Gynecologic Problems of Adolescence and Puberty

Gynecologic care of the adolescent presents challenges and opportunities for the physician who does not typically care for young women in this age group. These patients require a kind, gentle, and knowledgeable approach. They must be assured of a confidential doctor–patient relationship without risking alienating their parents.

This chapter deals with specific issues that may arise in the gynecologic examination of the adolescent. Discussion is limited to the ways in which the care of adolescents differs from the care of adults.

Interview

The most important part of the gynecologic interview may be the time spent gaining the patient's confidence. If an adolescent comes with her parent, it is helpful to discuss the visit up front describing rules of confidentiality, that the adolescent is the patient and at some point the parent will be asked to step out of the room to allow the daughter to speak to the clinician alone. The adolescent in turn needs reassurance that all communication will be confidential but good communication between the daughter and her parent is encouraged. For early adolescents, a few minutes alone with the clinician may be all that is necessary. For late adolescents the parent may not need to be present at all. The provider should be familiar with local regulations regarding a minor's rights to confidential care for contraception and sexually transmitted infections (STIs) and reporting requirements for suspected sexual abuse and suicide. The patient should be informed of these reporting requirements at the beginning of the interview.

The HEEADSSS interview offers a systematic approach to obtaining a psychosocial history. HEEADSSS stands for Home, Education/Employment, Eating, peer-group Activities, Drugs, Sexuality, Suicide/Depression, Safety and Spirituality.¹ It enables the interview to begin with the less sensitive questions and then progress to the more sensitive ones. The interview should be conducted without the parent present, though the less sensitive questions could be asked before the parent leaves the room. If the adolescent requests the parent's presence throughout the interview, it should be documented in the chart. The interview can also be supplemented by questionnaires answered before the clinician meets with the patient. The American Medical Association offers the General Adolescent Preventive Service questionnaire with separate forms for early and middle/late adolescents and parents to complete.² The American Congress of Obstetricians and Gynecologist's Committee on Adolescent Health has also created a sample intake form.³ Adolescents may be less intimidated by writing responses to sensitive questions.

History

The history should include the essentials of a detailed medical history, as well as specific ages of adrenarche, thelarche, and menarche. Each positive symptom should be questioned as to frequency, relationship to menstrual cycle, and to ameliorating and provocative events. Enquiring about how the patient is doing in school may be a tactful way to introduce questions about the patient's temperament, social history, and relationships.

A menstrual history should be ascertained through specific questions regarding amount, length, and frequency of flow. Questions such as, “Are your menses light or heavy?” may be too abstract or general for an early or middle adolescent. The number of pads or tampons used may also lead to an inaccurate assessment of menstrual pattern as some adolescents will change as soon as the pad is soiled, whereas others only when the pad is soaked. Less subjective questions more easily answered by an adolescent might center on whether bleeding is so heavy that it cannot be contained in a pad or tampon, whether it requires both a pad and tampon, whether the patient must awaken at night to change or whether she soils her clothing. These findings may indicate an abnormally heavy flow. Similarly, questions such as, "Are your periods regular?" may not be meaningful to an adolescent.

During the history, the clinician may also explain the significance of symptoms such as molimina (e.g. mood swings, mastalgia, food cravings, headaches, fluid retention) and mild symptoms such as dysmenorrhea which can reassure the patient that nothing is seriously wrong. Severe pain with menses, such as pain requiring absence from school, should be investigated. Attention should be given to the urologic history. Frequent urinary tract infections or previous urologic surgery may be related to a gynecologic problem.

Enquiries should be made regarding vaccines and use of the HPV vaccine, sexual activity, contraceptive use, smoking, alcohol, and drug use. At this age most health risk is due to health behaviors rather than medical issues and therefore attention to mental health, home life, and sexual activity is warranted. 

Adolescent patients have difficulty knowing what symptoms are important and require direct questioning in a specific manner. Open-ended questions, usually preferable in a medical history, are rarely beneficial in an adolescent history. Conversely, assumptions should not be made about sexual orientation or sexual experience. Thus questions must be asked in an open, non-judgmental way.

Examination

Prior to examining an adolescent, it is important to inform her and her family of what will happen during the visit. The provider can let the patient know whether a pelvic examination will not be needed at that visit. Often that knowledge will help to allay the patient's fears allowing for a more relaxed visit.

The patient's vital signs, including blood pressure with a properly sized cuff, should be taken. Her height and weight should be recorded and an age appropriate body mass index should be calculated as should an age-appropriate blood pressure. Internet-based calculators are very useful in obtaining an age-appropriate calculation. The patient's stature and posture should be noted.

