The breast examination should be part of the routine physical examination in girls as soon as breast budding occurs. The preadolescent will thus accept breast examination as a routine part of health care, and the procedure can serve as an opportunity to offer reassurance and education. The breast examination begins with inspection of the breasts for symmetry and SMR stage. Asymmetrical breast development is common in young adolescents, and is generally transient, although 25% of women may continue to have asymmetry as adults. Organic causes of breast asymmetry include unilateral breast hypoplasia, amastia, absence of the pectoralis major muscle, and unilateral juvenile hypertrophy, in which there is rapid overgrowth of breast tissue usually immediately after thelarche.
The breast examination is performed with the patient supine and the ipsilateral arm placed behind the head. Using flat finger pads, the examiner palpates the breast tissue in concentric circles starting at the outer borders of the breast tissue along the sternum, clavicle, and axilla and then moving in toward the areola. The areola should be compressed gently to check for nipple discharge. Supraclavicular and infraclavicular and axillary regions should be palpated for lymph nodes.
Teaching adolescents to perform breast self-examinations is controversial. Experts have recommended adolescent self-examination as a means of helping them develop comfort with their changing bodies and for future cancer detection. Experts have also questioned whether self-examination might in fact result in anxiety, increased physician visits, and unnecessary invasive procedures since the vast majority of breast masses in adolescents are benign. The U.S. Preventive Services Task Force found little evidence that teaching or performing routine breast self-examination in adolescents reduces breast cancer mortality. Despite the lack of data for or against teaching or performing breast self-examinations during adolescence, there is some consensus that young women at increased risk of breast cancer—adolescents with a history of malignancy, adolescents who are at least 10 years postradiation therapy to the chest, and adolescents 18–21 years of age whose mothers carry the BRCA1 or BRCA2 gene should perform monthly breast self-examinations after each menstrual period.
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Primary breast cancer during adolescence is exceptionally rare.
Fibroadenomas are the most common breast masses.
Typical features of fibroadenemas include: 2–3 cm, nontender, rubbery, smooth, well-circumscribed, mobile mass.
The majority of breast masses in adolescents are benign (Table 4–6). Rare malignancies of adolescent girls include juvenile secretory carcinoma, intraductal carcinoma, rhabdomyosarcoma, malignant cystosarcoma phylloides, and metastatic tumor. Retrospective studies indicate that biopsies of breast masses in adolescents most commonly show fibroadenoma (67%), fibrocystic change (15%), and abscess or mastitis (3%).
Table 4–6.Breast masses in adolescent females. ||Download (.pdf) Table 4–6.Breast masses in adolescent females.
Breast cysts (including subareolar cysts)
Breast abscess or mastitis
Fat necrosis (after trauma)
Less common (benign)
Nipple adenoma or keratoma
Mammary duct ectasia
Intramammary lymph node
Rare (malignant or malignant potential)
Juvenile secretory carcinoma
Sarcomas (fibrosarcoma, malignant fibrous histiocytoma, rhabdomyosarcoma)
Metastatic cancer (hepatocellular carcinoma, lymphoma, neuroblastoma, rhabdomyosarcoma)
Fibroadenomas are the most common breast masses of adolescent girls. These and other breast lesions are listed in Tables 4–6 and 4–7. Fibroadenomas are composed of glandular and fibrous tissue. A fibroadenoma is typically nontender and diagnosed clinically with examination findings of a rubbery, smooth, well-circumscribed, mobile mass most often in the upper outer quadrant of the breast, although fibroadenomas can be found in any quadrant. Ten to twenty-five percent of girls will have multiple or bilateral lesions. Fibroadenomas are typically slow growing with average size 2–3 cm. They may remain static in size for months to years with 10%–40% completely resolving during adolescence. The dense fibroglandular tissue of the adolescent breast may cause false-positive results on standard mammograms. Thus, ultrasonography is the best imaging modality with which to evaluate a breast mass in an adolescent if further evaluation beyond the clinical examination is necessary. Fibroadenomas less than 5 cm can be monitored for growth or regression over 3–4 months. Further evaluation will be dictated by the patient’s course with semiannual clinical examinations for a few years followed by annual examinations for a mass that is regressing. Patients with concerning breast masses including fibroadenomas that are larger than 5 cm, undiagnosed breast masses that are enlarging or have overlying skin changes, and any suspicious breast mass in a patient with a history of previous malignancy should be referred to a breast care specialist.
Table 4–7.Characteristics and management of breast lesions in adolescent females. ||Download (.pdf) Table 4–7.Characteristics and management of breast lesions in adolescent females.
|Fibroadenoma ||2- to 3-cm, rubbery, well-circumscribed, mobile, nontender. Commonly found in upper outer quadrant of the breast. Management is observation. |
|Giant juvenile fibroadenoma ||Large, > 5 cm fibroadenoma with overlying skin stretching and dilated superficial veins. Benign but requires excision for confirmation of diagnosis and for cosmetic reasons. |
|Breast cysts ||Usually caused by ductal ectasia or blocked Montgomery tubercles, both of which can have associated nipple discharge. Ultrasound can help differentiate from solid mass. Most resolve spontaneously. |
|Fibrocystic changes ||More common with advancing age after adolescence. Mild swelling and palpable nodularity in upper outer quadrants. Associated with cyclic premenstrual mastalgia. |
|Abscess ||Often associated with overlying mastitis and/or purulent nipple discharge. Culture abscess material and/or nipple discharge before starting antibiotics. |
|Cystosarcoma phyllodes ||Large, rapidly growing tumor associated with overlying skin changes, dilated veins, and skin necrosis. Requires excision. Most often benign but can be malignant. |
|Intraductal papilloma ||Palpable intraductal tumor, which is often subareolar with associated nipple discharge, but may be in the periphery of the breast in adolescents. Requires surgical excision. |
|Juvenile papillomatosis ||Rare breast tumor characterized by a grossly nodular breast mass described as having a “Swiss-cheese” appearance. Requires surgical excision. |
|Fat necrosis ||Localized inflammatory process in the breast; typically follows trauma (sports or seat belt injuries). Subsequent scarring may be confused with changes similar to those associated with malignancy. |
2. Fibrocystic Breast Changes
Fibrocystic breast changes are much more common in adults than adolescents. Symptoms include mild swelling and palpable nodularity most commonly in the upper outer quadrants. Mastalgia is typically cyclic, usually occurring just before menstruation. Reassuring the young woman about the benign nature of the process may be all that is needed. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen sodium help alleviate symptoms. Oral contraceptive pills (OCPs) can also be beneficial. Supportive bras may provide symptomatic relief. Studies have shown no association between methylxanthine and fibrocystic breasts; however, some women report reduced symptoms when they discontinue caffeine.
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Common causes of mastitis and breast abscess during adolescence include manipulation of periareolar hair and nipple piercing, with subsequent infection with normal skin flora.
Typical features include breast pain and overlying erythema and warmth.
Breast ultrasound may be helpful to differentiate between mastitis and breast abscess.
Although breast-feeding is the most common cause of mastitis, shaving or plucking periareolar hair, nipple piercing, and trauma occurring during sexual activity are predisposing factors in teenagers. The most common causative organisms are normal skin flora. The female with a breast abscess usually complains of unilateral breast pain, and examination reveals overlying inflammatory changes. The examination may be misleading in that the infection may extend deeper into the breast than suspected. Staphylococcus aureus is the most common pathogen. β-Hemolytic streptococci, Escherichia coli, and Pseudomonas aeruginosa have also been implicated. Fluctuant abscesses should be incised and drained and fluid cultured. Antimicrobial coverage for S aureus (including methicillin-resistant strains) should be given initially (generally orally, unless infection is severe) and the patient should be monitored closely for response to therapy until culture and sensitivity results are available.
Healing time after nipple piercing is 3–6 months. Health risks associated with nipple piercing, in addition to breast abscess, include allergic reactions to the jewelry, keloid scar formation, and increased risk of hepatitis B and C and HIV. Complications associated with abscess formation secondary to nipple piercing include endocarditis, cardiac valve injury, cardiac prosthesis infection, metal foreign body reaction in the breast tissue, and recurrent infection.
NIPPLE DISCHARGE & GALACTORRHEA
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Milky nipple discharge is typically galactorrhea; bloody or serosanguinous discharge may indicate a duct problem.
Galactorrhea is typically benign and caused by chronic nipple stimulation, certain prescription psychiatric drugs, or illicit drug use.
Ductal ectasia is a common cause of nipple discharge in the developing breast and is associated with dilation of the mammary ducts, periductal fibrosis, and inflammation. It can present with bloody, brown, or sticky multicolored nipple discharge and/or a cystic breast mass, which is usually in the subareolar region. Blocked ducts and fluid collections usually resolve spontaneously but can become infected, producing mastitis. Patients should look for erythema, warmth, and tenderness indicating mastitis. Oral antibiotics covering skin flora should be initiated if infection is suspected. Serous or serosanguineous nipple discharge is common and can be associated with fibrocystic breast changes. Montgomery tubercles are small glands located at the outer aspect of the areola that can drain clear or brownish fluid through an ectopic opening on the areola and may be associated with a small subareolar mass. These lesions and discharge typically resolve spontaneously. Intraductal papillomas arising from proliferation of ductal cells projecting into the duct lumen are a rare cause of bloody or serosanguineous nipple discharge and can also present with a subareolar or peripheral mass. These lesions are associated with increased risk of malignancy in adults.
Galactorrhea is distinguishable from other causes of nipple discharge by its milky character and tendency to involve both breasts. It is usually benign. The most common causes include chronic stimulation or irritation of the nipple, medications and illicit drugs (drugs causing galactorrhea are listed in Table 4–8), pregnancy, childbirth, or abortion. Prolactin-secreting tumors (prolactinomas) and hypothyroidism are common pathologic causes of galactorrhea during adolescence. Less common causes of hyperprolactinemia and galactorrhea include diseases in or near the hypothalamus or pituitary that interfere with the secretion of dopamine or its delivery to the hypothalamus. Included are tumors of the hypothalamus and/or pituitary, both benign (eg, craniopharyngiomas) and malignant (eg, metastatic disease), infiltrative diseases of the hypothalamus (eg, sarcoidosis), and pituitary stalk damage (eg, section due to head trauma or surgery or compression). Stimulation of the intercostal nerves (eg, chest wall surgery or herpes zoster infection), renal failure (decreased prolactin clearance), polycystic ovarian syndrome, and emotional or physical stress can also cause hyperprolactinemia, which can induce galactorrhea.
Table 4–8.Medications and herbs associated with galactorrhea. ||Download (.pdf) Table 4–8.Medications and herbs associated with galactorrhea.
Anticonvulsants (valproic acid)
Antidepressants (selective serotonin reuptake inhibitors, tricyclic antidepressants)
Antihypertensives (atenolol, methyldopa, reserpine, verapamil)
Typical (haloperidol, phenothiazine, pimozide)
Atypical (risperidone, olanzapine, molindone)
Herbs (anise, blessed thistle, fennel, fenugreek seed, nettle)
Illicit drugs (amphetamines, cannabis, opiates)
Motility agents (metoclopramide)
Muscle relaxants (cyclobenzaprine)
Breast ultrasonography can be helpful in determining the cause of nipple discharge and breast masses. Depending upon additional findings from the history and examination, evaluation of galactorrhea may include a pregnancy test, prolactin level, and thyroid function studies. If there is a question as to whether the discharge is true galactorrhea, fat staining of the discharge can be confirmatory. Elevated TSH confirms the diagnosis of hypothyroidism. Elevated prolactin and normal TSH, often accompanied by amenorrhea, in the absence of medication known to cause hyperprolactinemia suggests a hypothalamic or pituitary tumor. In such cases, magnetic resonance imaging (MRI) of the brain and consultation with a pediatric endocrinologist are indicated.
