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Adolescent Gyn Series

The College-aged Examination: A Comprehensive Approach to Preventive Medicine

Seema Menon, MD; Judith Burgis, MD; Janice Bacon, MD

Young women face many challenges as they negotiate the final steps to adulthood free of parental supervision. For the OB/GYN, these challenges represent opportunities to promote healthy behaviors to last a lifetime.

College-aged women are vulnerable to a unique set of health concerns, including sexuality, contraception, sexually transmitted infections (STIs), and sexual assault. Substance abuse, body image, nutrition, and exercise issues may also arise, along with screening tests and immunization. The gynecologic examination can serve as an introduction to health care issues that will have an impact on a woman throughout her life.

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CONTRACEPTION

Pregnancy prevention is a common concern in this population, and the method of contraception must be selected carefully. Pregnancy rates in young women using oral contraceptives (OCs) are estimated at 8% to 25% due to inconsistent use.1 The “quick-start” method in which patients begin use at the physician’s office may improve compliance.2 This method—along with close follow-up to detect early discontinuation or misuse—has been found to improve adherence.2,3

Long-acting contraceptive agents are invaluable in preventing pregnancies (Table 1). The transdermal contraceptive patch, transvaginal ring, intrauterine device (IUD), intramuscular depot medroxyprogesterone acetate (DMPA) injection, and subdermal etonogestrel implant all offer less frequent dosing than OCs. Indeed, the transdermal contraceptive patch has been shown to have superior compliance compared with OCs.4 However, noncompliance can still occur. The “depo now” strategy (like the quick-start method) involves immediate administration of DMPA postcounseling rather than waiting for menses. Pregnancy rates are lower in patients following this protocol.5

Table not available online

TABLE 1. Long-acting Contraceptive Agents CDMPA = depot medroxyprogesterone acetate; IUD = intrauterine device.

The US Food and Drug Administration (FDA) recently added a Àblack-box” warning to DMPA concerning a risk of bone loss; however, any such risks must be weighed against the risks of less effective contraception leading to pregnancy. Evidence of bone normalization after DMPA discontinuation and the lack of fractures in DMPA-treated patients should also be considered.6

The IUD and implantable etonogestrel rod are long-acting agents that require no patient dosing. Although the IUD was traditionally considered inappropriate for young women,7 the World Health Organization (WHO) supports its use in women under age 20 years.8 Concerns about pelvic inflammatory disease (PID) appear unwarranted even in populations with a high incidence of STIs.9 Two types of IUDs are available—one that has no hormones and is active for 10 years, and one that contains levonorgestrel (LNG) and is active for 5 years. An added benefit of the LNG-IUD is management of menorrhagia.

The etonogestrel-containing implant is another effective birth-control method for young women. The safety and efficacy of this device is well established, and effects on bone appear limited in early studies.10,11 It can be inserted during an office visit, and offers up to 3 years of protection.

Emergency contraception (EC) should be included in any discussion of birth control. This modality is effective when administered within 120 hours of unprotected intercourse.12 It is estimated that 70% of elective abortions could be prevented by proper administration of EC.13 Multiple regimens are available, but the progestin-only (LNG) regimen is thought to have better efficacy and fewer side effects than estrogen/progestin combination regimens.12

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SEXUALLY TRANSMITTED INFECTIONS

Regardless of contraceptive choice, consistent condom use is essential. The reported incidence of Chlamydia trachomatis (CT) and gonococcal (GC) infections is highest among girls aged 15 to 19 years.14 However, it is important to note that condoms have limited efficacy against human papillomavirus (HPV), herpes simplex virus (HSV), and syphilis. Abstinence remains the only guaranteed method for preventing STIs; if this is not a realistic option, patients must be educated about the need to limit the number of sexual partners.

With regard to STIs, the US Centers for Disease Control and Prevention (CDC) recommends CT screening annually for all sexually active women aged 25 years or younger, GC screening for high-risk patients, and screening women who seek STI evaluation or treatment for human immunodeficiency virus (HIV). Screening for HIV should always be voluntary and performed only with patient consent.14 Papanicolaou testing should begin at age 21 years or 3 years after the first sexual encounter, then repeated annually until age 30 years. The HPV vaccine is recommended for girls and women aged 9 to 26 years; it is estimated that vaccinating 12-year-old girls will eliminate 1,300 cases of cervical cancer.15

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IMMUNIZATIONS

In addition to the HPV vaccine, a complete immunization history should be obtained; 88% of adolescents aged 10 to 19 years have missed one of the recommended vaccinations (Table 2).15 Incomplete immunity against tetanus, diphtheria, pertussis, measles, mumps, rubella, hepatitis B, and varicella (if no previous infection) requires administration of Àcatch-up” vaccines.16 Reported cases of pertussis have been increasing in US teenagers15; a catch-up dose of tetanus-diphtheria-pertussis vaccine should be followed by tetanus-diphtheria vaccination every 10 years. While pertussis is relatively mild in adolescents, it can easily be transmitted to others in whom infection could be severe.

