Inadequate vitamin D status in adolescents with substantial bone mineral density loss during the use of depot medroxyprogesterone acetate injectable contraceptive: a pilot study.

STUDY OBJECTIVE: To examine vitamin D and parathormone (PTH) levels in adolescents who experienced substantial bone mineral density (BMD) loss during depot medroxyprogesterone acetate (DMPA) use. DESIGN: A non-randomized, multi-center study, during which DMPA was administered every 12 weeks and evaluation of lumbar spine and hip BMD by dual-energy X-ray absorptiometry (DXA) was conducted every 6 months. A blood sample for vitamin D and PTH measurements was obtained from adolescents who experienced >5% BMD loss. Vitamin D deficiency was defined as 25-hydroxyvitamin D (25OHD) level of <20 ng/mL, insufficiency as 25OHD level of 20-30 ng/mL, and sufficiency as 25OHD level of >30 ng/mL. RESULTS: Evaluation of vitamin D and PTH was carried out in 15 participants who experienced BMD loss of > or = 5% during DMPA use. At initiation of DMPA, participants had mean (+SE) age 17+1 years, gynecologic age 61+4 months, and body mass index 24+1.5 kg/m2. Racial/ethnic distribution was: Caucasian--7 girls, Hispanic--4 girls, African-American--3 girls, and other--1 girl. Six participants had BMD loss of >5% after 2 DMPA injections, five after 3 injections, one after 5 injections, one after 8 injections, one after 10 injections, and one after 13 injections. Only one girl (7%) had sufficient vitamin D. The other participants had vitamin D insufficiency (50%) or deficiency (43%). Participants' mean (+SE) PTH was 22+4 pg/mL (reference range 7-53 pg/mL), and mean (+SE) 1,25-dihydroxyvitamin D was 56+5 pg/mL (reference range 22-67 pg/mL). CONCLUSIONS: Inadequate vitamin D status was evident among the majority of female adolescents who experienced a substantial BMD loss while using DMPA.

Update on pubertal development.

This review provides updated information relating to the timing of pubertal onset from a large study of girls seen in pediatric practices. In addition, new studies investigating the relationship of the hormone leptin to the onset of puberty are discussed, as well as new information on the neuroendocrine control of pubertal regulation. A provocative study documenting poor mental health, more behavior problems, and lower IQ in children with premature adrenarche when compared with controls raises the question of whether psychological stress triggers premature adrenarche or whether the early increase in adrenal hormone secretion causes psychosocial problems. Finally, significant advances in the management of central precocious puberty in girls have been made over the past year.

Depot medroxyprogesterone acetate use in inner-city, minority adolescents: continuation rates and characteristics of long-term users.

OBJECTIVE: To identify continuation rates of depot medroxyprogesterone acetate (Depo-Provera) and characteristics of long-term users in a population of inner-city, minority adolescents with high pregnancy rates. DESIGN: Retrospective medical record review. SETTING: An inner-city adolescent clinic and an adolescent pregnancy program. METHODS: A review of the medical records of 250 females aged 13 to 20 years (mean +/- SD, 16.8 +/- 1.1 years), 62.9% Hispanic and 34.2% African American, receiving a first depot medroxyprogesterone acetate injection for contraception between August 1993 and June 1996 was conducted using a standardized form. The mean +/- SD age at menarche of the subjects was 11.6 +/- 1.4 years, and the mean +/- SD age at first intercourse was 14.1 +/- 1.3 years; the mean number of lifetime sex partners was 2.4. Of the subjects, 73.6% had used condoms, 32.0% used oral contraceptives, and none used implants. Of the 201 subjects for whom there were data in the medical records regarding prior fertility, 172 (85.6%) had been pregnant, and 145 (72.1%) had a child. Life table analysis was used to measure depot medroxyprogesterone acetate continuation rates and to compare subgroups of adolescents. RESULTS: Depot medroxyprogesterone acetate continuation rates were found to be 70.3% at 6 months, 48.3% at 9 months, 31.5% at 12 months, and 12.8% at 24 months. The most common reason for depot medroxyprogesterone acetate discontinuation was missed appointments (41.7%). Subjects were followed up for a mean +/- SD of 1.3 +/- 0.7 years after discontinuation of depot medroxyprogesterone acetate use; 46.7% became pregnant. Among those 156 adolescents who discontinued depotmedroxyprogesterone acetate use, 40.0% restarted the method at some later time. Continuation of depot medroxyprogesterone acetate use was more likely if age at first intercourse was younger than 13 years (P = .04). Continuation rates were not related to age, ethnicity, age at menarche, number of sex partners, use of other contraceptives, prior pregnancy, or having a child. CONCLUSIONS: In this study, just less than one third of the adolescents continued depot medroxyprogesterone acetate use for 1 year or longer. This suggests that depot medroxyprogesterone acetate does not function as a long-term method for most inner-city adolescents. The only characteristic that was associated with successful continuation of depot medroxyprogesterone acetate use was young age at first intercourse, implying that experience may be the main determinant of continuation.

