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Clinical Report—Gynecologic Examination for Adolescents in the Pediatric Office Setting

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Clinical Report—Gynecologic Examination for Adolescents in the Pediatric Office Setting FROM THE AMERICAN ACADEMY OF PEDIATRICS Guidance for the Clinician in Rendering Pediatric Care Clinical Report—Gynecologic Examination for Adolescents in the Pediatric Office Setting Paula K. Braverman, MD, Lesley Breech, MD, and THE COMMITTEE ON ADOLESCENCE abstract KEY WORDS The American Academy of Pediatrics promotes the inclusion of the pelvic examination, Pap smear, sexually transmitted infections, menstrual disorders, pubertal development gynecologic examination in the primary care setting within the medical home. Gynecologic issues are commonly seen by clinicians who pro- ABBREVIATIONS STI—sexually transmitted infection vide primary care to adolescents. Some of the most common concerns AAP—American Academy of Pediatrics include questions related to pubertal development; menstrual disor- NAAT—nucleic acid amplification test ders such as dysmenorrhea, amenorrhea, oligomenorrhea, and abnor- This document is copyrighted and is property of the American mal uterine bleeding; contraception; and sexually transmitted and Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American non–sexually transmitted infections. The gynecologic examination is a Academy of Pediatrics. Any conflicts have been resolved through key element in assessing pubertal status and documenting physical a process approved by the Board of Directors. The American findings. Most adolescents do not need an internal examination involv- Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of ing a speculum or bimanual examination. However, for cases in which this publication. more extensive examination is needed, the primary care office with the The guidance in this report does not indicate an exclusive primary care clinician who has established rapport and trust with the course of treatment or serve as a standard of medical care. patient is often the best setting for pelvic examination. This report Variations, taking into account individual circumstances, may be reviews the gynecologic examination, including indications for the pel- appropriate. vic examination in adolescents and the approach to this examination in the office setting. Indications for referral to a gynecologist are included. The pelvic examination may be successfully completed when conducted without pressure and approached as a normal part of routine young women’s health care. Pediatrics 2010;126: 583–590 INTRODUCTION Gynecologic issues are commonly seen by clinicians who provide pri- mary care to adolescents. Some of the most common problems include www.pediatrics.org/cgi/doi/doi:10.1542/peds.2010-1564 questions related to pubertal development; menstrual disorders such doi:doi:10.1542/peds.2010-1564 as dysmenorrhea, amenorrhea, oligomenorrhea, and abnormal uter- All policy statements from the American Academy of Pediatrics automatically expire 5 years after publication unless ine bleeding; contraception; and sexually transmitted infections (STIs) reaffirmed,revised, or retired at or before that time and non–STIs. Approximately one-half of adolescents attending high PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). school have been sexually active, which places them at risk for STIs and 1 Copyright © 2010 by the American Academy of Pediatrics pregnancy. Younger adolescents often have questions about pubertal development, and the gynecologic examination is a key element in assessing pubertal status and documenting physical findings. The American Academy of Pediatrics (AAP) promotes the inclusion of the pelvic examination in the primary care setting within the medical home. The examination can be a positive experience when conducted without pressure and approached as a normal part of routine young women’s health care. At a minimum, examination of the external geni- talia should be included as part of the annual comprehensive physical examination of children and adolescents of all ages. Routinely explain- ing and including this examination normalizes the experience rather PEDIATRICS Volume 126, Number 3, September 2010 583 Downloaded from www.aappublications.org/news by guest on September 28, 2021 than setting it apart as something that formation relayed by peers or family development, and look for evidence of is only performed as an exception. members, the adolescent may be fear- abnormal lesions, infection, or Most adolescents do not need an inter- ful or anxious about the examination. It trauma. However, with the availability nal examination involving a speculum is important to proactively allay any of urine-based and vaginal-swab STI or bimanual examination. However, for fears before performing the