Table not available online

Table 2 . Recommended Immunizations for Adolescents

Likewise, immunizing this population against influenza can reduce transmission to others at higher risk for severe infection. Indeed, widespread immunization can reduce influenza-related mortality by 90%.15 This vaccine should be strongly considered in college students every autumn. High-risk patients should be immunized against hepatitis A and pneumococcus. All patients entering college should be immunized against meningococcus; if no vaccination was administered at age 11 or 12 years, a catch-up dose is recommended. Ensuring complete vaccination of young adults not only keeps them healthy but also reduces transmission of infectious diseases from this population—which often lives in communal conditions—to other, more vulnerable populations.17

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LIFESTYLE

Healthy lifestyle choices should be reviewed with patients. Morbidity and mortality occurring later in life can often be attributed to lifestyle and health behaviors that develop during adolescence.18 Through its Healthy People 2010 initiative, the CDC identified 21 critical health objectives for young adults in six major categories (Table 3).19 Approximately 75% of all young-adult deaths are secondary to motor vehicle accidents, homicide, and suicide.20 Seatbelt use, substance abuse prevention, and mental health screening can effectively reduce the number of these deaths in this population. Suicide is the third leading cause of death among adolescents, and this examination affords the opportunity to review risk factors—including depression, previous suicide attempt, and feelings of isolation and hopelessness.

Table not available online

Table 3. US Centers for Disease Control and Prevention: Health Focus Areas for Adolescents and Young Adults

Especially significant is the high prevalence of substance abuse in patients with an underlying mental illness. Alcohol or drug abuse may be the only sign of a serious mental disorder in adolescents. Substance abuse contributes to mortality not only because of involvement in motor vehicle accidents but also from overdose. The prevalence of binge drinking on many college campuses has led to deaths from alcohol poisoning. Definitions of binge drinking vary; a commonly accepted medical definition is intoxication lasting for 2 days, leading to inability to perform responsibilities. Another definition of binge drinking for women is the consumption of four alcoholic beverages during a period of time set aside for drinking.

Cigarette smoking is among the leading causes of death because of its link to multiple chronic diseases.20 Adults aged 18 to 25 years have the highest prevalence of smoking,20 and it is essential to include abstinence from, or cessation of, tobacco use during substance abuse counseling.

Lifestyle education for adolescents must include a candid discussion of sexual assault. Most victims are women, with the peak incidence of victimization at age 16 to 19 years. The rate of sexual assault is 10.4 per 100,000 women in this age group, falling to 5.4 per 100,000 in those aged 20 to 24 years.19 Traveling in groups, refusing beverages in open containers that could be contaminated with the Àdate rape” drug flunitrazepam, and programming emergency numbers into cellular phones are strategies that can lower vulnerability.

Obesity also contributes to mortality, again because of links to multiple chronic medical conditions.18 Healthy eating habits and an active lifestyle must be encouraged in adolescents to promote lifelong habits. Obesity is approached a bit differently in this population, using the terms Àoverweight” and Àat risk for overweight.” ÀOverweight” is defined as a body mass index (BMI) greater than the 95th percentile of an age- and sex-matched group, rather than applying strict cutpoints. ÀAt risk for overweight” is defined as a BMI exceeding the 85th percentile of an age- and sex-matched group.21 Obesity must be addressed with sensitivity due to the high rate of eating disorders (EDs), which comprise the third most common chronic medical disorder in young adults.22 Consequences can include pancreatitis, cardiac arrhythmias, and dehydration. These disorders include anorexia nervosa (severe restriction of food intake) and bulimia nervosa (binge eating followed by vomiting, catharsis, exercise, or fasting). Slight cognitive immaturity in young adults may impair their ability to express abstract concepts such as the need for perfection or control, making diagnosis of EDs challenging.22 A multidisciplinary approach is most effective in treating EDs, as 20% to 50% of patients have psychiatric comorbidities. In general, healthy eating habits must be emphasized during all medical examinations in young women.

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CONCLUSION

A comprehensive approach to college-aged patients not only addresses the immediate needs of this population but also provides counseling and interventions aimed at lowering morbidity and mortality in adulthood. Major threats to the health of adolescents include STIs, mental illnesses, and substance abuse. Diagnosis and prevention of these problems must be approached aggressively. Preventive counseling pertaining to tobacco use, nutrition, and exercise must also be emphasized (Table 4). Healthy habits discussed at this time can have a positive impact on morbidity and mortality throughout the patient’s lifetime.

