David S. Reitman, MD

On a warm spring day, Chris comes to your office for his "pre-college" physical examination and immunizations. Looking through his problem list, you remember rounding on him when he was hospitalized for asthma at age 5, counseling him about pubertal changes when he was 11, and treating his infectious mononucleosis when he was in high school. You are proud to see him growing into a fine young adult, but the sentiment is bittersweet when you realize that this may be one of the last times that you take care of him as your patient. Like many of your graduating high school seniors, Chris will need to go to the college health service to meet his future health needs. 

You sign his required college forms and give him his meningitis vaccine. As you prepare to say "good luck," you wonder what counsel you can offer to help him become a healthy and educated medical consumer and patient. 

As a graduating high school senior prepares for college, his or her thoughts are inevitably focused on the exciting prospect of a new dormitory, roommates, college food, parties, friends, and (of course) academics. Unless the student has a chronic medical condition, he will probably spend little time thinking about what he would do if or when he gets sick. 

 Unfortunately, most students need to enlist the aid of the university health services at some point in their college careers and this may be the first time that they see a clinician who is not their own pediatrician. Furthermore, this will probably be their first time navigating the US health care system without their parents' guidance. While most college students relish their independence, they are frequently overwhelmed by the responsibility of managing their own health care-especially in an environment with myriad insurers, all with their own complicated rules and procedures.

 So when "Chris" comes in for his pre-college physical examination, what kinds of anticipatory guidance and counseling-beyond advice about good sleeping and eating habits, reproductive and mental health, and use of illicit drugs and alcohol-might benefit him most? This brief review will provide an outline of key issues that you may wish to discuss with your patient and his family.

Approximately 1600 colleges and universities have a student health service that provides a variety of health services for their students. Frequently, the institutions' needs and funding determine the breadth of services offered. Some universities may simply provide a small office for urgent care services. Other institutions may offer a broader variety of services that may include specialty services such as orthopedics, gynecology, mental health services, and alternative health modalities. 

 Undergraduates often have a difficult time transitioning their care from their pediatrician to a different provider. Their first visit to the college health clinic can be daunting. For some students, this may be the first time they have visited a health provider without a parent-or even the first time they have had to make and keep their own appointments. In any case, the experience is likely to be vastly different from their norm.

     Decide with the patient what role,     if any, the home pediatrician will     play in meeting a patient's health     needs while he attends college.     Some physicians don't mind practicing     long distance medicine, while     others will not do so. The outcome     of this discussion can have an important     impact on a patient's transition     to adult care. 

     Nurse practitioners (NPs) or     physician assistants (PAs) frequently     help staff a student health practice.     This may seem unusual to the     patient who has only seen a physician.     It is important to reinforce that     NPs and PAs can provide excellent     patient care and that not all illnesses     require physician intervention. 

Occasionally, students mistakenly     believe that physicians would only     work in a university health care setting     because they lack clinical skills     or they could not succeed in a private     practice setting. In reality, many     university physicians are accomplished     physicians who practice     college health because they consider     it a wonderful, challenging     environment. 

PAST MEDICAL HISTORY AND FAMILY MEDICAL HISTORY.

The pre-college physical examination is a great time to review past medical history and family medical history. Undergraduates are frequently oblivious; as the adolescent prepares for college, it may be important for him to understand significant and relevant details (such as a family history of alcoholism or mental illness) so as to make the best overall health decisions. 

Review any pertinent medical history     with the family and patient. Parents     occasionally withhold family     medical history from their children     as they are growing. Now may be     the time to facilitate a revealing discussion     about such matters. 

Review any pertinent medical history.     Some schools require parents     or physicians to complete a medical     health background form before matriculation.     Others rely on the student     to provide relevant medical     background. Because many adolescents     are poor historians, this information     gap can potentially delay diagnoses     and the implementation of     treatment. 

Review the student's medications.     The student should understand why     he is taking certain medications and     what the dosages are. Ideally, this is     a good time to discuss potential adverse     drug effects and how to manage     them if necessary.

MENTAL HEALTH AND CHRONIC DISEASE MANAGEMENT

Students with chronic medical problems or mental health issues have probably seen their specialist for years before they start college. Before the student leaves for school, explore how he plans to manage these health issues. Make sure that some transitional care plan is in place before the student leaves home. Ideally, this plan should include some written communication between the specialist and the college health service. This may seem like stating the obvious. Nevertheless, I frequently see freshmen in crisis because of a lack of planning. 

     Consider whether the specialist     will continue to follow the patient's     chronic medical problems when he     leaves for school-or whether the     specialist will arrange for transfer of     care to a local specialist in the collegiate     community? 

If medications need to be continued,     who will arrange for the refills?     If the student changes health     insurers (see below), will the home clinician be able to continue as a     provider under the new insurance     plan?

 Seventy percent of college students have health insurance-either through a sponsoring educational institution or through their parents. Unless insurance has been a problem in the past, most pediatricians probably do not discuss the topic with the college-bound patients. However, many families must consider either enrolling in student insurance or keeping their child on their current plan. The family should review these policies with their child ahead of time: a sick visit during final exam week is not the time to learn that there are potential snafus in coverage. 

     If a student decides to purchase a     university-sponsored insurance plan,     he must make sure that it meets     any anticipated needs. For example,     if the student has been taking a     medication for a long time, will it be     covered under the new plan? If the     student wishes to continue seeing a     certain specialist for a chronic medical     condition, will the specialist     accept the new plan? 

Almost all health plans have some     limitations, and the student must understand     those limitations. Some     plans require that the subscribers     designate the student health services     as a primary physician. Will this limit     access to their home pediatrician?     How will you manage that situation     with your patient and his family? 

     If the family plans to keep their     child enrolled in their own health     plan, they need to review the contract     carefully for any restrictions it     might impose on their child in college.     In particular, if the student     needs a specialist referral, can this     be generated by the student health     services or must the home primary     care provider do this?

     After a student sees a health care     provider, an explanation of benefits     (EOB) is frequently mailed to the     primary policy holder-which may     be the student or parent (depending     on who holds the policy). Occasionally,     details of procedures or lab test     results may be listed on the EOB. If     the parent is the policy holder, how     might this affect the student's right     to confidentiality and subsequent     access to care?

