Nupur Gupta

Bone Metabolism in Adolescent Athletes With Amenorrhea, Athletes With Eumenorrhea, and Control Subjects

OBJECTIVE. We hypothesized that, despite increased activity, bone density would be low in athletes with amenorrhea, compared with athletes with eumenorrhea and control subjects, because of associated hypogonadism and would be associated with a decrease in bone formation and increases in bone-resorption markers. METHODS. In a cross-sectional study, we examined bone-density measures (spine, hip, and whole body) and body composition by using dual-energy radiograph absorptiometry and assessed fasting levels of insulin-like growth factor I and bone-turnover markers (N-terminal propeptied of type 1 procollagen and N-telopeptide) in 21 athletes with amenorrhea, 18 athletes with eumenorrhea, and 18 control subjects. Subjects were 12 to 18 years of age and of comparable chronologic and bone age. RESULTS. Athletes with amenorrhea had lower bone-density z scores at the spine and whole body, compared with athletes with eumenorrhea and control subjects, and lower hip z scores, compared with athletes with eumenorrhea. Lean mass did not differ between groups. However, athletes with amenorrhea had lower BMI z scores than did athletes with eumenorrhea and lower insulin-like growth factor I levels than did control subjects. Levels of both markers of bone turnover were lower in athletes with amenorrhea than in control subjects. BMI z scores, lean mass, insulin-like growth factor I levels, and diagnostic category were important independent predictors of bone mineral density z scores. CONCLUSIONS. Although they showed no significant differences in lean mass, compared with athletes with eumenorrhea and control subjects, athletes with amenorrhea had lower bone density at the spine and whole body. Insulin-like growth factor I levels, body-composition parameters, and menstrual status were important predictors of bone density. Follow-up studies are necessary to determine whether amenorrhea in athletes adversely affects the rate of bone mass accrual and therefore peak bone mass.

Hormonal contraception for the adolescent.

1. Nupur Gupta, MD, MPH* 2. Stephanie Corrado, MD* 3. Mark Goldstein, MD* 1. *Division of Adolescent Medicine, Massachusetts General Hospital for Children, Boston, Mass After completing this article, readers should be able to: 1. Discuss the oral contraceptive pill, its contraceptive and noncontraceptive benefits, and its absolute contraindications. 2. Identify the different routes of administration that have been developed, newer formulations of conventional methods, and novel contraceptive agents that are being developed. 3. Describe each of the contraceptive methods, including adverse effects, efficacy, and compliance. 4. Recognize external and internal barriers to use, commonly held misperceptions by adolescents, and the relation of such misperceptions to developmental stages. 5. Explain how to provide effective and acceptable contraceptive services for adolescents. The United States has the highest rate of teen pregnancy and births in the western industrialized world, with more than 750,000 women ages 15 to 19 years old becoming pregnant each year. About 80% of these pregnancies are unintended and occur in unmarried teens. Of these, about 30% end in abortions, 57% in live births, and 14% in miscarriage. In the United States, oral contraceptive pills (OCPs) remain the most common form of hormonal contraception for adolescents and reproductive-age women. (Technically, these drugs are dispensed as tablets, but the term “pill” is so closely linked with oral contraception that it will be used in this article.) Although the failure rate of the OCP is 0.3 per 100 women-years with ideal use, typical use failure rates, particularly for adolescents, are much higher (3 to 8/100 women-years). Contraception efficacy for the most common methods used by adolescents (Table 1) indicates the continued need for more effective and nonuser-dependent contraception. | Method | Percent of Women Experiencing an Unintended Pregnancy Within The First Year of Use | Percent of Women Continuing Use at 1 Year3 | |:----------------------------------------:| ---------------------------------------------------------------------------------- | ------------------------------------------ | --- | | Typical Use1 | Perfect Use2 | | (1) | (2) | (3) | (4) | | No method4 | 85 | 85 | | | Spermicides5 | 29 | 18 | 42 | | Withdrawal | 27 | 4 | 43 | | Condom6 | | | | | Female | 21 | 5 | 49 | | Male | 15 | 2 | 53 | | Combined pill and minipill | 8 | 0.3 | 68 | | Combined hormonal patch | 8 | 0.3 | 68 | | Combined hormonal ring | 8 | 0.3 | 68 | | Depot medroxyprogesterone acetate (DMPA) | 3 | 0.3 | 56 | | Combined injectable7 | 3 | 0.05 | 56 | | Intrauterine device | | | | | Copper T | 0.8 | 0.6 | 78 | | Levonorgestrel intrauterine system | 0.2 | 0.2 | 80 | | Levonorgestrel implants | 0.05 | 0.05 | 84 | | Female sterilization | 0.5 | 0.5 | 100 | | Male sterilization | 0.15 | 0.10 | 100 | * Emergency contraceptive pills: Treatment initiated within 72 hours after unprotected intercourse reduces the risk of pregnancy by at least 75%. * ↵1 Among typical United States couples who initiate use of a method (not necessarily for the first time), the percentage who experience an accidental pregnancy during the first year if they do …

