Adolescent Gynecology pptx

After the initial gynecologic visit, which may or may not include a pelvic examination, based on the clinical circumstance, annual/semiannual visits should be scheduled thereafter.. Tool

Clinical Expert Series

Continuing medical education is available online at www.greenjournal.org

Adolescent Gynecology

Given new developments in the field of adolescent reproductive health, this review focuses on

highlighting new guidelines and practice patterns in evaluation and management of adolescent

gynecologic problems First, understanding the proper techniques for the initial examination is key

to establishing a long-term relationship with this age group Reservations about the first gynecologic

examination are common, and the practitioner’s goal is foremost to make the patient as comfortable

as possible Preventive health in this patient population is key, and practitioners should become

comfortable with providing education about topics as diverse as sexuality, eating disorders, and

dating violence Furthermore, the frequency with which teenagers report sexual activity and the high

unintended pregnancy rate in this age group makes counseling regarding effective contraception

essential Additionally, practitioners are encouraged to take the opportunity to discuss the availability

of the human papillomavirus (HPV) vaccine with adolescents In 2007, adolescents were designated

as a special population, given the frequency with which they acquire and clear mild HPV-related

cervical dysplasia More conservative treatment in this population is generally favored During their

transition through puberty, disorders of menstruation become the most common complaint

requiring the attention of the gynecologist Most commonly, anovulation serves as the cause behind

such abnormal bleeding Polycystic ovarian syndrome can develop in early puberty and carry its

consequences into adulthood Infertility, diabetes, and hirsutism mark the most important

compo-nents of the syndrome and require age-appropriate management Finally, the consequences of

endometriosis on the future fertility of adolescents have brought early intervention to light.

Recognition and prompt treatment are advocated to prevent the future implications of this disease.

(Obstet Gynecol 2009;113:935–47)

Given new developments in the field of adoles-cent reproductive health, this article focuses

on highlighting new guidelines and practice pat-terns in evaluation and management of adolescent gynecologic problems Unique clinical problems in adolescents require particular expertise, caring, and consideration

THE ADOLESCENT GYNECOLOGIC EVALUATION

The adolescent patient may present a challenge for the practitioner Understanding the proper tech-niques for the initial examination is key to estab-lishing a long-term relationship with this age group

In these patients, self-consciousness about their own body may make the examination more difficult

to perform The extreme variation in psychosocial and sexual development among teenagers

contrib-From the Department of Obstetrics and Gynecology and Reproductive Sciences,

Center for Fertility and Reproductive Endocrinology, University of Pittsburgh

Physicians, Magee-Womens Hospital, Pittsburgh, Pennsylvania; and

Ambula-tory Gynecology and Pediatric and Adolescent Gynecology, Carilion Medical

Center, Roanoke, Virginia.

The authors thank Dr Serena Dovey for her constructive comments.

Continuing medical education for this article is available at http://links.lww.

com/A816.

Corresponding author: Joseph S Sanfilippo, MD, MBA, Professor, Department

of Ob-Gyn & Reproductive Sciences, Vice Chairman, Reproductive Sciences,

Director, Center for Fertility & Reproductive Endocrinology, University of

Pittsburgh Physicians, Magee-Womens Hospital, 300 Halket Street, Room

2309, Pittsburgh, PA 15213; e-mail: jsanfilippo@mail.magee.edu.

Financial Disclosure

Dr Sanfilippo did not report any potential conflicts of interest Dr Lara-Torre

has been a speaker for Merck (Whitehouse Station, NJ) and Werner-Chilcott

(Rockaway, NJ), and he has been an Implanon trainer for Organon (Roseland, NJ).

© 2009 by The American College of Obstetricians and Gynecologists Published

by Lippincott Williams & Wilkins.