Observation with serial examination is recommended for nipple discharge associated with breast mass unless a papilloma is suspected by the presence of bloody or serosanguineous nipple discharge with or without a subareolar or peripheral mass. This entity requires further evaluation and excision by a breast surgeon. Treating the underlying cause of galactorrhea is usually effective. Galactorrhea due to hypothyroidism should be treated with thyroid hormone replacement. An alternative medication can be prescribed in cases of medication-induced galactorrhea. Adolescents with galactorrhea without a breast mass who have normal prolactin and TSH levels can be followed clinically and counseled about supportive measures such as avoidance of nipple stimulation, stress reduction, and keeping a menstrual calendar to monitor for oligomenorrhea, which might indicate a systemic hormonal problem such as hyperprolactinemia or thyroid disease. In many cases, symptoms resolve spontaneously and no underlying diagnosis is made. Medical management of prolactinomas with dopamine agonists such as bromocriptine is the favored approach.
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Gynecomastia is common in males during puberty and may last 1–3 years.
Typical features include a palpable fibroglandular mass located concentrically beneath the nipple-areolar complex. It may be unilateral or bilateral.
Clinical observation is appropriate; however, further evaluation may be necessary for atypical cases including: prepubertal gynecomastia, eccentric position, rapid breast enlargement, presence of testicular mass, or prolonged persistence.
Gynecomastia, benign subareolar glandular breast enlargement, affects up to 65% of adolescent males. It typically appears at least 6 months after the onset of secondary sex characteristics with peak incidence during SMR stages 3 and 4. Breast tissue enlargement usually regresses within 1–3 years, and persistence beyond age 17 years is uncommon. Approximately half of young men with gynecomastia have a positive family history of gynecomastia. The pathogenesis of pubertal gynecomastia has long been attributed to a transient imbalance between estrogens that stimulate proliferation of breast tissue and androgens which antagonize this effect. Leptin has recently been implicated in the development of gynecomastia as levels are higher in healthy nonobese adolescent males with gynecomastia when compared to controls. There are several proposed mechanisms in which leptin acts biochemically to alter the estrogen-androgen ratio.
Palpation of the breasts is necessary to distinguish adipose tissue (pseudogynecomastia) from the glandular tissue found in true gynecomastia, which is palpable as a fibroglandular mass located concentrically beneath the nipple-areolar complex. Gynecomastia is bilateral in almost two-thirds of patients. Findings that indicate more serious disease include hard or firm breast tissue, unilateral breast growth, eccentric masses outside of the nipple-areolar complex, and overlying skin changes. A genitourinary examination is needed to evaluate pubertal SMR, testicular volume and masses, or irregularities of the testes.
In the absence of abnormalities on history or physical examination, clinical monitoring of male gynecomastia for 12–18 months is sufficient. Laboratory evaluation is warranted if the patient with gynecomastia is prepubertal, appears undervirilized, has an eccentric breast mass, has a rapid progression of breast enlargement, has a testicular mass, or has persistence of gynecomastia beyond the usual observation period. The initial laboratory evaluation includes thyroid function tests, testosterone, estradiol, human chorionic gonadotropin (hCG), and LH. Additional studies depending on preliminary findings include karyotype, liver and renal function studies, dehydroepiandrosterone sulfate, and prolactin. Any patient with a testicular mass or laboratory results suggesting possible tumor, such as high serum testosterone, hCG, or estradiol, should have a testicular ultrasound. Further evaluation includes adrenal or brain imaging if a prolactin-secreting pituitary tumor or adrenal tumor is suspected.
Gynecomastia may be drug-induced (Table 4–9). Testicular, adrenal, or pituitary tumors, Klinefelter syndrome, secondary hypogonadism, partial or complete androgen insensitivity syndrome, hyperthyroidism, or chronic diseases (eg, cystic fibrosis, ulcerative colitis, liver disease, renal failure, and AIDS) leading to malnutrition may be associated with gynecomastia. Breast cancer in the adolescent male is extraordinarily rare.
Table 4–9.Drugs associated with gynecomastia. ||Download (.pdf) Table 4–9.Drugs associated with gynecomastia.
| ||Examples |
|Antiandrogens ||Cyproterone, finasteride, flutamide, ketoconazole, nilutamide, spironolactone |
|Antineoplastic and immunomodulators ||Alkylating agents, bleomycin, cisplatin, cyclosporine, imatinib, methotrexate, nitrosurea, vincristine |
|Antiulcer drugs ||Cimetidine, metoclopramide, omeprazole, ranitidine |
|Cardiovascular drugs ||Amiodarone, angiotensin-converting enzyme inhibitors, calcium channel blockers, digitoxin, reserpine, spironolactone |
|Drugs of abuse ||Alcohol, amphetamines, marijuana, opiates |
|Hormones ||Anabolic androgenic steroids, estrogens, testosterone, chorionic gonadotropin |
|Infectious agents ||Antiretrovirals, ketoconazole, isoniazid, metronidazole |
|Psychoactive medications ||Diazepam, tricyclic antidepressants, haloperidol, atypical antipsychotics, phenothiazines |
If gynecomastia is idiopathic, reassurance about the common and benign nature of the process can be given. Resolution may take up to 2 years. Surgery is reserved for those with persistent severe breast enlargement and/or significant psychological trauma. In cases of drug-induced gynecomastia, the inciting agent should be discontinued if possible. The patient should be referred to an endocrinologist or oncologist if other pathologic etiologies are diagnosed.
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DP (eds): Pediatric and Adolescent Gynecology. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2012:405–420.
PM: Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents. 3rd ed. Elk Grove Village, IL: American Academy of Pediatrics, 2008.
CA, Di Vasta
AD: Gynecomastia in adolescents. Curr Opin Pediatr 2008;20(4):375–382
GYNECOLOGIC DISORDERS IN ADOLESCENCE
Physiology of Menstruation
The ovulatory menstrual cycle is divided into three consecutive phases: follicular (days 1–14), ovulatory (midcycle), and luteal (days 16–28). During the follicular phase, pulsatile gonadotropin-releasing hormone from the hypothalamus stimulates anterior pituitary secretion of FSH and LH. Under the influence of FSH and LH, a dominant ovarian follicle emerges by day 5–7 of the menstrual cycle, and the other follicles become atretic. Rising estradiol levels produced by the maturing follicle cause proliferation of the endometrium. By the midfollicular phase, FSH begins to decline secondary to estradiol-mediated negative feedback, while LH continues to rise as a result of estradiol-mediated positive feedback.
Rising LH initiates progesterone secretion and luteinization of the granulosa cells of the follicle. Progesterone in turn further stimulates LH and FSH. This leads to the LH surge, which causes the follicle to rupture and expel the oocyte. During the luteal phase, LH and FSH gradually decline. The corpus luteum secretes progesterone. The endometrium enters the secretory phase in response to rising levels of estrogen and progesterone, with maturation 8–9 days after ovulation. If pregnancy and placental hCG release do not occur, luteolysis begins; estrogen and progesterone levels decline and the endometrial lining is shed as menstrual flow approximately 14 days after ovulation. In the first 2 years after menarche, the majority of cycles (50%–80%) are anovulatory. Between 10% and 20% of cycles are anovulatory for up to 5 years after menarche.
Indications for a pelvic examination in an adolescent include abdominal or pelvic pain, intra-abdominal or pelvic mass, abnormal vaginal bleeding or other menstrual disorders, pathologic vaginal discharge, or need for cervical cytology screening. The American College of Obstetricians and Gynecologists advocates starting Papanicolaou (Pap) cytology screening at age 21 years for both sexually experienced and sexually inexperienced women. This is based on the low incidence of cervical cancer in younger women and the potential for adverse effects associated with follow-up of young women with abnormal cytology screening results. Similarly, although reflex testing for high-risk cervical human papillomaviruses (HPV) genotypes for women with an ASC-US (atypical squamous cells of undetermined significance) cytology result can help guide the frequency of follow-up screening, co-testing for HPV is not recommended for women younger than 30 years because of the very high prevalence of high-risk HPV infections, a high rate of spontaneous clearance, and the low incidence of cervical cancer in sexually active women in this age group. Pregnancy during adolescence does not alter screening guidelines. The Centers for Disease Control and Prevention (CDC) recommends that HIV-positive adolescents should have cervical cytology screening twice (every 6 months) within the first year after initial HIV diagnosis even if younger than 21 years and, if both tests are normal, annual screening thereafter. Algorithms for managing abnormal cervical cytology can be found at the American Society for Colposcopy and Cervical Pathology website: http://www.asccp.org/asccp-guidelines. Guidelines for management of abnormal cytology in HIV positive women can be obtained from the CDC and partner organizations at https://aidsinfo.nih.gov/guidelines/html/4/adult-and-adolescent-oi-prevention-and-treatment-guidelines/343/hpv.
The adolescent may be apprehensive about the first pelvic examination. Sensitive counseling and age-appropriate education about the purpose of the examination, pelvic anatomy, and the components of the examination should occur in an unhurried manner. The use of diagrams and models may facilitate discussion. Time should be allotted for the adolescent to ask questions. Ideally, the examination should occur in a controlled and comfortable setting. The adolescent may request to have her mother or family member present during the examination for reassurance; however, in many instances an adolescent will request that the examination occur confidentially. Having another female staff present to support the adolescent in this setting may be helpful. A female staff chaperone should be present with male examiners.
The pelvic examination begins by placing the patient in the dorsal lithotomy position after equipment and supplies are ready (Table 4–10). Patients with orthopedic or other physical disabilities require accommodation for proper positioning and comfort. The examiner inspects the external genitalia, noting sexually maturity rating, estrogenization of the vaginal mucosa (moist, pink, and more elastic mucosa), shape of the hymen, the size of the clitoris (2–5 mm wide is normal), any unusual rashes or lesions on the vulva such as folliculitis from shaving, warts or other skin lesions, and genital piercing or body art. It can be helpful to ask an adolescent if she has any questions about her body during the inspection as she might have concerns that she was too shy to ask (eg, normalcy of labial hypertrophy). In cases of alleged sexual abuse or assault, the presence of any lesions, including lacerations, bruises, scarring, or synechiae about the hymen, vulva, or anus, should be noted.
Table 4–10.Items for pelvic examination. ||Download (.pdf) Table 4–10.Items for pelvic examination.
|General ||Gloves, good light source, appropriate-sized speculums, sterile cotton applicator swabs, large swabs to remove excess bleeding or discharge, patient labels, hand mirror for patient education |
|Wet prep of vaginal discharge ||pH paper, microscope slides and cover slips, NaCl and KOH solutions |
|Pap smear ||Pap smear liquid media or slides with fixative; cervical spatula and endocervical cytologic brush; or broom for collection |
|STI testing ||Gonorrhea and Chlamydia test media with specific collection swabs |
|Bimanual examination ||Gloves, water-based lubricant |
The patient should be prepared for insertion of the speculum to help her remain relaxed. The speculum should be inserted into the vagina posteriorly with a downward direction to avoid the urethra. A medium Pedersen speculum is most often used in sexually experienced patients; a narrow Huffman is used for virginal patients. In a virginal female prior to the speculum examination, a one-finger examination in the vagina can help the provider identify the position of the cervix and can give the patient an appreciation for the sensation she can expect with placement of the speculum. Warming the speculum with tap water prior to insertion can be more comfortable for the patient and also provide lubrication. Simultaneously touching the inner aspect of the patient’s thigh or applying gentle pressure to the perineum away from the introitus while inserting the speculum helps distract attention from the placement of the speculum. The vaginal walls and cervix are inspected for anatomical abnormalities, inflammation, and lesions and the quantity and quality of discharge adherent to the vaginal walls and pooled in the vagina are noted. The presence of a cervical ectropion is commonly observed in adolescents as erythema surrounding the cervical os. The ectropion is the extension of the endocervical columnar epithelium outside the cervical os onto the face of the cervix.
