned that substance use is a problem for your patient

3.5 Contraception²

3.5.1 Emergency Contraception (EC)

	Notes	Access
Ella (ulipristal acetate)	- Most effective EC pill to prevent pregnancy up to 5 days after unprotected sex - Do NOT give if starting any form of hormonal contraception (ulipristal binds the progesterone receptors and blocks the hormone’s effects)	- Rx ONLY - Safe to call in a prescription w/o pregnancy test or seeing patient
Plan B One-Step (levonorgestrel 1.5mg)	- Works to prevent pregnancy for the first 3 days after unprotected sex - Works less well in patients who are overweight or obese - Discuss with your preceptor if you should recommend a double dose for your overweight patients	- Sold (at cost $$, w/o Rx) to anyone of any age at most pharmacies, though access is still difficult for adolescents. Much cheaper w/ Rx. - Safe to call in a prescription w/o pregnancy test or seeing patient
Copper IUD (Paragard)	- Most effective form of EC (>99%), effective up to 7 days after unprotected sex - Can provide up to 12 years of highly effective contraception after placement	Must be placed in a clinic setting by a trained provider

For more information on emergency contraception (EC), please see the following resources: Bedsider, reproductiveaccess.org, Mass.gov EC site

3.5.2 Shared Decision Making (SDM)

Collaborative process, allows patients and their providers to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient’s values and preferences
Provider role: knowledge of the medical information
Patient role: expert regarding their own values and preferences

3.5.3 Applying SDM Principles to Contraceptive Counseling Visits

3.5.3.1 Establish rapport

“What brings you in today? What’s happening with your birth control?”
“Why did you decide to choose ____?”
Ask interactive open-ended questions. The HEEADSSS assessment is a great way to establish rapport for new patients.

3.5.3.2 Assess patient readiness

“What are important features that your birth control should have?”
“What did you like/dislike about the birth control methods you used in the past?”
“Different types of birth control affect your period differently. Some make your period a bit heavier, lighter, sporadic, or may take your period away. Which do you think will be best for you?”

3.5.3.3 Tailor information and discussion to patient preferences/needs

Your patient says they want a method where they will still have a regular period. Counsel them on the contraceptive ring, patch, pill, and copper IUD and NOT on the shot, implant, or LNG IUDs.
Your patient says they want a method that is easy to keep private. Counsel them on the contraceptive implant, shot, IUD, and ring and NOT on the pill or patch.
Your patient has heavy periods and doesn’t want them to be any heavier. Provide information on any method other than the copper IUD.
Your patient says they absolutely want to have a period every month. Provide more information on the LNG 15 and 19.5mg IUDs, and Copper IUD, and NOT the LNG 52mg IUD (Mirena).
Use patient’s identified preferences for discussing particular methods. Being knowledgeable of contraceptive mechanisms of action, side effects, and delivery routes is important to provide this tailored information.

3.5.3.4 Discuss contraception side effects

“Patients who begin the birth control pill may have breast tenderness or a mild headache during the first month. These usually go away.”
“With the LNG 52mg IUD, you may have spotting for about 4 months after placement, then your period will become lighter. After a year with the IUD, some patients stop getting their period.”
Many patients feel they do not receive adequate information about side effects, and that providers often overlook possible side effects in counseling discussions. It is important to discuss the specific side effects that patients should expect with the contraception type that is aligned with their preferences.

3.5.3.5 Identify misconceptions about specific contraception methods

“I’m sorry that your friend had a bad experience with the vaginal contraceptive ring and weight gain. This isn’t typical with most ring users. I support you in using this method because it aligns with your preferences. If you experience weight gain, you can absolutely choose a different option.”
“I hear your concern that your friend had worsening acne with her IUD. We usually don’t see this in the majority of patients, so it’s not likely that it will happen to you.”
Respectfully addressing myths or misconceptions about IUD types helps to keep conversations open, while providing patients with accurate information.

