Adolescent

Question 1

If a girl has breast buds and no pubic hair, what is the problem?

Answer 1

Androgen insensitivity - testicular feminization (XY chromosome)

• Receptor insensitivity to androgens
• No male external genitalia
• Blind ending vagina, lack of uterus, lack of ovaries
• Testes in inguinal canal

Question 2

If a girl has no breast buds but has pubic hair, what is the problem?

Answer 2

Androgen excess

OR

Low Estrogen

Question 3

What is the first step in evaluation of a patient with pubic hair but no breasts or testicular enlargement?

Answer 3

Bone age films

If within 1-2 years of chronological age, observe.
If not -> endocrinologist

Question 4

What is the first step in evaluation of precocious puberty?

Answer 4

Check for ovarian or testicular tumors

Question 5

What tests would you do to differentiate between Central versus peripheral precocious puberty?

Answer 5

LH
FSH
Adrenal steroids

Question 6

What are the features of gonadotropin independent precocious puberty?

Answer 6

• Normal LH and FSH levels
• Puberty occurring in the proper timeline except for one abnormality
• There is sex steroid production somewhere else in the body

Question 7

How would you treat central precocious puberty in girls?

Answer 7

• Breasts + vaginal bleeding or accelerated growth
• If idiopathic (elevated LH and FSH)
• Tx: GnRH analogue

Question 8

What feature must be present in order to diagnose a boy with precocious puberty?

Answer 8

Testicular enlargement

Question 9

What can cause a boy to have signs of precocious puberty who does not yet have testicular enlargement?

Answer 9

• Evidence of extra hair, penile enlargement, growth spurt
• Non-Central and non-gonadal problem
• Late onset congenital adrenal hyperplasia, virilizing tumor, exogenous steroids

Question 10

What is the definition of delayed puberty in girls?

Answer 10

No breast buds by the age of 13

OR

No menses within two years of the presence of both SMR 4 breasts and pubic hair

Question 11

What are the features of Kallmann syndrome?

Answer 11

• Hypogonadotropic hypogonadism
• Anosmia
• Hypoplasia of the optic nerve
• Absence of septum pellucidum
• The only Disease with a smelling problem

Question 12

What is the normal discrepancy between a bone age film and chronological age?

Answer 12

2 years

Question 13

What is the formula for midparental height?

Answer 13

[Dad’s height + Mom’s height +/- 5 inches or 13 cm] / 2

Add length for boys
Subtract length for girls

Question 14

How is growth hormone deficiency diagnosed?

Answer 14

Noting a lack of GH release following insulin or arginine stimulation.

Findings will include micropenis or clitoris and hypoglycemia.

Decelerated growth rate.

Question 15

What stimulates the production of progesterone?

Answer 15

LH

Question 16

What stimulates the production of estrogen?

Answer 16

FSH

Question 17

What is the first step in an amenorrhea work up?

Answer 17

Rule out pregnancy, anatomic obstruction, malformation

Question 18

What is the second step in an amenorrhea work up?

Answer 18

Progesterone Challenge:

• If positive (bleeding within 2 weeks of administration) = plenty of estrogen, missing progesterone -> get LH level
  
  • High LH: PCOS
  • Low LH: Get prolactin and TSH
    
    • High PRL and TSH: hypothyroidism
    • High PRL: prolactinoma
• If negative = not enough estrogen -> get FSH
  
  • High FSH: Ovarian failure (Turner’s, autoimmune, chemo, premature menopause),
  • Low FSH: central problem (mass, prolactinoma, craniopharyngioma, hypothyroid)

Question 19

What is the definition of secondary amenorrhea?

Answer 19

• Six months without menses after a patient was regular

- 12 months without menses if the patient was previously irregular

Question 20

What is the differential diagnosis for secondary amenorrhea?

Answer 20

Asherman's syndrome (intrauterine adhesions)
Cystic fibrosis
Sarcoidosis
Phenothiazines
Nutrition
Brain tumor
Tuberculosis

Question 21

What percentage of suicide attempts are successful?

Answer 21

90%

Question 22

How long are exogenous anabolic steroids detectable in the blood?

Answer 22

• If IM: 6 + months

- If PO: 1 month