Table not available online

Table 4. Preventive Medicine Codes

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Seema Menon, MD, is clinical instructor; Judith Burgis, MD, is assistant professor; and Janice Bacon, MD, is EJ Dennis professor and chair. All are in the Department of Obstetrics and Gynecology, University of South Carolina School of Medicine, Columbia.

References

1. Kaunitz AM. Long-acting hormonal contraceptives?indispensable in preventing teen pregnancy. J Adolesc Health. 2007;40(1):1-3.
2. Westhoffw C, Kerns J, Morroni C, Cushman LF, Tiezzi L, Murphy PA. Quick start: novel oral contraception initiation method. Contraception. 2002;66(3):141-145.
3. Pons JE. Hormonal contraception compliance in teenagers. Pediatr Endocrinol Rev. 2006;3(suppl 1):164-166.
4. Archer DF, Cullins V, Creasy GW, Fisher AC. The impact of improved compliance with a weekly contraceptive transdermal system (Ortho Evra) on contraceptive efficacy. Contraception. 2004;69(3):189-195.
5. Rickert VI, Tiezzi L, Lipshutz J, Leon J, Vaughan RD, Westhoff C. Depo Now: preventing unintended pregnancies among adolescents and young adults. J Adolesc Health. 2007;40(1):22-28.
6. Cromer B, Scholes D, Berenson A, et al. Depot medroxyprogesterone acetate and bone mineral density in adolescents?the Black Box Warning: a Position Paper of the Society for Adolescent Medicine. J Adolesc Health. 2006;39(2):296-301.
7. Toma A, Jamieson M. Revisiting the intrauterine contraceptive device in adolescents. J Pediatr Adolesc Gynecol. 2006;19(4):291-296.
8. O¡Brien P. New WHO medical eligibility criteria for contraceptives: adaptation for use in a local service in UK. J Fam Plann Reprod Health Care. 2001;27(3):149-152.
9. Mohllajee AP, Curtis KM, Martins SL, Peterson HB. Hormonal contraceptive use and risk of sexually transmitted infections: a systematic review. Contraception. 2006;73(2):154-165.
10. Funk S, Miller MM, Mishell DR, et al. Safety and efficacy of Implanon, a single-rod implantable contraceptive containing etonogestrel. Contraception. 2005;71(5):319-326.
11. Beerthuizen R, van Beek A, Massai R, Mäkäräinen L, Hout J, Bennink HC. Bone mineral density during long-term use of progesterone contraceptive implant Implanon compared to a non-hormonal method of contraception. Hum Reprod. 2000;15(1):118-122.
12. Gold MA, Sucato GS, Conard LA, Hillard PJ; Society for Adolescent Medicine. Provision of emergency contraception to adolescents. J Adolesc Health. 2004;35(1):67-70.
13. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists, Number 69, December 2005 (replaces Practice Bulletin Number 25, March 2001). Emergency contraception. Obstet Gynecol. 2005;106(6):1443-1452.
14. Centers for Disease Control and Prevention; Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR-11):1-94.
15. Sanfoni Pasteur. Bridging the gap: adolescent immunization challenges and strategies for disease prevention. Monthly Prescribing Reference. 2006;2:1-4.
16. Recommended immunization schedules for persons aged 0-18 years—United States, 2007. MMWR Recomm Rep. 2007;55(51-52):Q1-14.
17. Middleman AB, Rosenthal SL, Rickert VI, et al. Adolescent immunizations: a position paper of the Society for Adolescent Medicine. J Adolesc Health. 2006;38(3):321-327
18. Ma J, Wang Y, Stafford RS. U.S. adolescents receive suboptimal preventive counseling during ambulatory care. J Adolesc Health. 2005;36(5):441.
19. US Department of Health and Human Services. Healthy People 2010. Volumes 1 and 2. 2^nd ed. Washington, DC: Government Printing Office; November 2000.
20. Park MJ, Paul Mulye T, Adams SH, Brindis CD, Irwin CE. The health status of young adults in the United States. J Adolesc Health. 2006;39(3):305-317.
21. Hedley AA, Ogden CL, Johnson CL, Carroll MD, Curtin LR, Flegal KM. Prevalence of overweight and obesity among US children, adolescents, and adults, 1999-2002. JAMA. 2004;291(23):2847-2850.
22. Golden N, Katzman D, Kreipe R, et al. Eating disorders in adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health. 2003;33(6):496-503.

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