     Finally, the family needs to consider     the impact that an unanticipated     academic leave of absence may have     on their child's coverage. Some     plans cover adult children (older     than 18) only if they are enrolled in     college. Conversely, many university-     sponsored plans provide coverage     only if the student is actively     enrolled in their school. While most     high school seniors do not plan for     this contingency, it is not uncommon     and is best considered ahead     of time if possible.

Without wishing to state the obvious, a quick note on confidentiality in college health is appropriate. Most college freshmen are at least 18 years old when they start college; as such, they are afforded the privileged right to confidentiality that comes with adulthood. With those rights, however, comes the responsibility for their own health care. 

 From a medicolegal standpoint, strict confidentiality must be maintained in college health settings. Regardless of who pays the tuition and insurance bills, college health providers cannot legally discuss a clinical encounter with an outside party- unless the patient gives them express permission to do so (in writing). If your patient has a medical issue that requires you to communicate with the student health service, make sure that all confidentiality releases and permissions are granted before the patient leaves for college. Unless the student's health and life (or another person's health and life) are jeopardized, confidentiality is rarely (if ever) broken in these settings. 

A patient's departure for college is a bittersweet experience for all involved. The pre-college physical is a great time to ensure that any clinical care loopholes are closed and that your patients (and their families) are adequately prepared for any unanticipated health issues. Appropriate preparation can ease a difficult transition and help ensure that your patients will remain happy and healthy as they take their first real steps to independence and adulthood. 

     Goldstein MA. Preparing adolescent patients for     college. Curr Opin Pediatr. 2002;14:384-388.

Neinstein L, Swinford P, Farrow J. Overview of     health issues for college students. In: Neinstein L,     Gordon CM, eds. Adolescent Health Care: A Practical     Guide. 5th ed. Philadelphia: Wolters Kluwer/     Lippincott Williams & Wilkins; 2008:1080-1110. 


Stashwick CA. The pre-college visit: make the     most of it. Intern Med. 1997;14:89.

Articles

To Their Good Health: Key Points About College Health Care for High School Grads

Oral contraceptive (OC) pills are frequently prescribed for a variety of clinical purposes. These medications--which contain varying amounts of estrogen- and progestin-based compounds--essentially "override" a woman's innate hypothalamic-pituitary-ovarian axis and frequently help ameliorate the effects of a maturing reproductive system while preventing pregnancy.

This article reviews the clinical effects of hormonal contraception. Five clinical vignettes are presented that focus on diagnosis and management of problems that may occur when teenagers take OCs.

The typical OC pill contains a combination of an estrogen (usually ethinyl estradiol) and a progestin. To understand how OCs work, remember that ovulation occurs because the hypothalamus secretes gonadotropin-releasing hormone (GnRH), which stimulates the pituitary gland to produce follicle-stimulating hormone (FSH) and luteinizing hormone (LH). High levels of estrogen and progesterone inhibit secretion of FSH and LH at the level of the hypothalamus (via GnRH) via the pituitary gland. Thus, the body requires sufficiently low levels of estrogen to allow for FSH secretion and follicular maturation, followed by an estradiol surge that prompts secretion of LH to stimulate ovulation (

To prevent follicular maturation, a patient requires consistent, high levels of estrogen to provide feedback inhibition on the hypothalamus (which subsequently inhibits FSH secretion). In addition, high levels of estrogen combined with progesterone effectively inhibit the LH surge, which inhibits ovulation. Therefore, the estrogen and progesterone in OCs provide an exogenous level of inhibitory control to the hypothalamus and pituitary gland. The result is decreased FSH and LH secretion and prevention of ovulation.

OCs typically come in packages of 21 to 28 pills so that the patient can easily keep track of her menstrual cycle. The 21-day packages require the patient to stop taking pills once all 21 pills have been consumed; after waiting a week (while menses occur), a new package is started. Many adolescents find it less confusing to use a 28-day package (

). The 7 placebo pills taken at the end of the month allow them to maintain their routine without having to remember to reinstate the regimen the following week.

The estrogen component of most OCs is ethinyl estradiol. Over the past 30 years, the concentration of this hormone has dramatically decreased from that used in initial OC studies. After the patient ingests the pill, the liver provides a significant first-pass metabolic effect such that most of the hormone is metabolized before it reaches its target organs. Most commercially available combination hormonal contraceptive pills contain between 20 and 35 µg of ethinyl estradiol. Patients generally do not notice significant differences in clinical efficacy based on a difference of 15 µg of hormone.

Progestin, the other active component in OCs, primarily binds to progesterone receptors; it may also cross-react with androgen receptors throughout the body. Therefore, androgenic potential is frequently the major consideration when choosing an OC. The progestins, norethindrone and levonorgestrel, both tend to cross-react with androgen receptors. They also displace testosterone from sex hormone binding globulin (leading to an increase in free testosterone levels), thereby providing a fairly strong androgenic effect.

In contrast, norgestimate has decreased androgen affinity and also functions as a 5a-reductase inhibitor. Because of its androgen- minimizing effects, norgestimate may be more appropriate for the adolescent with severe inflammatory acne. Another new progestin, drosperinone (Yasmin) is a spironolactone analog with excellent anti- androgen and anti-mineralocorticoid properties.

OCs are also distinguished by the amount of hormone they deliver throughout the 4-week cycle. A constant rate of estrogen is typically maintained in all of the bioactive pills. In a "monophasic" OC, the progestin concentration remains constant. A "biphasic" or "triphasic" pill has varying progestin concentrations over the first 3 weeks of the cycle. In my experience, multiphasic pills do not provide significant benefit over a monophasic option except in certain scenarios (discussed below).

Nausea is a common complaint among patients who start OC therapy. This problem (caused by the estrogen component) usually lasts for a few hours immediately after the pill is taken. I recommend that patient take the medication just before going to sleep. The nausea tends to disappear with consistent use: most patients report that it resolves within 1 to 2 months.

