2025 – PAGE 61 – ADOLESCENT MEDICINE

BREAST MASSES – FIBROADENOMAS AND FIBROCYSTIC CHANGE

Breast masses in children are usually benign and due to fibrocystic change or fibroadenomas. Check the masses at the end of menstrual periods. Mammography is NOT needed until patients are much older since their breast tissue is dense. To evaluate, use ULTRASOUND. Excisional biopsy is almost never indicated (only if aspirate is bloody).

• FIBROCYSTIC CHANGE is usually bilateral and tender. Treat with NSAIDs, elimination of caffeine and possibly OCPs.
• FIBROADENOMAS are the most common breast lesions in adolescents. They are unilateral and ESTROGEN-dependent (bigger with OCPs/pregnancy). Refer to gyne­cology if there is bloody aspirate or if it persists beyond 3 cycles.

PUBERTY GONE HAYWIRE

PRECOCIOUS PUBERTY

The age range for puberty is generally 8 to 13 for girls, and 9 to 14 for boys, with some differences based on race and ethnicity. If puberty begins before 8 for girls, and before 9 for boys, that is considered precocious puberty. Precocious puberty can be due to a brain hormone problem OR a problem with hormone production from somewhere else. If you suspect precocious puberty on the exam → start to rule out TESTICULAR/OVARIAN TUMORS by your EXAM! LOOK at, and FEEL, the size/consistency of your patient’s gonads. Then move on to getting LH and FSH levels (look for elevations) to look for a central disorder, doing a pelvic ultrasound in girls. For boys, pubarche (adrenarche/hair growth) + an enlarged phallus without testicular enlargement means there is the presence of excess androgens from outside the normal gonads. Remember, testicular enlargement is the FIRST sign of puberty in boys, so if other signs of puberty exist without testicular enlargement, something is wrong!

• ­ULTRASOUND is useful to look for adrenal or ovarian masses.
• ­CENTRAL (GONADOTROPIN-DEPENDENT) VS. PERIPHERAL (GONADOTROPIN-INDEPENDENT) PRECOCIOUS PUBERTY: Get LH, FSH, and adrenal steroid levels to help differentiate. In Central Precocious Puberty (CPP), there is an elevated basal LH level and on the GnRH stimulation test, the LH level and LH:FSH ratio will be elevated. Estradiol and testosterone levels will be at pubertal or prepubertal levels and steady (NOT rising). The stages of pubertal development will the SAME as in normal puberty, but starting earlier. In Peripheral Precocious Puberty (PPP), LH and FSH will NOT be elevated. Females will have pubertal estradiol levels that are RISING, and males will have pubertal testosterone levels that are RISING. In PPP, the sequence of pubertal development will be ABNORMAL. Both CPP and PPP have an advanced bone age on x-ray.