Jean S. Emans
A gynecological examination is an essential component of the health care of adolescent girls. This is especially important because the first pelvic examination can influence an adolescent's attitudes about reproductive health care for the rest of her life. Most adolescents are apprehensive about the examination of their genitalia, especially during a first examination. A sensitive approach to the adolescent's concerns and needs can aid in creating a positive and instructive experience.
The office setting is particularly important in creating a positive atmosphere for the adolescent girl. To create such an atmosphere a clinician should do the following:
Indications for Gynecological Examinations
The indications for a complete or modified pelvic examination in an adolescent vary with the patient's complaint. For example, a 13-year-old girl who is not sexually active and who has a white vaginal discharge may be evaluated by obtaining one or two saline-moistened cotton-tipped applicator samples of the discharge and by examining the samples under the microscope for physiological discharge or Candida vaginitis. In contrast, a 16-year-old, sexually active girl who has had lower abdominal pain for 2 days and has a vaginal discharge deserves a complete pelvic examination. It is also important for clinicians to assess whether the answer can be obtained by the use of urine-based STD screening for Chlamydia trachomatis and/or Neisseria gonorrhea or by pelvic ultrasonography. For example, a girl with primary amenorrhea may be willing to allow only an external genital inspection; the internal genital structures can then be assessed by transabdominal ultrasonography.
Most professional organizations suggest that cervical cancer screening be initiated at 21 years of age or 3 years after the onset of sexual activity, whichever occurs first. Girls receiving episodic care or who are immunosuppressed (e.g., HIV infection) should be screened earlier. The American College of Obstetricians and Gynecologists recommends annual Pap tests in women younger than 30 years after initiation of screening. An adolescent who is not sexually active can begin routine gynecological care whenever she feels comfortable, with the hope that by the age of 18 to 21 years she will have initiated routine care. However, the age of 18 to 21 years should be seen as a general guideline, and the wishes and background of the patient should be respected. It should be stressed that adolescents should have routine health guidance initiated before becoming sexually active. The American College of Obstetricians and Gynecologists recommends that the first visit for health guidance, screening, and preventive services should take place approximately at 13 to 15 years of age. It is an ideal time to provide education about preventive care needs, including the need for STD testing in sexually active females. Providers should separate the provision of contraceptive services and STD screening from requirements of cervical cancer screening. Pelvic examinations should not be a barrier to the prescription of oral contraception and other effective hormonal methods. In addition, patients and parents need to understand that there is still a need for preventive health care other than Pap testing. It is important for patients (and their parents) to realize that a pelvic examination and a Pap test are not the same. Most importantly, the first pelvic examination should be an educational and positive experience. Indications for modified or complete pelvic examinations therefore include the following:
Obtaining The History
The history should include a gynecological assessment, general health history, review of systems, and information on risk behaviors. The HEADSS framework can be used; it focuses onHome, Education/career plans, Activities, Drugs/alcohol/tobacco, Depression, Suicidality, Sexuality, and Safety. These questions can be asked through a clinical interview, a written questionnaire, or a computer-aided questionnaire. Most of the visit should be devoted to seeing the teenager alone, because her presenting complaint is often different from her parents' concerns. However, it is essential to understand the concerns and the family history of the parent or parents. Mothers often attribute symptoms of their daughters to diagnoses that they themselves have had, such as ovarian cysts or other gynecological problems within the family. Although some medical conditions (e.g., polycystic ovary syndrome, endometriosis) clearly can occur within families, many other conditions are not related to the complaint that brings the teen to the clinician.
It is essential to know what the parent told the patient regarding the reason for the visit and whether the examination was explained. If the parent discussed the examination with the patient, it is important to gather information on how it was explained. Some patients are told, “Don't worry, you don't need an examination,” and others are told about the full speculum examination when potentially they only need one or two cotton-tipped applicator samples. It is also important to know what and how the parent has explained about menstrual periods, sexuality, and other issues to the young adolescent.