Estrogen-sensitive patients may complain of fluid retention, headaches, intermittent spotting, and/or mood changes. If these symptoms are not severe, then "watchful waiting" or a decrease in the ethinyl estradiol content may suffice. If symptoms are severe, however, consider other contraceptive options.

No discussion of OCs would be complete without mentioning the black box warnings of potential venous thromboembolism. The risk of deep venous thrombosis (DVT) increases dramatically if the patient smokes tobacco or has a history of DVT. Therefore, all patients must be screened for a personal or family history of DVT and counseled about DVT risk before OC therapy is started. Patients who complain of leg swelling, shortness of breath, or chest pain need an immediate workup to determine whether a thromboembolic event has occurred.

Adverse effects of progestin are generally related to the degree of androgenicity described earlier. The more androgenic progestins, such as levonorgestrel, may cause acne, appetite increases (with possible weight gain), male pattern hair loss, and hirsutism. When a patient taking an OC reports these effects, consider switching to an agent that contains norgestimate or drospirenone.

Regardless of whether you actively prescribe combined OCs, you probably encounter adolescents who take these medications for various reasons. The following clinical vignettes illustrate some of the more common issues that may be encountered. I invite you to consider the physiology involved and potential solutions before you read the explanations.

Sixteen-year-old Amelia is concerned about her lack of menses. Her periods began when she was 11, and by age 13 she had regular monthly periods. Over the past year, however, her periods have become irregular. She has not menstruated in over 6 months.

Amelia is an overweight Latina in no distress. She has mild inflammatory acne over her face and chest as well as some hair growth on her chin and naval area. She has mild acanthosis nigricans around her neck.

Amelia denies ever having engaged in sexual activity. Pelvic examination reveals an intact hymen and a urine pregnancy test result is negative.

Results of thyroid studies are normal. LH level is 22 mIU/mL; FSH is 8 mIU/mL. Dihydroepiandrosterone (DHEAS) and testosterone concentrations are both mildly elevated.

As you finish your examination, Amelia blurts out,"Doctor, is there anything you can do about this facial hair? I feel like I am growing a beard!"

What's happening with Amelia? Can anything help her hirsutism?

Amelia probably has polycystic ovarian syndrome (PCOS). This process, characterized by amenorrhea, hirsutism, obesity, and acne, may be caused by abnormal function of the hypothalamic-pituitary-ovarian axis, leading to excessive androgen production in the form of androstenedione and DHEAS. These androgens may be converted peripherally to testosterone, resulting in hirsutism. Insulin resistance frequently exacerbates the condition.

OCs are frequently used to manage PCOS. While OCs probably do not treat the disease, they can ameliorate many of its troubling androgenic symptoms (such as hirsutism and acne). An OC that contains norgestimate would therefore be appropriate; this hormone has low androgen receptor binding affinity and its 5a-reductase inhibition effect results in decreased testosterone production. An OC with drospirenone as the progestin (eg, Yasmin) is another reasonable choice.

Regardless of the progestin you choose, counsel the patient that while the OC may effectively regulate her menses, it may take up to a year of therapy before the hirsutism and acne improve. Other cosmetic approaches such as shaving, waxing, or electrolysis may be considered if the adolescent is distressed by her appearance. An acne management regimen can be prescribed if the patient's skin troubles her.

Amy, 18, has been taking Lo-Ovral for the past 3 years. She initially started taking the pill because of some moderate dysmenorrhea with heavy menses. Since then, she has had normal, regular periods. Over the past 3 to 4 months, however, Amy has experienced breakthrough bleeding and intermittent spotting throughout her cycle. She reports that she has been sexually active only with her current boyfriend of 2 years and that they always use condoms as a form of back-up protection.

Amy's vital signs are normal. Pelvic examination reveals a normal cervix without cervical motion tenderness or adnexal tenderness. You recommend follow-up in 3 days to review lab results.

At the follow-up visit, you tell Amy that cultures for 

 were negative. Her hemoglobin and platelet counts are normal; and her white blood cell count is 5000/µL. While Amy expresses relief about these results, she still wants you to do something about the annoying menstrual bleeding.

Assuming that there is nothing physiologically wrong, how might you help Amy's symptoms?

Breakthrough bleeding is a common yet manageable effect of OC use. While it most frequently occurs during the first few cycles of use, spotting can develop later for no apparent reason. The most common cause of breakthrough bleeding in adolescents is inconsistent pill use, but non-hormonal causes of bleeding (such as endometritis, pregnancy, and trauma) need to be assessed.

The adolescent who religiously takes her pills but who experiences this phenomenon may not have the patience to "wait it out until it resolves," as an adult might. For this reason, be sure to let the adolescent know that you hear her concerns.

When breakthrough bleeding develops and persists, consider changing the estrogen and progestin concentrations in the OC. Find out when the bleeding typically begins. If the bleeding begins toward the end of the cycle, there may be insufficient progestin to stabilize the endometrium. A triphasic pill (such as Ortho Tri-Cyclen or Ortho-Novum 7/7/7) with increasing progesterone over the 3 weeks of hormone administration would be appropriate in this scenario. Alter- natively, some practitioners may continue to prescribe the monophasic pill but during the cycle's third week will add in 7 days of the progestin-only "mini-pill" to provide additional endometrial stabilization.

Conversely, if the spotting begins in the 10 days after menses, the problem may be that insufficient ethinyl estradiol is present to stabilize the endometrial lining. An increase in the estrogen content frequently solves the problem. If this approach does not work, try switching to a triphasic pill in which the progestin dose is decreased in the early part of the cycle relative to the estrogen. In this setting, the triphasic OCs may have a clinically observable benefit over the monophasic OCs.

April began taking a triphasic OC approximately 2 months ago. At her first follow-up visit, she has no complaints. For the first 2 weeks, the pills made her slightly nauseous.

April describes a headache she experienced about 2 weeks earlier. She had been watching television when she began to see flickering lights in front of her left eye. This phenomenon lasted for about 10 minutes; within an hour, a pounding left-sided headache developed. April took 3 ibuprofen tablets and fell asleep for a few hours. When she awoke, she felt somewhat better. Now she is worried that she has a brain tumor.