ISSN: 0029-7844/09

utes to the challenge Teenagers develop at varying

rates; whereas some are menarcheal at the age of 10

years, others may just be starting their pubertal

development at age 13 years Therefore, careful

interviewing and counseling should precede an

examination Although some teenagers may like to

know and see everything that will happen, some

prefer otherwise Using educational videos that

explain the examination process and the common

reasons why they are done may benefit the

inter-action with the patient Delaying the genital

exam-ination, even in some sexually active teenagers,

may prevent the patient from having reservations

about her examiner and allow rapport to be

estab-lished in a facilitated manner These preferences

should be taken into account to make the

gyneco-logic experience as comfortable as possible

Preventive health care is one of the most

impor-tant parts of the clinical visit in this age group As

recommended by the American College of

Obstetri-cians and Gynecologists (ACOG), the initial visit to

the obstetrician– gynecologist should occur between

the ages of 13 and 15 years.1 During this visit,

important components of general health, such as

immunizations, risk prevention, intimate partner and

dating violence, sexual orientation and history of

involuntary sexual experiences, and eating disorders,

including issues with obesity, should be evaluated

Additionally, screening for tobacco and substance

abuse and depression should be completed As the

human papillomavirus (HPV) vaccine has been

ap-proved by the U.S Food and Drug Administration

(FDA), new challenging horizons await the

obstetri-cian– gynecologist health care provider as a

“vaccina-tor.” Opportunities to interact with the adolescent will

present during these immunization visits, which allow

for practitioners to improve their relationships with

the parents and teenager as other reproductive needs

arise After the initial gynecologic visit, which may or

may not include a pelvic examination, based on the

clinical circumstance, annual/semiannual visits

should be scheduled thereafter In those not sexually

active, a visit in each stage of adolescence may be

preferred (early adolescence, ages 13–15 years;

mid-dle adolescence, ages 15–17 years; late adolescence,

ages 17–19 years)

With adolescents, if possible, it is important to

meet initially together with the teenager and her

parents/guardian to explain the concept of

confiden-tiality and privacy Remember when screening, begin

with less sensitive issues like safety (eg, seat belt use)

before addressing emotional and sexual issues A

sexual history is an integral component of the initial gynecologic visit Tools for this purpose are available through a number of professional societies, including the North American Society for Pediatric Adolescent Medicine and the Society for Adolescent Medicine as well as ACOG.2

As discussed, this examination does not neces-sarily include a pelvic examination Box 1, “Com-mon Indications for Pelvic Examination in the Adolescent,” lists indications for a pelvic examina-tion in the adolescent Besides the components of a complete physical examination, key points should

be included in the adolescent examination such as body mass index (BMI) Assessment of breast de-velopment should precede the pelvic examination; the external genitalia should be inspected, if al-lowed, in all patients who present for preventive care, even if not sexually active This will allow determining any genital anomalies in this age group

as well as facilitating the first step toward a com-plete pelvic examination Asymptomatic patients who are not sexually active may delay their initial pelvic examination up to the age of 21.3After the initiation of intercourse, teenagers may choose to delay their cervical cytology screening up to 3 years Annual Pap testing should be considered beginning with the initial visit in those patients with multiple partners or immunocompromised condi-tions and in whom follow-up is unlikely Care should be taken to obtain sexually transmitted diseases (STD) screening with each new sexual partner With the development of urine and vaginal

swab testing for gonorrhea and Chlamydia, STD

screening has become easier without the need for a pelvic examination

BOX 1 COMMON INDICATIONS FOR PELVIC EXAMINATION IN THE ADOLESCENT

Delayed puberty Precocious puberty Abnormal vaginal bleeding Abdominal or pelvic pain History of vaginal intercourse Pathologic vaginal discharge Suspicion of intraabdominal pathology Presented with permission from Lara-Torre E The physical examination in the pediatric and adolescent patient In Sanfilippo JS, Lara-Torre E, Templeman C, Edmonds K, eds Clinical pediatric and adolescent gynecology London (UK): Informa Healthcare; 2009 p 120.

Proper examination equipment for this age group

should be available and provided as clinically

indi-cated The use of tampons before their examination in

the presence of menses may facilitate the use of a

speculum, because they may be more comfortable

with vaginal manipulation The use of a pediatric or a

Huffman speculum (1/2 inch wide ⫻ 4 1/4 inches

long) may be of help in those patients not sexually

active, along with the use of a water-based lubricant

A Huffman or Pederson speculum (7/8 inch wide⫻ 4

1/2 inches long) may be used in those sexually active

The use of a finger applying pressure to the perineal

area, away from the introitus, allows for lessening or

diffusing of the sensation from the examination

(“ex-tinction of stimuli”) and may be of benefit in those

undergoing their first pelvic examination Once a

finger has been placed in this area, the insertion of a

speculum may be easier

When clinically indicated, attempting to palpate

the internal reproductive organs may require the use

of a rectovaginal or single-digit bimanual

examina-tion The approach used will depend on the patient’s

preference, tolerance, and sexual history as well as the

pathology suspected All adolescents should be

reas-sured that the examination, although uncomfortable,

is not painful and will not alter their anatomy This

may reassure parents and teenagers who may believe

that the examination will alter their “virginity.”

