Gynecologic Disorders

35 Gynecologic Disorders



Teral Gerlt, Nancy Barber Starr


Pediatric gynecology can provide the health care provider with varied and interesting challenges. Knowledge, sensitivity, and comfort with gynecology aid the pediatric provider in working with the child or adolescent and the parent. Educating children and adolescents about their bodies as they mature is essential. Approaching issues that may be considered personal or embarrassing openly and directly allows more comprehensive care and an opportunity for anticipatory guidance. Establishing and maintaining a good relationship with parents and adolescents helps ease the transition during which adolescents take an increasingly larger role in determining their own care.


Gynecologic issues range from normal transitions that may be perceived as abnormal to serious systemic diseases or abnormalities. The provider should have an elevated index of suspicion in all cases so as to not overlook significant signs and symptoms. At the same time, most conditions are normal and can be easily addressed, reassuring the child, adolescent, and/or parent that all is well and that her body is developing normally.



image Standards of Care


Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2009) has multiple objectives that are applicable to children and adolescents. Those that fall into pediatric gynecology are to promote responsible sexual behaviors, and reduce teen pregnancies, sexually transmitted infections (STIs), and human immunodeficiency virus (HIV) infections in adolescents. These objectives remain mostly unchanged from the Healthy People 2010 (USDHHS, 2000).


Bright Futures (Hagan et al, 2008) recommends as a routine part of annual health supervision asking all adolescents about sexual health behaviors that place them at risk for pregnancy, STIs, and HIV. Further, they should receive counseling about responsible sexual behavior, including abstinence and the use of contraception and condoms to prevent pregnancy and infection with STIs and HIV. All sexually active adolescents should be screened for STIs (gonorrhea [GC], chlamydia, and syphilis if living in an endemic area) and HIV infection. The Guide to Clinical Preventive Services (U.S. Preventive Services Task Force [USPSTF], 2009) also recommends screening all sexually active women 24 years old and younger for chlamydia.



image Anatomy and Physiology


For the first 6 to 7 weeks of gestation, male and female fetuses are sexually undifferentiated, both having two bipotential gonads and bilateral paramesonephric (müllerian) and mesonephric (wolffian) ducts. At this point testicular differentiation begins at the direction of the testes-determining factor on the Y chromosome. In the male gonad, the Sertoli cells produce antimüllerian hormone (AMH) that inhibits müllerian duct development, and the Leydig cells produce testosterone, which maintains wolffian duct development and causes them to differentiate into the epididymis, vas deferens, and the seminal vesicles.


Without the influence of the Y chromosome, the female gonads develop into ovaries by about 8 weeks’ gestation, and by 20 weeks the fetal ovary reaches mature compartmentalization. The müllerian ducts become the uterus and fallopian tubes, and the wolffian ducts regress. By week 22 of gestation, canalization to create the uterine cavity, cervical canal, and the vagina is complete.


The external genitalia are neutral primordial and able to develop into either male or female structures. The presence of testosterone from the testes masculinizes the external genitalia, whereas the lack of androgens allows female genitalia to form.


In utero, maternal estrogen thickens and enlarges the female genital structures. After birth, maternal hormones are withdrawn resulting in the desquamation of the hypertrophic walls of the uterus. The mucus from the cervix results in the physiologic leukorrhea of the newborn period. As the hormonal influences continue to decrease, the endometrial shedding may be accompanied by bleeding.


Between 8 weeks and 7 years of age, without maternal or endogenous estrogens, the labia majora are flat, the labia minora are thin, and neither offers protection to the genitalia. The absence of fat pads results in an open labia whenever the child is in the squatting position. In addition, this thin atrophic genital epithelium is readily traumatized.


The function of the reproductive system is controlled by the hypothalamic-pituitary-ovarian (HPO) axis. This complex process begins in the neurologic system (the hypothalamus), involves the endocrine system (the anterior pituitary), and completes its cycle with the gonads (ovaries). Initially this cycle causes sexual maturation, and once that is completed the ongoing release of hormones controls the menstrual cycle, pregnancy, and lactation.