3.5.3.6 Ensure access to method discontinuation at any time

“If you decide you don’t like this birth control, you can switch to something else at any time.”
“If you decide that you want to stop your birth control, I’m always here to talk about it and to support you.”
“If for whatever reason you decide that you don’t want the IUD anymore, I will remove it.”
Patients should be informed at the time of insertion that they can have their IUD removed at any time, and for any reason.
IUD removal should be provided with the immediacy as “same-day” IUD placement is provided.

For more information on contraceptive methods, minor consent laws, as well as medical eligibility criteria and selected practice recommendations, please see the following resources: Center for Young Women’s Health, Bedsider, Reproductive Access, CDC MEC, CDC SPR, Guttmacher Institute

3.6 Tanner Staging³

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3.7 Vaginal Discharge and Infections

** NOTE: Treatments change frequently! Check the CDC Treatment Guidelines or download the “CDC STD Tx Guide” app.

	Signs & Symptoms	Diagnosis	Management
Physiologic (leukorrhea)	- Clear, white, or grey discharge; no offensive odor - No burning or itching	- pH < 4.5 - Wet mount: epithelial cells w/ no or few leukocytes	Reassurance
Candida vaginitis (“yeast infection”)	- Odorless curd-like white clumpy discharge - Intense burning and pruritus	- pH < 4.5 - KOH: No fish odor, +budding yeast and pseudohyphae, +WBC - Vaginitis Panel via vaginal swab (tests for BV, Candida Vaginitis, Trich)	- Fluconazole 150 mg PO (single dose) - Miconazole or clotrimazole intravaginal cream
Trichomoniasis	- Malodorous, frothy, yellow-green or cream colored discharge - Pruritus, dysuria	- pH > 4.5 - KOH: Fish odor may be present - Wet mount: WBC and pear shaped organism w/ motile flagella - Vaginitis Panel via vaginal swab (tests for BV, Candida Vaginitis, Trich) - NAAT dirty urine collection	- Metronidazole 2g PO (single dose) or 500mg PO BID for 7 days Partner: treat and refrain from intercourse for 7 days
Bacterial vaginosis (BV)	- Malodorous, increased mild grey-white discharge - Mild or absent pruritis or burning	- pH > 4.5 - KOH: +Fish odor - Wet mount: >20% clue cells-epithelial cells covered w/ gram negative rods - Vaginitis Panel via vaginal swab (tests for BV, Candida Vaginitis, Trich)	- Metronidazole 500mg PO BID for 7 days, OR - Metronidazole gel 0.75% one applicator (5g) intravaginally daily for 5 days Partner: treat if recurrent infection
Gonorrhea (GC)	- Majority asymptomatic - Grey-white cervical discharge	GC/CT NAAT vaginal swab or dirty urine	- Ceftriaxone 250mg IM + azithromycin 1g PO (co-tx chlamydia and covers resistant gonorrhea) - Refrain from intercourse x7 days Partner: Evaluate and treat contacts w/i prior 60 days
Chlamydia (CT)	- Majority asymptomatic - Yellowish vaginal discharge	GC/CT NAAT vaginal swab or dirty urine	- Azithromycin 1g PO x1 - If allergic to azithro, can do doxycycline 100mg PO BID x7 days - Refrain from intercourse x7 days Partner: Evaluate and treat contacts w/i prior 60 days
Retained tampon	Malodorous discharge	History and PE	Remove tampon
Allergic vaginitis	Local pain, vaginal erythema	History of exposure to deodorant spray, scented tampons, etc.	Cessation of sensitizing agent

3.8 HIV

3.8.1 Signs & Symptoms

Acute HIV infection: mono-like illness w/ nonspecific sxs (fever, lymphadenopathy, sore throat, rash, myalgia/arthralgia, diarrhea, mucocutaneous ulcers, weight loss, headache) usually ~2-4 weeks after exposure, sometimes up to 10 months after exposure
Early infection is asymptomatic in 10-60% of cases