Specimens are obtained in the following order: vaginal pH, saline and KOH wet preparations, cervical cytology (Pap) screening if indicated, and endocervical swabs for gonorrhea and Chlamydia (Table 4–11). STIs are discussed in further detail in Chapter 44. The speculum is then removed, and bimanual examination is performed with one or two fingers in the vagina and the other hand on the abdomen to palpate the uterus and adnexa for size, position, and tenderness.
Table 4–11.Diagnostic tests and procedures performed during speculum vaginal examination. ||Download (.pdf) Table 4–11.Diagnostic tests and procedures performed during speculum vaginal examination.
|Vaginal pH ||Use applicator swab to sample vaginal discharge adherent to the wall or in the vaginal pool if a speculum is in place; immediately apply it to pH paper for reading. |
|Saline and KOH wet preparations ||Sample discharge as above with different swabs, smear small sample on glass slide, apply small drop of saline or KOH and immediately cover with coverslip, and evaluate under microscope. |
|Pap smeara ||Gently remove excessive discharge from surface of cervix. Exocervical cells are sampled with a spatula by applying gentle pressure on the cervix with the spatula while rotating it around the cervical os. Endocervical cells are sampled by gently inserting the cytologic brush into the cervical os and rotating it. Both cell types are collected by the broom when it is centered over the cervical os and rotated. |
|STI testinga ||Insert specific test swabs (eg, Dacron for most Chlamydia test media) into the cervical os and rotate to obtain endocervical samples for Chlamydia and gonorrhea, or if using approved test for vaginal collection, insert the swab into the vagina and rotate, touching the vaginal wall. Vaginal testing for Trichomonas vaginalis is also available. |
Primary amenorrhea is defined as having no menstrual periods or secondary sex characteristics by age 13 years or no menses in the presence of secondary sex characteristics by age 15 years. In the adolescent who has achieved menarche, secondary amenorrhea is defined as the absence of menses for three consecutive cycles or for 6 months in a patient with irregular cycles.
A. Evaluation of Primary and Secondary Amenorrhea
In evaluating amenorrhea, it is helpful to consider anatomical levels of possible abnormalities from the hypothalamus to the genital tract (Table 4–12).
Table 4–12.Differential diagnosis of amenorrhea by anatomic site of cause. ||Download (.pdf) Table 4–12.Differential diagnosis of amenorrhea by anatomic site of cause.
Drugs (haloperidol, phenothiazines, atypical antipsychotics)
Central nervous system lesion
Pituitary lesion: adenoma, prolactinoma
Craniopharyngioma, brainstem, or parasellar tumors
Head injury with hypothalamic contusion
Infiltrative process (sarcoidosis)
Vascular disease (hypothalamic vasculitis)
Kallmann syndrome (anosmia)
Turner syndrome (XO)
Injury to ovary
Autoimmune disease (oophoritis)
Toxins (alkylating chemotherapeutic agents)
Trauma, torsion (rare)
Polycystic ovary syndrome
Uterovaginal outflow tract
Congenital deformity or absence of uterus, uterine tubes, or vagina
Imperforate hymen, transverse vaginal septum, vaginal agenesis, agenesis of the cervixa
Androgen insensitivity syndrome (absent uterus)a
Uterine lining defect
Asherman syndrome (intrauterine synechiae postcurettage or endometritis)
Defect in hormone synthesis or action (virilization may be present)
Ovarian tumor (rare)
Drugs (steroids, ACTH)
A stepwise approach, using clinical history, growth charts, physical examination, and appropriate laboratory studies will allow providers to determine the etiology of amenorrhea in most adolescents. Evaluation begins with a thorough developmental and sexual history. Establishing a pubertal timeline including age at thelarche, adrenarche, growth spurt, and menarche is helpful in evaluating pubertal development. Although there can be variations in the onset, degree, and timing of these stages, the progression of stages is predictable. Adrenal androgens are largely responsible for axillary and pubic hair. Estrogen is responsible for breast development; maturation of the external genitalia, vagina, and uterus; and menstruation. Lack of development suggests pituitary or ovarian failure or gonadal dysgenesis. Determining the patient’s gynecologic age (time in years and months since menarche) is helpful in assessing the maturity of the hypothalamic-pituitary-ovarian axis. A menstrual history includes date of last menstrual period (LMP), frequency and duration of periods, amount of bleeding, and premenstrual symptoms. Irregular menstrual cycles are common in the first 1–2 years after menarche. Two-thirds of adolescents with a gynecologic age more than 2 years have regular menstrual cycles.
Relevant components of the past medical and surgical histories include the neonatal history, treatment for malignancies, presence of autoimmune disorders or endocrinopathies, and current medications (prescribed and over-the-counter). Family history includes age at menarche of maternal relatives, familial gynecologic or fertility problems, autoimmune diseases, or endocrinopathies. A review of systems should focus on symptoms of hypothalamic-pituitary disease such as weight change, headache, visual disturbance, galactorrhea, polyuria, and/or polydipsia. A history of cyclic abdominal and/or pelvic pain in a mature adolescent with amenorrhea may indicate an anatomic abnormality such as an imperforate hymen. Acne and hirsutism are clinical markers of androgen excess. Both hypo- and hyperthyroidism can cause menstrual irregularities. Changes in weight, quality of skin and hair, and stooling pattern may indicate a thyroid problem. A confidential social history should include sexual activity, contraceptive use, the possibility of pregnancy, and use of tobacco, drugs, or alcohol. The patient should also be questioned about major stressors, symptoms of depression and anxiety, dietary habits including any disordered eating or weight-loss behaviors, and athletic participation.
A thorough physical examination should include the components listed in Table 4–13. If a patient cannot tolerate a pelvic or bimanual examination, the presence of the uterus can be assessed by rectoabdominal examination or ultrasonography. Ultrasound provides evaluation of pelvic anatomy and possible genital tract obstruction, measurement of the endometrial stripe as an indicator of estrogen stimulation, and identification of ovarian cysts or masses.
Table 4–13.Components of the physical examination for amenorrhea. ||Download (.pdf) Table 4–13.Components of the physical examination for amenorrhea.
|General appearance ||Syndromic features (eg, Turner syndrome with webbed neck, shield chest, widely spaced nipples, increased carrying angle of the arms) |
|Anthropometrics ||Height, weight, BMI and percentiles for age, vital signs (HR, BP) |
|Ophthalmologic ||Visual field cuts, papilledema |
|Neck ||Thyromegaly |
|Breast ||SMR staging, galactorrhea |
|Abdomen ||Masses |
|Genital ||SMR staging, estrogenization of vaginal mucosa (pink and moist vs thin red mucosa of hypoestrogenization), hymenal patency, clitoromegaly (width > 5 mm) |
|Pelvic and bimanual ||Vaginal depth by insertion of a saline moistened applicator swab into the vagina or by bimanual examination (normal >2 cm); palpation of the uterus and ovaries by bimanual examination |
|Skin ||Acne, hirsutism, acanthosis nigricans |
Figure 4–6 illustrates an approach to the laboratory and radiologic evaluation of primary or secondary amenorrhea. Initial studies should include a urine pregnancy test, complete blood count, TSH, prolactin, and FSH. If there is evidence of hyperandrogenemia (acne, hirsutism) and PCOS is suspected, total and free testosterone and dehydroepiandrosterone sulfate (DHEAS) should be obtained. If systemic illness is suspected, a urinalysis and a chemistry panel (including renal and liver function tests) and erythrocyte sedimentation rate should be obtained. If short stature and delayed puberty are present, a bone age and karyotype should be done.
Evaluation of primary amenorrhea and secondary amenorrhea. CNS, central nervous system; DHEAS, dehydroepiandrosterone sulfate; FSH, follicle-stimulating hormone; TSH, thyroid-stimulating hormone; UA, urine analysis.
If pelvic examination or ultrasonography reveals normal female external genitalia and pelvic organs and the patient is not pregnant, the patient should be given a challenge of oral medroxyprogesterone, 10 mg daily for 10 days. Positive response to the progestin challenge with withdrawal bleeding is suggestive of the presence of a normal, estrogen-primed uterus.
Elevated serum prolactin indicates a possible prolactin secreting tumor. Prolactin testing is sensitive and can be elevated with stress, eating, or sexual intercourse. A mildly elevated test should be repeated prior to MRI of the brain for a prolactinoma. Elevated FSH indicates ovarian insufficiency or gonadal dysgenesis and a karyotype for Turner syndrome or Turner mosaic should be obtained. Autoimmune oophoritis should be assessed by antiovarian antibodies if the chromosome analysis is normal. Normal or low serum gonadotropins indicate hypothalamic suppression and functional amenorrhea if the patient’s weight is normal and there is a reasonable explanation such as vigorous exercise. Functional amenorrhea, although relatively common, is a diagnosis of exclusion. Low serum gonadotropin concentration can also be caused by malnutrition as in anorexia nervosa, endocrinopathies, and chronic diseases or by a central nervous system tumor.
If the physical examination or ultrasound reveals an absent uterus, chromosomal analysis and serum testosterone should be obtained to differentiate between Mullerian dysgenesis and androgen insensitivity. Mullerian dysgenesis or Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is the congenital absence of the vagina with variable uterine development. These women have normal serum testosterone levels. Pelvic MRI is helpful to clarify the nature of the vaginal agenesis and to differentiate it from low-lying transverse vaginal septum, agenesis of the uterus and vagina, and imperforate hymen. Individuals with androgen insensitivity are phenotypically female but have an absent upper vagina, uterus, and fallopian tubes; a male karyotype; and an elevated serum testosterone (normal range for males).
The management of primary or secondary amenorrhea depends on the underlying pathology. Hormonal treatment is used in patients with hypothalamic, pituitary, and ovarian causes. Surgical repair may be required in patients with outflow tract anomalies.
B. Polycystic Ovary Syndrome
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Typical features of polycystic ovary syndrome include: menstrual irregularities, clinical signs of hyperandrogenism (eg, hirsutism and moderate-to-severe acne), and overweight or obesity.
In addition to the laboratory evaluation for secondary amenorrhea, testing for hyperandrogenemia includes: total and free testosterone, dehydroepiandrosterone sulfate, and androstenedione.
Obese adolescents with polycystic ovary syndrome should be screened for lipid abnormalities, glucose intolerance and/or type 2 diabetes, obstructive sleep apnea and depression and anxiety.
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder of reproductive-aged women. It affects 6%–15% of women of reproductive age. PCOS is characterized by ovarian dysfunction, disordered gonadotropin secretion, and hyperandrogenism, which cause irregular periods, hirsutism, and acne. Many adolescents with PCOS are overweight and the association of PCOS with insulin resistance in adults is well established. Adolescents with PCOS are at increased risk for obesity-related morbidities including type 2 diabetes mellitus, cardiovascular disease including dyslipidemia, obstructive sleep apnea, low self-esteem, depression and anxiety; and adult reproductive health problems including infertility and endometrial cancer.
Hyperandrogenemia occurs during normal puberty and also as a function of prolonged anovulatory cycles as the hypothalamic-pituitary-ovarian axis matures during the first few years of typical pubertal development. The normalcy of this hyperandrogenemia confounds the diagnosis of PCOS in early adolescence if the adult criteria of evidence of chemical hyperandrogenemia are applied. Therefore, many authors recommended avoiding testing androgen levels until 2 years after menarche for symptomatic adolescents. The current diagnostic criteria for PCOS in adolescents include clinical signs and symptoms of androgen excess, increased androgen levels, and exclusion of other causes of hyperandrogenemia in the setting of oligomenorrhea.