Regional Fat Depots and their Relationship to Bone Density and Microarchitecture in Young Oligo-amenorrheic Athletes

CONTEXT Various fat depots have differential effects on bone. Visceral adipose tissue (VAT) is deleterious to bone, whereas subcutaneous adipose tissue (SAT) has positive effects. Also, marrow adipose tissue (MAT), a relatively newly recognized fat depot is inversely associated with bone mineral density (BMD). Bone mass in athletes depends on many factors including gonadal steroids and muscle mass. Exercise increases muscle mass and BMD, whereas, estrogen deficiency decreases BMD. Thus, the beneficial effects of weight-bearing exercise on areal and volumetric BMD (aBMD and vBMD) in regularly menstruating (eumenorrheic) athletes (EA) are attenuated in oligo-amenorrheic athletes (OA). Of note, data regarding VAT, SAT, MAT and regional muscle mass in OA compared with EA and non-athletes (C), and their impact on bone are lacking. METHODS We used (i) MRI to assess VAT and SAT at the L4 vertebra level, and cross-sectional muscle area (CSA) of the mid-thigh, (ii) 1H-MRS to assess MAT at L4, the proximal femoral metaphysis and mid-diaphysis, (iii) DXA to assess spine and hip aBMD, and (iv) HRpQCT to assess vBMD at the distal radius (non-weight-bearing bone) and tibia (weight-bearing bone) in 41 young women (20 OA, 10 EA and 11 C 18-25 years). All athletes engaged in weight-bearing sports for ≥ 4 h/week or ran ≥ 20 miles/week. MAIN OUTCOME MEASURES VAT, SAT and MAT at L4; CSA of the mid-thigh; MAT at the proximal femoral metaphysis and mid-diaphysis; aBMD, vBMD and bone microarchitecture. RESULTS Groups had comparable age, menarchal age, BMI, VAT, VAT/SAT and spine BMD Z-scores. EA had higher femoral neck BMD Z-scores than OA and C. Fat mass was lowest in OA. SAT was lowest in OA (p = 0.048); L4 MAT was higher in OA than EA (p = 0.03). We found inverse associations of (i) VAT/SAT with spine BMD Z-scores (r = -0.42, p = 0.01), (ii) L4 MAT with spine and hip BMD Z-scores (r = -0.44, p = 0.01; r = -0.36, p = 0.02), and vBMD of the radius and tibia (r = -0.49, p = 0.002; r = -0.41, p = 0.01), and (iii) diaphyseal and metaphyseal MAT with vBMD of the radius (r ≤ -0.42, p ≤ 0.01) and tibia (r ≤ -0.34, p ≤ 0.04). In a multivariate model including VAT/SAT, L4 MAT and thigh CSA, spine and hip BMD Z-scores were predicted inversely by L4 MAT and positively by thigh CSA, and total and cortical radius and total tibial vBMD were predicted inversely by L4 MAT. VAT/SAT did not predict radius or tibia total vBMD in this model, but inversely predicted spine BMD Z-scores. When L4 MAT was replaced with diaphyseal or metaphyseal MAT in the model, diaphyseal and metaphyseal MAT did not predict aBMD Z-scores, but diaphyseal MAT inversely predicted total vBMD of the radius and tibia. These results did not change after adding percent body fat to the model. CONCLUSIONS VAT/SAT is an inverse predictor of lumbar spine aBMD Z-scores, while L4 MAT is an independent inverse predictor of aBMD Z-scores at the spine and hip and vBMD measures at the distal tibia and radius in athletes and non-athletes. Diaphyseal MAT independently predicts vBMD measures of the distal tibia and radius.