3.8.2 Diagnosis

Suspected case: HIV-1/2 Combo Ag/Ab + RT-PCR HIV viral load test
- If testing is negative, but very-high risk exposure was recent, repeat test in 1-2 weeks
- For cases of presumed sexual assault, repeat HIV testing in 6 wks, 3mo and 6mo
Routine screening: Fourth gen HIV-1/2 Combo Ag/Ab reflex to confirmatory subtyping HIV1/HIV2 differentiation immunoassay, followed by viral load testing only if there is a discrepancy

3.8.3 PEP vs. PrEP

	PEP = Post-Exposure Prophylaxis	PrEP = Pre-Exposure Prophylaxis
EBG	Sexual Assault EBG	PrEP EBG
What is it?	Always a 3 drug regimen: - Preferred regimen (tablets only): Truvada (tenofovir and emtricitabine) + Raltegravir - Alternative regimen (if unable to swallow pills): Zidovudine + Lamivudine, + Raltegravir (chewtab) OR Lopinavir/Ritonavir (liquid)	Daily Truvada (tenofovir-emtricitabine)
Who’s it for?	Consider PEP if the following three statements apply to the patient: - Isolated anal, vaginal, percutaneous or oral exposure to possibly or definitely HIV infected blood or semen - Exposure occurred within 72 hours of presentation - Patient/family will consent to treatment and agree to follow-up	HIV neg Adolescents/Adults weighing >35 kg and meeting one of the following indications: - Men who have sex with men - Person who injects drugs - Heterosexual men and women at substantial risk of acquiring HIV infection (any sex partner w/ HIV or HIV risk factors, hx of bacterial STI, hx injecting drugs, used non-occupational PEP, survival/transactional sex, been in drug tx program, interest in trying to conceive w/ a discordant partner)

3.9 Genital Ulcers and Warts

	Signs & Symptoms	Diagnosis	Treatment
Genital herpes	Grouped vesicles, painful shallow ulcers, tender inguinal adenopathy	- Tzanck smear and viral culture - Antigen testing to determine HSV1 vs. HSV2 can give more information about recurrence prognosis	First episode: - Acyclovir 400mg TID x5-10 days, OR - Valacyclovir 1g BID x7-10 days Recurrent episodes: - Acyclovir 400mg TID x5 days, OR - Valacyclovir 500 mg BID x3 days Daily suppressive (maintenance) therapy: - Acyclovir 400 PO BID - Valacyclovir 500mg-1g PO daily
Genital warts	- Single or multiple soft fleshy papillary or sessile painless growths around genitals - No inguinal lymphadenopathy	- Initial: clinical presentation - Final: Pap test revealing typical cytologic changes	Goal: remove exophytic warts; exclude cervical dysplasia before treatment Medication (not in preg): - Podophylin 0.5% gel BID x3 days then off x4 days, and repeat up to 4 times; OR - Imiquimod 5% cream 3x/wk on alternate days until resolution (<16 wks) Prevention: Gardasil 9-valent vaccine (HPV(6, 11, + 7 others)
Syphilis	- Primary: Indurated, well defined, usually single painless ulcer “chancre” - Secondary: weeks to months later; systemic infection w/ rash, fever, HA, malaise, anorexia, adenopathy - Latent → Leads to Tertiary in 25%: CNS, cardiac manifestations; gummatous lesions	- Initial: FTA-ABS, MHA-TP, dark-field microscopy or DFA test of exudate or tissue - Final: VDRL, RPR (reverse sequence screening @ BCH) - False seronegatives seen in first 3 months; presumptive tx recommended	Primary and Secondary: - Benzathine Penicillin G: 2.4 mil U IM x1 dose - Doxycycline 100mg BID x14 days for allergy/preg Latent: infected but no sx - Benzathine Penicillin G: 2.4 mil U IM qweekly x3 wks Partner: evaluate if contact w/i 3 mo for primary, 6 mo for secondary, 1 year for latent
Chancroid	- Multiple, ragged, painful, non-indurated ulcers - Painful suppurative inguinal adenopathy	- Initial: clinical presentation, neg syphilis and HSV - Final: culture of haemophilus ducreyi	- Azithromycin 1g PO x1 dose - Ceftriaxone 250 mg IM x1 dose - Ciprofloxacin 500 mg BID x3 days - Erythromycin 500 mg TID x7 days Partner: evaluate and treat contacts w/i 10 days of symptoms