Table 4–14 outlines a standard laboratory evaluation for PCOS. If other etiologies of virilization such as late-onset congenital adrenal hyperplasia (history of premature pubarche, high DHEAS, clitoromegaly) are suspected, a first morning 17-hydroxyprogesterone should be collected to look for 21-hydroxylase deficiency. Urine cortisol or a dexamethasone suppression test is performed if Cushing syndrome is suspected. If the patient is overweight and/or has acanthosis nigricans, a fasting lipid panel and glucose testing are recommended. A 2-hour oral glucose tolerance test (OGTT) to evaluate for impaired glucose tolerance should also be considered as a normal fasting glucose may be falsely reassuring. A hemoglobin A1C test may be considered if a patient is unable or unwilling to complete an OGTT. Additionally, as obstructive sleep apnea, depression and anxiety have been associated with the diagnosis of PCOS, clinicians should screen for patients for these comorbidities. Consultation with a pediatric endocrinologist can assist in further evaluation and management of significantly elevated androgens and possible endocrinopathies.
Table 4–14.Laboratory evaluation for polycystic ovary syndrome (PCOS). ||Download (.pdf) Table 4–14.Laboratory evaluation for polycystic ovary syndrome (PCOS).
|Pregnancy test || |
|Testosterone (total and free) ||> 200 ng/dL suggests tumor |
|Sex hormone-binding globulin (SHBG) || |
|Dehydroepiandrosterone sulfate (DHEAS) ||> 700 mcg/dL suggests tumor |
|Androstenedione || |
Encouraging lifestyle changes that will promote weight loss is a primary goal of therapy for PCOS in adolescence. Weight loss is associated with improved menstrual regulation, decreased symptoms of hyperandrogenemia, and improved obesity-related comorbidities. Use of combination hormonal contraceptives will improve menstrual regularity, decrease ovarian and adrenal androgen production, and increase sex hormone–binding globulin (SHBG). There are no current guidelines for the use of insulin-sensitizing medications such as metformin to treat PCOS in adolescents; however, it is prescribed for impaired glucose tolerance or type 2 diabetes. Providers should be aware that metformin will improve the frequency of ovulation, and contraception should also be prescribed for sexually active teens.
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
The majority of adolescent girls experience primary dysmenorrhea.
Typical features include lower abdominal cramps radiating to the lower back and thighs and nausea and/or vomiting starting a few days before the onset of menses and lasting a few days into the period.
Use of scheduled NSAIDs and contraceptives to suppress ovulation are mainstays of treatment.
Dysmenorrhea or pain with menstrual periods is the most common gynecologic complaint of adolescent girls, with up to 90% of adolescent girls reporting some symptoms. Fifteen percent of adolescent women describe their symptoms as severe. The prevalence of dysmenorrhea increases with gynecologic age due to its association with ovulatory cycles. Dysmenorrhea can be designated as primary or secondary depending upon the absence or presence of underlying pelvic pathology (Table 4–15). Potent prostaglandins are the mediators of dysmenorrhea, producing uterine contractions, tissue ischemia, and hypersensitivity of pain fibers in the uterus.
Table 4–15.Dysmenorrhea in the adolescent. ||Download (.pdf) Table 4–15.Dysmenorrhea in the adolescent.
| ||Etiology ||Onset and Duration ||Symptoms ||Pelvic Examination ||Treatment |
|Primary Dysmenorrheaa |
|Primary ||Excessive amount of prostaglandin F2α, which attaches to myometrium, causing uterine contractions, hypoxia, and ischemia. Also, directly sensitizes pain receptors. || |
Begins just prior to or with the onset of menstrual flow and lasts 1–2 days.
Typically does not start until 1–2 y after menarche, when cycles are more regularly ovulatory.
|Lower abdominal cramps radiating to lower back and thighs. Associated nausea, vomiting, and diarrhea due to excess prostaglandins. ||Normal. May wait to examine if never sexually active and history is consistent with primary dysmenorrhea. || |
Mild—menstrual calendar, start NSAIDs day before bleeding or at the onset of bleeding or pain if timing of cycle is difficult to predict.
Moderate to severe—NSAIDs and OCPs or other birth control product to suppress ovulation.
|Secondary Dysmenorrheab |
|Infection ||Most often due to an STI such as Chlamydia or gonorrhea. ||Recent onset of pelvic pain. Can also have chronic pain with prolonged untreated infection. ||Pelvic pain, excessive or irregular menstrual bleeding, unusual vaginal discharge. ||Mucopurulent or purulent discharge from cervical os, cervical friability, cervical motion, uterine or adnexal tenderness, positive wet prep for bacterial vaginosis, positive test for STI. ||Appropriate antibiotics. |
|Endometriosis ||Ectopic implants of endometrial tissue in pelvis or abdomen; may result from retrograde menstruation. Definitive diagnosis requires laparoscopy. ||Generally starts > 2 y after menarche, is not significantly responsive to standard NSAID and suppression of ovulation therapies, and worsens through time. ||Cyclic or acyclic chronic pelvic pain. ||Mild to moderate tenderness typically in the posterior vaginal fornix or along the uterosacral ligaments. ||Suppression of ovulation with combined hormonal contraceptive methods. Continuous use may provide additional control. If pain persists, refer to a gynecologist for further evaluation of chronic pelvic pain and consideration of gonadotropin-releasing hormone agonists. |
|Complication of pregnancy ||Spontaneous abortion, ectopic pregnancy. ||Acute onset. ||Pelvic or abdominal pain associated with vaginal bleeding following missed menstrual period. ||Positive hCG, enlarged uterus, or adnexal mass. ||Pelvic US if hemodynamically stable to evaluate for intrauterine pregnancy. Immediate obstetric or surgical consult with concern for ectopic pregnancy. |
|Congenital anomalies ||Outflow tract anomalies: imperforate hymen, transverse or longitudinal vaginal septum, septate uterus. ||Onset at menarche. ||Cyclic pelvic or abdominal pain which can become chronic. ||Imperforate hymen may be visible on external examination. Pelvic US for general anatomy. Pelvic MRI is most sensitive and specific test for septums. ||Gynecology consult for further evaluation and management. |
|Pelvic adhesions ||Previous abdominal surgery or pelvic inflammatory disease. ||Delayed onset after surgery or PID. ||Abdominal pain, may or may not be associated with menstrual cycles; possible alteration in bowel pattern. ||Variable. ||Gynecology consult for possible lysis of adhesion. |
In addition to taking a gynecologic and sexual history, an accurate characterization of the pain (timing with menses, intensity, duration, use of pain medications) is important in determining functional impairment. The pelvic examination can usually be deferred in nonsexually active adolescents with probable primary dysmenorrhea. Adolescents should be encouraged to keep track of their menstrual cycles using a calendar to predict when a period is imminent, thereby allowing for more proactive use of NSAIDs 1–2 days before the start of the anticipated period or with the first indication of discomfort. NSAIDs are typically continued for an additional 2–3 days after onset of pain. Recommended medications are ibuprofen 400–600 mg every 6 hours or naproxen 500 mg twice a day. If the patient does not respond to NSAIDs, suppression of ovulation with OCPs or other combined hormonal contraceptives such as the transdermal patch or intravaginal ring can be effective. OCPs and the intravaginal ring can also be used continuously for extended cycling to decrease the frequency of menstrual periods. This is accomplished by skipping the placebo pill week and immediately starting a new package of birth control pills or skipping the standard 1-week break after removal of the intravaginal ring and immediately placing a new ring. Depot medroxyprogesterone acetate (DMPA) and long-acting reversible contraceptives (LARCs) including the etonogestrel implant and levonorgestrel intrauterine system are also effective and may be preferable for patients who may have challenges with compliance. If patients have persistent symptoms despite use of a contraceptive for suppression of ovulation and scheduled NSAIDs, further evaluation for secondary dysmenorrhea is indicated. A pelvic examination, pelvic imaging with ultrasonography or MRI, and diagnostic laparoscopy may be necessary for diagnosis. Secondary dysmenorrhea is more likely to be associated with chronic pelvic pain, midcycle pain, dyspareunia, and metrorrhagia.
3. Abnormal Uterine Bleeding
ESSENTIALS OF DIAGNOSIS & TYPICAL FEATURES
Typical features of abnormal uterine bleeding include heavy menstrual bleeding for longer than 7 days or blood loss that exceeds 80 mL per menses.
The severity of abnormal uterine bleeding is categorized according to hemodynamic status and degree of anemia and classified as mild, moderate, or severe.
Acute management depends on the severity of the problem and its specific etiology and typically consists of hormonal management.
Abnormal uterine bleeding (AUB) describes any aberration of menstrual volume, regulation, frequency, and duration. Examples of AUB include periods that are characterized by heavy menstrual bleeding (HMB) such as menorrhagia (prolonged bleeding that occurs at regular intervals) and menometrorrhagia (heavy prolonged bleeding that occurs irregularly and more frequently than normal). The differential diagnosis of common and less common etiologies in adolescences are listed in Table 4–16.
Table 4–16.Differential diagnosis of AUB in adolescents. ||Download (.pdf) Table 4–16.Differential diagnosis of AUB in adolescents.
|Condition ||Examples |
|Anovulation || |
|Sexually transmitted infections ||Cervicitis, pelvic inflammatory disease |
|Pregnancy complications ||Ectopic, miscarriage |
|Bleeding disorders ||von Willebrand disease, platelet function abnormalities, thrombocytopenia, coagulopathy |
|Endocrine disorders ||Hypo-/hyperthyroidism, hyperprolactinemia, adrenal insufficiency, PCOS |
|Anatomic abnormalities ||Congenital anomalies, ovarian cysts or tumors, cervical polyps |
|Trauma ||Vaginal laceration |
|Foreign body ||Retained tampon |
|Chronic illness ||Liver, renal, inflammatory bowel, lupus |
|Malignancy ||Leukemia |
|Drugs ||Contraception, anticoagulants |
In addition to a menstrual and sexual history, the bleeding pattern should be characterized by cycle length, duration, and quantity of bleeding (eg, number of soaked pads or tampons in 24 hours, number of menstrual accidents). Bleeding for longer than 7 days or blood loss that exceeds 80 mL per menses is considered as abnormal. The patient should be assessed for symptoms of anemia including fatigue, lightheadedness, syncope, tachycardia, and for other abnormal bleeding (gingivae, stool, easy bruising). The physical examination includes an assessment of hemodynamic stability with orthostatic heart rate and blood pressure measurements. Mucous membranes and skin should be evaluated for pallor; the heart for tachycardia and murmur; the abdomen for organomegaly; and the external genitalia for signs of trauma or congenital anomalies. If the patient has never been sexually active and the external examination is normal, a pelvic examination is usually unnecessary. In a sexually experienced female, a pelvic and bimanual examination to examine the vagina, cervix, and adnexa may be helpful to elucidate the diagnosis. Initial laboratory studies should include a pregnancy test, complete blood cell count, prothrombin time, partial thromboplastin time, TSH, fibrinogen level, and iron studies. If the patient has signs of hemodynamic compromise potentially requiring blood transfusion, blood type and cross-match should be obtained. Among adolescents with HMB, up to 20% are reported to have an underlying bleeding disorder. Evaluation for underlying bleeding disorders such as von Willebrand deficiency should be considered for patients who endorse any of the following: insignificant wounds that lead to prolonged bleeding; heavy, prolonged, or recurrent bleeding after surgery or dental procedures; epistaxis greater than 10 minutes in duration or requiring medical attention; unexplained bleeding from the gastrointestinal tract; HMB with iron deficiency; postpartum hemorrhage; and/or a family history of bleeding disorders. Abnormalities in platelet function and/or aggregation can also be considered and consultation with a pediatric hematologist for further evaluation of these potential etiologies can be helpful. For patients suspected of having PCOS, total and free testosterone, DHEAS and androstenedione should be obtained. For sexually experienced females, cervical or vaginal or urine-based testing for Chlamydia and gonorrhea should be obtained.