April reports that her mother and aunt get bad headaches that force them to stay in bed.

Is April's headache related to her OC? What would you do next?

April's headache sounds typical of migraine with aura. Patients who are prone to migraine with aura tend to have more frequent headaches (or even have a first headache)when they take an OC. In contrast, OCs may actually help patients prone to migraine 

Patients who have migraine with aura are at significant risk for stroke if they start taking combination OCs. Because migraine with aura is an absolute contraindication to OC use, April will need another form of birth control, such as a progestin-based intervention.

The 2 most common delivery methods for progestin-based contraception are the mini-pills and depomedroxyprogesterone injections. Currently, approved mini-pills contain either norethindrone or norgestrel. They must be taken at exactly the same time every day to maintain their efficacy. Common adverse effects include amenorrhea and menstrual spotting. While probably safe to use in patients having migraine with aura, the mini-pill must be discontinued if symptoms persist (or worsen) while taking the progestin-based contraceptive.

Michelle, 16, has been taking OCs for 2 years. This weekend, she was hospitalized after experiencing fever and vomiting for 24 hours. A complete blood cell count and a comprehensive metabolic panel were ordered.

The aspartate aminotransferase (AST) level was mildly elevated at 41 U/L (normal, 0 to 35 U/L), but the rest of the results were normal. Because of the elevated AST, a hepatitis panel was ordered. Results showed the patient to be anti-HAV IgM-negative, anti-HCV IgM-negative, hepatitis B surface antigen-positive, hepatitis B virus core IgM-negative, and hepatitis B core IgG-positive. Given the positive serologies, Michelle was told that she had hepatitis B and that she should not be taking OCs.

Twenty-four hours later, Michelle's liver function test results were all normal. Her health had improved, and she was discharged. On her follow-up visit to your office, she asks about what birth control options are available for someone with hepatitis.

What do you tell her? Was it appropriate to stop Michelle's OCs?

When active hepatitis B is suspected, it is appropriate to discontinue the OCs. It is not clear, however, whether Michelle really has active hepatitis B. The mildly elevated AST level is probably the result of vomiting and dehydration related to a simple viral gastroenteritis. The hepatitis B serology results suggest that she had hepatitis B and is now a carrier (as evidenced by the presence of the hepatitis B surface antigen).

According to the World Health Organization's guidelines for OC use, a patient who is a hepatitis carrier should not be restricted from using oral estrogen-based contraceptives. However, the patient who is acutely ill with hepatitis A, B, or C (or any other type) must avoid these medications until the infection resolves and any concurrent liver abnormalities normalize. This is because the ethinyl estradiol is primarily metabolized via the liver's cytochrome P-450 system.

Michelle's hepatic function is intact. She does not have active hepatitis. Therefore, she can start a new pill package as soon as her next period begins.

Christine, a 19-year-old college sophomore, comes to see you over her winter break. She has been taking Ortho Tri-Cyclen for the past year and a half to treat moderate inflammatory acne and for birth control. Until the past few months, the OCs did an admirable job of regulating her periods such that she could "set her clock" by the timing of her menses.

Last summer, Christine began to experience symptoms consistent with bipolar depression. Her psychiatrist prescribed carbamazepine, which yielded excellent clinical results.

Christine is now concerned because her last 3 menstrual cycles have become erratic. She has experienced significant breakthrough bleeding at various times throughout her cycle. She does not have abdominal pain or clinical signs of anemia (her hemoglobin level is 14 g/dL), but she is increasingly annoyed with the bleeding. "I'm doing everything right. I take the pill at the same time every day. I eat well and get plenty of sleep. Why can't I just have the normal periods that I used to have?"

Why should Christine suddenly be having these symptoms? What are her options?

When a patient with a mature menstrual pattern experiences more than 1 to 2 cycles of menstrual irregularities, an investigation is warranted. A sexually active adolescent with frequent spotting or breakthrough bleeding could have endometritis from pelvic inflammatory disease. A pelvic examination with cultures and a urine pregnancy test are therefore warranted.

Once infection and pregnancy have been ruled out, other causes of metromenorrhagia must be examined. Often, the contributing causal factor relates to inconsistency in OC administration. Many middle adolescents require some degree of parental supervision (if appropriate) to remind them to take their pill. Even college students may use their medication inconsistently. It appears that Christine has been taking her pills fairly reliably, however.

In this scenario, the introduction of carbamazepine should be a diagnostic consideration. In theory, many anticonvulsants can stimulate the cytochrome P-450 system, thus facilitating the metabolism of ethinyl estradiol in the liver. The effect ranges from breakthrough bleeding to contraceptive failure. Antibiotics such as rifampin or griseofulvin may have similar characteristics and could decrease the hormone levels and their subsequent efficacy.

I must qualify these statements because they are primarily based on long-standing expert opinion and anecdotal case reports rather than controlled trials. In actuality, there is no clear evidence that these medications decrease the hormone levels, increase breakthrough bleeding, or increase undesired pregnancies. Despite this controversy, I would still discuss with patients the potential for decreased OC efficacy when these pills are taken concurrently with other medications that can induce the cytochrome P-450 system. At the very least, the sexually active patient who takes OCs should consider using a back-up (barrier) form of contraception while taking these medications.

If Christine wants to continue to take combination OCs, she might benefit from a pill containing 50 µg of ethinyl estradiol (such as Ovral or Ovcon 50). While the high dose of estrogen in these formularies could be considered excessive for most adolescent girls, the cytochrome P-450 system theoretically metabolizes a significant portion of the estrogen before any clinical effect is noted.

Some adolescent medicine clinicians advocate use of the estrogen patch (Ortho Evra) or the estrogen vaginal ring (NuvaRing) because the absorbed estrogen bypasses the hepatic first-pass metabolism. This may indeed be a reasonable course of action, but currently there are few data to substantiate these options and they should be approached with caution.

Christine could switch to a progestin-based form of birth control, but she will probably lose the acne-treating benefits of the norgestimate/ethinyl estradiol combination. Many progestins actually exacerbate acne because of their androgenic potential. She needs counsel- ing and a birth control option that will minimize the risk of androgenic effects.