examina- testing, examination with a speculum cases in which more extensive exami- tion. Issues that need to be addressed in an asymptomatic patient is not nec- nation is needed, the primary care of- up front with the patient include fear of essary for diagnosing asymptomatic fice is often the best setting for pelvic discovering a disease or abnormality, STIs.2,3 Other non–sexually transmitted examination. The primary care clini- possible pain or discomfort, embar- vaginal infections, such as bacterial cian, who has established rapport, rassment in undressing or exposing vaginosis and yeast infections, can trust, and a comfort level with the pa- the genital area, and uneasiness with also be diagnosed with a vaginal swab tient, is allowed to prepare the patient the examiner, particularly when the obtained by either the provider or the in advance and to more successfully clinician is male or a trainee. Clini- patient.4,5 address preconceived negative atti- cians should always be sensitive to the Previous recommendations to per- tudes and fears. possibility of past or current sexual form Pap tests at the onset of sexual Although pediatric residency training abuse, which can affect the patient’s activity have changed. Current guide- comfort with the examination and her includes instruction in performing the lines state that the first Pap test preference regarding the gender of pelvic examination, many pediatri- should be performed at 21 years of the examiner. When performed in a cians may not use these skills in their age, except if a patient has immune thoughtful and sensitive manner, the current practice setting. The purpose suppression or infection with HIV, in pelvic examination can be a positive ex- of this report is to provide pediatri- which case annual Pap tests are perience. In some cases, it may be cians with background information re- started with the onset of sexual activ- helpful to have the patient make an ap- garding indications for the pelvic ex- ity. Adolescents who had been pointment specifically for the pelvic ex- amination, along with information screened previously and had docu- amination to ensure that the provider about the equipment and supplies mented cervical intraepithelial neopla- does not feel rushed in the midst of a needed and techniques used in per- sia (CIN) 2 or 3 or carcinoma would busy day of clinical practice. forming the examination in the pri- require continued screening as out- mary care office setting. Indications for the pelvic examination lined in the new recommendations.6 are listed in Table 1. In the past, a his- Cervical cancer generally develops tory of sexual activity was an auto- INDICATIONS FOR THE PELVIC several decades after initial exposure matic indication for a full pelvic exam- EXAMINATION to human papillomavirus (HPV) and is ination to perform Pap tests and STI Fewer adolescents require a complete rare in women younger than 21 years. testing and to act as a prerequisite to screening pelvic examination because Although many sexually active adoles- prescribing hormonal contraception. of recent changes in recommenda- cents are exposed to HPV, and some Certainly, the external genitalia of all develop abnormal cervical cells, these tions for the initiation and follow-up of patients should be examined to con- changes resolve without intervention abnormal Papanicolaou (Pap) test re- firm normal anatomy, assess pubertal sults, as well as newer tests available in the vast majority of adolescents. to screen for STIs, which can be per- Furthermore, there are indications formed on urine specimens, vaginal that interventions for abnormal cervi- swabs, or cervical samples. However, TABLE 1 Indications for a Pelvic Examination cal cytology in this age group cause there are instances in which the pelvic Persistent vaginal discharge unnecessary anxiety and have the po- Dysuria or urinary tract symptoms in a sexually examination is a crucial part of the active female tential to contribute to pregnancy com- medical evaluation. The goals of a Dysmenorrhea unresponsive to nonsteroidal anti- plications in the future. pelvic examination are primarily to inflammatory drugs A speculum or bimanual examination Amenorrhea screen for and diagnose diseases and Abnormal vaginal bleeding is now considered unnecessary before abnormalities but also to provide edu- Lower abdominal pain prescribing most forms of contracep- cation about gynecologic issues and Contraceptive counseling for an intrauterine tion. The package insert for oral con- device or diaphragm reassure the patient about normal, Perform Pap test traceptive pills specifically states that healthy anatomy. Because of previous Suspected/reported rape or sexual abuse a gynecologic examination is not nec- negative experiences or inaccurate in- Pregnancy essary. The rationale is that there is
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