The use of nonhormonal methods of contraception in adolescents.

Although the 1990s have seen a reduction in unintended pregnancy rates and improved contraceptive-use rates, the negative consequences of unintended pregnancy and STD acquisition continue to plague our youth. Primary health care providers, including pediatricians, play an essential role in further reducing unintended teen pregnancy and STD acquisition rates through the promotion of effective and consistent contraception. Pediatricians need to be aware that now, more than ever, nonhormonal contraceptive methods should be used by every sexually active youth, and counseling of both boys and girls should be routine. Although not as effective at preventing pregnancy as hormonal methods of contraception, many nonhormonal methods provide excellent STD protection. Condoms plus spermicide continue to be a very popular and effective method of pregnancy and STD prevention. The newer polyurethane male and female condoms provide alternative, safe barrier protection, although their efficacy at preventing HIV in vivo needs further study. Diaphragms and cervical caps, in conjunction with spermicide, also provide pregnancy and STD prevention, but not as effectively as male condoms plus spermicide. Although most likely to use condoms in association with another birth control method, adolescents often find dual-method use cumbersome and difficult to comply with. Finally, although IUDs and periodic abstinence are safe methods of birth control for older women in monogamous relationships, they are unlikely to be appropriate for most adolescents. In many respects, we have come full circle back to our "nonhormonal contraceptive roots." As we enter the twenty-first century, we have found that no single "miracle" approach can be used to reduce adolescent pregnancy and STD rates. Rather, pediatricians are obliged to offer nonhormonal methods of contraception, often in conjunction with other birth control methods, as a means of preventing unwanted STDs and pregnancy. Through a comprehensive community approach that uses sex education, abstinence programs, condom-availability programs, and contraceptive-skills training, however, pediatricians can play a central role in the promotion of effective and consistent contraception by adolescents.

Menstrual cycle abnormalities: diagnosis and management.

In summary, the diagnosis and management of menstrual disorders in adolescent girls is a particular challenge. The clinician must keep an open mind and consider physical conditions as well as psychosocial factors that may play a role in the menstrual dysfunction. Knowledge of congenital and genetic conditions, chronic biomedical as well as psychosomatic disorders, lifestyle choices, and complications of sexual behavior are essential to properly diagnose and treat menstrual disorders in young women. A detailed and confidential medical and psychosocial history and a thorough physical examination, including external genital examination, rectoabdominal or vaginal bimanual examination, and speculum examination (if indicated) are necessary.

Attitudes of inner-city female adolescents toward medical and surgical abortion.

STUDY OBJECTIVE: To explore the attitudes of inner-city minority female adolescents toward medical and surgical abortion to determine if medical abortion methods, which have been shown to be both effective and safe, might have greater appeal than surgical abortion. DESIGN: A cross-sectional, self-administered survey. SETTING: The waiting room of an inner-city hospital-based adolescent clinic. PARTICIPANTS: At total of 157 female adolescents aged 13 to 21 years; Hispanic (56%) and African American (31%). Most (94%) were sexually active, 43% had been pregnant, and 29% had previously had a surgical abortion. OUTCOME MEASURES: An 86-item questionnaire examining attitudes toward medical and surgical abortion safety and impact on future fertility, and pregnancy, abortion, and sexual history. RESULTS: A total of 68% believe that abortion is safe, and 55% believe that having an abortion is better than having an unwanted child. Belief in the safety of abortion was significantly associated with older age and with never having had an abortion. Almost three fourths (72%) believe that having an abortion might impair future fertility either from surgical damage (73%) or "as a punishment for having an abortion" (38%). The majority (72%) believe that "the more abortions you have, the harder it will be to get pregnant in the future." Regardless of personal abortion experience, 51% believe that a medical abortion would be safer than a surgical abortion. A minority (34%) believe that it would be easier to get pregnant after a medical abortion than after a surgical one. CONCLUSIONS: Although most inner-city, minority adolescents believe that abortion is safe, they also believe they risk their future fertility by having an abortion. The availability of medical abortion regimens would greatly influence decisions regarding abortion.

