Gynecologic Examination of the Adolescent and Young Adult Female

Sarah Pitts

Merill Weitzel

THE GYNECOLOGIC EXAMINATION

A gynecological examination is an essential component of the health care of female patients from birth onward. Reassuring and educating girls about their normal external anatomy is as important as addressing the concerns and needs of an adolescent or young adult woman in advance of her first internal examination.

INDICATIONS FOR GYNECOLOGIC EXAMINATIONS

Indications

The indications for a complete or modified gynecologic examination vary with the patient’s complaint. A 13-year-old girl presenting for a physical examination can be reassured that external structures appear healthy and normal. A virginal 15-year-old girl with complaint of white vaginal discharge may be evaluated by obtaining a sample to differentiate physiologic discharge from a Candidal vaginitis. In contrast, a sexually active 20-year-old woman with lower abdominal pain and vaginal discharge deserves a complete pelvic examination (Table 45.1).

Providers should separate the provision of contraceptive services from gynecologic examinations. Such an examination should not be a barrier to the provision of hormonal contraceptives unless a patient is requesting an intrauterine device (IUD). It cannot be emphasized enough that physical examination of the external genitals should be a routine part of preventive care for girls and women alike, but not if the patient is resistant or uncomfortable, or if such an examination is in conflict with their cultural or religious beliefs. Patients and parents should also be informed that a bynecologic examination and Papanicolaou test (Pap test) are not the same. While external genital examination is routine from birth onward, there are several indications for a modified or complete internal pelvic examination in addition to cervical cancer screening. These include symptoms of a vaginal or uterine infection, menstrual disorders, pelvic pain, sexual assault, suspected pelvic mass, or request by the patient.

TABLE 45.1 Indication for Modified or Complete Pelvic Examination

Female over 21 y of age

Symptoms of vaginal or uterine infection

Menstrual disorders including amenorrhea, dysfunctional uterine bleeding, severe dysmenorrhea, or mild to moderate dysmenorrhea unresponsive to therapy

Undiagnosed lower abdominal pain

Sexual assault (modified to collect the appropriate information and samples)

Suspected pelvic mass

Request by the adolescent or young adult

Cervical Cancer Screening

Cervical cancer screening¹,² or a Pap test should be initiated at 21 years of age in most cases. Exceptions to this rule include sexually active adolescents with acquired HIV who should be screened twice in the year following diagnosis and annually thereafter as recommended by the US Centers for Disease Control and Prevention (CDC). There are no studies to support similar recommendations in women immunosuppressed from other causes (e.g., transplant recipients), and the American College of Obstetricians and Gynecologists (ACOG) recommends screening at 21 years of age in such populations. Screening assesses cellular changes of the cervix that may put a woman at risk for cancer associated with prior genital exposure to the human papillomavirus (HPV). ACOG recommends Pap tests every 3 years without co-testing for HPV strains in women younger than 30 years. Should abnormal cytologic changes be noted, reflex HPV testing and/or colposcopy is warranted. Chapter 50 provides a detailed review of Pap tests and management.

Sexually Transmitted Infection Screening

Screening for sexually transmitted infections (STIs)³ should be conducted once a female patient has had a sexual experience, including genital to genital, or mouth to genital contact, penetrative vaginal contact (digital, penile, or foreign body), or penetrative anal contact. While urine-based screening tests for Chlamydia trachomatis and/or Neisseria gonorrhoeae exist, nucleic acid amplification testing (NAAT) of the vagina or cervix may be more sensitive. Without a genital complaint, asymptomatic sexually active adolescent and young adult (AYA) women under the age of 21 years do not require an internal gynecologic examination, but a thorough external examination is highly recommended. Screening urine or a vaginal swab for C. trachomatis, and also for N. gonorrhoeae depending on the local prevalence, is recommended annually in asymptomatic sexually active patients.

OBTAINING THE HISTORY

Building rapport and developing a trusting relationship with the adolescent or young adult prior to examining her is important. In order to reduce patient anxiety, it is essential that the office setting be comfortable and friendly. Creating an environment in which private and confidential matters can be discussed without judgment and with reassurance is of the upmost importance. This may require a special waiting area for AYA, evening clinic hours, and age-appropriate reading materials. Front desk staff, clinical assistants, nurses, and providers should be trained to address confidentiality and the unique psychosocial needs of AYAs. While parents are welcome and often essential in providing key pieces of history or support during gynecologic examinations, a separate time and space to interview the patient privately and to answer her questions is essential. Confidentiality and its limits must be addressed early in all clinical encounters with patients and parents (see Chapter 4).⁴,⁵ Doing so will encourage more open discussions and better care.

The history should include a gynecologic assessment, general health history, review of systems, and information on risk behaviors. The HEEADSSS psychosocial screening framework as outlined in Chapter 4 can be used. Answers to these questions must be obtained confidentially. Some adolescents, and even some young adults, may feel more comfortable if most of the history is obtained with a parent in the room. A few moments of privacy are all that is needed to obtain pertinent negatives about risk behaviors, safety, and sexual activity. It is not uncommon for AYAs to feel uncomfortable discussing such topics. Acknowledging this and normalizing questions or concerns about sexual health can put a young person at ease and facilitate the discussion.

It is essential to know what the patient’s reason for the visit is and whether there is any expectation for a gynecologic examination. If possible, doing this early on in the history can help allay fears and put the patient at ease. It is also important to gauge a patient’s understanding of menstrual periods, sexuality, and genital hygiene. Providing proper education during the interview and normalizing the patient’s questions and concerns help build rapport. Establishing a trusting relationship makes the gynecologic examination more comfortable.

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