After the examination, it is helpful to meet again

with the family and the teenager together to explain

the examination findings and to further plan

manage-ment In the sexually active teenager, if

confidential-ity is a concern, first discuss findings with the patient

alone while in the examination room Encourage the

patient to allow you to be the liaison between her and

the family, stressing the benefits of education

regard-ing contraceptive use and her particular situation; if

the patient disagrees, confidentiality should be

main-tained according to local law Because each state varies

in its specific legal rights for adolescents, the Guttmacher

Institute has established a Web site where the

practitio-ner may access state-specific information and handouts,

which is updated frequently Practitioners may access

this site at www.guttmacher.org

CERVICAL CYTOLOGY, HISTOLOGY, AND

HUMAN PAPILLOMAVIRUS

In 2006, ACOG published a Committee Opinion

regarding cervical cytology screening and histology in

adolescents.4In late 2007, the American Society for

Colposcopy and Cervical Pathology published their

revised management of abnormal cytology and

his-tology, and in their review, they considered

adoles-cents as a special population with significant differ-ences in their management (Table 1).5,6 One main difference was to better define how to perform cervi-cal cytology in adolescents (defined as those 20 years

of age or younger) and the management of those with low-grade squamous intraepithelial lesions and atyp-ical squamous cells of undetermined significance (ASC-US) Previous guidelines indicated that patients with ASC-US should have a human papillomavirus (HPV) test If the test was positive, then a colposcopy was recommended Since then, new guidelines have determined that, given the high prevalence of HPV in these patients as well as the high rate of spontaneous resolution, it is recommended that this population not have an HPV test in the presence of ASC-US If the HPV test is performed, then the result should not be used for deciding upon colposcopy, and patients should be observed with annual cytology for up to a period of 2 years These guidelines hold true as long

as the results are not consistent with a high-grade squamous intraepithelial lesion, in which case a col-poscopy is recommended In those patients with high-grade squamous intraepithelial lesion, the man-agement did not change.5,6

The Committee also reemphasized the impor-tance of observation and repeat testing as the first line

of management for patients with mild and moderate dysplasia, rather than using ablative or excisional procedures The management of severe dysplasia did not change and still requires treatment

The availability of the quadrivalent HPV vaccine and soon-to-be-released bivalent vaccine provides

Table 1 Recommendations for Adolescents’

Cervical Cytology and Histology Management

Diagnosis Recommendation

ASC-US (no HPV testing) Repeat cytology in 12 mo

LSIL (no HPV testing) Repeat cytology in 12 mo

refer to a specialist)

cytology in 4–6 mo Severe dysplasia or CIS Treat per ASCCP

guidelines ASC-US, atypical squamous cells of undetermined significance; HPV, human papillomavirus; ASC-H, atypical squamous cells cannot exclude high grade; LSIL, low-grade squamous intraepi-thelial lesion; HSIL, high-grade squamous intraepiintraepi-thelial lesion; AGC, atypical glandular cells; CIS, carcinoma in-situ; ASCCP, American Society for Colposcopy and Cervical Pathology.

new challenges to the gynecologist Manufacturers’

information on the effectiveness of these vaccines

shows a prevention rate of more than 90% with HPV

types 6, 11, 16, and 18 (quadrivalent) and 16 and 18

(bivalent) in patients not previously exposed to

HPV.7,8The duration of protection seems to be longer

than 4 years, but the exact duration of protection is

still not known Some details on the future of the

vaccine, such as ideal age of initial dosing, use in boys,

and boosters, are still not clear, but current trials are

under way to answer these questions

Gynecologists involved with the care of teenagers

should be well-versed on the new recommendations

for cervical and histologic management of cervical

disease as well as the indications, risks, and benefits of

the HPV vaccine Many adolescents seen for the

provision of other reproductive health care would

benefit from our knowledge in these topics The need

to properly counsel these patients on the implications,

natural history, and prevention of HPV disease is part

of the daily practice of an adolescent provider

ABNORMAL UTERINE BLEEDING

In the adolescent, abnormal uterine bleeding is, more

often than not, secondary to anovulation This is a

reflection of the immaturity of the hypothalamic–

pituitary– ovarian axis In fact, in 55– 82% of

adoles-cents, it takes up to 24 months for onset of regular

ovulatory cycles after menarche; after 24 months,

22% of girls remain either anovulatory or

oligoovula-tory Furthermore, in some teenagers, it may take up

to 5 years postmenarche to establish regular ovulatory

cycles.9 As an aside, persistence of irregular menses

after menarche may be indicative of problems such as

polycystic ovarian syndrome and should be further

investigated Recently, ACOG and the American

Academy of Pediatrics published recommendations

regarding the menstrual cycle as a “vital sign.”

