Gynecologic Problems of Adolescence and Puberty
Sandra A. Carson
Table Of Contents
Sandra A. Carson, MD
THE INITIAL MEETING
Gynecologic care of the adolescent presents specific problems to the physician not used to dealing with this age group. These patients require a kind, gentle, knowledgeable approach. They must be assured of a confidential doctor-patient relationship without risking the alienation of their parents.
This chapter deals with specific problems that may arise in the gynecologic exam of the adolescent. Discussion is limited to adolescents' problems and their treatment only as they differ from treatment in adults.
|THE INITIAL MEETING|
Most women are uncomfortable and somewhat apprehensive about consulting a gynecologist. These feelings are even more intense in teenagers who have heard various horror stories from their peers about such experiences-stories they are much more likely to believe than any realistic communication coming from an adult. Therefore, the most important part of the gynecologic interview may be the time spent by the physician to gain the patient's confidence. A survey of 84 adolescents reveals that most concerns about the pelvic examination were fear of the discovery of pathology, fear of pain, and embarrassment.1
One technique useful in beginning the adolescent interview is to explain pelvic anatomy. Most adolescents have a burning desire to learn the facts of life and facts about their bodies. A brief discussion directed to the adolescent will quickly put her parent (who usually is present during the interview) in the background. This will then lead to direct questioning of the adolescent herself, encouraging her to provide useful information. The conversation can thus be comfortably geared toward identifying the adolescent as the patient without alienating the mother. In general, adolescents relish the opportunity to assume adult roles and, in return, become cooperative and trusting.
In fact, propriety of parental presence in the interview is itself a point of debate. It is usually necessary to have a parent in the initial interview to complete the medical history for the patient; however, the presence of a parent may also inhibit the patient's free speech and prevent a trusting doctor-patient relationship from developing. Adolescents over 18 may be treated without parental consent; some states allow treatment of younger adolescents for venereal disease or drug abuse without parental consent.2
One compromise is to begin the interview with the parent present and then to dismiss him/her before the examination, thus giving the patient confidential time alone with her doctor. This is also a good time to inform the patient that you will tell her parent only that which she herself allows you to tell, and it is for this reason that her parent will not be invited into the examination room. Some patients will protest, but most will cooperate better without a parent in the room. Both the patient and her parent should be reassured that a gynecologic examination will not damage the patient's hymen, and the exam will not change her virginity. A diagrammatic explanation of the pelvic exam will help the patient understand exactly what is to be done.
The history itself should include all the essentials of a detailed medical history, as well as specific ages of adrenarche, thelarche, and menarche. This obvious point is all too often taken lightly by the gynecologist accustomed to dealing with adults referred to them by internists. (Adults usually have a complete examination only by the integration of the examinations of a few consultants: internists, gynecologists, ophthalmologists.) Adolescents often have not seen their pediatricians in years; thus, they require careful, thorough reviews of systems. Each positive symptom should be questioned as to frequency, relationship to menstrual cycle, and to ameliorating and provocative events. Inquiring how the patient is doing in school may be a tactful way to introduce questions about the patient's temperament, social history, and boyfriends.
Menstrual history of the patient's mother may help to explain a precocious or delayed menarche. Similarly, maternal drug ingestion during the patient's gestation may be relevant to the patient's complaint.
A menstrual history should be ascertained through specific questions regarding amount, length and frequency of flow. Questions such as, “Are your menses light or heavy?”, may not elicit correct information from a patient who has had only a few menstrual periods and is unaware of what is normal, light, or heavy. The number of pads or tampons used may also lead to an inaccurate assessment of menstrual pattern, Some females will change as soon as the pad is soiled, whereas others only when the pad is soaked. Questions are better focused on whether bleeding is so heavy that it cannot be contained in a pad or tampon, whether it requires both a pad and tampon, or whether the patient must awaken at night to change. All these findings indicate an abnormally heavy flow.
Dysmenorrhea usually does not occur until after the patient begins to ovulate. Because over 80% of the first years' menses are anovulatory,3 dysmenorrhea does not usually occur in early cycles.4 Severe pain with menses. requiring absence from school, must be investigated. During the history, the physician may also explain symptoms such as molimina and dysmenorrhea to reassure the patient that nothing is seriously wrong.
