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5th ed. Philadelphia, PA: Lippincott Williams and Wilkins; 2007.

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28th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2009.

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CASE 76: A 17-YEAR-OLD GIRL WITH HEAVY, IRREGULAR MENSES

A 17-year-old girl presents to the teen clinic with her mother, complaining of irregular menstrual bleeding for the past 6 months. You have been her pediatrician for the past 4 years, and upon reviewing her chart you find that she has had mild intermittent asthma and eczema in the past but no other chronic conditions. She started her periods at age 11 years, and menses have been regular every 28 days until 6 months ago. Menstrual flow has always been heavy, and she has always been using 5 pads a day for the duration of her period. Lately her menses have been somewhat irregular, lasting up to 10 days. There is no history of dysmenorrhea. She lives with both parents and a younger sister. She is a good student and participates in many extracurricular activities. She started dating 18 months ago and has been sexually active for the past 7 months. She has been using condoms “most of the time.” Family history is remarkable for hyperlipidemia and hypertension on the maternal side of the family. Her mother had a history of heavy periods all along. The younger sister has grand mal seizures.

The physical examination is normal except for the patient being mildly overweight and moderate facial acne.

SELECT THE ONE BEST ANSWER

1.
What other elements of the clinical history will you need to assess now?

(A) first day of the last menstrual period

(B) duration of bleeding

(C) amount of bleeding

(D) abdominal pain

(E) all of the above

2.
The following statements regarding the normal menstrual cycle in adolescents are true except

(A) normal duration is 2-7 days

(B) average blood loss is about 100 mL

(C) normal intervals are 21-40 days

(D) menses occur approximately 14 days after the LH midcycle surge

(E) ovulation occurs about 12 hours after the LH peak

3.
Which of the following definitions of abnormal vaginal bleeding patterns is incorrect?

(A) metrorrhagia: uterine bleeding at irregular but frequent intervals

(B) polymenorrhea: uterine bleeding at regular intervals of less than 28 days

(C) menorrhagia: prolonged or excessive bleeding at regular intervals

(D) hypermenorrhea: prolonged or excessive bleeding at regular intervals

(E) menometrorrhagia: prolonged or excessive bleeding at irregular intervals

4.
The great majority of cases of abnormal uterine bleeding in adolescence result from

(A) STDs

(B) dysfunctional uterine bleeding

(C) complications of pregnancy

(D) coagulopathies

(E) medications and drugs

5.
Which of the following conditions would be an unlikely cause of abnormal vaginal bleeding in this patient?

(A) spontaneous abortion

(B) dysfunctional uterine bleeding

(C) endometrial cancer

(D) cervicitis

(E) blood dyscrasias

6.
Which among the following elements of the physical examination would be the least relevant for the diagnosis and immediate management of this patient’s menstrual problem?

(A) pelvic examination

(B) heart rate

(C) BP

(D) pallor

(E) moderate acne

7.
The laboratory evaluation of abnormal vaginal bleeding in adolescents requires all of the following except

(A) pregnancy test

(B) hemoglobin and red blood cell indexes

(C) coagulation studies

(D) endometrial biopsy

(E) gonorrhea and chlamydia probe

8.
The physical examination reveals that the patient is hemodynamically stable with a BP of 110/60 mm Hg and a heart rate of 84 bpm. The pelvic examination shows moderate bleeding. There is no clinical evidence of infection. The hemoglobin comes back at 10.5 g/dL and the pregnancy test is negative. All of the following treatments will be acceptable for this patient except

(A) hospitalization (intravenous [IV] estrogens followed by conjugated estrogens orally plus medroxyprogesterone acetate orally for 7-10 days)

(B) medroxyprogesterone acetate 10 mg/day for 10-14 days

(C) oral conjugated estrogens 2.5 mg 4 times a day for 21 days plus medroxyprogesterone 10 mg orally on days 17-21

(D) any of the combined oral contraceptives 1 pill orally 4 times a day for 3-5 days to stop the bleeding followed by tapering to 1 pill a day until the pack is finished

(E) observation, menstrual calendar, and iron therapy

9.
Which among the following is not a common side effect of the monophasic combined oral contraceptive pills in adolescents?

(A) weight gain

(B) nausea

(C) breast tenderness

(D) breakthrough bleeding

(E) headaches

10.
The patient returns for follow-up 1 week later. She is now taking a combined pill containing a fixed amount of 35 micrograms of ethynyl-estradiol and 0.25 mg of norgestimate orally once a day. Her bleeding has stopped. She has not had any side effects from the medication except for some nausea during the first 2-3 days while she was taking “the pill” 3 times a day. She is also taking ferrous sulfate tablets 325 mg orally twice a day. A review of all laboratory tests obtained on the previous visit shows normal or negative results. The patient states that she is interested in long-term contraception and wants to know what methods you would recommend.

Among the following, which contraceptive method has the lowest failure rate during typical use in adolescents?

(A) combined oral contraceptives

(B) male condom

(C) progestin-only contraceptives

(D) periodic abstinence

(E) injectable depo-medroxyprogesterone

11.
Beneficial effects of the combined oral contraceptive pills include all of the following except

(A) effective in the treatment of acne

(B) improvement of bone mineralization

(C) menstrual regulation

(D) decreased risk of endometrial cancer

(E) decreased risk of thromboembolism

12.
Combined oral contraceptive pills can be safely used by an adolescent with any of the following conditions except

(A) postabortion

(B) active viral hepatitis

(C) hypothyroidism

(D) PID

(E) varicose veins

13.
Which of the following antibiotic medications interferes with the contraceptive effectiveness of the pill?

(A) amoxicillin

(B) rifampin

(C) cephalosporin

(D) sulfonamides

(E) all of the above

14.
All of the following medications decrease the clearance of combined oral contraceptives, potentially leading to increased estrogen levels and side effects except

(A) selective serotonin reuptake inhibitors

(B) fluconazole

(C) ritonavir

(D) nefazodone

(E) carbamazepine

15.
The combined oral contraceptive pill decreases the clearance of all of the following medications except

(A) benzodiazepines

(B) theophylline

(C) tricyclic antidepressants

(D) aspirin

(E) prednisolone

16.
The mother expresses some concerns about this patient’s ability to take a pill every day. Of the following methods, which one has the lowest contraceptive failure rate in typical users?

(A) contraceptive patch

(B) progesterone IUD

(C) vaginal ring

(D) diaphragm

(E) medroxyprogesterone acetate IM injection

17.
On discussing the benefits and disadvantages of all contraceptive options with the patient, you decide to keep her on the same combined oral contraceptive she has been on so far. She will also need to use condoms consistently to prevent STDs. All of the following statements regarding male condoms are accurate except