Puberty


Puberty is the “coming together of multiple systems and influences, including genetic, metabolic, and hormonal factors” (Speroff and Fritz, 2005, p 178). It is a process usually starting with early breast development (thelarche), then growth of pubic and axillary hair (pubarche), and finally the first menses (menarche).


What sets this all in play is the reactivation of the HPO axis that has been suppressed since shortly after birth. The catalyst for this is unknown; however, there is a reduction of gonadotropin-releasing hormone (GnRH) suppression and decreased sensitivity of the negative feedback to estrogen, which leads to increasing GnRH pulsations to the anterior pituitary. This stimulates the anterior pituitary to release the gonadotropins, follicle-stimulating hormone (FSH) and luteinizing hormone (LH). These in turn stimulate the ovaries to synthesize estrogen (gonadarche). Increasing estrogen stimulates breast development, vaginal and uterine growth, skeletal growth, and female fat distribution. Independent of the HPO axis, increasing levels of adrenal androgens (adrenarche) lead to the growth of pubic and axillary hair. Finally, by midpuberty there is enough estrogen to cause endometrial proliferation, and the first menses occurs (menarche). Because early cycles are anovulatory 50% to 80% of the time in the first 2 to 3 years after menarche, menstrual irregularities and 21- to 45-day cycle lengths are common. Anovulatory cycles may continue 10% to 20% of the time up to 5 years after menarche (Harel, 2005).


On average it takes approximately 4.5 years to traverse all the pubertal stages. The mean age of menarche in Caucasian American girls is between 12 and 13 years and slightly earlier for African-American girls. This age has remained unchanged for more than 50 years. If a girl has not started breast development by 13 years of age or had menarche by 16 years of age, she is experiencing delayed puberty and should be evaluated for medical or genetic conditions. Likewise, precocious puberty, the early development of secondary sex characteristics, needs further evaluation. However, the age at which a further workup is recommended varies by source. Traditionally the definition of precocious puberty is breast or pubic hair development in girls younger than 8 years old. In 1999 the Lawson Wilkins Pediatric Endocrine Society developed revised guidelines in response to research findings. Their recommendation, which remains unchanged since 1999, is to evaluate only if secondary sexual characteristics develop before 7 years old in Caucasian American girls and before 6 years old in African-American girls (Kaplowitz and Oberfield, 1999). Others argue that lowering the age of workup will miss girls with significant pathology. Mansfield and Neinstein (2008) recommend that girls with both breast development and pubic hair at age 7 to 8 should have a review of history and growth and bone age testing for height prediction.



Menstrual Cycle


The menstrual cycle is controlled by the HPO axis. It is essential that pediatric providers have an understanding of this complicated feedback system for the evaluation of menstrual disorders.


The average adult menstrual cycle is 28 days with a range of 21 to 34 days. Figure 35-1 illustrates the female reproductive cycle. The four phases of the cycle are:



• Menses—4 days plus or minus 2 days


• Follicular—10 to 14 days


• Ovulation—10 to 12 hours after LH surge


• Luteal—consistently close to 14 days plus or minus 3 days


image

FIGURE 35-1 Female reproductive cycle showing changes in hormone secretion and in the ovary and the uterine endometrium.


(From Gorrie T, McKinney E, Murray S: Foundations of maternal newborn nursing, ed 2, Philadelphia, 1998, Saunders.)



The Follicular Phase


Initial follicular development occurs without hormonal influence. However, it is the stimulation by FSH that moves the follicles to the preantral stage.



Antral Follicle


The dominant follicle is established during cycle days 5 to 7, leading to increased levels of estradiol by day 7 (Figs. 35-1 and 35-2). The increasing estradiol suppresses FSH and leads to LH secretion. Estrogen also modifies the gonadotropin molecule, increasing the quality and the quantity of FSH and LH midcycle. LH levels rise steadily during the late follicular phase, stimulating the theca in the production of androgen. The action of FSH in the granulosa permits the dominant follicle to use androgen to make estrogen, further increasing estrogen production. FSH also stimulates LH receptors to form on the granulosa cells.


image

FIGURE 35-2 Early follicular to midfollicular phase. FSH, Follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone; IGF, insulin-like growth factor; dark box represents negative feedback.