3.10 Pelvic Inflammatory Disease (PID)

** NOTE: Epididymitis is the male equivalent of female PID!

3.10.1 PowerPlans / Order Sets / EBGs

Pelvic Inflammatory Disease EBG

3.10.2 Pathophysiology

Infection of upper genital tract (cervix, uterus, fallopian tubes, ovaries)

3.10.3 Etiology

N. gonorrhea, C. trachomatis or other anaerobic organisms

3.10.4 Clinical Manifestations

Pelvic pain, dyspareunia, vaginal discharge, fever, menstrual irregularities associated w/ lower abdominal tenderness, adnexal tenderness, and/or cervical motion tenderness

3.10.5 Physical Exam

Uterine, adnexal, or cervical motion tenderness +/- LQ or RUQ tenderness

3.10.6 Evaluation

STI testing (GC/CT, trich, BV, RPR, HIV)
Consider CBCd, ESR, urine hCG, UA, UCx

3.10.7 Management

3.10.7.1 Outpatient

Ceftriaxone 250 mg IM in a single dose PLUS doxycycline 100 mg PO BID for 14 days w/ or w/o metronidazole 500mg PO BID for 14 days

3.10.7.2 Inpatient

IV regimen A: cefoxitin 2g IV q6h plus doxycycline 100mg PO BID
IV regimen B: clindamycin 900 mg IV every 8 hours plus gentamicin 3 mg/kg IV q24h
Following A, B: doxycycline 100mg PO BID for 14 days. If with pelvic abscess, BV, trich, or recent instrumentation also give 14 days of metronidazole.
Alternative regimens: Levofloxacin +/- Metronidazole; Ofloxacin +/- Metronidazole; Amp/Sulbactam + Doxy

Partner: Evaluation and treatment of contacts w/i prior 60 days recommended. Refrain from intercourse in the meantime

3.11 Heavy or Irregular Menstrual Bleeding

3.11.1 PowerPlans / Order Sets / EBGs

Heavy/Irregular Menstrual Bleeding EBG

3.11.2 Definition

Abnormalities in the frequency, duration, volume, and/or timing of menstrual bleeding

3.11.3 Differential Diagnosis

Anovulatory bleeding (most common cause in adolescents), pregnancy (must rule out even w/o report of sexual activity), coagulopathy, recent start/stop of contraception

3.11.4 Clinical Manifestations

Menses prolonged or cycle shortened w/ frequent menses (normal menses happen every 21-45 days)
Flow moderate to heavy
May present w/ anemia leading to orthostasis, fatigue, tachycardia, syncope/ presyncope or exercise intolerance
Other changes may include: weight change, visual changes, headache, heat or cold intolerance, skin changes (hirsutism or acne), palpitations, cyclic abdominal pain

3.11.5 Evaluation

Labs: CBC w/ diff, urine hCG, gonorrhea and chlamydia testing, coagulation studies, von Willebrand panel, TSH, LH, FSH, prolactin, free/total testosterone, DHEAS
Imaging: Pelvic ultrasound if mass palpable, uterine abnormality suspected, or patient is not responding to typical therapies
Exam: External GU exam to evaluate for active bleeding, masses, signs of trauma, virilization
Ask about personal and family history of bleeding

3.11.6 Management

Consider NSAID trial (ibuprofen or naproxen), OCPs (screen for estrogen contraindications to determine type of OCP) continuously (occasionally BID-QID) until bleeding stops, daily iron supplements for anemia.
Send to ED if vital signs unstable or with severe anemia (for further workup for surgical cause of bleed, possible transfusion, and possible tranexamic acid or aminocaproic acid)
Antiemetic PRN nausea associated w/ hormone therapy