Adolescent preferences for rooming during hospitalization.

PURPOSE: To determine adolescents' rooming preferences during hospitalization. METHODS: A questionnaire designed by the authors was administered to 95 adolescents (59 inpatients and 36 outpatients) in 1996. Differences between groups were analyzed by Chi-square. RESULTS: The adolescents were equally divided between a preference to room alone (40%) or with one other person (39%). Fewer adolescents (20%) preferred more than one other roommate. When analyzed by gender, females were significantly more likely than males to prefer to room alone [53% vs. 28% (chi(2) = 5.34; p < 0.05)]. The majority of both inpatient and outpatient groups (93%) indicated a preference for a companion-in particular their mother-to stay with them overnight in the hospital during medically difficult times. CONCLUSIONS: These findings support our recommendation that there should be equal numbers of single and double rooms in adolescent inpatient units to accommodate these divided preferences among adolescents. Individual adolescent rooming preferences should be elicited and honored whenever feasible.

Adolescent girls and pelvic inflammatory disease: experience and practices of emergency department pediatricians.

OBJECTIVE: To describe the experience and practices of emergency department pediatricians in the United States related to the diagnosis and management of pelvic inflammatory disease (PID) in adolescent girls and to compare this experience with Centers for Disease Control and Prevention recommended management guidelines. DESIGN: National telephone survey. SUBJECTS: One hundred four pediatricians randomly selected from the 659 members of the Section on Emergency Medicine of the American Academy of Pediatrics. Response rate was 56%. MEASURES: A 42-item structured interview questionnaire assessed physician demographics, practice characteristics, PID diagnosis and management, and attitudes about sexually transmitted diseases in adolescents. RESULTS: Fifty-one (94%) of 54 emergency department pediatricians had diagnosed PID in adolescents at least once within the past 2 years, and 35 (69%) had diagnosed PID, on average, once per month or more. Less than half the pediatricians (23/51 [45%]) routinely recommended hospital admission for adolescents with PID as suggested by the Centers for Disease Control and Prevention, and among those treating adolescents with PID as outpatients,just over half (20/37 [54%]) arranged close follow-up within 72 hours of initiating antibiotic treatment. Although most emergency department pediatricians routinely suggested condom use (47/54 [87%]) and human immunodeficiency virus testing (34/54 [63%]) after diagnosing a sexually transmitted disease, a minority routinely provided contraceptive counseling (23/54 [43%]) or written partner notification (17/54 [31%]). Approximately two thirds of pediatricians surveyed indicated that they thought that the care of an adolescent with a sexually transmitted disease should be different from that of an adult (35/54 [65%]) and that this age group was more prone to medical complications (38/54 [70%]). CONCLUSIONS: The results of this survey suggest that emergency department pediatricians frequently diagnose PID in adolescent girls and understand the high risk of medical complications in this age group, but their management is often less aggressive than that recommended by Centers for Disease Control and Prevention guidelines and sexually transmitted disease experts.

Are there risk factors for hepatitis B infection in inner-city adolescents that justify prevaccination screening?

PURPOSE: This study was undertaken to determine if homelessness could serve as a marker for previous hepatitis B infection (HBI), and thus justify prevaccination screening. METHODS: One hundred sexually active 13-21-year-olds (mean = 17 years), 74% female, attending an inner-city hospital-based adolescent clinic (HOSP), and 48 sexually active 13-21-year-olds (mean = 19 years), 40% female, attending a clinic based at an urban drop-in center (UDC) for street youth were consecutively enrolled, screened for HBI serum markers and administered a structured interview about sexual practices, sexual abuse, prior sexually transmitted diseases (STDs), and injection drug use. RESULTS: For the HOSP group, 7% were homeless and 4% were HBI positive. In the UDC group, 96% were homeless and 23% were HBI positive. Homelessness was significantly associated with HBI (p < 0.001), and this was corroborated by logistic regression analysis (p < 0.01). Other factors significantly associated with HBI in adolescents included a history of anal sex (p < or = 0.002), anal-receptive sex (p < or = 0.01), genital Chlamydia (p < or = 0.03), prostitution (p < or = 0.03), and sexual abuse (p < or = 0.002). For both populations, gender, sexual orientation, intravenous drug use, and genital sex were not related to HBI. CONCLUSION: These data indicate that homelessness and associated high-risk sexual practices may be indications for prevaccination screening for HBI in adolescents.