Particular attention should be given to the urologic history. Frequent urinary tract infections or previous urologic surgery may be related to a gynecologic problem. It may be difficult for some patients to distinguish between hematuria and intermenstrual spotting. It is usually difficult for all patients to distinguish between hematuria and menstrual blood in urine.
Adolescent patients have difficulty knowing what symptoms are important and require direct questioning in a specific manner, Open-ended questions, usually preferable in a medical history, are rarely beneficial in an adolescent history.
With the help of a nurse, the patient should be instructed to empty her bladder and then disrobe completely. A hospital gown will make the patient feel much more comfortable than a sheet alone. The patient's vital signs, including blood pressure with a properly sized cuff, should be taken. Her height and weight should be recorded along with arm span. The patient' s stature and posture should be noted. Congenital abnormalities, hair distribution, and skin lesions may suggest systemic disease. Similarly, an examination of the head and neck may reveal changes associated with systemic disease, such as lymphadenopathy, mucosal changes, or scleral icterus.
A heart and lung examination should be performed. Auscultation of the patients' abdomen prior to palpation will prevent falsely heightened bowel sounds. Abdominal contour and scars will uncover previous surgery, hernias, and masses. Palpation of the liver edge, spleen, and kidneys should be attempted; abdominal tenderness, rebound, or guarding should be noted. The presence of ascites should be ruled out. The Tanner stage of breast development must be recorded.
The breast examination must include an exam to elicit masses as well as nipple secretion. Usually, breast development is staged according to the Tanner classification, but this morphologic classification does not always reflect actual glandular development.5 In patients with precocious or delayed puberty, or with abnormal breast development, ultrasound examination of the breast is more reproducible and documentable. In addition, serial ultrasound examinations over time may prove a more reliable reflection of pubertal progression and therapeutic efficacy than Tanner staging alone.5
The pelvic examination of an adolescent should always be done on an examining table. The patient must be informed of what is to happen before each step. It is just as unwise to inform the patient, “This is not going to hurt,” as it is to inform her, “This is going to hurt.” It is much better to explain what is going to be done, perform the pelvic exam as gently as possible, and allow the patient to decide how painful it was or was not.
The external genitalia should also be staged according to the Tanner classification. The clitoris should be measured with a small ruler. The clitoris should not be larger than the average adult clitoris, 5.4 × 4.4 mm.6
The patient's hymen should be examined for patency as well as for caruncles. The secretions normally covering the hymen originate from the vestibular glands. An imperforate hymen will, of course, preclude the vaginal exam until hymenotomy is performed. At the superior aspect of the hymen lies the urethral meatus. which should be palpated to elicit tenderness and thickening, both signs of infection.
Visual examination of the vagina and cervix is best performed with a Huffman adolescent speculum (Fig. 1). This instrument has a 1.5-cm diameter and an 11-cm length. If the patient has been using tampons or having intercourse, the Huffman speculum will not be too big. However, if the introitus is too narrow to admit a speculum, a limited exam can be performed with a pediatric vaginoscope (Fig. 2). Unfortunately, visualization with this instrument is so poor that in most cases this exam yields little information and causes so much discomfort that the patient is less cooperative for the bimanual examination. The vaginoscope is useful, however, for removal of a foreign body. If the patient's complaint or symptoms mandate cervical visualization and the Huffman speculum is too large for her, it may be preferable to perform an examination under anesthesia than to perform inadequate vaginoscopy. In any case. the instrument used should be warm and lubricated. If a cytologic smear is to be taken, then lubrication with warm water is substituted for jelly. The instrument is inserted with the speculum blades closed and pointed posteriorly toward the coccyx. The patient may be asked to perform a valsalva maneuver while pressure is simultaneously exerted on the perineal body by the speculum. Posteriorly directed pressure avoids pressure on the anterior wall of the vagina and more sensitive urethra. Insertion is more comfortable if done slowly. The cervix should be examined for lesions, infection, or congenital anomalies. Directing the patient to flex her knees onto her abdomen will help position an eccentrically placed cervix.