ACOG Practice Bulletin 73: Use of hormonal contraception in women with coexisting medical conditions. 

2006;107:1453-1472.m Calderoni ME, Coupey SM. Combined hormonal contraception. 

2005;16:517-537.
Calderoni ME, Coupey SM. Combined hormonalcontraception. 

. 2005;16:517-537.
Faculty of Family Planning and Reproductive Health Care Clinical Effectiveness Unit. FFPRHC Guidance (April 2005). Drug interactions with hormonal contraception. 

Adolescent Medicine Update: Oral Contraceptives: Five Vignettes Illustrate Dx and Rx Problems-- and Solutions

For many practitioners, teenagers with eating disorders elicit a visceral reaction. Many clinicians find it difficult to imagine why an adolescent might choose to starve herself or even make herself vomit. Understandably, they become increasingly frustrated with the emaciated- appearing patient who insists that she is "too fat" and "needs" to lose 10 more pounds. Anorexic teenagers tend to take a great deal of the physician's time and usually demonstrate few (if any) appreciable short-term improvements. The knee-jerk reaction may be to immediately refer these "frustrating" patients to a local academic center's adolescent medicine specialist. While consultation with a specialist may be appropriate, the primary care physician still plays a fundamental role in the initial diagnostic workup and in long-term management.

Here I review some of the information that a primary care physician needs to remember when evaluating a patient who may have anorexia nervosa (AN). Rather than attempting to offer a comprehensive review, I present a basic framework for understanding malnutrition. I also focus on clinical clues, physical examination findings, and laboratory tests that help streamline referral to a tertiary care eating disorder specialist.

Kristen, 16, is an all-around "good kid." You have known her and her family since she was a preschooler. Aside from the occasional "strep" throat or flu, she has been in excellent health. She comes to your office today for her annual sports physical examination. Kristen is a junior varsity long-distance runner; she hopes to make the varsity team next year. She played the leading role in her high school musical this year and has made the honor roll every semester.

Kristen has no physical complaints. She denies any alcohol, cigarette, or drug use and says she has never engaged in any sexual activity. 

A look at Kristen's growth chart reveals that her weight has dropped from 125 to 108 lb since you last saw her. An eating disorder comes to mind.

What do you do now? What will you say or ask?

Termed "nervous consumption" in the 19th century, AN is characterized by a dramatic weight decrease accompanied by an obsession with nutritional intake. The disease affects as many as 1 in 200 white adolescent girls; the mean age at onset is between 13 and 14 years. The risk of AN is 10-fold higher in girls than in boys.

The diagnostic criteria for AN as defined in the 

Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR)

 In brief, patients with AN have a disturbed perception of their body shape that is accompanied by an intense fear of gaining weight. They become obsessed with their weight and caloric intake such that they cannot rationally interpret their situation.

Patients are classified (by subtype) according to the methods used to lose weight:

In the "restricting" subtype, patients either severely limit their caloric intake or exercise excessively to burn off calories.

In the "binge-eating/purge" subtype, the adolescent engages in binge-eating episodes followed by purging through laxative use or self-induced vomiting.

Patients with either subtype maintain and amplify their weight loss to the point at which symptoms and signs of malnutrition develop. Associated morbidity and mortality correlate with the degree of malnutrition.

Typically, weight loss troubles the patient's friends and family--not the patient. Most adolescents with AN present for medical care because their family and friends are concerned about their dramatic weight loss and its biologic effects.

The diagnosis and treatment of AN frequently involves a multidisciplinary team that includes an eating disorder specialist, a psychotherapist, a nutritionist, and the primary care physician. While the primary care physician may not have time and/or expertise to perform a comprehensive evaluation, he or she can play a vital role in manag-ing the nutritional sequelae of the patient's disease.

You ask Kristen about her weight loss. She knows she has lost a "little" weight but attributes this to the attention she is giving to her diet as well as her running. Kristen says she eats "well" and has no concerns about her weight. She denies any purging behaviors and insists: "Believe me, I'm not bulimic or anything like that! That's gross."

On hearing this, Kristen's mother--who has been present during the history taking-- interrupts and asks to speak with you alone. You both go to a consultation room where her mother says: "Kristen is lying to you, just like she lies to everyone these days. She has been dieting since last year when a boy made a mean comment about her being a little overweight. At first she just cut out the junk food and she started to look really healthy. Lots of people told her how good she looked, which in- creased her desire to lose even more weight. Over the past few weeks, her dieting has really gotten out of control. I spent the entire day with her last Saturday and she ate 1 piece of toast for breakfast, a small salad (with no dressing) for lunch, and a half a bagel for dinner. That was it! On top of that, I found out that she is doing 800 to 1000 sit-ups a day on top of her track exercises. Don't you think she is overdoing it?"

Does Kristen have an eating disorder? In retrospect she may, after all, fit the eating disorder stereotype--an adolescent white female from an upper-middle-class family who excels at school, sports, and social activities. You recall that AN begins as an innocent diet inspired by comments made by friends, coaches, or parents. As the initial weight loss elicits positive feedback from peers, the simple diet transforms itself into an obsession with thinness and food intake.

Kristen vehemently denies any obsessional thoughts about food and intake. However, further questioning reveals that she religiously limits her caloric intake to 1000 calories a day! She blames her decreased intake on a lack of appetite. Kristen admits that she frequently feels fatigued and often feels depressed. She also reports that she has problems with constipation, although she has never needed or taken laxatives. Kristen occasionally experiences heartburn. She never faints or has palpitations but occasionally becomes dizzy when standing. Her last menstrual period was 3 months ago.

Consider a broad differential before you diagnose AN in an adolescent who presents with weight loss and malnutrition. As with most diseases, the clinical history provides important clues to ruling out (or in) other processes. For example, inflammatory bowel disease frequently presents with weight loss, but it is often accompanied by bloody stools, diarrhea, abdominal cramps and, occasionally, findings such as joint inflammation and mouth sores. Other inflammatory processes such as systemic lupus erythematosus and juvenile rheumatoid arthritis may manifest with fatigue, fevers, joint pains, weight loss, and rashes. Such complaints should prompt an investigation to rule out these processes. Consider infectious disease, such as HIV, tuberculosis, and intestinal parasitosis, when the history reveals any associated risk factors.