Young women's attitudes toward injectable and implantable contraceptives.

STUDY OBJECTIVE: To assess the potential acceptability of implantable and injectable contraceptive characteristics by young women of diverse ethnic and educational backgrounds. DESIGN: A cross-sectional self-administered survey. SETTINGS: The waiting room of three clinical sites: an elite women's college health service, a coeducational state university health service, and an inner city hospital-based adolescent clinic. PARTICIPANTS: 328 young women awaiting medical care in one of three clinical sites, aged 13 to 21 years (85% 18-21 years); ethnic distribution differed significantly by site. The majority (83%) were sexually active, and of those who were sexually experienced, 25% had been pregnant. OUTCOME MEASURES: A 47-item questionnaire examining attitudes toward characteristics of injectable and implantable contraceptive methods, menstrual, sexual, and gynecologic history. RESULTS: Sixty-two percent of the sample agreed that they would get an injectable method. There was little variation in agreement to get an injectable method by sexual or pregnancy history. Fewer subjects (24%) agreed that they would like to get subdermal implants and agreement to get an implantable method of contraception did not vary by sexual history; however, ever-pregnant young women (33%) were significantly more likely to agree to implants than never-pregnant subjects (21%; chi2, 4.109; p = 0.04). Seventy-four percent of subjects said they would stop using a contraceptive that caused irregular menses, whereas 65% would stop using a method that caused amenorrhea. CONCLUSIONS: An injectable contraceptive method has universal appeal across ethnic, educational, and age categories, whereas implants are less appealing. Irregular bleeding and amenorrhea are poorly perceived side effects of long-acting contraceptives.

Interviewing adolescents.

Incorporating a functional approach within the traditional structure of the medical interview allows for improved communication with adolescent patients. Using these techniques results in improved patient satisfaction, more accurate psychosocial diagnosis, and better adherence to treatment recommendations. Many physicians think that using patient-centered interviewing techniques is time-consuming and inefficient, but, in fact, a higher quality and quantity of information usually is obtained per unit time using these techniques. An additional benefit is that this approach is more satisfying for the physician; the enhancement of the therapeutic relationship works both ways. Adolescents become more interesting as people; communication barriers become challenges to be creatively solved rather than annoyances to complain about. Adolescents need and deserve high-quality health care to grow into physically and mentally healthy adults, and effective physician-patient communication skills are the key to delivering that care.

Barbiturates.

Barbiturate use by adolescents has increased gradually in the past several years, but few adolescents use this class of drugs regularly. Instead, these sedatives are used most often to treat unpleasant effects of illicit stimulants, to reduce anxiety, and to get "high". Short-acting barbiturates such as pentobarbital and secobarbital are the preferred drugs of abuse. Barbiturates are dangerous drugs, with a narrow therapeutic index between the dose required for sedation and the dose that will cause coma and death. They are physiologically addicting if taken in high doses over 1 month or more, and the abstinence syndrome can be life-threatening. Pregnant women who take barbiturates during the third trimester can give birth to addicted infants who undergo an extended withdrawal syndrome. It is important to educate adolescent patients about the hazards of sedative/hypnotic use, particularly frequent barbiturate use. As indicated in the findings from the 1995 annual survey of United States high school seniors, many young people are not aware of the significant danger and toxicity of this class of drugs.

New contraceptive options for adolescents.

PIP: Among adolescents in the US, poor contraceptive use is compounded by a lack of understanding of the fertility risk, fear of the side effects of hormones, confidentiality issues, and low self-esteem. This article reviews the advantages and disadvantages of three new methods considered particularly appropriate for adolescents: third-generation low-dose oral contraceptives; long-acting progestin-only contraception (e.g., Norplant, Depo-Provera); and polyurethane male (Avanti) and female (Reality) condoms. Adolescents must be fully informed about all aspects of method use so that they will not be surprised by side effects that could lead to premature discontinuation of a safe, effective contraceptive method. There is a particular need for increased awareness and counseling about the barrier methods, given their ability to protect against STDs. Contraceptive vaccines, improved hormonal methods, and new barrier methods are under development.^ieng

Emergency contraception: a national survey of adolescent health experts.