The severity of AUB is categorized according to hemodynamic status and degree of anemia and classified as mild, moderate, or severe (Table 4–17). The goals of treatment include (1) establishment and/or maintenance of hemodynamic stability, (2) correction of acute or chronic anemia, (3) resumption of normal menstrual cycles, (4) prevention of recurrence, and (5) prevention of long-term consequences of anovulation. Management depends on the severity of the problem and its specific etiology (see Table 4–17). Monophasic OCPs containing a potent progestin such as norgestrel 0.3 mg with ethinyl estradiol 30 mcg or levonorgestrel 0.15 mg with ethinyl estradiol 30 mcg are frequently used for patients without medical contraindications to exogenous estrogens. (See Table 4–21 for information about individual characteristics or preexisting medical conditions that are contraindications for the use of exogenous estrogen.) The active pills in monophasic formulations contain the same concentration of progestins and estrogen and are preferred over multiphasic formulations which contain variable concentrations of estrogen which could potentially increase the risk of breakthrough bleeding. It is important to remind adolescents and their families that compliance with medications to control bleeding and treat anemia is imperative. Adolescents should be treated until the anemia is resolved and often for an additional 6 months or longer if there is an underlying problem such as platelet function abnormality or von Willebrand disease. For patients with contraindications to the use of exogenous estrogens, there are progestin-only methods available for acute management and maintenance treatment of AUB (Table 4–18).
Table 4–17.Management of AUB. ||Download (.pdf) Table 4–17.Management of AUB.
| ||Mild ||Moderate ||Severe |
|Hgb value (g/dL) ||Hgb >12 ||Hgb 9–12 ||Hgb < 9 |
|Acute treatment ||Menstrual calendar; iron supplementation. NSAID with menses may help reduce flow. Consider OCPs if patient is sexually active and desires contraception. ||OCP bid until bleeding stops, continue active pill qd for 21 days followed by 1 wk of placebo pills. || |
Admit to hospital if Hgb < 7 g/dL or patient is hemodynamically unstable. Transfusion based on degree of hemodynamic instability and ability to control bleeding.
Conjugated estrogens, 25 mg IV every 4 h for up to 48 h. Provide scheduled IV antiemetic. When bleeding stops, step down to 50 mcg OCP PO qid (or tid), then taper as below. If bleeding doesn’t stop, gynecology consultation for further evaluation and possible dilation and curettage.
One 30–35 mcg OCP PO qid until bleeding stops, then decrease to tid for 2 days (and up to 7 days), then bid for 2 days (and up to 7 days), then qd (skipping placebo pills) until Hct > 30%. Antiemetic 2 h prior to OCPs as needed for nausea.
|Long-term management ||Monitor menstrual calendar and Hgb. Follow-up in 2–3 mo. || |
Iron supplementation. Monitor Hgb closely for improvement. May need to revert to bid OCP dosing if bleeding persists.
If bleeding controlled, cycle with OCPs (28 days pack) or other combined hormonal contraceptive agent for minimum 3–6 mo.
|Iron supplementation. Serial hematocrits. If Hct > 30%, cycle with OCPs (28-day pack) or other combined hormonal contraceptive agent for minimum 3–6 mo. Consider placement of levonorgestrel intrauterine system once anemia improved as alternative to short-acting method. |
Table 4–18.Progesterone-only hormone regimens for management of AUB. ||Download (.pdf) Table 4–18.Progesterone-only hormone regimens for management of AUB.
|Hormone ||Tapering Regimen |
|Norethindrone acetate ||5–10 mg PO every 4 h until bleeding stops, then qid for 4 days, then tid for 3 days, then bid for 2 days–2 wk, then qd. Once anemia improved, can transition to DMPA 150 mg IM q12 weeks or levonorgestrel intrauterine system placement. Progesterone-only OCPs can also be an alternative, they but require excellent compliance. |
|Medroxyprogesterone ||10 mg PO every 4 h (max 80 mg) until bleeding stops, then qid for 4 days, then tid for 3 days, then bid for 2 days–2 wk, then qd. Once anemia improved, can transition to DMPA 150 mg IM q12 weeks or levonorgestrel intrauterine system placement. Progesterone-only OCPs can also be an alternative, they but require excellent compliance. |
Mittelschmerz is midcycle discomfort resulting from ovulation. The cause of the pain is unknown but irritation of the peritoneum due to spillage of fluid from the ruptured follicular cyst at the time of ovulation has been suggested. The patient presents with a history of midcycle, unilateral dull or aching abdominal pain lasting a few minutes to as long as 8 hours. Rarely, the pain mimics that of acute appendicitis, torsion or rupture of an ovarian cyst, or ectopic pregnancy. The patient should be reassured and treated symptomatically.
5. Premenstrual Syndrome & Premenstrual Dysphoric Disorder
It is estimated that 51%–86% of adolescent women experience some premenstrual symptoms. Premenstrual syndrome (PMS) is a cluster of physical and psychological symptoms that occur during the luteal phase of the menstrual cycle and resolve with menstruation. Physical symptoms include bloating, breast tenderness, fatigue, headache, myalgia, increased appetite, and food craving. Premenstrual emotional symptoms may include fatigue, mood lability, anxiety, depression, irritability, hostility, sleep dysfunction, and impaired social function. PMS can be diagnosed when at least one disabling physical or psychological symptom is documented prospectively for at least two consecutive menstrual cycles, is restricted to the luteal phase of the menstrual cycle, resolves by the end of menses, results in functional impairment, and is not an exacerbation of another underlying disorder. Severe PMS with functional impairment affects 1.8%–5.8% of women of reproductive age and is classified in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5), as premenstrual dysphoric disorder (PMDD). The clinical diagnosis of PMDD requires a combination of a minimum of five physical and psychological symptoms in the majority of cycles that must be present in the final week before onset of menses, start to improve within a few days after the onset of menses, and become minimal or absent in the week postmenses.
The pathophysiology of PMS is not well understood; however, there is some evidence of dysregulation of serotonergic activity and/or of GABAergic receptor functioning during the luteal phase of the menstrual cycle with heightened sensitivity to circulating progesterone metabolites. PMS and PMDD are highly associated with unipolar depressive disorder and anxiety disorders, such as obsessive-compulsive disorder, panic disorder, and generalized anxiety disorder. During adolescence, it may be difficult to determine if the affective symptoms represent a mood or anxiety disorder, a premenstrual exacerbation of a psychiatric disorder, or simple PMS.
Current treatment for PMS in adolescence is based on findings from adult studies and includes lifestyle recommendations and pharmacologic agents that suppress the rise and fall of ovarian steroids or augment serotonin. SSRIs are increasingly used as first-line therapy for PMS and PMDD in adults, and a recent Cochrane review of SSRIs in severe adult PMS determined that SSRIs administered continuously or during the luteal phase were effective in reducing premenstrual symptoms. Once a diagnosis is made, proven effective interventions including education about pathophysiology, lifestyle changes (eg, increasing physical activity and smoking cessation), stress reduction, cognitive behavioral therapy, and nutritional counseling to improve calcium intake and/or calcium supplementation should be attempted. If contraception or cycle control is important, a combined hormonal contraceptive pill may be beneficial. The pill containing 20 mcg ethinyl estradiol and 3 mg drospirenone with a 24/4 formulation has been shown to be therapeutic in studies of adult women with PMDD. If these interventions do not adequately control symptoms, luteal phase or continuous administration of SSRIs can be considered. Case reports indicate that adolescents with PMDD respond well to luteal phase dosing of fluoxetine at the standard adult dosage of 20 mg/day. SSRIs are not formally approved by the FDA for treatment of PMS or PMDD in adolescents.
Functional ovarian cysts account for the majority of benign ovarian tumors in postpubertal adolescents and are a result of the normal process of ovulation. They may be asymptomatic or may cause menstrual irregularities or pelvic pain. Large cysts can cause constipation or urinary frequency. Follicular cysts are the most common functional cysts. They are usually unilateral, less than 3 cm in diameter, and resolve spontaneously in 1–2 months. Cyst pain occurs as the diameter of the cyst increases, stretching the overlying ovarian cortex and capsule. If the patient’s discomfort is tolerable, she can be reexamined monthly and observed for resolution. Hormonal contraceptive products that suppress ovulation can be started to prevent additional cysts from forming. Patients with cysts should be counseled about the signs and symptoms of ovarian and/or tubal torsion, which are serious complications. Adnexal torsion presents with the sudden onset of pain, nausea, and vomiting. Low-grade fever, leukocytosis, and the development of peritoneal signs with rebound and guarding can be found. Torsion is a surgical emergency due to the risk of ischemia and death of the ovary. Patients should be referred to a gynecologist for potential laparoscopy if the cyst has a solid component and measures more than 6 cm by ultrasonography, if there are symptoms or signs of hemorrhage or torsion, or if the cyst fails to regress within 2 months. Corpus luteum cysts occur less commonly and may be large, 5–10 cm in diameter. The patient may have associated amenorrhea, or as the cyst becomes atretic, heavy vaginal bleeding. There may be bleeding into the cyst or rupture with intraperitoneal hemorrhage. To determine whether the bleeding is self-limited, serial hematocrit measurements and ultrasounds can be used. If the patient is stable, hormonal contraception that suppresses ovulation can be started to prevent additional cyst formation and the patient may be monitored for 3 months for resolution. Laparoscopy may be indicated if the cyst is larger than 6 cm or if there is severe pain or hemorrhage.
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According to the CDC 2015 Youth Risk Behavior Survey, 41% of high school students reported having had sexual intercourse and 30% reported being currently sexually active. Fifty-seven percent reported using a condom at their latest intercourse. Most young people have sex for the first time at about the age of 17, but do not marry until their middle or late twenties. This means that young adults are at risk of unwanted pregnancy and STIs for nearly a decade. A sexually active female who does not use contraceptives has almost a 90% chance of becoming pregnant within a year.
Abstinence & Decision Making
Talking with teenagers about sexual intercourse and its implications can help teens make informed decisions regarding engaging in sexual activity. The American Academy of Pediatrics endorses a comprehensive approach to sexuality education that incorporates encouraging abstinence while providing appropriate risk reduction counseling regarding sexual behaviors. Counseling should include discussions about confidentiality, STI prevention and testing, and contraceptive methods including abstinence and emergency contraception (Table 4–19). Best-practice guidelines recommend that an adolescent sexual history be taken with the adolescent alone in an honest and caring manner with a nonjudgmental attitude and a comfortable, matter-of-fact approach to asking questions. The CDC has a useful Guide to Taking a Sexual History for providers, which covers the “five Ps” of sexual health: partners, practices, protection from STIs, past history of STIs, and prevention of pregnancy (see http://www.cdc.gov/std/treatment/SexualHistory.pdf). Encouraging adolescents to use contraception when they do engage in sexual intercourse does not lead to higher rates of sexual activity. Adolescents often delay seeing a clinician for contraceptive services after initiating sexual activity. Concern about lack of confidentiality is an important reason for this delay.
Table 4–19.Contraceptive efficacy. ||Download (.pdf) Table 4–19.Contraceptive efficacy.
| Method ||Percentage of Women Experiencing an Unintended Pregnancy Within the First Year of Use |
|Typical Use ||Perfect Use |
|No method ||85 ||85 |
|Spermicides only ||28 ||18 |
|Withdrawal ||22 ||4 |
|Diaphragm ||16 ||6 |
|Condom || || |
| Female ||21 ||5 |
| Male ||18 ||2 |
|Oral contraceptive pill ||9 ||0.3 |
|Evra Patch ||9 ||0.3 |
|NuvaRing ||9 ||0.3 |
|Depo-Provera ||6 ||0.2 |
|IUD || || |
| ParaGard ||0.8 ||0.6 |
| Mirena ||0.2 ||0.2 |
|Nexplanon ||0.05 ||0.05 |
The goals of counseling adolescents about contraception include promoting safe and responsible sexual behavior through delaying the initiation of sexual activity, reinforcing consistent condom use for those who are sexually active, and discussing other contraceptive options to provide protection from unwanted pregnancy. Motivational interviewing can be used to address the ambivalence and discrepancies among adolescents’ sexual and contraceptive behaviors, their sexual and relationship values, and future life goals. Providers should familiarize themselves with their state policies regarding the ability of minors to consent for sexual and reproductive health care services. These data are accessible on the Internet from the Guttmacher Institute (http://www.guttmacher.org) and the Center for Adolescent Health and the Law (http://www.adolescenthealthlaw.org).
Providers should consider the adolescent’s lifestyle, potential challenges to compliance, the patient’s need for confidentiality around the use of contraception, previous experiences with contraception and reasons for discontinuation, and any misconceptions regarding contraceptive options. Barriers to health care access including transportation and financial limitations should be identified. Prescribing contraception for other medical reasons (eg, management of dysmenorrhea) can create opportunities for providers and adolescent patients to make parents aware of the use of the medication while maintaining confidentiality around the sexual behaviors.
The primary mechanism of action for combined hormonal contraceptives containing estrogen and progestin (OCPs, transdermal patch, intravaginal ring) and the progestin-only methods (pills, DMPA, and the etonogestrel implant) is inhibition of ovulation. Thickening of the cervical mucus also makes sperm penetration more difficult, and atrophy of the endometrium diminishes the chance of implantation. (The mechanisms of action for intrauterine systems and devices are discussed later in this chapter in the section Intrauterine Systems & Devices.)
Starting all birth control methods during the menstrual period (either first day of bleeding or first Sunday of bleeding) produces the most reliable suppression of ovulation. Conventional OCPs, transdermal patches, and intravaginal rings typically require that the adolescent wait for her next period to begin before starting. Data show that many women who receive prescriptions or even samples of medication never begin the prescribed method. Furthermore, these women could become pregnant while waiting to start. “Quick start” is an alternative approach to starting contraception that allows the patient to begin contraception on the day of the appointment regardless of menstrual cycle day, following a negative pregnancy test. This approach has been studied in adolescent women and increases adherence with the method of choice. Unfortunately, these studies also highlight the generally poor long-term compliance with contraceptive treatment in this age group.
Evaluation of an adolescent female requesting contraception should include a review of current and past medical conditions, current medications and allergies, menstrual history, confidential social history including sexual history, and family medical history. Important components of a sexual history include age at first intercourse, number of partners in lifetime, history of STIs and pelvic inflammatory disease (PID), condom use, current and past use of other contraceptives and reasons for discontinuation, and pregnancy history and outcomes. It is helpful to have a baseline weight, height, BMI, and blood pressure. A pelvic examination is not necessary before initiating contraception. However, if the woman is sexually active and has missed menstrual periods or has symptoms of pregnancy, a pregnancy test is warranted. Screening for STIs should be offered if a sexually experienced woman is asymptomatic and testing for STIs is indicated if she is symptomatic.
The World Health Organization’s publication, Improving Access to Quality Care in Family Planning: Medical Eligibility Criteria for Contraceptive Use is an evidence-based guide providing criteria for initiating and continuing contraceptive methods based on a risk assessment of an individual’s characteristics or known preexisting medical condition. Table 4–20 lists absolute (a condition which represents an unacceptable health risk if the contraceptive method is used) and relative (a condition where the theoretical or proven risks usually outweigh the advantages of using the method) contraindications to using combined hormonal birth control pills. These contraindications can be extended to other combined hormonal products that contain estrogen and progestins including the transdermal patch and intravaginal ring. The CDC has also published the US Medical Eligibility Criteria for Contraceptive Use which was adapted from the WHO publication and allows the consideration of use of combined hormonal contraceptive products for women who are currently receiving anticoagulation therapy.
Table 4–20.Contraindications to combined oral contraceptive (COC) pills. ||Download (.pdf) Table 4–20.Contraindications to combined oral contraceptive (COC) pills.
Breast-feeding (within 6 wk of childbirth)
Hypertension SBP > 160 mm Hg or DBP > 100 mm Hg
History of thrombophlebitis; current thromboembolic disorder, cerebrovascular disease, or ischemic heart disease
Known thrombogenic mutations (factor V Leiden; prothrombin mutation; protein S, protein C, and antithrombin deficiencies)
Systemic lupus erythematosus
Complicated valvular heart disease (with pulmonary hypertension; atrial fibrillation; history of bacterial endocarditis)
Diabetes with nephropathy; retinopathy; neuropathy
Liver disease: active viral hepatitis; severe cirrhosis; tumor (hepatocellular adenoma or hepatoma)
Breast cancer (current)
Migraine headaches with aura
Major surgery with prolonged immobilization
Postpartum (first 3 wk)
Breast-feeding (6 wk–6 mo following childbirth)
Hypertension (adequately controlled HTN; any history of HTN where BP cannot be evaluated; SBP 140–159 mm Hg or DPB 90–99 mm Hg)
Migraine headache without aura (for continuation of COC)
Breast cancer history with remission for 5 y
Active gallbladder disease or history of COC-induced cholestasis
Use of drugs that affect liver enzymes (rifampin, phenytoin, carbamazepine, barbiturates, primidone, topiramate, oxcarbazepine, lamotrigine, ritonavir-boosted protease inhibitors)
It is important to assess patients for possible risk factors for venous thromboembolic events (VTEs) prior to initiating any contraceptive product containing estrogen. The risk of VTE for reproductive-aged women is extremely low (4 per 100,000 women per year for nonpregnant women not using contraceptive product containing estrogen). The use of estrogen increases the risk of VTE for nonpregnant women (10–30 per 100,000 women per year); however, pregnancy itself markedly increases the risk of VTE (60 per 100,000 women per year). In light of the low population risk of VTE, it is not cost-effective to screen all reproductive-aged women for inherited thrombophilia (factor V Leiden, prothrombin mutation, protein S, protein C, and antithrombin deficiencies). Table 4–21 shows helpful screening questions for personal and family history of VTE. If a close relative had a VTE, determine whether testing for inherited thrombophilia was conducted. If a specific defect was identified, testing the patient for that defect prior to initiating a product containing estrogen is warranted. If testing is unknown but the family history is highly suggested of inherited thrombophilia, testing for all of the inherited thrombophilic disorders prior to initiating estrogen should be considered. Additionally, if testing is indicated but not possible, providers should consider alternative contraceptive products that do not contain estrogen.
Table 4–21.Screening questions for inherited thrombophilia. ||Download (.pdf) Table 4–21.Screening questions for inherited thrombophilia.
|Have you or a first-degree relative… || |
… ever had blood clots in the legs or lungs?
… ever been hospitalized for blood clots in the legs or lungs?
|What were the circumstances in which the blood clot took place? ||Cancer, air travel, obesity, immobility, postpartum |
|Did you or a family member require blood thinning medication? || |
Tips for Prescribing & Monitoring Contraceptive Use
It is important to thoroughly review the advantages, disadvantages, potential side effects, and instructions for use of contraceptive methods in a concise and age-appropriate manner with adolescent patients. Written instructions that are clear and at an appropriate educational level can also be helpful (www.youngwomenshealth.org is a useful source for instructions). Some offices utilize consent forms to further ensure that the adolescent has a full understanding of the chosen contraceptive method. Teens need to be reminded that hormonal contraception will not protect them from STI transmission (including HIV infection) and condoms need to be used consistently. Encouraging teens to be creative about personal reminders such as setting a cell phone alarm to take a pill can help with compliance. Teens often discontinue birth control for nonmedical reasons or minor side effects and should be encouraged to contact their providers if any questions or concerns about the chosen method arise to avoid unintentional pregnancy. Frequent follow-up visits every few months with a provider may also improve adherence. These visits also provide opportunities for further reproductive health education and STI screening.
Male condoms have been used more widely in the last several decades as a result of educational and marketing efforts driven by the AIDS epidemic. All sexually active adolescents should be counseled to use condoms correctly and consistently with all intimate behaviors (oral, vaginal, and anal intercourse). Condoms offer protection against STIs by providing a mechanical barrier. Polyurethane condoms can be used by adolescents with an allergy to latex. Spermicides containing nonoxynol-9 are no longer recommended, as exposure to spermicide can cause genital irritation which may facilitate the acquisition of STIs including HIV. Patients should be counseled to use water-based lubricants with condoms.
Vaginal barrier methods include the female condom, diaphragm, and cervical cap. The female condom is a polyurethane vaginal pouch that can be used as an alternative to the male condom. Female condoms have lower efficacy in preventing pregnancy and STIs and are more expensive than male condoms. Diaphragms and cervical caps may not be feasible for adolescents as they require prescription, professional fitting, and skill with insertion.
Combined Hormonal Methods
Oral Contraceptive Pills, Transdermal Patch, & Intravaginal Ring
Combined oral contraceptive pills (COCs) are the most commonly used contraceptive method in the adolescent age group. COCs are also utilized for noncontraceptive indications (Table 4–22). All COCs contain estrogen (ethinyl estradiol). “Low-dose” COCs contain 20–35 mcg of ethinyl estradiol per pill. There are a variety of progestins used in COCs, most made from testosterone with differing androgenic profiles. Drospirenone is a progestin derived from spironolactone that possesses antiandrogenic and antimineralocorticoid activity. This formulation has appeal for use with patients who have PCOS but should not be prescribed for patients with risk of hyperkalemia (those who have renal, hepatic, or adrenal insufficiency or take certain medications including angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists). Extended cycle regimens are available which allow women to decrease menstrual frequency from four menstrual cycles per year to formulations that provide hormonal pills daily for the whole year, eliminating menstrual periods altogether. New formulations with fewer placebo pills (4 vs the standard 7) decrease the duration of the menstrual period. There is also a chewable COC for those who cannot swallow pills.
Table 4–22.Noncontraceptive health benefits of oral contraceptive pills. ||Download (.pdf) Table 4–22.Noncontraceptive health benefits of oral contraceptive pills.
Protection against life-threatening conditions
Pelvic inflammatory disease
Morbidity and mortality due to unintended pregnancies
Alleviate conditions affecting quality of life
Iron deficiency anemia
Benign breast disease
Irregular menstrual cycles
Functional ovarian cysts
In general, contraceptive side effects are mild and improve or lessen during the first 3 months of use. Table 4–23 shows the more common estrogenic, progestogenic, and combined (estrogenic and progestogenic) effects of COCs. In general, these symptoms can also be extended to the other combined hormonal methods. If a patient taking contraceptive pills has persistent minor side effects for more than 3 months, a different type of COC can be tried to achieve the hormonal effects desired (eg, decreasing the estrogen content or changing progestin). Breakthrough bleeding is a common side effect in the first few months of COC use and generally resolves without intervention. If breakthrough bleeding is persistent, the provider should rule out other possible etiologies such as missed pills, pregnancy, infection, or interaction with other medications. For women who have spotting or bleeding before completing the active hormonal pills, increasing the progestin content will provide more endometrial support. For those with continued spotting or bleeding after the period, increasing the estrogen content will provide more endometrial support.
Table 4–23.Estrogenic, progestenic, and combined effects of COCs by system. ||Download (.pdf) Table 4–23.Estrogenic, progestenic, and combined effects of COCs by system.
|System ||Estrogen Effects ||Progestin Effects ||Estrogen and Progestin Effects |
|General || ||Bloating ||Cyclic weight gain due to fluid retention |
|Cardiovascular ||Hypertension || ||Hypertension |
|Gastrointestinal ||Nausea; hepatocellular adenomas ||Increased appetite and weight gain; increased LDL cholesterol levels; decreased HDL cholesterol levels; decreased carbohydrate tolerance; increased insulin resistance || |
|Breast ||Increased breast size ||Increased breast tenderness or breast size ||Breast tenderness |
|Genitourinary ||Leukorrhea; cervical eversion or ectopy || || |
|Hematologic ||Thromboembolic complications, including pulmonary emboli (rare), deep venous thrombosis, cerebrovascular accident, or myocardial infarction (rare) || || |
|Neurological || || ||Headaches |
|Skin ||Telangiectasia, melasma ||Acne, oily skin || |
|Psychological || ||Depression, fatigue, decreased libido || |
The transdermal patch, Ortho Evra, releases 20 mcg of ethinyl estradiol and 150 mcg of norelgestromin daily. One patch is worn for 7 days and changed weekly for 3 consecutive weeks. The patch is an attractive alternative to COCs for adolescents who have difficulty remembering to take a pill every day; however, the higher bioavailability of estrogens delivered transdermally (60% higher than with 35 mcg COCs) has raised concern that the patch might increase the risk of VTE over other estrogen-containing contraceptive products. Studies evaluating this risk have shown conflicting results. The FDA updated the safety labeling for Ortho Evra in September 2009 to include its interpretation of these studies showing a zero to twofold increase in the risk of thromboembolic events. The FDA maintains that Ortho Evra is a well-tolerated and effective contraceptive for women with low-risk profile for VTE. As with other estrogen-containing contraceptive products, patients should be advised to avoid smoking and consider planned discontinuation of these methods around major surgery and prolonged immobilization. In clinical trials, the most common side effects included breast disorders (pain and swelling), headache, nausea, and skin irritation. The patch may be less effective in women weighing more than 90 kg and those with skin conditions preventing absorption.
The NuvaRing is a vaginal ring that releases 15 mcg of ethinyl estradiol and 120 mcg of etonogestrel per day. The patient places the ring inside the vagina for 3 weeks, and removes it the first day of the fourth week to allow for withdrawal bleeding. A new ring is inserted each month. In clinical trials, the most common side effects included vaginitis and vaginal discharge, headache, weight gain, and nausea.
Progestin-only pills (POPs) do not contain estrogen. They are used in women with contraindications to estrogen-containing products such as the presence of inherited risk factors for thrombophilia or unacceptable estrogen-related side effects with COCs. The efficacy of POPs in preventing pregnancy is slightly less than COCs. They require strict compliance and regular dosing schedule due to the shorter half-life of the progestin. A patient must take POPs daily at the same time (within 3 hours). The primary mechanisms by which pregnancy is prevented includes thickening cervical mucous and thinning the endometrial lining. Ovulation is inhibited in approximately 50% of women. The main side effect of POPs is unpredictable menstrual patterns. The need for strict compliance and the possibility of breakthrough bleeding may make POPs a less desirable method for teens.
Injectable Hormonal Contraception
Depot medroxyprogesterone acetate (DMPA), or DepoProvera, is a long-acting injectable progestin contraceptive. It is injected into the gluteal or deltoid muscle every 12 weeks at a dose of 150 mg. The first injection should be given during the first 5 days of the menstrual cycle to ensure immediate contraceptive protection. The quick-start method may also be used with DMPA following a negative pregnancy test. Adolescents who have been sexually active within the previous 2 weeks of administration of DMPA using the quick-start method should be informed of the chance of pregnancy and instructed to return for a repeat pregnancy test 2 weeks after receiving DMPA. With a failure rate of less than 0.3%, long-acting nature reducing compliance issues, reversibility, and lack of estrogen-related side effects, it is an attractive contraceptive option for many adolescents. The hypoestrogenic state that results from DMPA suppression of the hypothalamic-pituitary-ovarian axis reduces the normal effect of estrogen to inhibit bone resorption. The FDA issued a black box warning in 2004 that long-term (> 2 years) use of DMPA was a cause of decreased bone density. This is of particular concern as adolescence is the critical time of peak bone accretion. Current recommendations are that long-term use of DMPA should be limited to situations where other contraceptive methods are inadequate. Although DMPA use is associated with decreased bone density, there are studies showing that bone mineral density recovers after stopping DMPA. There are no studies to date that can answer the question of whether decreased bone density from adolescent DMPA use increases the risk of osteoporosis and fractures in adulthood. The consensus of experts in the field at this time is that the advantages of using DMPA generally outweigh the theoretical risks of fractures later in life. As with every other contraceptive method, providers need to help their patients weigh the pros and cons of initiating and continuing with this method of contraception. Adolescents using DMPA should be counseled to take adequate dietary calcium (1300 mg/day) and vitamin D (400 IU/day), to avoid tobacco smoking and to have regular weight-bearing physical activity for overall bone health. Other adverse effects of DMPA include unpredictable menstrual patterns, weight gain (typically 5 lb/y for the first 2 years of use), and mood changes.
Adolescents most commonly use short-acting hormonal contraceptive methods described previously. Unfortunately, these methods have relatively high typical use failure rates (see Table 4–19) and low continuation rates. Higher failure rates combined with poor continuation rates decrease the efficacy of short-acting contraceptive methods in adolescents. Long-acting reversible contraceptives (LARCs), which include the contraceptive implants and intrauterine systems and devices, have lower rates of failure and discontinuation. In one study comparing 1-year continuation rates for short-acting contraceptives versus LARCs, the continuation rate for short-acting methods was 55% versus 86% for LARCs. The pregnancy rate associated with use of short-acting contraceptives was 22 times higher than the rate of unintended pregnancy associated with the use of LARCs. Adolescents should be encouraged to consider LARCs as the best reversible methods for preventing unintended pregnancy, rapid repeat pregnancy, and abortion.
Implanon and Nexplanon are single-rod implant LARCs that contain the progestin etonogestrel, a metabolite of desogestrel. Nexplanon also contains barium sulfate which makes it radiopaque. Etonogestrel implants are placed subdermally and provide highly effective contraception for 3 years, with failure rates less than 1%. Implanon and Nexplanon suppress ovulation and thicken cervical mucous like DMPA, but do not suppress ovarian estradiol production or induce a hypoestrogenic state. The risk of decreased bone density is less than that associated with DMPA. Placement should occur during the first 5 days of the menstrual period or at any time if a woman is correctly using a different hormonal contraceptive method. Proper timing minimizes the likelihood that the implant is placed during an early pregnancy or in a nonpregnant woman too late to inhibit ovulation in the first cycle of use. Irregular menstrual bleeding is the single most common reason for stopping use in clinical trials. On average the volume of bleeding is similar to the woman’s typical menstrual periods but the schedule of bleeding is irregular and unpredictable. Other side effects include headache, weight gain, acne, breast pain, and emotional lability. Return to fertility is rapid following removal. The efficacy of Implanon and Nexplanon has not been formally defined in women with elevated BMIs greater than 130% ideal and could theoretically be less effective in these women. Etonogestrel implants are not recommended for women who chronically take medications that are potent hepatic enzyme inducers because etonogestrel levels may be substantially reduced in these women.
Intrauterine Systems & Devices
Intrauterine systems (IUSs) and devices (IUDs) are LARCs approved for use in nulliparous as well as parous teens and have high efficacy with failure rates of less than 1%. There are four forms of IUS that release the progestin levonorgestrel: Mirena, which releases 20 mcg of levonorgestrel per day and is approved for contraception for up to 5 years; Skyla, which releases an average of 6 mcg/day and is approved for contraception for up to 3 years; Liletta, which releases 18.6 mcg/day initially and declines progressively to 12.6 mcg/day at 3 years after insertion and is approved for contraception for up to 3 years; and Kyleena, which has a release rate of 17.5 mcg/day after 24 days, declining to 7.4 mcg/day after 5 years and is approved for contraception for up to 5 years. The levonorgestrel IUSs have many contraceptive actions including thickening of cervical mucous, inhibiting sperm capacitation and survival, suppressing the endometrium, and suppression of ovulation in some women. Given that the contraceptive effect of levonorgestrel in the IUS devices is mainly due to its local effect versus systemic absorption, ovulation is not always suppressed and cysts related to normal ovulation can occur. Irregular bleeding is common in the first few months following insertion because endometrial suppression takes several months to evolve. Bleeding is then markedly decreased and secondary amenorrhea can occur. Other side effects include abdominal and/or pelvic pain, acne, ovarian cysts, and headache. In addition to pregnancy prevention, women with the IUS report reduced symptoms of dysmenorrhea and reduced pain from endometriosis. Cramping is common during insertion and spontaneous expulsion can occur. Uterine perforation during insertion is an uncommon risk.
The copper T 380A IUD, ParaGard, does not contain hormones and can provide contraception for up to 10 years. Its contraceptive actions include the release of copper ions which inhibit sperm migration and development of a sterile inflammatory reaction which is toxic to sperm and ova and prevents implantation. Menstrual pain and heavy bleeding are the most common reasons for discontinuation.
A common misconception about IUS and IUD use is that they increase the risk of PID. Current research shows that the risk of PID is increased above baseline only for the first 20 days after insertion. IUS and IUD have also not been shown to increase the risk of tubal infertility or ectopic pregnancy. Contraindications for placement of IUS/IUD include pregnancy, PID, or postabortion sepsis within the past 3 months, current STI, purulent cervicitis, undiagnosed abnormal vaginal bleeding, malignancy of the genital tract, uterine anomalies, or leiomyomata distorting the uterine cavity making insertion incompatible. Allergy to any component of the IUS/IUD is a contraindication. Patients with disorders of copper metabolism (Wilson disease) should not use the copper-containing IUD. Adolescents should be screened for STIs prior to insertion of an IUS or IUD.
Emergency contraception (EC) is the only contraceptive method designed to prevent pregnancy after unprotected or underprotected intercourse (Table 4–24). Indications for EC include unprotected vaginal intercourse, failure of contraceptive methods (broken condoms, missing three or more active COC pills, detached contraceptive patch, removed vaginal ring, or late DMPA injection), and sexual assault. EC medications include products labeled and approved for use as EC by the FDA (levonorgestrel and ulipristal acetate) and the “off-label” use of COCs (the Yuzpe method).
Table 4–24.Emergency contraception regimens. ||Download (.pdf) Table 4–24.Emergency contraception regimens.
Plan B One-Step, Take Action, Next Choice One Dose, My Way
|Ulipristal Acetate ||Dose: Once |
|Ella ||1 pill |
|Estrogen and Progestin ||Dose: Repeat in 12 h |
|Ovral, Ogestrel ||2 white pills |
|Levlen, Nordette ||4 orange pills |
|Lo/Ovral, Low-Ogestrel, Levora, Quasense, Cryselle ||4 white pills |
|Jolessa, Portia, Seasonale, Trivora ||4 pink pills |
|Triphasil, Tri-Levlen ||4 yellow pills |
|Seasonique ||4 light blue-green pills |
|Enpresse ||4 orange pills |
|Alesse, Lessina, Levlite ||5 pink pills |
|Aviane ||5 orange pills |
|Lutera ||5 white pills |
Levonorgestrel EC, marketed as Plan B One-Step and its generic formulations, Take Action, Next Choice One Dose and My Way, is a one-pill progesterone-only regimen that contains 1.5 mg of levonorgestrel, taken immediately after unprotected intercourse. The exact mechanism of levonorgestrel EC is unknown but is thought to inhibit ovulation, disrupt follicular development, or interfere with the maturation of the corpus luteum. EC is not teratogenic and does not interrupt a pregnancy that has already implanted in the uterine lining. Therefore, pregnancy testing before use is not required. It is recommended that patients take these products within 72 hours of unprotected intercourse. EC has been studied up to 120 hours following unprotected intercourse; however, its efficacy diminishes with time from the event. EC is 90% effective if used within 24 hours, 75% effective if used within 72 hours, and approximately 60% effective if used within 120 hours. It is therefore important to counsel patients to take the medication as soon as possible following unprotected intercourse or contraception failure. EC could potentially prevent approximately 80% of unintended pregnancies and should be part of anticipatory guidance given to sexually active adolescents of both genders. These products are available without prescription and for purchase over the counter by adolescents aged 17 years and older; however, proof of age is not required for purchase. A follow-up appointment should be conducted 10–14 days after administration of EC for pregnancy testing, STI screening, and counseling regarding reproductive health and contraceptive use. A helpful resource for information about EC can be found at http://ec.princeton.edu/index.html.