One lubricated finger can usually be inserted in the vagina for a bimanual exam. If the introitus is too small, the digital exam must be rectal. After .entry, it is advisable to stop and allow the patient to regain composure and become accustomed to the finger in her vagina or rectum before proceeding with actual palpation. Palpation of the cervix will elicit tenderness produced by inflammation, ectopic gestation, and perhaps endometriosis. The uterine fundus can be palpated and its position, size, shape. and consistency noted. Normal tubes cannot be palpated. Normal ovaries can usually be palpated in thin patients. Any abnormal enlargement of the adnexae requires further investigation.
A rectovaginal exam with one finger in each orifice is too painful for the adolescent patient unless the introitus is well dilated. Thus, this exam should be avoided. A rectal exam alone will suffice.
Findings of the exam should be discussed with the patient immediately upon completion. Parenthetically, the adolescent should be informed that intercourse does not feel the same as a pelvic exam. The physician should stress that foreplay will increase vaginal compliance and lubrication to allow pleasurable lovemaking. This is, of course, a good time to inform the patient of her contraceptive choices. She should also be informed that when she decides to have intercourse, it should be pleasurable for her as well as her partner. A man mature enough for intercourse should be mature enough to understand the needs of his partner. It is a nice gesture to ask her permission to explain the findings to her mother and then repeat the discussion to both with the addition of therapeutic plans.
The adolescent gynecologic exam can be performed successfully only if enough time is allotted for the patient. One full hour is necessary for such exams. Physicians desiring to provide care for adolescents should be willing to amend their office schedule accordingly.
Prescribing for Minors
American law has traditionally considered an individual younger than twenty-one to be a minor, but most states have now lowered the age to eighteen.7 Of relevance is the concept of an emancipated minor, defined as an individual younger than eighteen who is married, has parental consent, is self-supporting, and is living apart from his or her parents, has parents who have failed their legal responsibilities, or has a judicial decree deeming him or her to be of the majority.7 Many states consider a pregnant female emancipated and therefore able to consent to abortion without the consent of her own parents. Many states consider the minor able to consent to medical care for herself if she is able to understand the risks and complications. This, of course, puts the physician in a difficult spot when dealing with a minor who has no parental consent. Indeed, the physician should consult with legal advisors as to what rights and responsibilities he or she has to the patient under the state law.
Vulvitis and Vaginitis
The presence of vulvar pruritus or any vaginal discharge must be investigated to exclude the presence of an infection or foreign body. A microscopic examination of the discharge should be performed to search for Candida albicans, Trichomonos vaginalis, Gardnerella vaginalis, and pinworm ova, as discussed elsewhere. A culture for gonorrhea should be taken from the endocervix, periurethral glands, and rectum.
The most common cause of adolescent vulvovaginitis is E. coli colonization resulting from poor perineal hygiene.6 In most cases, however, it is probably useless to attempt to change an adolescent's direction of tissue wiping after a bowel movement from “back to front” to “front to back.” It is much more important to stress daily bathing and judicious perineal drying.
Prior to menarche, the unopposed estrogen secreted from the ovaries stimulates vaginal and cervical secretions resulting in leukorrhea. These secretions may be interpreted by an adolescent or her mother as evidence of infection, Microscopic examination of discharge, which grossly appears cloudy white and thick, will reveal voluminous squamous cells without white blood cells or organisms. Although usually physiologic, leukorrhea may be the first sign of vaginal adenosis or even clear-cell carcinoma. Although it is unlikely that anyone born after 1970 will have been exposed in utero to diethylstilbestrol, such conditions do result de novo. In addition to a wet mount examination of the vaginal discharge, these patients require a careful cervical examination. If no pathology is found, the patient should be reassured she has no infection and should be instructed in proper perineal hygiene. Cotton panties, dresses, and panty hose with cotton crotches will help to keep the perineum dry. To prevent local pruritis, itching, odor, maceration, and infection. the perineum should remain dry. Talcum powder has a drying effect but tends to be messy and therefore uncomfortable. The patient should be advised to wear mini-pads or panty liners and to change frequently during the day. Cautery and cryosurgery should be avoided. Although perhaps beneficial, oral testosterone may have virilizing side-effects.