Impor-tant information and guidelines are included in the

document and guide the practitioner in identifying

those patients with possible pathology.10A number of

causes of abnormal uterine bleeding have been

pro-posed, as outlined in Box 2, “Causes of Abnormal

Vaginal Bleeding.” A menstrual calendar is often

useful to document the exact bleeding pattern and can

help in narrowing the differential diagnosis In

addi-tion to anovulaaddi-tion, bleeding diatheses, stress, and

pregnancy are all common causes of abnormal

bleed-ing in adolescents A thorough history and physical

examination, in addition to basic laboratory tests such

as human chorionic gonadotropin,

thyroid-stimulat-ing hormone, complete blood count, and platelet

level can help guide the physician in determining the

cause of bleeding If a bleeding diathesis is suspected based on the patient’s history, clinicians can proceed with the laboratory assessment as described in Box 3,

“Laboratory Assessment of the Adolescent With Dys-functional Uterine Bleeding.”

Treatment will clearly be based on the patient’s presumptive diagnosis However, for those patients whose bleeding is deemed secondary to oligoovula-tion, specific management can be provided based upon the degree of anemia:

• Mild anemia: hematocrit greater than 33% or he-moglobin greater than 11 g/dL can be treated with iron supplementation If there is a need for contra-ception, combined oral, transdermal, or intravagi-nal methods can also be prescribed to aid with anemia

• Moderate anemia: hematocrit 27–33% or hemoglo-bin 9 –11 g/dL can be treated with oral contracep-tives to control the abnormal menstrual bleeding

• Severe anemia: hematocrit less than 27% or hemo-globin less than 9 g/dL should be addressed with oral contraceptives prescribed as one every 6 hours until bleeding decreases and then a tapered dose to complete a 21-day pill pack This dosage of estro-gen will require an antiemetic.11The patient should then be placed on oral contraceptives in the manner prescribed for contraception over the following 3 months to allow improvement in her anemia The patient can then be reevaluated to determine whether there is a continued need to remain on oral contraceptives

Other therapies to treat anovulation include use

of progestins either cyclically or in depot form, eg, depomedroxyprogesterone acetate

POLYCYSTIC OVARIAN SYNDROME AND OTHER ANDROGEN DISORDERS

First described by Stein and Leventhal in 1935, this common endocrine disorder affects 4 – 6% of the female population and is characterized by in-creased androgens emanating from the ovary and possibly the adrenal gland.12,13 The earliest clinical manifestations can occur in the adolescent and carry its consequences into adulthood In 2003 in Rotterdam, an international reproductive medicine group met and reached the current consensus to establish the diagnostic criteria14as outlined in Box

4, “Rotterdam Diagnostic Criteria for Polycystic Ovary Syndrome.”

Because oligoovulation and acne can be common

in adolescence, the diagnosis may be less straightfor-ward in this patient population, and evidence of

hy-BOX 2 CAUSES OF ABNORMAL VAGINAL

BLEEDING

Vaginal or uterine abnormalities

Trauma (coitus; rape; abuse)

Foreignbody(intrauterinedevice,tampon,andsoforth)

Infection

• Vaginitis (Trichomonas; gonorrhea)

• Cervicitis

• Endometritis (tuberculosis)

• Pelvic inflammatory disease

• Sexually transmitted condylomata (human

papillomavirus

• HPV of cervix or vagina

Tumors

• Botryoid sarcoma

• Polyps (uterine; cervical)

• Ovarian cyst or tumor (mature teratoma;

endometrioma)

• Leiomyomatosis

• Clear cell carcinoma of cervix or vagina

(diethylstilbestrol)

• Other ovarian malignancy and metastatic

malignancy

Endometriosis

Congenital malformations of uterus

Complications of pregnancy

• Threatened or spontaneous abortion

• Ectopic pregnancy

• Molar pregnancy

• Self- or medically induced abortion

Coagulopathies

• Generalized coagulopathy

• Thrombocytopenia (idiopathic

thrombocytopenic purpura, leukemia,

lymphoma, aplastic anemia, hypersplenism)

• Platelet dysfunction (von Willebrand’s disease,

Glanzmann’s disease)

• Clotting disorders (hemophilia; other

coagulation factor deficiencies)

• Uterine production of menstrual anticoagulants

Dysfunctional uterine bleeding

Normal variation

• Midcycle ovulatory bleeding

• Early postmenarcheal anovulation

• Early postmenarcheal estrogen irregularities

(continued)

Chronic anovulation Exogenous steroids Oral contraception

• Midcycle breakthrough bleeding

• Relative luteal progesterone deficiency

• Progestogens (oral agents, Norplant, Depo-Provera)

• Continuous estrogens Other drugs

• Danazol

• Spironolactone

• Anticoagulants

• Platelet inhibitors

• Chemotherapy drugs

• Natural hormones from plant extracts (Dehydroepiandrosterone [DHEA]; dong quai; yam extract)