(Data from Speroff L, Fritz MA: Clinical gynecologic endocrinology and infertility, ed 7, Philadelphia, 2005, Lippincott Williams & Wilkins.)


It is not the gonadotropins alone acting on the follicle; growth factors and autocrine and paracrine peptides also influence the feedback loop. Inhibin B, which is secreted by the granulosa cells in response to FSH, suppresses pituitary FSH. Activin, from the pituitary and the granulosa, augments FSH secretion and action, and insulin-like growth factor (IGF) acts to enhance all actions of FSH and LH (Speroff and Fritz, 2005).



Preovulatory Follicle


When the estrogen levels are sufficient to induce the LH surge, the increasing LH initiates luteinization and progesterone production in the granulosa. This rise in progesterone assists the positive feedback action of estrogen and may be needed to stimulate the FSH peak midcycle. An increase in local and peripheral androgens also occurs midcycle from the thecal tissue of lesser follicles (Fig. 35-3).


image

FIGURE 35-3 Late follicular phase to ovulation. FSH, Follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone; IGF, insulin-like growth factor; dark circle represents positive feedback.


(Data from Speroff L, Fritz MA: Clinical gynecologic endocrinology and infertility, ed 7, Philadelphia, 2005, Lippincott Williams & Wilkins.)



Ovulation


The LH surge stimulates continuation of miosis in the oocyte, luteinization of the granulosa, and production of progesterone and prostaglandins within the follicle. Progesterone augments the activity of the proteolytic enzymes that, together with prostaglandins, are responsible for the digestion and rupture of the follicular wall. The progesterone-influenced midcycle rise in FSH assists to free the oocyte from follicular attachments, to convert plasminogen to the proteolytic enzyme, plasmin, and to guarantee that adequate LH receptors are present to allow a normal luteal phase.



The Luteal Phase


A normal luteal phase requires both consummate preovulatory follicular development and the continued support of LH. Centrally, progesterone, estrogen, and inhibin A suppress new follicular growth. The regression of the corpus luteum may involve the luteolytic action of estrogen produced by the corpus luteum itself and is interceded by a modification in local prostaglandin and endothelin-1 concentrations (Fig. 35-4).


image

FIGURE 35-4 Early luteal to midluteal phase. FSH, Follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone; dark boxes represent negative feedback.


(Data from Speroff L, Fritz MA: Clinical gynecologic endocrinology and infertility, ed 7, Philadelphia, 2005, Lippincott Williams & Wilkins.)



Luteal-Follicular Transition


The loss of the corpus luteum causes a fall in circulating levels of estradiol, progesterone, and inhibin A. The decreasing inhibin A eliminates the suppression of FSH secretion in the pituitary. The decrease in estradiol and progesterone permits a rapid increase in the frequency of GnRH pulsatile secretion and the elimination of negative feedback on the pituitary. The loss of inhibin-A and estradiol and the increasing GnRH pulsations join to permit greater secretion of FSH as compared with LH, which in turn increases in the frequency of episodic secretion of FSH. This increase in FSH is influential in rescuing an approximately 70-day-old group of follicles from atresia. This allows a dominant follicle to begin its emergence, and the cycle begins again (Fig. 35-5).


image

FIGURE 35-5 Luteal-follicular transition. FSH, Follicle-stimulating hormone; GnRH, gonadotropin-releasing hormone; LH, luteinizing hormone.