Vulvovaginal infection is treated with the same medicines in the adolescent as in the adult; however, application must be modified to take into account the smaller introitus and less experienced person. Douching and vaginal suppositories should not be prescribed. If the medication is packaged as a urethral suppository, this may be used intravaginally, as urethral suppositories are much narrower than the vaginal suppository. Vaginal ointments and cremes may be applied into the vagina with a screw-on tip designed for pediatric intrarectal creams. In most cases, the patient will require parental assistance.
Dysmenorrhea in adolescents rarely occurs with the first menstrual period, Eighty-five percent of the first year's menses are anovulatory3 and usually not associated with menstrual pain. Montagu correlated the onset of primary dysmenorrhea with fertility in the adolescent.8 Similarly, a Finnish study revealed that fewer than 10% of young ladies developed dysmenorrhea during their first menstrual year, but the incidence increased rapidly thereafter.9 The pathophysiologic basis of primary dysmenorrhea-menstrual pain without detectable disease remains undefined. Jones and Wentz produced dysmenorrhea in normal women by infusing intravenous prostaglandin F2. Their subjects also experienced nausea, vomiting, diarrhea, leg cramps, headache, and depression.10 Dawood's data relating dysmenorrhea to increased prostaglandin content of the endometrium is the most convincing evidence. 11
No matter what the actual pathogenesis, dysmenorrhea is real pain and should not be attributed to hysteria or emotional problems. Although young ladies with psychological problems may, of course, have dysmenorrhea, they do not have a higher incidence of dysmenorrhea than psychologically well-adjusted females. 12 Primary dysmenorrhea is a diagnosis of exclusion. Secondary dysmenorrhea (dysmenorrhea resulting from organic disease) must be excluded by the physician. Historical inquiry about associated symptoms, such as diarrhea, nausea, vomiting, and irritability, suggests prostaglandin association. Gentle questions should be used to determine if the patient is trying to use dysmenorrhea as an excuse for school absence in order to avoid undesirable situations. During the pelvic exam. sources of dysmenorrhea should be sought: endometriosis, blind vaginal pouch, rudimentary uterine horn, or cervical stenosis.
Treatment of primary dysmenorrhea begins by informing the patient that her physical examination is normal and by educating her about theories of dysmenorrhea. Often, anxiety that the pain is reflecting pathology intensifies the pain itself. Depending upon the incapacitating nature of the pain, the patient may or may not require treatment with prostaglandin inhibitors. These are discussed in full elsewhere in this volume. Oral contraceptives should be started if prostaglandin inhibitors fail to relieve symptoms or if dysmenorrhea remains so severe as to confine the patient to bed several days each month. A trial period of a low-dose oral contraceptive for 6 months often relieves dysmenorrhea, not only for the period of treatment but often for several ovulatory cycles thereafter. If menstrual pain is not relieved by these measures, a more thorough search for an organic cause must be made. Examination under anesthesia. ultra-sonography, and even laparoscopy may be necessary.
Surgical therapy for primary dysmenorrhea in the adolescent is rarely indicated. Cervical dilatation offers no long-term solution. Suspension of a retroverted uterus is not indicated. Primary sacral neurectomy should be held as only a last resort in these patients.
Secondary dysmenorrhea resulting from a congenital abnormality of the genital tract should be relieved by corrective surgery. Retrograde menstruation superior to an imperforate outlet will lead to dysmenorrhea, as well as later development of endometriosis. Endometriosis in the absence of a congenital anomaly is rare in adolescents. When it does occur, however. endometriosis is a cause of painful menstruation. Endometriosis may be treated by continuous daily administration of an oral contraceptive for 6 months. The best choices are those pills containing strong progestins, such as norgestrel or norethynodrel diacetate. Danazol should be reserved for adolescents not responsive to continuous estrogen-progesterone treatment. Similarly, narcotics should be a last resort.
Kantero and Widholm noted a high prevalence of dysmenorrhea among patients whose mothers had dysmenorrhea: 30% of daughters of dysmenorrheric patients experienced painful menses. as opposed to 7% of daughters of pain-free mothers.9 This study has been interpreted to imply that the psychological factors (i.e., the family's perception of menstrual pain) may environmentally influence the daughter's reaction to her menses. However, the results could also be interpreted to reflect genetic predisposition: Perhaps prostaglandin synthesis is regulated by an autosomal dominant gene with variable expressivity.