Consider an endocrine abnormality, such as undiagnosed diabetes mellitus, if the patient describes persistent thirst and urination accompanying her weight loss. Hyperthyroidism frequently can lead to weight loss, despite increased food intake; this disorder is generally accompanied by heat intolerance, palpitations, nervousness, sweating, and increased stool frequency. Hypothyroidism can also mimic the failure to thrive seen in AN.

Be sure to assess the adolescent's social environment to determine whether there are any correlating factors that are contributing to the weight loss. For example, teenagers who are homeless, impoverished (and unable to access food), or extremely depressed, or who are abusing illicit substances are frequently malnourished. These underlying factors must be addressed appropriately.

Kristen's physical examination reveals a thin, malnourished- appearing girl who makes poor eye contact and who is occasionally teary. She is 67 inches tall and weighs 108 lb. Her BMI is 16.9 (4th percentile for age). Vital signs: temperature 35.9°C (96.7°F); blood pressure, 110/78 mm Hg; pulse, 61 beats per minute; respiratory rate, 16 breaths per minute. HEENT evaluation is unremarkable. There is fine hair growth (similar to that seen on a baby) on Kristen's arms and legs. The skin is dry and looks slightly yellow. Results of the cardiac evaluation are unremarkable. Her abdomen is noticeably thin. Her hands and feet are cold and her distal digits appear purple.

General pediatricians rarely see patients with severe malnutrition. Thus, the clinician's mental picture of malnutrition may reflect images from underdeveloped areas where children present with kwashiorkor or marasmus. In this country, most adolescents who present with moderate or severe malnutrition demonstrate more subtle physical findings. The most striking initial finding frequently involves muscle and adipose wasting, which accentuates the bony structures (as when Kristen's mother bemoans "She looks like a skeleton!").

When I discuss the effects of malnutrition with my patients, I frequently liken the condition to hibernation. Hibernation sustains animals during seasons in which food will be scarce. Their metabolism essentially slows down so that only the fewest calories necessary to maintain life are burned. Human metabolism undergoes a similar transformation when challenged by a dramatic caloric decrease. This "metabolic hibernation" explains many of the physical findings seen in a malnourished patient with AN.

For example, in a severely malnourished patient, core body temperature is decreased--often to less than 36.1°C (97°F). Heart rate may also be decreased (fewer than 60 beats per minute) and relative hypotension may be present. Using the hibernation analogy, this should make sense because the body is not going to waste extraneous calories to maintain a normal heart rate, blood pressure, or body temperature if caloric intake is unavailable to maintain these functions.

Other stigmata of malnutrition can include lanugo hair on the extremities; yellow-orange discoloration of the hands and feet (caused by carotenemia); and brittle, ridged nails. The distal extremities may appear purple and feel cold to the touch as peripheral blood vessels constrict in an attempt to preserve body heat and caloric energy. Pitting edema of the extremities often occurs as a by-product of severe protein malnutrition. Also, a flat affect and some degree of neurocognitive impairment are frequently present in the anorexic, malnourished patient.

The diagnosis of AN is primarily clinical based on the history and physical examination results. There is no diagnostic laboratory test. However, when you suspect this diagnosis, some basic laboratory evaluations are needed to:

Determine the extent of the malnutrition.

Assess immediate and long-term morbidity risks.

Help determine what interventions are needed at the time of diagnosis.

A basic electrolyte panel will reveal any significant electrolyte imbalances that exist secondary to the decreased food and energy intake. Patients with the purging subtype of AN often have elevated bicarbonate levels from loss of hydrogen ions through vomiting. Hyponatremia may be present if the patient consumes excess water to artificially augment her weight for the doctor visit. This suspicion can be confirmed by a urinalysis. An elevated BUN to creatinine ratio may also suggest the extent of dehydration present in the event of severe intake restrictions.

A complete blood cell count and erythrocyte sedimentation rate (ESR) screening generally do not contribute much to the diagnosis and management of AN. However, a significantly elevated white blood cell count or ESR might suggest an infectious or inflammatory cause of malnutrition rather than a psychiatric cause. Measurement of prothrombin and partial thromboplastin times is not routinely indicated; however, these tests should be ordered if the patient shows evidence of bruising.

Liver function tests frequently reveal a mild transaminitis during severe malnutrition, which tends to self-resolve as the patient's nutritional status improves. The serum albumin level is frequently decreased, especially if the patient presents with distal extremity edema.

Other investigations, such as an examination for stool ova and parasites or fecal fat, an upper GI series, or an anti-endomysial antibody test (for Celiac disease) may be useful if the history suggests a primary pathologic process. However, if you are certain that the diagnosis is AN, such investigations are unnecessary.

Levels of thyroid-stimulating hormone and T

 are usually normal in patients with AN. Hyperthyroidism can often be suggested by the history and physical examination. Measurement of T

) can be useful in that levels typically reflect long-term (2- to 4-month) nutritional status. Because the thyroid gland controls metabolism, it makes sense (using the hibernation analogy) that during times of long-standing caloric deficiency this conversion would subsequently decrease. At our facility, we often use a markedly decreased T

 to help demonstrate the severity of the patient's malnutrition to themselves and their families.

Severe, long-standing malnutrition frequently leads to decreased bone mineral density--regardless of whether the patient is amenorrheic. Because adolescence is a time of maximal bone mineral deposition, the net losses of bone minerals sustained during severe malnutrition often place the patient at a lifelong risk for pathologic stress fractures from osteopenia. The absence of menses for more than 6 months increases the risk and intensity of the bone mineral density loss. Therefore, I recommend a dual-energy radiograph absorptiometry (DEXA) bone density scan in any patient who has had amenorrhea for more than 6 months and/or severe malnutrition for over 9 months.