A heart and lung examination should be performed. Abdominal contour and scars will uncover previous surgery, hernias, and masses. Palpation of the liver edge, spleen, and kidneys should be attempted; abdominal tenderness, rebound, or guarding should be noted. The Tanner stage of breast development should be recorded.

The breast examination can elicit masses, cysts or nipple secretions and should be staged according to the Tanner classification. The clinician can often provide the adolescent with reassurance as common findings such as fibrocystic changes may be a source of worry for an adolescent. Unusual masses can be evaluated with an ultrasound. Mammogram is very rarely indicated in an adolescent. Unequal breast size is a common finding in adolescents and the provider can give reassurance that this finding is normal.

A pelvic examination of an adolescent is often not necessary at all or may be deferred to a subsequent visit. In particular, if the adolescent is without symptoms an examination may not be needed. Examination of the external genitalia may be all that is required. The external genitalia should also be staged according to the Tanner classification. The patient's vulva should be examined for lesions. The hymen should be assessed for patency of the opening (i.e. to verify the presence of the hymenal opening). 

Should visual examination of the vagina and cervix be required some providers use the Huffman adolescent speculum. This instrument has a 1.5-cm diameter and an 11-cm length. Others use the Pederson speculum which is commonly available and most providers are comfortable inserting it. The emphasis should be on providing an atraumatic examination.

Given the availability of urinary testing for gonorrhea and Chlamydia, and new guidelines limiting the Papanicolaou smear to age 21, pelvic examination has become less common. Similarly, if ultrasound is available, a full bladder will enable a transabdominal scan to visualize the pelvic anatomy. A single-digit bimanual examination or rectal examination can also be performed. The important thing is to make certain the visit is not painful, so the clinician can gain the trust of the adolescent.

Ultimately, the initial examination takes time and patience, so it is important that enough time be allotted for the visit.

Prescribing for minors

Almost all US states allow minors to consent for care related to STIs and many states allow adolescents to obtain contraceptive services. American law has traditionally considered an individual younger than 21 to be a minor, but most states have now lowered the age to 18.⁴ Of relevance is the concept of an emancipated minor, defined as an individual younger than 18 who is married, has parental consent, is self-supporting, and is living apart from his or her parents, has parents who have failed their legal responsibilities, or has a judicial decree deeming him or her to be of the majority.⁴ Many states consider a pregnant female emancipated and therefore able to consent to abortion without the consent of her own parents. Many states consider the minor able to consent to medical care for herself if she is able to understand the risks and complications. Thus, it is important to be aware of local legal requirements.

Pediatric vulvitis and vaginitis

Vulvovaginitis is a common condition in the pediatric patient. The child will typically present with chronic discharge, odor, and redness.  Patients presenting with chronic discharge should undergo a careful history including questions regarding history of upper respiratory tract infections, whether the child uses the bathroom on her own, history of skin rashes or sensitive skin, allergies and asthma, and suspicion of sexual assault. Enquiries should be made regarding the volume of discharge, color, and presence of blood, and all measures taken to relieve discharge. While the differential diagnosis includes infection, pin worms, and foreign bodies, the most common cause is a nonspecific vulvovaginitis. Due to the low estrogen state, the vulvar and vaginal skin is sensitive and easily irritated. Careful inspection of the child in the supine position with labial extension and retraction will allow visualization of the labia and vaginal introitus. The clinician should make note of the Tanner stage and whether the vagina appears estrogenized, as without estrogen the discharge is unlikely to be due to a yeast vaginitis. If the hymen appears thickened and inflamed, and copious discharge is present, then a bacterial infection is more likely. If these signs are not present and the appearance is one of erythema, it is more likely to be a non-specific vaginitis. Cultures can be performed using a small syringe to irrigate the vagina. In the knee chest position, the cervix and vagina can be visualized for the presence of a foreign body. In the case of a foreign body, a foul odor and vaginal spotting or bleeding are often part of the history. Positive cultures should be treated with the appropriate antibiotic (commonly a rectal or oral pathogen). A non-specific vulvovaginitis can be managed by removing irritants (shampoo, dyes in washing detergents, bubble bath, perfumed soaps), warm baths followed by careful drying (a blow dryer can be used), and creating a barrier layer when the skin becomes very irritated using petroleum jelly or other ointment. If there is a suspicion of sexual assault or abuse, it must be reported. People who are not experienced in the initial evaluation or management of pediatric sexual assault should make a referral for these patients, as expertise is needed and it is important not to inhibit proper management of the criminal or medical situation. Clinicians should be aware of local laws and resources.

