The History

A pediatric and adolescent gynecology (PAG) clinical history and examination require both the expertise of a pediatrician in terms of communicating and engaging with a child and the expertise of a gynecologist in addressing sensitive and intimate issues that inevitably form part of such an assessment. The first pelvic examination experienced by an adolescent may shape her future approach to reproductive health issues.

The child must remain at the center of the interaction and her interests must always come first, although the parent or guardian often leads in the interaction. The circumstances under which a history is taken for the first time therefore requires an appropriate environment. Children with gynecological problems should not be seen in the setting of an adult gynecology clinic. There should instead be a designated regular PAG clinic supported by a pediatric and/or specialist nurse [1], the presence of whom is important in terms of support, often providing a different perspective to the consultation from that of the gynecologist.

With young children it may be best for the pediatric nurse to usher the child into the consultation room with the parent or care provider before meeting the gynecologist so that the child can be introduced to the surroundings and begin playing. Distraction tools are important in a PAG consultation. Once the child has settled, then the gynecologist can introduce himself/herself, greeting the child and asking the child to introduce her parent or care provider. Questions need to be posed according to the child’s age, understanding, and development, but simple questions can be addressed to the child alternating with the adult who can provide answers to other more complex questions. In this way the child is absorbed into the consultation. The younger the child the more reliable the answers can be. In addition, parental anxiety can impair communication in the course of the consultation. An empathetic approach by the gynecologist is more likely to improve communication.

The structure employed when taking a child’s medical history may differ from that with an adult. With adults the history of the presenting complaint is often addressed first. With children it may prove helpful to start by asking general questions such as past medical and family history to set the scene and help relax and engage the child before addressing the often more sensitive reasons for the visit.

The history should include pregnancy and birth details, developmental milestones, family history, and safeguarding issues. The clinician should remain open minded throughout and not necessarily accept all the information given at face value – for instance, what is purported to have been the menarche might not have been the first menstrual period at all. Child protection needs to be at the forefront of all PAG consultations. All the information provided needs to be absorbed and fully documented for future reference.

Language used must be age and developmentally appropriate. Children use proper names for other body parts, and there should not be any particular part of the body that is designated as being too shameful to call by its proper name. Whereas best practice should be to encourage accurate anatomical descriptors, the clinician should nevertheless be aware of alternative terms familiar to that particular child. In one retrospective study exploring children’s knowledge of human genital anatomy, only 6.1 percent of females learned correct names for female genitalia. Female respondents did not complete their anatomical vocabulary for female genitalia until a mean age of 15.6 years [2]. Clinical terminology should also accord with the Chicago Consensus 2011 [3]. The use of new terms under the umbrella of disorders of sex development was believed to improve communication and parental understanding while being acceptable to affected individuals [4]. This approach appears to have been accepted by participants including parents with broad support for the terminology.

Different approaches are needed when interacting with adolescents. The gynecologist should try and avoid being paternalistic and didactic, yet maintain a comfortable patient-clinician relationship. Introductions can be on first name terms, difficult as it might be to those clinicians used to more formal introductions. Questions should be open ended so that “yes/no” answers can be avoided and the adolescent encouraged to express herself. The gynecologist should follow the one-minute rule when speaking to an adolescent and limit the time spent talking at any one time to no more than a minute.

The HEADSS [5] framework (Home, Education, Activity, Drugs, Sexuality, Suicide/Depression) first introduced in 1972, is a useful tool to aid consultations with adolescents and provides an opportunity to facilitate rapport and risk assessment (Table 3A.1). A psychosocial review of systems is considered to be essential and to be at least as important as the physical examination. The framework develops from expected and less threatening questions to more personal and intrusive questions, allowing the clinician an opportunity to establish trust and rapport with the adolescent before addressing more difficult questions. In particular, difficult questions should be best presented in a factual and nonjudgmental manner (e.g., while exploring any current relationship, also ask “when was the last time you had sex with anyone else?”).

Adolescents often attend the consultation with a parent or guardian, and this can influence the extent to which sensitive matters can be broached. The gynecologist should try and engage with the parent but focus on the presenting complaint and accompanying story. The sexual history is crucial, with many parents volunteering (often mistakenly) that mother and daughter are completely open in such matters. Using the line that the adolescent probably has friends who are sexually active is a potential icebreaker, allowing for anonymity in front of the parent. In this respect there is no harm in inquiring about the sexual history with the mother present, but the clinician should engineer an opportunity to speak to the adolescent alone to allow her to share her history with the assurance of patient confidentiality.

Discussing confidentiality at the forefront of the visit can be helpful in managing expectations of the parent and patient. A model visit with an adolescent patient can include a time of discussion with both parent and patient together, followed by a confidential discussion with the patient alone.

If a new disclosure relating to sexual abuse is made during the course of the consultation, more detailed questioning should cease and immediate contact made with the local child protection/safeguarding team to enable the child’s immediate safety and arrange for a formal interview to take place. It is only once the clinician has satisfied himself/herself with the history that an examination of the child or adolescent is offered.