Severely malnourished teenagers may be at risk for fatal arrhythmias secondary to electrolyte imbalances, cardiac muscle wasting, and/or the use of exogenous substances (such as ipecac syrup) to maintain weight loss. Consider ordering an ECG to assess for low-voltage changes and T-wave inversions caused by potential electrolyte imbalances.

Echocardiography is not routinely recommended, but it may demonstrate decreased left ventricular wall thickness and/or mitral valve prolapse. Some data suggest that the decrease in ventricular wall thickness relative to the unchanged mitral valve size contributes to this finding, but this is controversial.

Typically, girls with moderate to severe malnutrition will stop menstruating as their malnutrition progresses. This is most likely a function of decreasing levels of gonadotropin-releasing hormone secreted by the hypothalamus. With the hibernation analogy in mind, one could speculate that amenorrhea is the body's defense against a potential pregnancy. After all, if the body cannot find enough calories to sustain its own metabolism, it surely will be unable to expend calories sufficient to sustain a fetus.

I recommend a urine pregnancy test in any patient who has missed 1 or more periods--regardless of her nutritional status. Follicle-stimulating hormone and luteinizing hormone levels are typically decreased if tested, but many eating disorder specialists forgo these tests if the patient's malnutrition is clearly contributing to the amenorrhea.

Menses generally resume as the patient recovers from anorexia and regains lean body mass. As a rule, menses return when the patient attains the weight at which her periods stopped.

A discussion of the treatments and prognoses for patients with AN extends beyond the scope of this article and will be discussed in a future issue. Suffice it to say that affected patients deserve at least some consultation with a team of eating disorder specialists that includes a physician, a psychologist, and an experienced nutritionist. Also key to the team's success is the primary care doctor, who provides monitoring and continuity of care--a critical role for the patient's long-term success.

Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision.

 Washington, DC: American Psychiatric Institute; 2000:583-589.

 Mitan LA. Menstrual dysfunction in anorexia nervosa. 

2004;17:81-85.m Rome ES. Eating disorders. 

2003;30:355-377, vii.m Sigman GS. Eating disorders in children and adolescents. 

Anorexia nervosa (AN) affects as many as 1 in 200 white adolescent girls. Mean onset of this disorder, which is characterized by dramatic weight loss, a disturbed perception of body shape, and an intense fear of weight gain, is between 13 and 14 years.

Adolecent Medicine Update:

Fourteen-year-old JT is worried. During health class last week, he learned about the different sexually transmitted infections as well as about testicular self-examination. While practicing his monthly testicular examination in the shower, he noticed that he had a number of small growths on his penis that he thought could be genital warts. On further questioning, JT insists that he has never been sexually active with another person.  

Approximately 15% of pubertal and postpubertal males have the normal finding of 

 The practitioner usually notices these lesions on routine genital examination. Occasionally, however, a teen will notice them and mistake them for condylomata acuminata. These fleshy or whitish papules tend to be about 1 to 3 mm in diameter. They most frequently present in linear rows on the penile corona. Unlike genital warts, the pink pearly penile papules are of similar size and shape and their appearance does not change over time.

Patients like JT require little more than reassurance that this is a normal part of their anatomy and that no treatment is required.

Seventeen-year-old Felicia has an appointment to see you for "the flu." She denies any upper respiratory tract symptoms but she states that all her muscles hurt and she has had temperatures up to 39.2°C (102.5°F) over the past 2 days. It especially hurts her to walk because of pain in her knees. On physical examination, you note this rash on her hands.  

. Further questioning reveals that Felicia has had a purulent vaginal discharge for the past few weeks. She did not want to have it evaluated because she was afraid her parents might find out that she was sexually active. A patient with DGI often presents with fevers, rigors, and arthralgias of the knees, elbows, wrists, and hands. The hemorrhagic pustules seen in DGI frequently occur over the affected joints.

Although DGI is most likely caused by gonococcal bacteremia, blood cultures are only somewhat sensitive in isolating an organism. However, culturing the initial site of inoculation (such as the genitals) often yields more accurate results. 

Treatment consists of intravenous or intramuscular antibiotics (preferably ceftriaxone) for 48 hours, followed by a week of oral antibiotic therapy.

Jim, 20 years old, recently returned from spring break vacation in the Caribbean with his fraternity brothers. After telling you about the sun, the food, and the fun, he nervously states that he has "an issue" he needs to talk about. During a night of drunken debauchery, the students wandered down to the local red light district with the intention of paying a prostitute to "take Jim's virginity."

Unfortunately, they were successful. Three weeks later, Jim now is complaining of large, painful ulcers along his penis, as well as large lumps in the groin area. He is reasonably sure he contracted herpes and asks you to confirm the diagnosis.

Jim probably does not have herpes genitalis. Rather, these large, ragged ulcers are consistent with 

 Chancroid ulcers, caused by the bacterium 

 tend to become necrotic and erode into the skin. In addition, large unilateral inguinal lymph nodes (on the affected side of the genitals) frequently accompany these ulcers.

Chancroid is uncommon in this country, except in localized outbreaks among prostitutes or populations at high risk for STD. It is more typically found in socioeconomically disadvantaged populations, such as those in Asia, Africa, and the Caribbean. Males are affected more often than females. 

To make the diagnosis, one should have a high index of suspicion based on physical examination findings: large ulcers with unilateral tender (and occasionally suppurative) lymphadenopathy. Definitive diagnostic confirmation through polymerase chain reaction assay is quite reliable, but results may take days or even weeks to obtain.

Single-dose treatment with azithromycin, 1 g, or ceftriaxone, 250 mg, should sufficiently treat the infection. If the ulcers become secondarily infected, or if there is coinfection with another STD, then a more prolonged course of treatment may be required.

Fifteen-year-old Melanie comes to see your associate in the office for a "routine" pelvic examination. She has been sexually active with 1 partner for the past year. She swears that she always uses condoms during sexual intercourse and has never had any problems with a condom breaking. Melanie denies any symptoms of vaginal discharge, odor, or itching. On pelvic examination, your associate notices that Melanie's cervix appears erythematous and inflamed. She considers 

 cervicitis, which causes cervical friability, as a possible diagnosis. Melanie restates that she has been asymptomatic and has taken every precaution to protect herself from getting an STD. She asks your associate to get a second opinion. At your associate's request, you take a look at Melanie's cervix.