Abnormal Uterine Bleeding
Adolescents are very concerned about the regularity of their menses. Indeed, any patient presenting to the gynecologist with amenorrhea (no matter what age), irregular menses, or abnormal uterine bleeding deserves at least a physical examination.
The first year's menstrual cycles often have intervals as long as 6 months. This irregularity may continue as long as the first 15 cycles.13 Such abnormalities occurred in 43% of the over 5000 adolescents surveyed by Widholm and Kantero14 and in 68% of 1533 adolescents surveyed by Batrinos and co-workers,15 Although menstrual irregularities may be constitutional, only after a pelvic examination should the physician be convinced that the patient is free of disease.
Amenorrhea, whether primary or secondary in this age group, must be investigated. Evaluation of these disorders in the adolescent is described in the other volumes of this series.
Heavy uterine bleeding or menses more frequent than every 21 clays is abnormal. Although this is often attributed to anovulation, such bleeding has occurred with proliferative, secretory, or atrophic endometrium.16 If anovulation were, indeed. the cause of such bleeding, one would expect to see more adolescents with this problem since most adolescents are anovulatory, However, only 11% suffer from abnormal uterine bleeding.16 Even though such bleeding is associated with poorly understood factors associated width an immature hypothalmic-pituitary-ovarian axis, this symptom may be an early signal of a chronic disease. Therefore, these patients should be screened for pregnancy, hypothyroidism, hyperthyroidism, blood dyscrasias (e.g., von Willebrand's disease), and hepatic dysfunction. Thyroid profile, .complete blood count, platelet count, SMA-25, and clotting profile should be ordered if the pregnancy test is negative.
Pathologic changes are rarely a cause of abnormal uterine bleeding in adolescents. For this reason, initially treatment is with hormones. If medical therapy fails, a dilatation and curettage is indicated. The medical therapy used will depend on the severity of symptoms. Three choices are listed in Table 1. When prescribing these hormones the physician should stress to the patient: “DO NOT STOP THE DRUGS WITHOUT TALKING TO ME.”
* Greater than six well-soaked pads per day.
Use of menstrual calendars in these patients will help the physician follow post-therapy cycles more accurately. Adolescents treated with hormones should be informed that withdrawal bleeding in the first few cycles will be very heavy, and this is to be expected. The use of medroxyprogesterone acetate every 2 months will allow the adolescent to establish a pattern of her own when the hypothalamic-pituitary-ovarian axis is mature, but will prevent endometrial proliferation from unopposed estrogen. This therapy will help to avoid recurrence of the abnormal bleeding pattern.
Patients who present to the gynecologist with delayed puberty or absent menses have a high frequency of congenital anomalies. Only 20% have treatable causes, and 20% have developmental abnormalities.17 Pelvic examination will rule out most congenital anomalies of the vagina. Ultra-sound is helpful in determining the presence or absence of the uterus. (The detailed work-up of these patients is described elsewhere.)
These patients deserve at least a history and physical examination and must not just be told, “Don't worry, your period will come in a few years.”
A teenager who consults a physician for contraception should be applauded, not given a lecture on being too young to have sex. Such lectures are not contraceptive and may result in teenage pregnancy. A physician willing to give contraception to a teenager only after she has demonstrated a previous pregnancy should not be taking care of adolescents. The adolescent who has decided to have intercourse will not change her mind if not given contraception. In fact, most of these young women have already had intercourse before seeking contraception.18
Contraception does not necessarily increase adolescent promiscuity; it decreases adolescent pregnancy. Of course, it is difficult to make parents understand that withholding contraception will not decrease the sexual activity of their daughter or son. Nonetheless, one study has shown that teenage girls who have taken a sex education course have a lower pregnancy rate than those who have not taken the course.19 Certainly, it is easier to provide contraception with parental consent; indeed, the laws governing prescription of contraceptives to minors vary from state to state even though the U.S. Supreme Court has ruled that minors have a constitutional right to nonprescription contraceptives.20 Still, in all 50 states physicians can treat minors for venereal disease without parental consent.7
The physician should take the time to describe the risks and benefits of each contraceptive method. Included in this description should be a discussion of venereal diseases. including herpes and AIDS. This should not be designed to frighten the patient away from sex, but rather to educate her. She should also be informed that females require more time for sexual arousal than males. If sex is to be pleasurable for her, she must demand that her partner take time for foreplay.21 At this time, she can also be informed that her young man undergoes no physical trauma in waiting and being considerate. Most adolescents understand and are thankful for honest information provided in a sincere, nonjudgmental manner.