Bone accrual in oligo-amenorrheic athletes, eumenorrheic athletes and non-athletes

BACKGROUND Mechanical loading improves bone mineral density (BMD) and strength while decreasing fracture risk. Cross-sectional studies show that exercise advantage is lost in oligo-amenorrheic athletes (OA). Longitudinal studies examining the opposing effects of exercise and hypogonadism on bone are lacking in adolescents/young adults. OBJECTIVE Evaluate differences in bone accrual over 12 months in OA, eumenorrheic athletes (EA) and non-athletes (NA). We hypothesized that bone accrual would be lower in OA than EA and NA, with differences most pronounced at non-weight bearing trabecular sites. METHODS 27 OA, 29 EA, and 22 NA, 14-25 years old, completed 12-months of the prospective study. Athletes were weight-bearing endurance athletes. Subjects were assessed for areal BMD and bone mineral content (BMC) using DXA at the femoral neck, total hip, lumbar spine and whole body (WB). Failure load (a strength estimate) at the distal radius and tibia was assessed using microfinite element analysis of data obtained via high resolution peripheral quantitative computed tomography (HRpQCT). The primary analysis was a comparison of changes in areal BMD, BMC, and failure load across groups over 12-months at the respective sites. RESULTS Groups did not differ for baseline age, height or BMI. Percent body fat was lower in both OA and EA compared to NA. OA attained menarche later than EA and NA. Over the follow-up period, OA gained 1.9 ± 2.7 kg of weight compared to 0.5 ± 2.4 kg and 0.8 ± 2.3 kg in EA and NA respectively (p = 0.09); 39% of OA resumed menses. Changes in BMD, BMD Z-scores, and tibial failure load over 12-months did not differ among groups. At follow up, EA had higher femoral neck, hip and WB BMD Z-scores than NA, and higher hip BMD Z-scores than OA (p < 0.05) after adjusting for covariates. At follow-up, radial failure load was lower in OA vs. NA, and tibial failure load lower in OA and NA vs. EA (p ≤ 0.04 for all). Change in weight and fat mass were associated with changes in BMD measures at multiple sites. CONCLUSION Despite weight gain and menses recovery in many OA during follow-up, residual deficits persist without catch-up raising concerns for suboptimal peak bone mass acquisition.

The Pelvic Examination and Pap Smear in Adolescents and Young Adults

Cervical cancer takes many years to develop after exposure to the HPV virus and is rare in women below the age of 21. The American College of Obstetrics and Gynecology recommends that routine screening with Papanicolaou (Pap) smears start only at 21 years of age. A pelvic examination is thus often not required in adolescents who are sexually active as screening for sexually transmitted infections can be conducted by other methods. However, providers must know the indications for and be comfortable with conducting a pelvic examination and be familiar with the interpretation and management guidelines for Pap smears in young adults 21–29 years of age.

Contraceptive Options for Adolescents

• The oral contraceptive pill (OCP) remains the most common form of contraception for adolescents and reproductive-age women in the US. • Resource-limited settings require contraceptive methods that are more effective, less user dependent, and confi dential. Several newer hormonal methods that fulfi ll these criteria have been developed but may or may not be available around the world. • This chapter discusses different hormonal and nonhormonal methods that are available, their mechanism of action, side effects, and effi cacy. • Emergency contraception using progestin-only pills (POPs), the “Yuzpe Regime,” and the copper intrauterine device (IUD) are also reviewed.