Systemic diseases

• Hyperthyroidism or hypothyroidism

• Adrenal insufficiency

• Cushing’s syndrome

• Diabetes mellitus

• Chronic liver disease

• Crohn’s disease; ulcerative colitis

• Chronic renal disease

• Systemic lupus erythematosus

• Ovarian failure

• Hyperprolactinemia Androgen excess

• Exogenous androgens, polycystic ovary syndrome

• Congenital adrenal hyperplasias

• Androgen-producing ovarian or adrenal tumor Estrogen excess

• Granulosa-theca cell tumor of the ovary

• Other tumors Hypothalamic disorders Emotional stress Physical stress, especially exercise Ovulation disorders

• Short luteal phase

• Prolonged luteal phase (Halban’s disease)

• Luteal progesterone insufficiency Matytsina LA, Zoloto EV, Sinenko LV, Greydanus DE.

Dysfunctional uterine bleeding in adolescents: concepts of pathophysiology and management Prim Care 2006;33:503–15.

perandrogenism should be sought In fact, unlike the

Rotterdam criteria, in which patients can be classified as

having polycystic ovary syndrome (PCOS) based solely

on polycystic ovaries on ultrasound examination and

ovulatory dysfunction, the Androgen Excess Society

emphasizes the need to demonstrate hyperandrogenism

to truly secure the diagnosis.15 Tests to order to help

clarify the diagnosis include total testosterone,

dehydro-epiandrosterone sulfate, and 17-OH progesterone

An-drostenedione may be added to monitor response to

treatment, because this is the main androgen secreted by

the ovary in PCOS

The teenager with PCOS presents with hirsutism,

acne, irregular menstrual cycles, and obesity as

inte-gral components of the diagnosis Other manifesta-tions may include alopecia and acanthosis nigricans, a clinical expression of hyperinsulinemia The stringent criteria of a 2:1 or 3:1 ratio of luteinizing hormone (LH) to follicle stimulating hormone (FSH) are no longer required, because PCOS is now considered a clinical diagnosis.15

The pathophysiology behind PCOS remains an area of controversy Current research suggests that PCOS may be related to intrauterine growth restric-tion and premature pubarche, although the true cause

is not well understood.16,17 Recent advancements in the understanding of PCOS have demonstrated that patients with PCOS are much more prone to devel-oping the metabolic syndrome than those without PCOS The metabolic syndrome is defined as having

at least three of the following18:

• Increased abdominal fat mass (waist circumference more than 35 inches [more than 88 cm])

• Increased triglycerides (150 mg/dL or more)

• Decreased high density lipoproteins (50 mg/dL or less)

• Increase blood pressure (130/85 mm Hg or more)

• Increased plasma glucose (100 mg/dL or more) Given the serious health implications associated with the metabolic syndrome, patients with PCOS should be educated at an early stage, beginning in adolescence, about the importance of healthy lifestyle habits, and they should be counseled regarding the long-term sequelae of the disorder, which include type 2 diabetes and cardiovascular disease

Although the cause of PCOS remains an intrigu-ing question, currently it is thought that an increase in Gonadotropin-releasing hormone (GnRH) pulsatility results in an excess release of LH in relation to FSH from the pituitary.19 This elevated level of LH then drives the ovary to produce increased androgens, especially androstenedione, which is converted pe-ripherally to estrone Without sufficient levels of FSH

to promote follicle recruitment and dominant follicle development, ovulation is inhibited The lack of progesterone from anovulation promotes increased GnRH pulsatility, all of which result in a persistent feedback loop between the ovary and the central nervous system Additionally, elevated insulin levels act at the level of the ovary to promote androgen production Other metabolic factors thought to be involved in PCOS include dysregulation of ovarian thecal enzymatic machinery, ie, cytochrome P450c, promoting more efficient synthesis of androgens.20

Research has also demonstrated a genetic predisposi-tion to the syndrome.21,22

BOX 3 LABORATORY ASSESSMENT OF THE

ADOLESCENT WITH DYSFUNCTIONAL

UTERINE BLEEDING

Initial Evaluation

• Complete blood count and differential

• Platelet count

• Fibrinogen

• Prothrombin time

• Partial thromboplastin time

• Bleeding time

If bleeding is severe or prolonged or associated

with menarche or if the initial screen is abnormal

then other tests should be performed:

• von Willebrand’s factor antigen

• Factor VIII activity

• Factor XI antigen

• Ristocetin C cofactor

• Platelet aggregation studies

Reprinted from Strickland JL, Wall JW Abnormal uterine

bleeding in adolescents Obstet Gynecol Clin North Am

2003;30:321–35 Copyright 2003, with permission from

Elsevier http://www.sciencedirect.com/science/journal/

08898545

BOX 4 ROTTERDAM DIAGNOSTIC CRITERIA

FOR POLYCYSTIC OVARY SYNDROME

Two of the following three criteria must be met

after ruling out other causes of hyperandrogenic

disorders:

