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Adolescent Gyn Series

The Young Woman¡s Initial Gynecologic Visit

Geri D. Hewitt, MD

A girl¡s initial gynecologic visit involves much more than routine medical care. The right approach can shape a positive attitude toward self-care and personal responsibility for health that will last a lifetime.

Women often ask the OB/GYN when their daughters should undergo their first gynecologic examination. The American Col- lege of Obstetricians and Gynecologists recommends that young women initiate reproductive health care when they reach age 13 to 15 years.1,2 Indeed, the organization has developed a "tool kit" for teen care—an excellent educational resource with information for patients, parents, clinicians, and office staff. 3

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STAGES OF ADOLESCENCE

The initial gynecologic visit should occur when the patient is aged 13 to 15 years. When examining a young woman for the first time, clinicians must be able to recognize and appreciate the unique developmental milestones that are the hallmarks of early, middle, and late adolescence. Behavioral characteristics of early adolescence include challenging authority, mood swings, rejecting certain aspects of childhood, and a desire for more privacy. These girls often become preoccupied with physical changes, and may have anxiety about menstruation and their body’s new characteristics. Peers gain in influence, with intense same-gender friendships as well as new contacts with the opposite sex. Sexual feelings are emerging, and girls may participate in sexual exploration. Typically egocentric, they may magnify their own problems, thinking that no one understands them or can help.

Characteristics of middle adolescence include heightened family conflict, increased attention to physical appearance, even stronger peer influences, heightened sense of sexuality, initiation of dating, experimentation, and risk-taking behaviors. In late adolescence, young women become more comfortable with body image, have more complex personal relationships, are more likely to be sexually active, and usually relate to the family in a more mature, adult manner. They are less likely to be influenced by their peers, have developed their own moral and ethical codes, and have begun to pursue a vocation.4

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LEGAL CONSIDERATIONS

Other unique aspects of caring for young women include confidentiality, autonomy, and consent. The groundwork for these important issues should be laid at the initial visit. Optimally, clinicians can serve as a nonparental adult figure for young patients, and may be perceived as less judgmental than parents.5 The initial gynecologic visit provides an opportunity to begin building trust with the patient by expressing empathy toward her complaints and genuine interest in her life and concerns, without judgement.5 Confidentiality should be discussed openly with the patient and her parent(s) together so that everyone knows when and how parents would be informed about the patient¡s medical concerns. Confidential issues should be clearly marked in the chart. Patients should be interviewed alone to both allow for confidential disclosure and practice patient autonomy. Clinicians should encourage them to become responsible for and participate actively in their own health care by giving concrete instructions on calling the office, leaving messages, talking with office staff, making appointments, getting prescriptions filled, and using medication appropriately. Girls in early and middle adolescence should be urged to take over self-care. They should answer questions about their own medical history and/or symptoms, and should be included in all decision-making. Laws regulating what types of medical care can be rendered without parental consent vary by state, and clinicians must familiarize themselves with the local statutes.

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MEDICAL ISSUES

In addition to building a rapport with the patient, the focus of the initial office visit in most healthy young women will be on prevention, education, and screening for both medical and behavioral issues. A speculum examination and Papanicolaou (Pap) smear are rarely required. The greatest dangers most young women face are risky behaviors, as opposed to significant medical problems.6 Clinicians should anticipate spending more time talking with young women than performing medical assessment/testing. A pelvic examination may be indicated if the patient has been sexually active for 3 years or is age 21 years, which is when Pap smears should be initiated; or in sexually inactive girls with significant complaints of vaginal discharge, pain, or dysmenorrhea/menorrhagia unresponsive to medical intervention.

Table 1 lists important issues that should be addressed with young women. Identification of risky behaviors may require involving her parents and/or referral to community mental health resources. Counseling on healthy behaviors—eg, delaying sexual activity and pregnancy, preventing sexually transmitted infections (STIs), using seat belts, and maintaining appropriate diet and exercise—should also be included in the discussion.