--a common, nonpathologic finding in adolescents. Remember that the normal female cervix typically consists of squamous epithelial cells on the exocervix with columnar epithelial cells lining the endocervix. The cervical transformation zone represents the area in which the squamous and columnar epithelial cells meet. In most mature women, this transformation zone occurs well within the cervical os. The cervix of young adolescents (and pregnant women) often demonstrates ectropion, in which the columnar cells and transformation zone actually extend onto the exocervix. These cells appear deep red in contrast with the pink squamous epithelial cells. While this can be a normal physical finding, the presence of the columnar cells on the exocervix places adolescents at higher risk for contracting infection with 

Culture specimens are mandatory during a routine pelvic examination. However, many clinicians would not prescribe antibiotics unless the cultures demonstrated infectious growth.

Chris arrives at your office for his pre-college physical examination. He appears to be a fairly mature 18-year-old who will be attending an Ivy League university on a full scholarship. He denies any drug or alcohol use. While Chris states that he wants to postpone sexual intercourse until after marriage, he does admit to engaging in oral sexual activity with about 10 different girls in his school within the past year. You counsel him on the risks of this large number of partners, but he insists that "oral sex is safe sex." His physical examination proves him wrong. You point out an ulcer on the side of his penis.

Chris is shocked because he never even felt any discomfort. The presence of a small, painless genital ulcer suggests that this is the chancre seen in 

 While the ulcer may appear herpetic, the herpes lesions tend to be acutely painful. In fact, many patients with syphilis never notice the chancre and are unaware of their infection until they present with rashes consistent with secondary syphilis.

The diagnosis should be confirmed by sending a smear from the lesion for dark-field microscopy or direct fluorescent antibody testing. Rapid plasma reagin (RPR) or VDRL antigen testing of the blood may also be used if those tests are not available.

Treatment consists of intramuscular penicillin G (weekly for 3 weeks) or ceftriaxone (daily for 2 weeks).

Jackson, a gay 17-year-old with HIV infection, has been your patient since he was 8 years old. Since his diagnosis of HIV 2 years ago, you have provided his medical care in conjunction with the regional tertiary care center's infectious disease clinic. One month ago his CD4

 cell count was 504/µL. Today Jackson complains of blood in his stools. He denies diarrhea or any systemic symptoms. He vehemently denies any anal sexual contact since his HIV diagnosis 2 years ago. Further questioning reveals that his stools are frequently painful and difficult to pass. Jackson has already searched the Internet and is concerned that he might have hemorrhoids.

--also known as Buschke-Lowenstein tumors. These lesions are most frequently seen in persons who may be immunosuppressed. They are usually caused by HPV types 6 and 11. Patients complain about pain on defecation or bright red blood in their stools caused by trauma to the warts during defecation. Because of the bulkiness of these warts, topical treatments frequently fail to resolve the lesions and the patients may have to be referred to an anorectal surgeon for surgical removal. 

Even though the lesions are called Buschke-Lowenstein "tumors," they do not carry malignant potential. Remember that HPV types 6 and 11 are considered lower-risk for anorectal cancer. However, immunocompromised patients are at increased risk for neoplastic changes when infected with these (or for that matter any) subtypes of anogenital HPV. Furthermore, the possibility of coinfection with higher-risk HPV types (such as types 16 and 18) clearly places these patients at increased risk for anorectal cancer.

While moonlighting in the local university's student health service, you meet Antonio, a 19-year-old Central American male complaining of "groin pain." He states that he has found a lump in his inguinal area and he is worried that he may have a hernia. Antonio denies any recent strenuous exercising or lifting of heavy objects. Over the past few days he thinks that he may have had some chills and fever, but he has not taken his temperature. He is now afebrile.

Physical examination reveals a large, inflamed-appearing lymph node. This finding is a hallmark of 

(serovars L1, L2, and L3), is uncommon in the United States and Europe and is usually found in the Caribbean, Africa, India, and Central America. The bacterium infects the person through breaks in the skin or mucous membranes incurred during sexual activity. 

Male patients may initially recall a small, nontender herpetic-appearing lesion in the genital area that quickly self-resolves. Two to 6 weeks later, large, tender unilateral inguinal lymphadenopathy develops and further enlarges to form the buboes pictured above. Occasionally, the patient will present with a "groove sign": lymphadenopathy above and below the inguinal ligament. The buboes ulcerate and drain.

In females, the primary lesion is often inside of the vagina. Those affected are often unaware of its presence. As the disease progresses, the deep iliac or perirectal nodes usually enlarge rather than the inguinal nodes. Therefore, pelvic or back pain is typically the presenting sign instead of inguinal pain. The lack of external physical findings makes it more difficult to diagnose this disease in women.

Persons of both sexes can see progression of the lymphadenopathy to form fistulas, abscesses, strictures, and proctocolitis. Occasionally, lymph tract fibrosis can lead to genital elephantiasis. Complications of systemic spread can include arthritis, hepatitis, meningitis, carditis, and occasional pulmonary involvement.

Diagnosis is primarily based on history and physical findings. Nucleic acid amplification tests on a bubo aspirant provide reliable sensitivity and specificity for determining the 

serovars that cause LVG. Complement fixation tests are also useful in establishing a diagnosis, but 

cultures do not have sufficient sensitivity to be routinely employed.

Treatment consists of 21-day courses of doxycycline or erythromycin. Surgical intervention may be required to drain the larger buboes and/or to treat fistula formation.

 Neinstein LS, Goldenring J. Pink pearly papules: an epidemiologic study. 



•Workowski KA, Levine WC. Sexually transmitted diseases treatment guidelines--2002. 

Fourteen-year-old JT is worried. During health class last week, he learned about the different sexually transmitted infections as well as about testicular self-examination. While practicing his monthly testicular examination in the shower, he noticed that he had a number of small growths on his penis. On further questioning, JT insists that he has never been sexually active with another person.

David S. Reitman, MD

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