The younger teen may feel more comfortable if most of the history is obtained with parent or parents in the room. A few moments of privacy are all that is needed to obtain pertinent negatives about risk behaviors. It is often best to begin the interview by asking the adolescent why they have come to the office for an evaluation that day. It is imperative to address the chief complaint and to relate the gynecological examination (modified or complete) to that concern. Reasons for the visit may include pelvic pain, vaginal discharge, a menstrual disorder, or a possible pregnancy. A presenting complaint such as irregular menses may actually lead to a diagnosis of pregnancy; in such cases, the patient may be denying the possibility of pregnancy, or a menstrual complaint may be the only way for her to access medical care. Dysmenorrhea may mask a “hidden agenda” for obtaining oral contraceptives. The sexual history should be part of the structured questioning: “Have you ever had sexual intercourse?” “How old were you when you first had sex?” “Tell me about your partners.” “Are you sexually active with men? Women? Both?” “How many partners have you had?” “Have you ever been pregnant?” “Have you ever had a STD?” “Have you ever been forced to have sexual intercourse?” “Have you ever used condoms?” “If yes, how often?” It is important that these questions be preceded by the comment, “I ask all my patients these questions.”
The history should include the following:
whether the patient uses tampons or pads and how often during the day she needs to change).
Gynecological Examination Equipment
Materials needed for the gynecological examination include the following:
A pelvic examination is generally performed annually for sexually active adolescents starting approximately three years after the initiation of sexual intercourse. The adolescent should be made to feel that she is in control and can stop the examination at any point to ask questions or, if need be, stop the examination entirely. A handheld mirror to permit viewing of her genitalia is helpful for some adolescents. The clinician should acknowledge that adolescent girls may feel nervous, particularly at the first examination. Explain that it takes only 2 or 3 minutes to perform the examination. Adolescents should be given the choice of whether to have their mother or another person (e.g., sister, aunt) stay in the room as support. The young adolescent may request that her mother stay with her during the pelvic examination; most older patients prefer that their mothers stay in the waiting room. The patient's wishes should be respected. Generally, male providers use a female chaperone for pelvic examinations. Female providers in some settings always use chaperones, and in other settings the use is considered optional. Many patients actually prefer to have only the provider in the room.
Before the examination begins, it is helpful to explain to the teen, while she is still fully clothed and seated, the various parts of the examination—general physical examination, inspection of the genitalia, speculum examination, and bimanual examination, indicating the reasons why each part is important for evaluating her medical complaint. It is also good, both in the early discussion and during the examination to talk about feelings related to the examination and ways to relax and feel in control, such as the use of imagery, deep breathing and other relaxation techniques, a mirror, a step-by-step format, or distraction from a family member. She should also be reassured that adequate drapes will be used. Each step is then explained again as the actual examination is done.
The steps are as follows:
separate them to examine the external structures. Check the size of the clitoris, which is typically 2 to 4 mm wide; a width of 5 to 10 mm is considered a possible sign of virilization, and >10 mm indicates definite virilization.
FIGURE 48.1 External genitalia of the pubertal female. (Reproduced from Emans SJ, Laufer MR, Goldstein DP. Pediatric and adolescent gynecology, 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005, with permission.)
(NAATs), DNA probes, immunoassays, and cultures. Endocervical Chlamydia NAAT screening has higher sensitivity than urine screening, but urine screening is an excellent option if a pelvic examination is not being performed. The speculum is removed after the samples for STD tests are obtained.
FIGURE 48.2 Types of specula (left to right): infant, Huffman, Pederson, and Graves. (Reproduced from Emans SJ, Laufer MR, Goldstein DP. Pediatric and adolescent gynecology, 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005, with permission.)
FIGURE 48.3 Speculum examination of the cervix. (From Clarke-Pearson D, Dawood M. Green's gynecology: essentials of clinical practice, 4th ed. Boston: Little, Brown and Company; 1990, with permission.)
If there is a history of significant pelvic pain or an adnexal mass is felt, a rectovaginal–abdominal examination can help complete the evaluation of the adnexa or uterus and the rectum, anus, and posterior cul-de-sac. A rectovaginal–abdominal examination is performed with the index finger in the vagina, the middle finger in the rectum, and the other hand on the abdomen. The examination permits evaluation of the uterosacral ligaments and cul-de-sac as well as the mobility of the uterus. It is important to inform the patient that she may experience an urge to defecate: “You may feel like you are having a bowel movement, but you won't go. Your brain is just giving you a different message.” The rectovaginal septum should be thin and pliable, and the pelvic floor should be free of masses and tenderness. On indication, stool retrieved can be tested for occult blood.
During the postexamination discussion, the patient should be congratulated for her cooperation, and the importance of the findings of the examination (positive or negative), should be discussed in relation to her chief complaint. All questions should be answered, and any therapy and further tests required should be outlined. This is an important time for discussion of the adolescent's concerns about normal anatomy and physiology, contraception (including emergency contraception), and sexuality. Reinforce the positive experience of sharing her information with you as a demonstration of her ability to think about her sexual health and be responsible. During this discussion with the adolescent, it is important for the examiner to listen carefully, remembering that teenagers may not communicate all their concerns initially. At the conclusion of the discussion, the parent or partner can be invited to join the health care provider and the teenager. The parent can be informed of the results of the examination and the treatment plan. Any confidential information that is revealed to the parent should have been previously agreed upon with the teenager, so as to maintain trust. Parents should be encouraged to ask questions and to voice concerns.
Helping a teen through her first gynecological visit sets the stage for reproductive health care for a life-time. The gynecological visit is an ideal opportunity to provide education, listen to concerns, assess medical and psychosocial complaints, and promote a healthy future. The examination also allows the clinician an opportunity to impart to the teenager a positive attitude toward her body and to stress the importance of health maintenance.
For Teenagers and Parents
http://www.youngwomenshealth.org/pelvicinfo.html. Information about your first pelvic examination from Boston Children's Hospital.
http://www.goaskalice.columbia.edu/0643.html. From Columbia University for college students and older teens. Questions and answers about reproductive health and specifically here about pelvic examination.
http://www.sa.psu.edu/uhs/womenshealth/pelvicexam. cfm. From Penn State University Health Service, information about pelvic examination and Pap smears.
www.cdc.gov/std/hpv. Centers for Disease Control about sexually transmitted diseases and HPV.
http://teenadvice.about.com/cs/girlstuff/ht/pelvicexamht. htm. A Web site on the first pelvic examination developed in collaboration with The New York Times.
References and Additional Readings
American College of Obstetricians and Gynecologists. Cervical cancer screening in adolescents. ACOG Committee OpinionNo.300. Obstet Gynecol 2004;104(4):885.
Emans SJ, Laufer MR, Goldstein DP. Pediatric and adolescent gynecology, 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005.
Emans SJ, Woods ER, Allred EN, et al. Hymenal findings in adolescent women: impact of tampon use and consensual sexual activity. J Pediatr 1994;125:153.
Ford CA, Millstein SG, Halpern-Feilsher BL, et al. Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care.JAMA 1997;278:1029.
Gray SH, Walzer TB. New strategies for cervical cancer screening in adolescents. Curr Opin Pediatr 2004;16: 344.
Kahn J, Chiou V, Allen J, et al. Beliefs about Pap smears and compliance with Pap smear follow-up in adolescents. Arch Pediatr Adolesc Med 1999;153:1046.
Larsen SB, Kragstrup J. Experiences of the first pelvic examination in a random sample of Danish teenagers. Acta Obstet Gynecol Scand 1995;74:137.
Millstein SG, Adler NE, Irwin CE Jr. Sources of anxiety about pelvic examinations among adolescent females. J Adolesc Health Care 1984;5:105.
Saslow D, Runowicz CD, Solomon D, et al. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin 2002;52:342.
Thrall JS, McCloskey L, Ettner SL, et al. Confidentiality and adolescents' use of providers for health information and for pelvic examinations. Arch Pediatr Adolesc Med 2000;154: 885.