Table not available online

Table 1. The Initial Gynecologic Visit: Behavioral Issues

The initial medical history should cover pubertal milestones, menarche, menstrual cycles, menstrual hygiene, and dysmenorrhea. Young women and their parents may have questions about tampon use. It is also important to ascertain if the young woman has become sexually active. If she has, the clinician must determine the type of sexual activity; how many partners, length of relationship, and ages; whether the behavior was/is consensual; risk of STI acquisition; and need for contraception. The patient must be counseled about her contraceptive options, and educated about STI prevention and emergency contraception.

The extent of the physical examination performed at the initial visit should be geared to the patient¡s physical complaints and whether she has initiated sexual activity. All patients should be assessed for height, weight, blood pressure, and secondary sexual characteristics. If the young woman is healthy and without complaints, a pelvic examination is rarely required. Hormonal contraception can be safely initiated for dysmenorrhea, abnormal bleeding, or even contraception without a pelvic examination.

If the patient has become sexually active, she requires immediate screening for STIs, plus a Pap smear within 3 years of initiating sexual activity. If she has not initiated sexual activity, the Pap smear can be delayed until age 21 years.1,2 Current guidelines from the Expert Panel of Blood Cholesterol in Children and Adolescents recommend total blood cholesterol screening in adolescents whose parents have serum cholesterol levels > 240 mg/dL or a family history of multiple risk factors for cardiovascular disease.7 Ideally, teenagers should have received immunizations at age 11 to 12 years, but the clinician should check for lapses in the vaccination schedule. Table 2 lists the currently recommended vaccinations.8

Table not available online

Table 2. Immunizations for Young Women

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CONCLUSION

The initial reproductive health visit need not be a cause of anxiety for the patient, her parents, or her physician. An understanding of adolescent developmental milestones, patient confidentiality/autonomy, and parental consent can help to ensure a positive experience. With an emphasis on empathetic counseling and education, the physician can lay the foundation for healthy physician-patient relationships as the patient matures and assumes responsibility for her own welfare.

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Geri D. Hewitt, MD, is chief, Section of Obstetrics and Gynecology, Columbus Children¡s Hospital; and clinical associate professor, Departments of Obstetrics and Gynecology and Pediatrics, Ohio State University College of Medicine and Public Health, Columbus.

References

1. American College of Obstetricians and Gynecologists. Guidelines for Women¡s Health Care. 2nd ed. Washington, DC: American College of Obstetricians and Gynecologists; 2002:126-127,145-146.
2. Committee on Adolescent Health, ACOG. ACOG Committee Opinion. Number 335, May 2006: the initial reproductive health visit. Obstet Gynecol. 2006;107(5):1215-1219.
3. American College of Obstetricians and Gynecologists. Tool Kit for Teen Care. Washington, DC: American College of Obstetricians and Gynecologists; 2003.
4. Characteristic behaviors of adolescents. In: American College of Obstetricians and Gynecologists. Tool Kit for Teen Care. Washington, DC: American College of Obstetricians and Gynecologists; 2003.
5. Pinto KC. Intersections of gender and age in health care: adapting autonomy and confidentiality for the adolescent girl. Qual Health Res. 2004;14(1):78-99.
6. Anderson RN. Deaths: leading causes for 2000. Nat Vital Stat Rep. 2002;50(16):1-85.
7. National Cholesterol Education Program. Report of the Expert Panel on Good Cholesterol in Children and Adolescents. Bethesda, Md: National Institutes of Health/National Heart, Lung, and Blood Institute; 1991.
8. Centers for Disease Control and Prevention (CDC). Recommended childhood immunization schedule United States, 2002. MMWR Morb Mortal Wkly Rep. 2002;51(2):31-33.
9. CDC¡s Advisory Committee Recommends Human Papillomavirus Virus Vaccination [press release]. Atlanta, Ga: Centers for Disease Control and Prevention; June 29, 2006.

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