3.12 Amenorrhea⁴

3.12.1 Definition

Primary: Absence of menses by age 15 or absence of menses 3 years following thelarche
Secondary: Absence of menses for three cycles or for three-six months w/ prior normal menses

3.12.2 Pathophysiology

Primary w/o secondary sex characteristics (no breast development) but normal genitalia (uterus and vagina): Turner syndrome, abnormal X chromosome, mosaicism, pure gonadal dysgenesis, 17 a-hydroxylase deficiency, hypothalamic failure secondary to inadequate gonadotropin- releasing hormone (GnRH) release, constitutional delay of puberty
Primary w/ normal breast development but absent uterus: Androgen insensitivity, congenital absence of uterus (MRKH)
Primary w/ no breast development and no uterus: 17,20 desmolase deficiency, agonadism, 17 -hydroxylase deficiency w/ 46 XY karyotype
Primary and secondary w/ normal secondary sex characteristics: Hypothalamic causes (idiopathic, phenothiazines, heroin, stress, exercise, weight loss, chronic illness, craniopharyngioma, tuberculous granuloma, meningoencephalitis, polycystic ovary syndrome), pituitary causes (Sheehan’s syndrome, aneurysm, empty sella, tumors), ovarian causes (premature ovarian insufficiency), uterine causes (Asherman syndrome), pregnancy

3.12.3 Clinical Manifestations

May see absence of secondary sex characteristics in conjunction w/ amenorrhea

3.12.4 Physical Exam

Height, weight
Signs of malnutrition, androgen excess, thyroid dysfunction
Tanner stage, breast exam and pelvic exam
Webbed neck, low set ears, broad shield-like chest in Turner’s syndrome

3.12.5 Evaluation

Pregnancy test, TSH, FSH, prolactin, ultrasound to evaluate for presence of uterus
Primary w/o secondary sex characteristics or absent uterus: Karyotype, FSH, Testosterone level.
Primary and secondary w/ normal secondary sex characteristics: Urine pregnancy; FSH; Testosterone level; prolactin level – if elevated, need MRI of head to evaluate for prolactinoma; Progestin withdrawal test: Positive response indicates the production of estrogen w/o normal cycling such as in PCOS (if evidence of hyperandrogenism or elevated testosterone). Negative test w/ low FSH suggests low estrogen state as is seen in hypothalamic amenorrhea from nutritional deficiency. Negative test w/ high FSH indicates ovarian insufficiency.

3.12.6 Management

PCOS: hormonal contraception or cyclical provera 10mg/day x 10d to induce bleeding
Irreversible hypopituitarism or ovarian insufficiency: Premarin 0.625-2.5 mg/day or transdermal estrogen and Provera 10mg/day medroxyprogesterone 10-14 days per month.
Hypothalamic amenorrhea related to nutritional deficiency: energy re-balance/weight restoration

3.13 Gender Affirming Care

3.13.1 Why

One of our roles as providers of gender diverse youth is to combat the adverse experiences and risk factors for developing mental health disorders by building safe communities for our patients and adopting a gender affirming approach to care.

3.13.2 How

Call patients by the name and pronouns that they tell you best describe them in all clinical settings.
Build our lexicon to help lead our co-workers by example in using appropriate and non-stigmatizing language to affirm the child’s or adolescent’s authentic self and gender identity (see gender-bread person below for review of terminology).
Ask about gender identity at routine healthcare visits.
Individuals who identify as transgender have higher rates of depression, anxiety, eating disorders, self-harm, and suicide compared to their cis-gendered peers. Screen for these when the opportunity arises and provide appropriate referrals/supports PRN.

3.13.3 Gender Affirming Care Clinics

At BMC: CATCH
At BCH: GeMs

3.13.4 The Genderbread Person

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3.14 Eating Disorders (ED)

3.14.1 Anorexia Nervosa (AN)

3.14.1.1 PowerPlans / Order Sets / EBGs

Restrictive Eating Power Plan and Admission Orderset
Restrictive Eating EBG

3.14.1.2 Definition

Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health
Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than minimally expected
Intense fear of gaining weight or of becoming fat, or persistent behavior that interferes w/ weight gain, even though at a significantly low weight
Disturbance in the way in which one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight

3.14.1.3 Clinical Manifestations

Weight loss, abdominal pain, bloating, constipation, cold intolerance, lanugo, fatigue, weakness, delayed puberty

3.14.1.4 Physical Exam

Low body temp, bradycardia, low blood pressure, orthostasis, lanugo, dry skin and hair, scalp hair thinning, scaphoid abdomen, palpable stool, breast atrophy, hypoestrogenized vaginal mucosa

3.14.1.5 Evaluation

Labs: CBCd, UA, urine pregnancy, chem 10, LFTs, TFTs, and EKG
Weight: Compared to prior growth charts; calculate IBW based off of 50% BMI for age (unless previously tracking on different percentile)

3.14.1.6 Inpatient Management

Restrictive Eating protocol
- If 18yo+, then must sign contract in ED agreeing to protocol
Goal is to medically stabilize (weight >80% of IBW), VSS (HR >50, no longer orthostatic), electrolytes stable (monitor potassium, phos and mag)
Refeed gradually to target meal plan while monitoring for refeeding syndrome (watch for edema, low phos)
Weight increase of 0.2kg/day, supplement if not gaining weight; 1750-2000kcal diet to be increased by 250 kcal per day until goal calories met, meals per EBG (set time for meal, replace w/ 120% ensure if <75% complete (either PO or via NG))
Check electrolytes daily and supplement w/ PhosNaK and/or MVI if abnormal (at BCH the protocol is to start both supplements on admission)
Activity: Bed rest while orthostatic. No physical activity while inpatient; can earn wheelchair rides, bathroom privileges, etc.
Consults: Psychiatry, Nutrition
Supervision: Sitter if active SI, Security if elopement risk

3.14.2 Bulimia Nervosa (BN)

3.14.2.1 Definition

Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
- Eating, in a discrete period of time (eg, w/i any two-hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances
- A sense of lack of control over eating during the episode (eg, a feeling that one cannot stop eating or control what or how much one is eating)
Recurrent inappropriate compensatory behavior to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise
The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months
Self-evaluation is unduly influenced by body shape and weight
The disturbance does not occur exclusively during episodes of anorexia nervosa

3.14.2.2 Clinical Manifestations

See AN, PLUS: Esophagitis and cavities

3.14.2.3 Physical Exam

See AN, PLUS: Calluses on fingers, cavities, and tooth decay

3.14.2.4 Evaluation

See AN

3.14.2.5 Inpatient Management

See AN, PLUS: Purge precautions (no bathroom privileges (use bedside commode), room searches)

3.14.3 Acute Refusal of Food Intake Disorder (ARFID)

3.14.3.1 PowerPlans / Order Sets / EBGs

ARFID protocol and PowerPlan

3.14.3.2 Definition

Persistent failure to meet appropriate nutritional and/or energy needs associated w/ one (or more) of the following:
- Significant weight loss
- Significant nutritional deficiency
- Dependence on eneteral feeding or oral nutritional supplements
- Marked interference w/ psychosocial functioning
Disturbance not better explained by lack of available food
No evidence of a disturbance in body image

3.14.3.3 Pathophysiology

Patients w/ autism, ADHD, and intellectual disabilities are more likely to develop ARFID
Often have co-occurring anxiety disorder; high risk for other psychiatric disorders

3.14.3.4 Clinical Manifestations

See AN, PLUS: Fear of choking or vomiting, limited range of preferred foods becomes narrower over time, will only eat certain textures of food, etc.

3.14.3.5 Evaluation