• Oligoovulation

• Clinical and/or biochemical evidence for

hy-perandrogenism

• Ultrasonographic evidence of polycystic ovaries

Clinically, quantification of the degree of

hirsut-ism is helpful The Ferriman Gallwey classification

assists in this goal (the classification system may be

reviewed in its original publication).23Although

clini-cians approach the evaluation differently, the basic

assessment should include early morning serum

tes-tosterone (total and free), 17-OH progesterone,

dehy-droepiandrosterone sulfate, prolactin, thyroid

stimu-lating hormone, and fasting glucose and insulin levels

Clinicians should emphasize counseling

adoles-cents with PCOS as an important part of their

man-agement Weight loss should be encouraged, because

it seems that a 10% reduction in weight is sufficient to

reestablish regular ovulatory menstrual cycles in

many women Because adolescents’ understanding

and commitment to treatment may vary throughout

their teenage years, education and counseling should

cater to the changing environments and maturity of

the patients

Pharmacologic treatment includes use of the oral

contraceptive pill and the insulin sensitizer metformin

as the mainstay and more common components of

management Combined oral contraception

pro-motes regular withdrawal bleeding and protects the

uterine lining against the effects of unopposed

estro-gen seen in PCOS, in addition to helping to improve

the hormonal milieu and lower circulating androgen

levels Metformin helps to address the component of

insulin resistance seen in PCOS Other medications,

depending on the clinical circumstance, include

glu-cocorticoids and anti-androgens such as

spironolac-tone Treatment with glucocorticoids is reserved for

the less common presentation of PCOS in nonobese

teenagers with a significant degree of functional

adre-nal hyperandrogenism If pregnancy is of interest and

oligoovulation persists, clomiphene citrate is usually

the initial treatment.24

ADOLESCENT CONTRACEPTION

Adolescent pregnancy rates in Europe and Canada

are approximately 50% lower than those in the US.25

For this reason, the use of appropriate contraception

is especially important in this age group As

adoles-cents mature and become capable of reproduction,

visits to their practitioner should include counseling

on adequate methods of birth control to target their

needs and abilities to improve their compliance (Fig

1) Providing this information does not result in

increased rates of sexual activity, earlier age of first

intercourse, or a greater number of sexual partners

On the contrary, if the adolescent perceives that there

is an obstacle to obtaining contraception, they are

more likely to experience negative outcomes related

to sexual activity.26 The 2007 Youth Risk Behavior Surveillance System that tracks different health risk behaviors among high school students, including sex-ual behaviors that contribute to unintended pregnan-cies, surveyed more than 14,000 high school students from every state and the District of Columbia.27

Important findings of this survey included

• A total of 47.8% of students reported ever having had sexual intercourse (46.8% in 2005)

• Only 7.1% of students reported having had sex before age 13 (6.2% in 2005)

• A total of 14.9% of students reported having had sex with four or more sexual partners (14.3% in 2005)

• A total of 35.0% of students reported being cur-rently sexually active, defined as having had sexual intercourse in the 3 months before the survey (33.9% in 2005)

• Only 61.5% of sexually active students reported that either they or their partner had used a condom during last intercourse (62.8% in 2005)

These finding reinforce the importance of ad-dressing contraception during the adolescents’ health care evaluation

Abstinence

During the first part of the decade, the U.S adminis-tration placed emphasis on abstinence-only education

Fig 1 Contraceptive methods Clockwise from top right:

intrauterine system, vaginal ring, single-rod implant, hor-monal patch Modified from Blumenthal PD, Edelman A Hormonal contraception Obstet Gynecol 2008;112:670 –

84 Illustration: John Yanson.

Sanfilippo Adolescent Gynecology Obstet Gynecol 2009.

for pregnancy prevention Unfortunately, recent data

suggests that abstinence-only programs are not as

effective as those in which other contraceptive options

are offered at the same time.28Although abstinence is

the most effective means of birth control, the lack of

other contraception education during their efforts has

caused controversy and disagreement with the

spe-cialty societies Although many teenagers who

present for contraception are already sexually active,

a review of abstinence as a choice should be an

integral part of the discussion of the options available

to the adolescent

Combined Oral Contraceptive Pills

The oral contraceptive pill (OCP) is the most

com-monly used method of contraception in the

adoles-cent group, with rates of use approaching 50%.29The

contraceptive and noncontraceptive benefits of the

pill, such as with acne, pelvic pain, and premenstrual

dysphoric disorder, may contribute to the preference

of adolescents’ for this contraceptive Extended

regi-mens such as the available 84/7 day and “no placebo”

