2025 – PAGE 71 – ADOLESCENT MEDICINE
OSTEOPOROSIS
Risk for developing osteoporosis increases with smoking and LOW estrogen exposure (late puberty/menses).
MNEMONIC: Estrogen is often given to little old ladies (post-menopausal) to protect them from osteoporosis!
ALCOHOL AND TOBACCO
Children are now starting to use alcohol and tobacco as young as 12 years old! Smoking has shown a decline in the last decade.
MNEMONIC: “Imagine kids having sleepovers and sneaking out in the middle of the night after drinking and smoking cigarettes. They stumble to their neighbor’s yard and throw A DOZEN EGGS at their home!”
MARIJUANA
Marijuana use is now common among 14-year-olds. It can cause GALACTORRHEA (even in boys!).
INHALANTS
Inhalants are abused more frequently in middle school than in high school.
CONDOMS
Always recommend the use of condoms!
EMERGENCY CONTRACEPTION
Levonorgestrel (LNG) can be taken up to THREE days after unprotected intercourse or condom failure. It prevents ovulation, fertilization and implantation, but does NOT do anything if implantation has already occurred. Ulipristal (UPA) can be used up to FIVE days after unprotected intercourse or condom failure.
MNEMONIC: For LNG, imagine a Lazy, Lazy, Lazy girl who forgot to take her OCPs for a few days. She parties on a FRIDAY and has sex without a condom. The clinics are all closed on Saturday, but lucky for her she can afford to be lazy this time and wait to seek medical attention until THREE days later when the clinics open again.
PAP SMEARS
The first PAP smear should be performed at age 21 regardless of other risk factors. Women between the ages of 21-30 years of age should have a PAP smear every 3 years. If a patient presents with a known (or likely) STD, it is okay to do a PELVIC EXAM. But, you should hold off on doing a PAP SMEAR of the cervix because the inflammatory changes can result in a false positive! Thin vaginal discharge is not a contraindication. Mucopurulent discharge suggesting an STD is a contraindication. If the patient is on her period, don’t do a pap smear.
ASCUS (ATYPICAL SQUAMOUS CELLS OF UNDETERMINED SIGNIFICANCE)
In general, pap smears are being performed less frequently in young adults. If a pap reveals ASCUS in a woman under age 24, then repeat a PAP smear in 1 year. If the second PAP smear also shows ASCUS, then consider a colposcopy.
(DOUBLE TAKE) HUMAN PAPILLOMA VIRUS (HPV)
Human papilloma virus (HPV) causes VERRUCA VULGARIS (warts). They can be on the hands, knees, and feet, and in the anogenital region. If genital, the condition is referred to as CONDYLOMA ACUMINATA. Genital human papilloma virus IS considered to be an STD. In fact, HPV is considered the most prevalent STD of all. Only a small percentage of patients actually carrying HPV get warts. More than 90% of infections are from HPV 6 or HPV 11, which are NOT likely to induce cervical cancer. The risk of cervical cancer is increased depending on the subtype (16 and 18 are most commonly associated with cervical cancer). Anogenital warts can be due to maternal-fetal transmission and may not present until 3 years after birth! BUT if you note anogenital warts AFTER 3 years of age, think SEXUAL ABUSE. Lesions are NOT tender but easily bleed with minimal trauma. Treat with self-applied topical podophyllotoxin or imiquimod. Treatment with cryotherapy or podophyllin is done by a physician.
PEARL: Cervical cytology (Pap test) is not recommended until 21 years of age for an average-risk asymptomatic woman.
IMAGE: www.pbrlinks.com/HPV1 (Acuminata)
IMAGE: www.pbrlinks.com/HPV2
MNEMONIC: Don’t get confused with molluscum. hpV = VVarts/Warts = Verruca Vulgaris = Venereal VVarts/Warts. “VVarts on your hands or knees? It’s probably from those darn V’s!”
MNEMONIC: The HPV 16 & HPV 18 strains are the two you should remember (associated with the highest risk of cervical cancer): Imagine an adolescent couple. Their birthdays are on the same day, 7/1 (Zodiac of CANCER). The boy is turning 18, and he’s excited to finally VOTE. His girlfriend is turning 16, and she’s excited because she’ll finally get her DRIVER’S LICENSE now that she’s celebrating her SWEET SIXTEENTH. As they go to blow out the BIRTHDAY CAKE candles, you notice that she has VVarts on her lips! It turns out he also has VVarts, but his are Venereal (anogenital).
NAME ALERT: An “A” in Acuminata looks like a flipped “V,” which may help you remember that a diagnosis of Condyloma Acuminata represents an hpV infection. The “L” in Condyloma Lata should remind you that you are dealing with syphiLis.