Guidelines Issued for Gynecologic Examination for Adolescents in the Pediatric Office Setting

From Medscape Medical News
Laurie Barclay, MD

August 31, 2010 — A clinical report from the American Academy of Pediatrics (AAP) offers recommendations for a gynecologic examination for adolescents in the pediatric office setting. The report, published in the September issue of Pediatrics, reviews indications for pelvic examination and gynecology referral and concludes that most adolescents do not need an internal examination, but when they do, the best setting is often in the primary care office with a pediatrician who has established trust and rapport with the patient.

"The ...AAP promotes the inclusion of the gynecologic examination in the primary care setting within the medical home," write Paula K. Braverman, MD, Lesley Breech, MD, and the Committee on Adolescence. "Gynecologic issues are commonly seen by clinicians who provide primary care to adolescents. Some of the most common concerns include questions related to pubertal development; menstrual disorders such as dysmenorrhea, amenorrhea, oligomenorrhea, and abnormal uterine bleeding; contraception; and sexually transmitted and non–sexually transmitted infections."

Because approximately half of high school students have been sexually active, they are at risk for sexually transmitted infections (STIs) and pregnancy. For younger adolescents, who often have questions about pubertal development, determining pubertal status and documenting physical findings are important objectives of the gynecologic examination.

For children and adolescents of all ages, the annual comprehensive physical examination should include, at a minimum, examination of the external genitalia. Routinely explaining and performing this examination normalizes the experience.

Indications for a pelvic examination include the following:

•Persistent vaginal discharge;
•Dysuria or other urinary symptoms in a sexually active adolescent girl;
•Dysmenorrhea unrelieved by treatment with nonsteroidal anti-inflammatory drugs;
•Amenorrhea;
•Abnormal vaginal bleeding;
•Lower abdominal pain;
•Contraceptive counseling regarding use of an intrauterine device or diaphragm;
•Performing a Papanicolaou test;
•Evaluating suspected or reported rape or sexual abuse; or
•Pregnancy.
A speculum or bimanual examination is no longer required before prescribing most forms of contraception. A speculum examination is not needed to diagnose asymptomatic STIs, now that urine-based and vaginal-swab STI testing methods are available. A vaginal swab obtained by either the provider or the patient can also be used to diagnose nonsexually transmitted vaginal infections, such as bacterial vaginosis and yeast infections.

Current guidelines state that the first Papanicolaou test should be done at age 21 years, unless a patient has immune suppression or HIV infection, in which case annual Papanicolaou tests should begin with the onset of sexual activity.

"Most adolescents do not need an internal examination involving a speculum or bimanual examination," the authors of the clinical report write. "However, for cases in which more extensive examination is needed, the primary care office with the primary care clinician who has established rapport and trust with the patient is often the best setting for pelvic examination....The pelvic examination may be successfully completed when conducted without pressure and approached as a normal part of routine young women's health care."

The report reviews procedures and techniques for performing the gynecologic examination. The patient should be reassured and the examination done in the presence of a chaperone or a female relative.

Findings often encountered on gynecologic examination of the adolescent external genitalia may include abscess of the Bartholin glands, infection in the Skene glands, genital ulcers or fissures, genital warts (condyloma acuminata), papular lesions (condylomata lata from syphilis), molluscum contagiosum, urethral prolapse, folliculitis, hidradenitis suppurativa, vulvitis, pigmentary changes, or papillomatosis.

Cervical findings could include ectropion, strawberry cervix, human papillomavirus/condyloma, cervical polyp, or cervical ulcers. Examination of the vagina may reveal ulcers, white adherent plaques caused by Candida species, or condyloma acuminata.

Indications for gynecology referral include the following:

•Adnexal mass;
•Vulvar or cervical lesion with undetermined cause;
•Possible anomaly of the genital tract, such as imperforate hymen, duplicated upper tracts, or absent vagina or uterus;
•Abnormal Papanicolaou test result requiring colposcopy;
•Acute pelvic pain possibly resulting from ovarian torsion, ectopic pregnancy, tubo-ovarian abscess, or adnexal mass;
•Pelvic inflammatory disease when the primary care provider is not comfortable with management;
•Chronic pelvic pain;
•Dysmenorrhea unrelieved by pharmacotherapy;
•Abnormal vaginal bleeding unrelieved by pharmacotherapy or causing severe anemia;
•Intrauterine device insertion; or
•Pregnancy.
"For conditions that require a complete pelvic examination, the patient may prefer to have it performed in a familiar setting rather than being referred to another provider," the report authors conclude. "There are instances in which the pelvic examination must be performed during a problem visit and cannot be deferred to a separate, dedicated appointment time slot. ...With appropriate backup from a gynecologist, most medical gynecologic issues can be managed by the clinician in the primary care office setting."

Pediatrics. 2010;126:583-590.