regimens have shown similar efficacy and compliance

with only mild increase in breakthrough bleeding in

the adult population; this may be a new option for

patients that desire lower frequency of menses, such

as athletes and military personnel, although studies in

adolescents are lacking.30Using a “quick start” (same

day as the visit) method compared with the traditional

Sunday start initiation seems to improve compliance

and still maintain an acceptable adverse effect profile

without any teratogenic effects even if pregnant.31

Other Combination Hormonal Methods

In the adult population, failure rates and adverse

effect profiles of other methods such as the patch and

the ring are similar to OCPs Recent safety data

released by the manufacturer of the patch warns of an

increased exposure to estrogen compared with the

average dose OCP, which may increase the risk for

cardiovascular events.32 Adolescents should be

cau-tioned about these risks and counseled about the

potential adverse effects before prescribing the

method The vaginal contraceptive ring requires

mo-tivation from the patient to insert and remove the

contraceptive device once a month from the vagina,

and has not been well studied in adolescents Both of

these methods may increase compliance and efficacy

in adolescents by reducing the number of doses per

month Adequate trials on adolescents are still underway

and should provide additional information regarding

other applications such as extended regimens

Progestin-Only Methods

These methods are used by adolescents with con-traindications to the use of estrogen, such as breast-feeding teenagers The oral formulation’s increase

in failure rate may be due to patient compliance and short half life, which requires taking the pill around the same time of the day (within 3 hours).33

Depot medroxyprogesterone acetate is a contra-ceptive frequently used by the adolescent population because of the minimal intervention required to achieve compliance Although its efficacy has been shown to be better than OCPs, most of its effect seems

to be related to compliance and ease of use Weight gain and irregular bleeding are common and unpleas-ant adverse effects for adolescents A recent concern has been the effect of the hypoestrogenic state created

by long-term use of depot medroxyprogesterone ac-etate on bone density in adolescents New trials have shown the recovery of bone density after discontinu-ation of the method Those patients who are smokers and sedentary should be counseled on the detrimental implication on bone health and encouraged to quit smoking, and ideally focus on athletic endeavors Appropriate calcium intake (1,200 –1,500 mg per day) should be encouraged in those adolescents The in-troduction in 2007 of a single etonogestrel implant, with a three-year contraceptive duration, and easy insertion and removal, will reopen new alternatives for adolescents looking for long-term contraception, although long-term studies in adolescents are not available at this time.34

Emergency Contraception

Emergency contraception, the use of nonabortifa-cient, hormonal medications within 72–120 hours after unprotected/underprotected coitus for the pre-vention of unintended pregnancy, is an important part of the contraception counseling in adolescents The use of levonorgestrel 1.5 mg divided into two doses taken 12 hours apart is the only FDA approved method available; recent studies show that taking a single dose of levonorgestrel 1.5 mg may be as efficacious as when taken in divided doses, possibly increasing compliance.35 Advanced prescription of emergency contraception has been shown to increase the likelihood of young women’s and teenagers’ use of emergency contraception when needed and yet not increase sexual or contraceptive risk-taking behavior when compared with those receiving only education about emergency contraception.36

Barrier Methods

Barrier methods include devices such as male

con-doms, female concon-doms, cervical caps, diaphragms,

spermicidals, and contraceptive film and ovules

Al-though effective, the use of these devices by

adoles-cents is not consistent, even when chosen as their

method to protect against STDs.37 The need for

application before each sexual encounter decreases

the use of the method by “decreasing the spontaneity”

of the act, as some teenagers explain Practitioners

should encourage the use of barrier methods, such as

the male and female condom, to prevent against

STDs, even when the teenager is on another form of

contraception

Intrauterine Devices and Systems

The available literature with intrauterine devices

(IUDs) in adolescents was very limited until

re-cently Traditionally, use of IUDs has been avoided

in adolescents, because this population has the

highest rates for STDs However, no increase in

infertility or STD incidence is seen with the use of

these devices.38Most of the ascending infections are

probably related to contracting the infection from

lack of condom use, rather than the presence of the

IUD facilitating it, and occur at the time of

inser-tion With proper counseling and condom use, an

intrauterine system may be a viable option for some

teenagers, regardless of their gravidity and parity

status, and should be considered as part of the

available armamentarium for contraception The

Adolescent Health care Committee of ACOG in

2007 advocated for the increase in use of this

method in this population.39

ENDOMETRIOSIS

From a historical perspective, von Rokitansky first

described evidence of endometriosis in 1860.40 In

1921, Sampson41 elaborated on the variable

appear-ance of endometriotic implants, and in 1946, Fallon42

suggested that the development of endometriosis

re-quires a minimum of 5 years of ovulatory menstrual

cycles Although the exact pathophysiology behind

endometriosis is not well understood, several theories

have been put forth The theory of retrograde

men-struation, or Sampson’s Theory, suggests that

endo-metrial implants arrive in the pelvis by retrograde

transportation through the fallopian tubes The theory

of coelomic metaplasia, or Myer’s theory, suggests

that the peritoneal cavity contains undifferentiated

cells capable of differentiating into endometrial tissue Other authors have suggested that endometrial tissue can also travel hematogenously or through lymphatic channels