In a survey of 167 physicians with expertise in adolescent health, 84% said they prescribe contraception to adolescents, but only 80% of these prescribe emergency contraception, generally a few times a year at most. Some 12% of respondents said they believe that providing emergency contraception to adolescents would encourage contraceptive risk-taking, 25% said they think it would discourage correct use of other methods and 29% said they think repeated use of the method could post health risks. Physicians who were more likely than their colleagues to prescribe emergency contraception included obstetrician-gynecologists (92%), those who graduated from medical school after 1970 (77%) and those who describe their practice as being in an "academic" setting (76%). Physicians may restrict use of the method by limiting treatment to adolescents who seek it within 48 hours after unprotected intercourse (29%), by requiring a pregnancy test (64%) or an office visit (68%), or by using the timing of menses as a criterion for providing the method (46%). While 41% of physicians who provide emergency contraception counsel adolescents about the method during family planning visits, only 28% do so during visits for routine health care; 16% counsel women who are not yet sexually active about the method.

Problem behaviors in inner-city adolescents with chronic illness.

This study examines the prevalence of problem behaviors (sexual activity, substance use, delinquency, and school failure) in a clinical hospital-based sample of 217 inner-city, 14 to 17 year olds with a variety of serious, chronic medical illnesses and compares this prevalence to that in a group of 121 similar-aged, healthy friends with no known chronic illnesses living in the same community. No differences were found between groups in substance use, delinquency, percent who had ever had sexual intercourse, or mean age at first intercourse. There was a significant interaction effect of chronic illness and gender on age at first intercourse (p = .015); boys without chronic illness initiated sexual intercourse at a younger age than their girlfriends without illness. Contrary to expectations, significantly more of the healthy friends had repeated a grade in school than had those with chronic illness (p = .002). Results are discussed in terms of the interrelationships of chronic illness, gender, and environment on problem behaviors.

Framework for identifying children who have chronic conditions: the case for a new definition.

Efforts to identify children with ongoing health conditions generally rely on lists of diagnoses. However, there has been a growing trend to use a noncategorical, or generic, approach in which such children are identified by the consequences of their condition. Recent legislation and the Supreme Court decision in Sullivan v Zebley adopt this broader concept and mandate that a noncategorical approach be used in determining eligibility for services and benefits. Traditional condition lists are less desirable because (1) every disorder to which children are subject cannot be included, (2) diagnoses may be applied inconsistently by clinicians and across settings, (3) condition labels alone do not convey the extent of morbidity for individuals, (4) there is a bias toward identifying only those children who have access to the medical care system, and (5) there is often a gap between emergence of symptoms or consequences and diagnosis. We developed a noncategorical framework for identifying children with ongoing health conditions that responds to the federal mandate and uses consequences of disorders, rather than diagnostic labels. It can be applied to meet the objectives of services, research, policy, reimbursement, or program eligibility; is consistent across diagnoses; is descriptive of the impact of morbidity; is adaptable to meet specific purposes; and can be modified by imposing different severity levels. Our screening tool will soon be available for practical use.

Utero-vaginal hypoplasia. Sonographic, embryologic and clinical considerations.

Congenital absence of hypoplasia of the uterus is a cause of primary amenorrhea in approximately 15% of cases. Ultrasound is often employed as an early imaging modality in the evaluation of patients with primary amenorrhea. Demonstration of total absence or marked hypoplasia of the uterus in the presence of normal ovaries during pelvic ultrasound examination, suggests the diagnosis of congenital uterine aplasia or hypoplasia. Sonography may obviate the need for laparoscopy and for other imaging modalities. A case report of uterovaginal hypoplasia in association with anal atresia and recto-vaginal fistula is presented, and the value of ultrasound in the diagnosis of this entity is discussed. The embryology and clinical features of this anomaly are also reviewed.

Ego development and chronic illness in adolescents.

To examine the effects of chronic illness on the psychological growth process known as ego development, scores were compared on the Loevinger Sentence Completion Test for 36 teens (16 boys, 20 girls) with chronic illness and 50 teens (16 boys, 34 girls) without chronic illness. Their ages ranged from 13 to 21 years, with a mean of 17.4 years. Most were Black (37%) or Hispanic (41%) and lived in poor or working-class neighborhoods. When age, sex, and Peabody Picture Vocabulary Test (PPVT) scores were controlled in multiple regression analyses, no direct association between ego development stage and presence of chronic illness, severity of illness, age at onset, or duration of illness was found. Analysis of the chronically ill group alone revealed a significant PPVT X Severity interaction, indicating that ego development in chronically ill teens is lower when illness is more severe and verbal IQ is higher.