Adolescent Gynecology at Children's Healthcare of Atlanta

Krista Childress, MD

Adolescent females can present with a wide spectrum of gynecologic complaints and the differential diagnosis can be broad. It is important for providers to be familiar with common gynecologic conditions and their treatment, and when it is appropriate to refer to or consult a gynecologic specialist or refer to the emergency room (ER). Below is an overview of some of the most common adolescent gynecologic diagnoses and management recommendations. 

Abnormal Uterine Bleeding (AUB)

AUB is defined as menses outside the range of normal defined as: every 21-45 days, last < 7 days, and < 6 pads or tampons per day. Menses can be irregular for 2-3 years after menarche, however, no adolescent should go more than 3 months without a menses. The most common causes of irregular menses and/or prolonged heavy menses include anovulation due to endocrine causes or immaturity of the hypothalamic pituitary axis and bleeding disorders, the most common being Von Willebrand Disease. Work up for irregular menses includes TSH, Prolactin, LH, FSH, Estradiol, 17 OHP, testosterone, and gonorrhea/chlamydia if sexually active. A bleeding disorder work up is warranted if girls are consistently having prolonged heavy menses leading to anemia, flooding, doubling up pads, or other concerning symptoms such as easy bruising or gum bleeding. Recommended work up includes CBC, coagulation panel, TSH, and Von Willebrand Panel. Menses can be controlled with combined (estrogen/progesterone) hormonal contraceptives (pill, patch, ring) or progesterone only options (pill, injection, arm implant, and intrauterine device) which are ideally initiated after hormone work up for AUB is completed. Girls warrant referral to the ER if they have prolonged bleeding leading to significant anemia (hemoglobin < 8), soaking 1 pad or tampon per hour, or have symptomatic anemia. Heavy menstrual bleeding can be stopped acutely with the assistance of combined hormone pill taper or progesterone only pill taper (e.g. norethindrone acetate).

Abdominal and Pelvic Pain

The differential diagnosis for gynecologic causes of abdominal pain is broad including: dysmenorrhea, ovarian masses, pelvic inflammatory disease, and mullerian anomalies. Treatment for dysmenorrhea includes scheduled NSAIDS starting 1-2 days prior to menses and lasting throughout followed by hormonal contraception if treatment fails. Persistent abdominal pain not relieved by NSAIDS or acute severe pelvic pain warrants a pelvic ultrasound to evaluate the uterus and adnexa (ovaries/fallopian tubes).  Adnexa > 5 cm with severe abdominal pain, nausea and vomiting warrant ER evaluation given the concern for ovarian torsion. Pelvic inflammatory disease is defined as uterine, adnexal, or cervical tenderness plus abdominal pain and should be prophylactically treated in any girl who is sexually active. Reasons for referral to the ER include nausea/vomiting, unable to tolerate oral medications, fever, or failed outpatient treatment. Obstructive mullerian anomalies such as imperforate hymen or non-communicating uterine remnants should also be considered when a patient has cyclical monthly pain or on examination has breast development and no vaginal opening. Patients with these diagnoses warrant ER evaluation if they have uncontrolled pain or difficulty with urination. 

Vulvar Trauma and Genital Ulcers

Straddle injuries are very common and warrant ER evaluation when a large laceration is present, persistent bleeding, or large vulvar hematoma causing severe pain or inability to urinate. Most vulvar hematomas, though frightening on examination, will resolve with conservative management (NSAIDS, ice, rest) on their own. Lipshultz or aphthous vulvar ulcers should be in the differential for genital ulcers. It is a diagnosis of exclusion after diagnoses such as HSV. They are commonly caused by a viral illness (e.g. upper respiratory illness or gastroenteritis) and typically present 3-4 days after prodromal viral symptoms. Treatment is symptomatic including scheduled pain medication and topical or oral steroids. Indications for referral to the ER include uncontrolled pain and difficulties with urination. 

Pediatric and Adolescent Gynecology in Atlanta!

Krista Childress, MD and Abigail Smith, PA-C are two pediatric gynecology providers at Children’s Healthcare of Atlanta that see patients birth to 21 years of age and treat a broad spectrum of gynecologic conditions from menstrual issues, contraceptive counseling, pre-pubertal complaints to surgical conditions including ovarian cysts and uterine/vaginal abnormalities. Don’t hesitate to reach out to Krista Childress, MD or Abigail Smith, PA-C for consultations, clinical questions, or patient referrals. They can be contacted at or or Pediatric and Adolescent Gynecology Clinic at (404)-785-1491. Please see their website for information and referral links:

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Eating Disorders Management at Children's Healthcare of Atlanta

Laura Elizabeth Doerr, MD, FAAP

When Karen Carpenter died of heart failure in 1983 from Anorexia nervosa, it raised awareness about the complications of eating disorders. Before her death there wasn’t much discussion about eating disorders and the dangers of rapid weight loss. Until recently, eating disorders were considered the most lethal of the mental health disorders. Now it is only second to opiate abuse as the most lethal of these conditions. 

Eating Disorder Admissions at Children’s Healthcare of Atlanta
            Recently, we have seen an exponential increase in the admissions of patients with Eating Disorders at Children’s Healthcare of Atlanta. The incidence has increased exponentially from 18 admissions in 2010 to over 110 in 2018. Eating Disorders are mental illnesses that can have serious medical complications that can affect almost every organ system. The median age of onset is 12-13 years of age, and it can affect both genders. There has also been an increase in the diagnosis of eating disorders among the transgender population.
            At Children’s Healthcare of Atlanta, there are protocols in place for the management of these patients in the ED and inpatient services. This assists in early recognition and triage of these patients as they are evaluated to see if they warrant admission for medical stabilization (see chart end of article). The American Academy of Pediatrics has come up with a list of objective criteria to help with determining who warrants admission to the hospital. This includes such objective measures as vital signs (i.e. heart rates < 50 beats per minute), electrolyte criteria (such as phosphorus < 3.0), and consideration of patients that are most at risk of refeeding syndrome. It is the hope that this triage system will help with early recognition of patients with these disorders and help with admitting those who warrant medical stabilization.

Atypical Anorexia Nervosa
            Some of the most challenging patients to recognize are those with atypical Anorexia nervosa. By definition these patients would meet DSM-V criteria for the condition except that they may present with a normal weight and/or BMI. This can make it a challenge to recognized and this is why these patients may present later or more ill-appearing, given if they are looked at as a single plot on the growth chart they may look like their weight or BMI is within normal range. 
            In conclusion, it is important to ask questions when a symptom raises a concern about an eating disorder. Is the patient overly concerned about his or her weight? Have they recently adopted a radical diet change, such as converting to a vegan diet? Have they developed primary or secondary amenorrhea? Or on their growth chart, have they plateaued or failed to achieve appropriate increases in their growth over time.?
            If you do have concerns about a patient that may have an eating disorder, it may be worth having them triaged at one of our Children’s Healthcare of Atlanta facilities. There if they meet criteria for medical stabilization, they can be admitted to our inpatient unit at Scottish Rite. We have a multidisciplinary team that includes psychiatry, hospitalist medicine, case management, nutrition and child life. Our goal is to help manage these patients medically and then transition them to an appropriate level of care post-discharge that could involve inpatient eating disorder treatment or outpatient therapy, depending on the needs of the patient and family. 
Contact information: Laura Doerr, MD, FAAP.

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