Dysmenorrhea

Dysmenorrhea is a common problem for adolescents. Approximately 85% of adolescents report experiencing dysmenorrhea and 15% describe it as severe.⁵ Dysmenorrhea is divided into primary and secondary. Primary being without an anatomical cause and secondary due to an organic pathology. Many adolescents do not seek treatment for dysmenorrhea including those with severe dysmenorrhea. As this problem can result in school absenteeism, it is essential that it be managed effectively. Commonly, over the counter non-steroidal anti-inflammatory medications are used for the treatment of dysmenorrhea. However, a randomized, double-blind, placebo-controlled trial demonstrated that adolescents aged 19 years or younger with moderate or severe dysmenorrhea treated with a 20 μg oral contraceptive pill scored lower on a standard menstrual pain scale compared to those randomized to placebo. More recently, the levonorgestrel intrauterine device has been shown to be an effective treatment for dysmenorrhea.⁶ 

Uterine bleeding

Uterine bleeding in the adolescent is rarely due to an anatomical cause and is therefore usually classified as anovulatory uterine bleeding. Ovulatory bleeding occurs with stimulation of the ovary, follicle recruitment and development, follicle rupture, and corpus luteum development and involution. This process results in hormonal changes leading to a proliferative then secretory endometrium which then desquamates and repairs. In early adolescents, due to underdevelopment of hormonal signaling along the hypothalamic–pituitary–ovarian axis anovulatory cycles are common and a normal finding. Anovulatory cycles are a common occurrence in the first 1 or 2 years following menarche. While a normal finding, these anovulatory cycles can result in significant blood loss requiring hospitalization, transfusion, and/or hormonal intervention. Bleeding disorders can present as menorrhagia. Von Willebrand's disease is the most common bleeding disorder occurring in 1–1.6% of people and can occur in 5–15% of women with menorrhagia.⁷ It is far more common in white women than in African American women. A careful history and physical examination are required including a family history of bleeding disorders. Clues to a bleeding disorder include a positive family history, history of spontaneous nose bleeds, petechiae, and bleeding gums. If a bleeding disorder is suspected, then a complete blood count including platelets, prothrombin time, and partial thromboplastin time are warranted. A hematology consultation can be helpful for further assessment.⁸ Treatment of an acute anovulatory bleed can be with high dose intravenous estrogen if the bleeding is severe requiring hospital-based treatment. Alternatively an oral contraceptive taper, in which two to three pills are given on day 1 and slowly reduced to one pill per day, can be used if outpatient treatment is appropriate. There are many approaches to oral contraceptive pill tapers, most use tablets containing 30 μg or more of estrogen and give two to three pills on the first day. If a patient has a contraindication to estrogen, then high dose progestins can be used instead. Combined hormonal contraceptives, depomedroxyprogesterone acetate or a progestin-containing intrauterine device provide treatment for chronic anovulatory bleeding. 

The US has one of the highest rates of adolescent pregnancy of all developed countries. However, preliminary birth data show that the number of births to women aged 15–19 has declined for all race and Hispanic origin groups since 2008.⁹ Nevertheless, almost half of all 15–19 year olds in the US have had sex at least once.¹⁰ Thus, the adolescent provider must be comfortable in prescribing and managing contraceptives. Furthermore, contraception is one of the most versatile tools that the adolescent provider will use. Contraception is the mainstay of managing medical problems in adolescents such as endometriosis, dysmenorrhea, menorrhagia, and polycystic ovarian syndrome among others. Thus, contraception is an important treatment option.

The clinician must be aware of local laws governing the provision of contraceptives to minors. Currently, in the US, 21 states and the District of Columbia allow minors to consent to services without parental involvement (as of January 2010). Two states (Texas and Utah) require parental consent for contraceptive services in state-funded family planning programs.¹¹ The adolescent contraceptive visit is the ideal time to talk about STIs including human papillomavirus and how to prevent these diseases through condom use and vaccination.

Barrier contraception

The male condom is the most common form of contraception used by adolescents. Favorable characteristics from the adolescent's perspective are ease of use, confidentiality, cost, dual protection from STIs and pregnancy, and it being a coital dependent method. Furthermore, many adolescents have concerns about real and perceived side-effects of other methods of contraception.¹² As condoms are the only method that offers dual protection from pregnancy and infection all adolescents should be encouraged to use condoms and instructed in the correct use of condoms. However, the failure rate of 15% for pregnancy prevention among adolescents using condoms alone suggests that adolescents should also be encouraged to use a highly effective method of contraception in addition to condoms. Recently, the US Food and Drug Administration approved the FC2 female condom and a natural latex condom made by Medtech Products Ltd, is available outside of the United States.

