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Pitfalls of Puberty
Several physiologic and psychological processes are experienced by many teens during the pubertal and postpubertal years of young adulthood. Some of these situations may be unknown to both teen and parent (for example, risk for anemia in girls following menarche) and/or carry emotional ramifications (for example, acne). Anticipatory counseling and sympathetically addressing issues are an important part of the doctor-patient relationship. The pitfalls of puberty include anemia, male gynecomastia, acne, musculoskeletal injuries, gynecological issues, myopia, scoliosis, sexually transmitted diseases (STDs), and psychological concerns.
The Third National Health and Nutritional Examination Survey (NHANES III) documented that approximately 10% of menstruating girls between 12-15 years of age are iron deficient. In the same age range, less than 2% of boys were iron deficient. Causes are felt to include the effect of male sex hormones (for example, testosterone), monthly menstrual bleeding, and insufficient dietary intake of iron by females. Encouraging routine intake of lean red meat (vs. poultry, fish, and/or green leafy vegetables) and a daily multivitamin supplement (which may also augment calcium intake) should be encouraged if dietary sources are inadequate.
Approximately 50% of boys will experience either one-sided or bilateral breast tissue swelling during puberty. The average age of such a process is 13 years (Tanner III), and such a situation may last for six to 18 months. The size of breast tissue swelling is generally about 2 cm in diameter. While the underlying cause is generally benign and self-resolving, other causes should be considered if indicated. Some of these alternative causes of gynecomastia include drugs, thyroid diseases, and testicular diseases. The importance of reassurance that this can be a normal part of puberty to the anxious male teen cannot be underestimated.
Perhaps the most dreaded consequence for the pubertal teen is acne. This rite of passage is a combination of plugged sebaceous glands and local infection. Three areas are most commonly involved: the face, upper chest, and upper back. Acne tends to become most impressive at the Tanner III-Tanner IV maturation level. Extreme acne or significant acne prior to or at the early onset of puberty should raise concerns. Acne is generally felt to be an unintended consequence of a common testosterone/progesterone metabolic breakdown hormone (DHEA-S). Multiple therapeutic agents may be considered if acne is severe, and the adolescent with acne should discuss his/her situation with their doctor.
An asynchronous maturation of bone growth, bone strength and calcification (see above), muscle mass and strength, and tendon/ligament strength is an underlying problem that can commonly lead to a high rate of musculoskeletal injuries in adolescents. Likewise, the level and intensity of sports competition is another factor. The likelihood of risk-taking behaviors and a perceived sense of invincibility cannot be ignored. The current pattern of year-round single sport participation (vs. multiple sports and "breaks" during the year) is also felt to be associated with the growing increase in sports-related injuries and conditions in adolescents. The much higher than expected frequency of anterior cruciate ligament (ACL) damage in female basketball players is a reflection of such underlying physiology and social changes in sports participation.
Sixty-five percent of females report that within one year of menarche they are having 10 or more periods per year. Studies have indicated that many (up to one-half) of these periods are not associated with ovulation. This information is sometimes used in an inappropriate manner by sexually active young teens believing that this provides a "natural" form of contraception. Counseling regarding the odds of such gambling should be presented to all young teens during their early menstrual life.
Because of asymmetric growth of the globe of the eye during puberty, many teens discover the need for corrective lenses.
Due to the accelerated growth of the skeleton during adolescence, it is important to screen for the development of or exaggeration of established scoliosis in both genders. Significant scoliosis is more common in females. The large majority of scoliotic curves "point" to the patient's right (when viewed from behind the patient). A curve directed to the left is more commonly a consequence of an underlying process and should warrant further diagnostic testing.
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