After learning about the contraception available, the patient should make her own choice. When given the opportunity, adolescents make surprisingly wise decisions for themselves. The physician, of course, may offer guidance. No matter what method is chosen, follow-up is essential, and this must be stressed to the patient.
One important advantage of condoms is that 'they protect against venereal diseases transmitted by genital contact. Condoms are inexpensive. Although adults have ready access to condoms, adolescents may find it difficult to walk into a drug-store and purchase them. Many states require the customer to be over 18. Condom vending machines are no longer commonly available. These drawbacks, in large part, deter adolescents from using condoms. Indeed, a study by Arnold and Cogswell in North Carolina revealed that adolescents increased condom usage from 20% to 91% after free condoms were made available in grocery stores, barber shops, and pool halls.22
Use of a diaphragm, aided by elective abortion, is probably the safest contraceptive method available. However, this method offers too many obstacles to be practical for the adolescent. Keeping a diaphragm available at all times when intercourse may be a possibility is often difficult, as the case may not easily fit into a purse. Similarly, if the patient is not confiding in her parents, a diaphragm may be difficult to justify to them. Since diaphragm failure may lead to elective abortion. the disadvantages of which are obvious, this method is impractical for most adolescents.
At first glance, the intrauterine device (IUD) would seem the ideal contraceptive for adolescents because the wearer would be prepared for spontaneous intercourse, not have to worry about privacy of storage, and have reliable contraception. However, the risks of the IUD on future fertility are maximized in adolescents who change partners frequently and have a high incidence of gonorrhea. Indeed, current restrictions imparted to physicians by IUD manufacturers make IUD use in adolescents a moot point.
Oral contraceptives (OCs) have a similar complication rate, pregnancy rate, and similar side-effects in adolescents as in adults. OCs offer reliable contraception without compromising the spontaneity of intercourse. Some adolescents have difficulty hiding the medicine from their parents. It is wise to encourage the adolescent to inform her parents of the drugs she is using in the event that she may require medicine for a medical problem or is involved in an accident that would lead to her parents finding out in an uncomfortable manner. Of course, such a situation depends on individual circumstances.
Oral contraceptives offer the adolescent particular advantages. By increasing the level of sex-hormone-binding globulin, OCs decrease the amount of bioavailable androgens and, thus, may reduce or lessen acne and decrease unwanted hair growth. In addition, menses are often less painful and lighter in patients using OCs. Certainly, the onset of menses is more predictable. OCs do not inhibit the hypothalamic-pituitary-ovarian axis after they are withdrawn, and adolescents ovulate just as frequently once they are off OCs as do those who were never treated with OCs.23 On the other hand, the risk-benefit rate of OCs make them ill-suited for adolescents who are not having frequent, regular intercourse, or for those who cannot remember to take a daily tablet. Intermenstrual spotting is not well tolerated by adolescents. As this frequently occurs on the low-dose pill, patients should be encouraged to continue rather than discontinue taking OCs and be reassured that this spotting will resolve in two or three cycles.
Irregular cycles in adolescents should not be treated with OCs. The first year's cycles are often irregular and anovulatory as result of an immature hypothalamic-pituitary axis, it is wisest to opt for another method of contraception as long as the axis is immature.
Coitus interruptus, labial intercourse, and rhythm may result in pregnancy. Adolescents should be advised that these methods are not reliable, and why.
23. Rey Stocker I, Zufferey MM, Lemarchand MT et al: Sensibilitat der hypophyse, der gonaden und der schiddruse beim jungen madchen vor und nach kombinierter oraler kontrazeption. Gynakol Rundsch 20: 135, 1980