A 16-year-old female came to clinic for her health maintenance examination. She had become sexually active in the past year with one partner. She did not anticipate being sexually active in the near future but she and her mother wanted to discuss options for possible birth control and sexually transmitted infection (STI) prophylaxis. She denied any gynecological problems. The resident did initial counseling with the adolescent but was unsure what, if any, testing needed to completed at this time.
The pertinent physical exam showed a healthy appearing adolescent female with growth parameters in the 10-50% and normal vital signs. Her general examination was normal including Tanner V staging and a normal external genital examination. The diagnosis of a healthy adolescent was made. During staffing, the attending physician also said that he was unclear if she needed a pelvic examination at this time because the guidelines had recently changed. Together they looked up the guidelines on the Internet and found that a pelvic examination was not indicated until she was 21 years of age. The adolescent and her mother were counseled that STI testing should be considered but that a pelvic examination was not needed at this time. The adolescent stated that she had used condoms and spermicidal jelly but she agreed to urine STI testing that eventually was negative. The adolescent was still unsure about initiating birth control, so additional handouts and website references were given to her.
In 2010, the American College of Obstetricians and Gynecologists changed the recommendations for Papanicolaou (Pap) testing. The first Pap test is at 21 years of age regardless of the onset of sexual activity unless the patient has HIV or is immune suppressed and patients are then followed yearly after initiation of sexual activity. The reasons for this change are that although about 50% of high school students are sexually active, and about 50% of young women will have a positive test for human papilloma virus (HPV) within 36 months of initiating sexual activity, over 90% of the HPV infections will resolve within 24 months in patients with intact immune systems. HPV is the most common STI worldwide.
Adolescent patients who have previously been screened and have cervical atypia or neoplasia have different recommendations for followup and can be reviewed in To Learn More below.
Indications for a pelvic examination are:
- Abnormal vaginal bleeding
- Menstrual irregularities – amenorrhea, dysmenorrhea that is unresponsive to nonsteroidal anti-inflammatory medication
- Lower abdominal pain
- Dysuria or urinary tract symptoms in a sexually active female
- Vaginal discharge that is persistent
- Papanicolaou (Pap) test
- Intrauterine device or diaphragm contraception initiation and use
- Suspected or reported sexual abuse or rape
Questions for Further Discussion
1. What are indications for referral to a gynecologist?
2. How common is adolescent pregnancy and what are its risks?
3. How common are STIs in adolescents?
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Age: Teenager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
To view images related to this topic check Google Images.
American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 463: Cervical cancer in adolescents: screening, evaluation, and management. Obstet Gynecol. 2010 Aug;116(2 Pt 1):469-72.
Braverman PK, Breech L; Committee on Adolescence. American Academy of Pediatrics. Clinical report–gynecologic examination for adolescents in the pediatric office setting. Pediatrics. 2010 Sep;126(3):583-90.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
6. Information technology to support patient care decisions and patient education is used.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
16. Learning of students and other health care professionals is facilitated.
17. A therapeutic and ethically sound relationship with patients is created and sustained.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital