Adolescent Gynecology: "Driver's Ed for the Sexual Superhighway"
I enjoy serving as a reproductive health speaker at elementary and high schools, and it’s an eye-opening experience every time. The usual scenario is as follows: the seventh or eigth grade girls are sequestered in a classroom, the teacher introduces me and leaves and the door clicks shut. From that moment on, the girls let the questions fly, their queries often prefaced by “My friend told me that...” I’m asked sophisticated questions that go way beyond anything I recall from my youth. As an elementary student at St. Matthew’s school, I recall one or two classes on “sex education”. The main visual aids were posterboard illustrations of female anatomy that resembled architectural plumbing blueprints more than human beings. The lecture (God forbid there was any discussion) would always be given by a stern faced teacher who made it clear she drew the short straw for this faculty assignment.
These recollections from decades ago have shaped my Gynecology practice - adolescents deserve care that is relevant, supportive and nonjudgemental. Unlike the lectures of yesteryear, I want to ensure that my adolescent patients feel comfortable enough to have a real dialogue with me about their sexual health concerns, which can allow me to truly help them.
What constitutes best practice for adolescent gynecology? The American Congress of Obstetrics & Gynecology (ACOG) released its revised “Guidelines for Adolescent Health Care” in August 2011.1 ACOG recommends that adolescent girls have their first visit with a gynecologic care provider (Gynecologist or Pediatrician) between the ages of 13 and 15, with annual visits thereafter. In some cases, these visits can begin earlier, according to the concerns of the parent.
The initial visit does not generally include a pelvic exam, unless indicated by medical history. The visit should address sexuality education and discussion of pubertal development, as appropriate. The HPV vaccine, which is FDA approved for ages 9 to 26, should also be discussed, preferably before the onset of sexual activity.
The average age at which menarche occurs is 11-13 years. Common concerns include irregular menstrual cycles, with the onset of menarche and dysmenorrhea. Severe cramping that is unresponsive to the usual analgesics may indicate endometriosis, and warrants further assessment.
If the adolescent has been sexually active, urine screening for sexually transmitted infections (STI) is appropriate. Discussion of safe sex and contraception should also include information on emergency contraception (EC). EC (such as Plan B One-Step) is available over the counter to women 18 years and older, but women under 18 require a prescription. ACOG and the American Academy of Pediatrics support making EC available to adolescents to help reduce unintended teen pregnancies.2 The first Pap test should be deferred until age 21, regardless of the age of sexual debut. However, proactive annual preventive care visits for reproductive health is optimal for adolescents, and fosters an ongoing trusting relationship with good communication.
Concerns about confidentiality are a major obstacle for adolescents in accessing health care. It is important to convey rules of confidentiality to patients and parents. This includes informing adolescents that billing for services under the parent’s insurance reveals information about her specific tests and services performed. ACOG recommends beginning the medical visit with patient and parent together, and then having the parent step out to allow for confidential dialogue with the patient alone. Information on sexuality, substance use, smoking, eating behaviors, violence or abuse and depression should be elicited. The physician should gather information from both the parent and the adolescent, and encourage honest communication.
States differ with regard to the rights of minors to reproductive health care. In California, minors can receive contraception as well as testing and treatment for STI without parental consent. Governor Brown recently signed bill AB499 (2011), which expands youth access (age 12 and above) to confidential preventive care for STI’s. The website, www.TeenHealthLaw.org, provides detailed information on medical rights of minors, confidentiality laws and reporting of sexual abuse.
Adolescents often turn to the web to answer their questions on sexual health. Websites for adolescents offering frank information include Go Ask Alice at www.GoAskAlice.columbia.edu and www.Scarleteen.com. The Scarleteen site offers “Driver’s Ed for Sexual Superhighway”. I think the analogy is apt. As physicians, our goal is to teach our younger patients how to navigate safely and reduce health risks for life. Ω
References:
1. American College of Obstetrics & Gynecology. “Guidelines for Adolescent Health Care”, 2011.
2. American Academy of Pediatrics. Policy Statement “Contraception and Adolescents”, 2007.
Dr. Spencer is a gynecologist/obstetrician practicing in San Mateo.