Combined hormonal contraceptives

Combination hormonal contraceptives in the form of a patch, pill or ring provide a number of health benefits typically making these methods outweigh the small risk of using contraceptives for most adolescents. Estrogen-progestin containing methods improve some conditions including dysmenorrhea, anemia, benign breast disease, acne, and menstrual irregularities. Estrogen-containing contraceptives decrease androgens by increasing sex hormone binding globulin thereby treating acne and hirsutism, and making it an ideal medication in the management of polycystic ovarian syndrome (PCOS). Young women who experience chronic anovulation, perhaps due to PCOS, are candidates for estrogen containing contraceptives. These methods regulate irregular menses, protecting the endometrium from hyperplasia, improve the hormonal milieu, and improve lipid profiles by lowering LDL levels and raising HDL levels, though androgenic progestins attenuate these effects. Long-term use of these methods lowers the risk of cancer of the uterus and cancer of the ovaries.¹³ Thus, for many reasons, combined hormonal methods are first line therapy for adolescents.

These methods are short-acting and easily reversible. As a result they are easy to initiate and discontinue. However, these properties also mean they must be used consistently in order to be effective. Consistent use of oral contraceptives proves a problem for many adolescents. Though non-daily methods may result in better adherence.¹⁴ Decreased contraceptive efficacy has been seen in women weighing over 196 pounds.¹⁵

LONG-ACTING PROGESTIN-ONLY METHODS: THE CONTRACEPTIVE IMPLANT AND 3-MONTH INJECTABLE

Depomedroxyprogesterone acetate (DMPA) is a long-acting, progestin-only contraceptive method used by many adolescents. DMPA suppresses the pituitary gonadotropins, thus inhibiting ovulation and reducing ovarian estrogen production. Secondary mechanisms of action include endometrial and cervical mucus changes preventing sperm penetration and migration. Given every 3 months, DMPA is easy to adhere to and thus typical use and actual use efficacy rates are similar.¹⁶ Yet, 55% of adolescents discontinue DMPA at 1 year.¹⁷ DMPA side-effects contribute to the discontinuation rates. DMPA is associated with weight gain, hair loss, and irregular menstrual bleeding. More recently, a black box warning has been added by the Food and Drug Administration due to a decrease in bone mineral density (BMD), although studies in young adult women have shown that this decrease plateaus at 1–2 years and is reversible.¹⁸ In adolescent users, the recovery occurred within 12 months of discontinuation and was associated with an increase in BMD.¹⁹ In contrast to the black box warning, major organizations have supported the initiation and continued use of DMPA in adolescents.²⁰ The American College of Obstetricians and Gynecologists does not recommend radiologic monitoring or hormonal supplementation for adolescent DMPA users.²¹

THE SINGLE ROD IMPLANT

In 2006, the single rod progestin-only implant became available. This 3-year implantable device is easy to insert and easier to remove than previous implantable contraceptive methods. While clinical trial data show that the number of overall bleeding days over the course of a year does not exceed that of normal menstrual cycles, the associated bleeding is irregular and unpredictable. Additional data are needed regarding acceptability among adolescents, continuation rates, and side-effects such as weight gain. In addition, clinical trials provide data for women within 130% of ideal body weight, so more data are needed regarding long-term effectiveness among obese women.

The intrauterine device

The intrauterine device (IUD) is a highly effective, long-acting method of contraception. The copper Tc380A is FDA approved for 12 years, while the levonorgestrel intrauterine system is approved for 5 years of use. Although there are limited data on the safety, efficacy, and acceptability of either IUD in populations under 18 years old, World Health Organization supports the use of the IUD in reproductive aged women from menarche to age 20 years.²² However, the IUD is not widely used by adolescents. Nevertheless, there are many properties that may make this method of benefit to young women. The levonorgestrel intrauterine system may protect from pelvic inflammatory disease, decrease menstrual bleeding, and prevent dysmenorrhea.^{23, 24, 25} Both IUDs decrease the rate of ectopic pregnancy and prevent uterine cancer. A recent randomized controlled pilot study comparing the two devices in adolescents found both methods to be highly acceptable.²⁶