If an approved EC medication is not available, certain COCs containing levonorgestrel or norgestrel can also be used for EC in a two-dose regimen separated by 12 hours; this approach is known as the Yuzpe method (see Table 4–24). An antiemetic drug takes 30 minutes prior to pills containing estrogen may help control nausea. A pregnancy test is not required prior to prescription and administration of EC.
Ulipristal, marketed as Ella, is a single pill containing 30 mg of ulipristal acetate that is available by prescription only and can be used within 120 hours after unprotected intercourse. Ulipristal binds to the human progesterone receptor and prevents binding of progesterone. Unlike levonorgestrel EC, a pregnancy test must be performed to exclude existing pregnancy before taking ulipristal because of the risk of fetal loss if used in the first trimester. Patients should also be counseled that a pregnancy test is indicated if their period is more than 7 days later than expected after taking ulipristal. Patients should be instructed to return for evaluation of the rare occurrence of ectopic pregnancy if severe abdominal pain occurs 3–5 weeks after use.
Providers should also be aware that insertion of ParaGard (copper IUD) within 5 days of unprotected intercourse is an additional method of emergency contraception available in the United States.
American College of Obstetricians and Gynecologists: Committee on Adolescent Health Care Long-Acting Reversible Contraception Working Group: ACOG Committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. Obstet Gynecol 2012;120(4):983–988
Committee on Adolescence: Contraception and adolescents. Pediatrics 2014;134:e1257–e1281
Committee on Adolescence: Emergency contraception. Pediatrics 2012;130(6):1174–1182
et al: Youth risk behavior surveillance-United States, 2015. MMWR Surveill Summ 2016;65(6):1–174
JC: Teenagers in the United States: sexual activity, contraceptive use, and childbearing, 2006–2010. National Survey of Family Growth. National Center for Health Statistics. National Vital Health Stat 2011;23(31):144
et al: Hormonal contraception and thrombotic risk: a multidisciplinary approach. Pediatrics 2011:127(2):347–357
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et al, eds: Contraceptive Technology. 20th ed (revised). New York, NY: Ardent Media; 2011.
In the United States, over 562,000 women younger than 20 years become pregnant every year. The majority of teen pregnancies are unintended. Approximately 60% of adolescent pregnancies result in live births, 26% end in abortion, and 14% in miscarriage. In the United States in 2011, the teenage pregnancy rate reached its lowest point in more than 30 years and was less than half of the peak rate in 1990, which has been attributed to changes in contraceptive practices including increased use of LARCs. However despite this trend, racial and ethnic disparities persist and in 2011, the pregnancy rate among non-Hispanic white teens (35.3 per 1000) was less than half that among non-Hispanic blacks (92.6 per 1000) and Hispanics (73.5 per 1000). Lower socioeconomic status and lower maternal education are risk factors for teen pregnancy regardless of racial or ethnic group. The birth rate for adolescents in 2011, 31.3 births per 1000 women was the lowest it has ever been for all racial and ethnic groups since the peak rate of 61.8 in 1991.
Pregnancy is the most common cause of secondary amenorrhea and should be considered as a cause of even one missed period. The level of denial about the possibility of pregnancy is high and adolescents with undiagnosed pregnancies may present with abdominal pain, nausea or vomiting, breast tenderness, urinary frequency, dizziness, or other nonspecific symptoms. In addition to denial, difficult social situations can delay diagnosis and contribute to delay in seeking prenatal care. Young newly pregnant adolescents may fear violence from their partner or abandonment by their family. Clinicians should have a low threshold for suspecting pregnancy and obtaining pregnancy tests.
Pregnancies are dated from the first day of the LMP. The estimated due date can be calculated by adding 7 days to the LMP, subtracting 3 months and adding 1 year. Pregnancy dating calendars are widely available on the Internet. A speculum examination is not mandatory at the time of pregnancy diagnosis for an asymptomatic adolescent. If there is vaginal spotting or bleeding, unusual vaginal discharge, symptoms of STI, pelvic pain, or abdominal pain, a speculum examination is required. The differential diagnostic possibilities include infection, miscarriage, ectopic pregnancy, and other disorders of early pregnancy. An 8-week gestational age uterus is about the size of an orange and a 12-week uterus is about the size of a grapefruit on bimanual examination. The uterine fundus is just palpable at the symphysis pubis at 12 weeks’ gestational age, midway between the symphysis and umbilicus at 16 weeks and typically at the umbilicus at 20 weeks. If the uterus is smaller than expected for pregnancy dates, possible diagnoses include inaccurate dates, false-positive test, ectopic pregnancy, or incomplete or missed abortion. A uterus that is larger than expected may be caused by inaccurate dates, twin gestation, molar pregnancy, or a corpus luteum cyst of pregnancy. Enzyme-linked immunosorbent assay test kits specific for the β-hCG subunit and sensitive to less than 50 mIU/mL of serum hCG can be performed on urine (preferably the day’s first voided specimen, because it is more concentrated) in less than 5 minutes and are accurate by the expected date of the missed period in almost all patients. Serum radioimmunoassay, also specific for the β-hCG subunit, is accurate within 7 days after fertilization and is helpful in ruling out ectopic pregnancy or threatened abortion. Serum hCG doubles approximately every 2 days in the first 6–7 weeks of the pregnancy and a gestational sac is identifiable using transvaginal ultrasonography at hCG levels of 1000–2000 mIU/mL. In the absence of an accurate LMP, ultrasonography for confirmation of the presence of an intrauterine pregnancy and accurate dating can be obtained.
A. Counseling at the Time of Pregnancy Testing
When an adolescent presents for pregnancy testing, it is helpful, before performing the test, to find out what she hopes the result will be and what she thinks she will do if the test is positive. The diagnosis of pregnancy may be met with shock, fear, anxiety, happiness, or most likely a combination of emotions. The clinician must discuss all pregnancy options with the patient including termination or continuing with the pregnancy and either placing the infant for adoption or raising the infant. Patients should be informed of the gestational age and time frames required for the different options. If providers are not comfortable discussing the option of termination, the adolescent should be referred to a provider who is comfortable with comprehensive options counseling. Many teenagers need help in telling and involving their parents. It is also important to ascertain the teen’s safety and make appropriate referral to social services if there are legitimate concerns. If the patient knows what she wants to do, she should be referred to the appropriate resources. If a teenager is ambivalent about her plans, it is helpful to follow up in 1 week to be certain that a decision has been made. Avoiding a decision reduces the adolescent’s options and may result in poor pregnancy outcomes. Providers can help ensure that the patient obtains prenatal care if she has chosen to continue the pregnancy. In addition, counseling about healthful diet; folic acid supplementation (400 mcg/day); and avoiding alcohol, tobacco, and other drugs is important.
Young maternal age, low maternal prepregnancy weight, poor weight gain, delay in prenatal care, maternal depression, exposure to domestic violence, and low socioeconomic status contribute to low birth weight and increased neonatal mortality. The poor nutritional status of some teenagers, substance abuse, and high incidence of STIs also play a role in poor outcomes. Teenagers are at greater risk than adults for preeclampsia, eclampsia, iron deficiency anemia, cephalopelvic disproportion, prolonged labor, premature labor, and maternal death.
Good family support, early prenatal care, and good nutrition can make a difference with several of these problems. The psychosocial consequences for the teenage mother and her infant are listed in Table 4–25. Teenagers who are pregnant require additional support from their caregivers. Multidisciplinary clinics for young mothers, if available, may be the best providers for pregnant adolescents. Adolescent mothers tend to be more negative and authoritative when disciplining their children. They may have inadequate knowledge of normal behavior and development. Providers can help by educating the adolescent mother during routine visits regarding appropriate discipline and expectations of her child’s behavior.
Table 4–25.Psychosocial consequences of pregnancy for the adolescent mother and her infant. ||Download (.pdf) Table 4–25.Psychosocial consequences of pregnancy for the adolescent mother and her infant.
|Mother ||Infant |
Increased morbidity related to pregnancy
Greater risk of eclampsia, anemia, prolonged labor, premature labor
Increased chance of miscarriages, stillbirths
Increased chance of maternal mortality
Decreased academic achievement
Less likely to get high school diploma, go to college, or graduate
Delayed education (average 2 y)
Lower occupational attainment and prestige
Less chance of stable employment (some resolution over time)
Lower job satisfaction
Lower income and wages
Greater dependence on public assistance
Less stable marital relationships
Higher rates of single parenthood
Earlier marriage (though less common than in the past)
Accelerated pace of marriage, separation, divorce, and remarriage
Faster pace of subsequent childbearing
High rate of repeat unintended pregnancy
More births out of marriage
Closer spacing of births
Greater health risks
Increased chance of low birth weight or prematurity
Increased risk of infant death
Increased risk of injury and hospitalization by age 5 y
Decreased educational attainment
Lower cognitive scores
Greater chance of being behind grade or needing remedial help
Lower chance of advanced academics
Lower academic aptitude as a teenager and perhaps a higher probability of dropping out of school
Greater risk of behavior problems
Higher probability of living in a nonintact home while in high school
Greater risk of adolescent pregnancy
Postpartum contraceptive counseling and follow-up may help prevent additional pregnancies. In untreated girls, the risk of a second unintended pregnancy within the next 2 years is approximately 30%. Combined hormonal contraceptive options can be started 6 weeks after delivery in non–breast-feeding adolescents; progestin-only methods can be started immediately postpartum, even in breast-feeding adolescents.
In the United States, approximately 1%–2% of pregnancies are ectopic. Adolescents have the highest mortality rate from ectopic pregnancy, most likely related to delayed diagnosis. Risk factors include history of PID or STIs. Repeat infections with Chlamydia increase risk for ectopic pregnancy, as does cigarette smoking. Conception while on progestin-only methods of contraception also increases the risk of ectopic pregnancy, because of the progestin-mediated decrease in tubal motility. The classic presentation is missed menstrual period, abdominal pain, and vaginal bleeding. A urine pregnancy test is usually positive by the time of presentation. The patient may have abdominal or pelvic tenderness, adnexal tenderness, and/or an adnexal mass on examination. The uterus is typically either normal sized or slightly enlarged. Diagnosis is based on serial serum quantitative hCG levels and transvaginal ultrasound. Patients should be referred urgently to an obstetrician gynecologist for management to avoid a ruptured ectopic pregnancy which is a surgical emergency. These patients often present in shock with an acute surgical abdomen.
et al: Addendum-adolescent pregnancy: current trends and issues. Pediatr 2014;133(5):954–957
et al: Care of adolescent parents and their children. Pediatr 2012;130(6):1743–1756
et al: Ectopic pregnancy: how the diagnostic and therapeutic management has changed. Fertil Steril 2012;98(5):1066–1073