More recently, it has been demonstrated that patients with endometriosis have both cell-mediated immunologic defects as well as humoral-related ab-normalities These immunologic deficiencies provide evidence for the theory of a defective immune sur-veillance, leading to an inability of the immune system to recognize autologous endometrial tissue in abnormal locations Research indicates that perito-neal macrophages and cytokines are found in in-creased concentration in patients with endometriosis Additionally, neovascularization, with associated re-lease of interleukins and chemokines, is felt to be an integral part of the pathophysiology Tumor necrosis factor (TNF) alpha, matrix metalloproteins, and other growth factors are associated with adhesion-promot-ing factors and thus set the ground work for develop-ment of endometrial implants.43

Reese and coworkers44described two premenar-cheal girls, aged 12 and 13 years, with evidence for endometriosis Subsequent to this, Marsh and Laufer reported on five premenarcheal patients with chronic pelvic pain (more than 6 months duration) with laparoscopically biopsied lesions indicative of endo-metriosis that, on histologic examination, noted me-sothelial hyperplasia, vascular proliferation, and fi-brous granulation.45There was no associated outflow tract obstruction in this study This is the earliest age-related evidence for endometriosis Others have reported documented endometriosis within 1 month after menarche.46

Table 2 describes the presence and appearance of lesions consistent with endometriosis in a series of adolescents presenting with chronic pelvic pain (Fig 2 and 3).47

The American Society for Reproductive Medi-cine Classification of Endometriosis describes the extent of disease based upon location, extent

(super-Table 2 The Presence and Appearance of Lesions

Consistent With Endometriosis in a Series of Adolescents Presenting With Chronic Pelvic Pain

ficial compared with deep lesions), size of lesions, and

presence of adhesions.48A major distinction between

adolescents and adults in the development of

endo-metriosis is its association with mu¨llerian anomalies in

the former age group A number of mu¨llerian

anom-alies, especially those associated with outflow tract

obstruction, have been reported to be associated with

endometriosis In a study by Schifrin and coworkers,49

15 patients (40%) younger than 20 years of age with

endometriosis had a genital tract anomaly This is as opposed to findings by Goldstein et al50 who noted congenital anomalies in 11% of 74 teenagers with endometriosis The clinical course of endometriosis associated with reproductive tract anomalies is quite different from that in the adult Sanfilippo et al51

reported a series of patients with extensive endome-triosis in association with outflow tract obstructions Once correction of the outflow tract occurred there was virtually 100% reversal of intraabdominal endo-metriosis on follow-up laparoscopy It is thought that the pathophysiology of the disease process is different

in the adult in comparison with the adolescent with an outflow tract obstruction.51

Others have reported no association between endometriosis, pelvic pain not responding to medical therapy, and mu¨llerian anomalies.52 One group of patients underwent laparoscopy; mu¨llerian anomaly was noted in 6.5% of patients.53Nonobstructive mu¨l-lerian anomalies do not seem to be associated with an increased incidence of endometriosis Important points regarding adolescent endometriosis are pre-sented in Table 3

In adolescents who present with chronic pelvic pain, the following systems should be considered with regard to the underlying cause of the problem:

• Gastrointestinal

• Genitourinary

• Musculoskeletal

• Gynecologic

• Psychological/psychiatric

Fig 3 Common location of endometriosis implants

Mod-ified from American College of Obstetricians and

Gynecol-ogists Endometriosis ACOG Patient Education Pamphlet

AP013 Washington, DC: ACOG; 2008 Illustration: John

Yanson.

Sanfilippo Adolescent Gynecology Obstet Gynecol 2009.

Fig 2 Endometriosis appearance

in adolescents A Clear vesicles.

B Small red punctuations C Red

polyps Reproduced with permis-sion from Martin DC, editor Laparoscopic appearance of en-dometriosis Web revision, color atlas 2nd ed Memphis (TN): Re-surge Press; 1990 p 16, 20, 23.

Sanfilippo Adolescent Gynecology Obstet Gynecol 2009.