Adolescent Gynecology

Amy Gregory Weeks, M.D.Vanderbilt University School of Medicine

February 20, 2007

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Grade 9 Grade 10 Grade 11 Grade 12

Ind

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s W

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Percentage of US High School Students Percentage of US High School Students Who Have Had Sexual IntercourseWho Have Had Sexual Intercourse11

1. Grunbaum JA, Kann L, Kinchen S, et al. MMWR. 2004;53(SS-2):1–96.

In addition, 7.4% of US adolescents reported sexual debut before 13 years of age.By Grade 12, 20.3% of US adolescents reported ≥4 lifetime sexual partners.

2003 US Youth Risk Behavior Survey (N=15,214)

Adolescent Gynecology Patient Encounter

Dramatis Personae

Amanda Jones . . . . . . . .Defensive Teenager

Mrs. Jones . . . . . . . .Protective Mother

Dr. Weisenkeind . . . . . . Average Gynecologist

Scene 1

Dr. Weisenkeind’s Office

Intermission

What else do we want to know about this patient’s menses?

• Age of menarche• Flow – duration, amount• Pads or tampons• Intermenstrual bleeding• Unusual discharge• Pain at other times during the

month• Bladder/bowel complaints

Do we ask the Question now?

General medical history: points specific to the adolescent

patient• Direct your questions to the patient• Adjust your language as necessary – use

slang terms as appropriate• She may not know her own PMHx/PSurgHx

– include parent when this is the case• Social history is an opportune time to

lighten things up.– What grade, what school?– Outside interests– Home situation, brothers/sisters, Mom and

Dad?– Grades?

General Medical History, continued

• Family history – again, teenagers may not know

• Review of Systems: - sleep- homework-dietary habits/exercise

Do we ask the Question now?

Scene 2

Still in the exam room

Intermission

What do we want to ask the patient now?

• Number of partners, consensual or not?

• STD screening/symptoms• Dyspareunia• Contraception!!• Is there anything else?

JUDGE NOT.

N.B. The patient is still dressed at this point.

Discussion of care with parents: you CAN talk about hormonal contraception, without specifically talking about the patient’s sexual activity.

Physical Examination

• NOW the patient gets undressed.• Confidence: If you don’t have it, fake

it.• Involve the patient: “verbal

anesthesia”• Least invasive to most invasive• Choice of speculum – ask if patient

wants to see it

Scene 3

Patient exam room. Mandy is dressed again.

Intermission

Is it okay to play this game?

. . . I have resolved to speak the rude truth in all ways.

Ralph Waldo Emerson

Is this the way everyone should approach this issue?

Contraceptive choices

• OCP’s• Patch• Ring• Depo Provera• IUD

Gardasil• TABLE 1 Summary of American Cancer Society (ACS) Recommendations for Human Papillomavirus

(HPV) Vaccine Use to Prevent Cervical Cancer and Its Precursors • Routine HPV vaccination is recommended for females aged 11 to 12 years.

• Females as young as age 9 years may receive HPV vaccination.

• HPV vaccination is also recommended for females aged 13 to 18 years to catch up missed vaccine or complete the vaccination series.

• There are currently insufficient data* to recommend for or against universal vaccination of females aged 19 to 26 years in the general population. A decision about whether a woman aged 19 to 26 years should receive the vaccine should be based on an informed discussion between the woman and her health care provider regarding her risk of previous HPV exposure and potential benefit from vaccination. Ideally the vaccine should be administered prior to potential exposure to genital HPV through sexual intercourse because the potential benefit is likely to diminish with increasing number of lifetime sexual partners.

• HPV vaccination is not currently recommended for women over age 26 years or for males.

• Screening for cervical intraepithelial neoplasia and cancer should continue in both vaccinated and unvaccinated women according to current ACS early detection guidelines.

• * Insufficient evidence of benefit in women aged 19 to 26 years refers to (1) clinical trial data in women with an average of 2, and not more than 4, lifetime sexual partners, indicating a limited reduction in the overall incidence of cervical intraepithelial neoplasia (CIN)2/3; (2) the absence of efficacy data for the prevention of HPV16/18-related CIN2/3 in women who have had more than 4 lifetime sexual partners; and (3) the lack of cost-effectiveness analyses for vaccination in this age group.

CA Cancer J Clin 2007;57:7-28

Every great and commanding moment in the annals of the world is the triumph of some enthusiasm.

Ralph Waldo Emerson