(Data from Speroff L, Fritz MA: Clinical gynecologic endocrinology and infertility, ed 7, Philadelphia, 2005, Lippincott Williams & Wilkins.)



image Pathophysiology and Defense Mechanisms of the Gynecologic System


The primary disorders of the gynecologic system can be classified as menstrual cycle disorders, inflammatory reactions, infection, and reproductive problems. Pubertal development is a complex but normal process. Adolescents may be seen with common menstrual problems, such as mittelschmerz or dysmenorrhea. Abnormal uterine bleeding, endometriosis, and amenorrhea are three less common menstrual cycle disorders that require the provider to differentiate normal growth and developmental variations from systemic disorders or disease (especially neurologic, endocrine, and reproductive problems). The female athlete is especially prone to exercise-related menstrual problems.


An inflammatory response can occur in either the external or internal genitalia. Local reactions involve the external genitalia and can be caused by dermatologic disorders or skin irritation from such factors as normal leukorrhea, chemical or allergic reactions, or nonspecific causes. Internal inflammation caused by infection is not always as obvious.


The warm, moist environment of the reproductive tract provides an ideal place for infection. Viral pathogens, such as herpes simplex virus (HSV) and human papillomavirus (HPV), or fungal infection can manifest as vulvitis or a vaginal infection. Trichomonas, a protozoal infection, colonizes the vaginal vault. By contrast, bacterial infections caused by chlamydia and GC can ascend into the upper genital tract where pelvic inflammatory disease (PID) can cause tubal damage.


Reproductive problems occur as a result of structural, hormonal, or endocrine disorders or as sequelae of infection. Refer to a gynecologic or endocrine text for further information.


The gynecologic system has both anatomic and physiologic defense mechanisms. The labia majora and the pubic hair provide a barrier that serves as the first line of defense. The vagina, serving as an exit for mucosal secretion, menstrual fluids, and products of conception, also provides a means of defense with its natural downward and outward flow of secretions. Additionally, with increasing estrogen exposure, the vaginal epithelial tissue thickens and an acid pH develops, discouraging infection. The small external cervical os, a thick mucous plug, and the downward flow of cervical secretions provide barriers to entry to the uterus. A chemical barrier is also established by the cervical enzymes and antibodies.



image Assessment of the Gynecologic System: Health Supervision Visits for Female Adolescents


The American Congress of Obstetricians and Gynecologists (ACOG) recommends that young female adolescents have an initial reproductive health visit between 13 and 15 years old to provide preventive care, anticipatory guidance, and screening (ACOG, 2010b). This visit includes discussions of sexual development and reproductive issues rather than problem-focused care (Holland-Hall et al, 2005). Counseling and education about normal menses and patterns, pregnancy prevention, STIs, and HIV are essential; a pelvic examination is performed only if concerning (discussed later).


This visit is the perfect opportunity to discuss confidentiality with the patient and her parents. All need to understand the importance of confidentiality in the health care provider–patient relationship and the limits to confidentiality imposed by state and local statutes and/or medical necessity. A relationship of trust and mutual respect is extremely important to establish so that the adolescent is willing to discuss intimate matters.



History


The history taken depends on the age of the child and chief complaint. Histories for specific conditions are included later in this chapter. An in-depth sexual history for the adolescent can be found in Chapter 18. The sexual history should be completed with the parent out of the room.



• Family history


• Maternal age at menarche and any problems encoun-tered


• Dysmenorrhea, dysfunctional uterine bleeding (DUB), or endometriosis


• Diabetes mellitus


• Thyroid disease


• Bleeding or clotting disorders


• Cancer of the female reproductive system


• Genetic disorders


• Pubertal development


• Knowledge of pubertal development


• Age at breast and pubic hair development


• Age at menarche


• Length of cycles, longest and shortest interval between menses, duration of flow, estimated blood loss


• Last normal menstrual period (LNMP)


• Dysmenorrhea


• Sexual history


• Knowledge about sexuality and discussions with parent or guardian (see Chapter 18)


• Age at first intercourse (voluntary or forced)


• Current sexual activity


• Type of activity (oral, vaginal, anal)


• Partners of opposite sex, the same sex, or both


• Number of sexual partners in previous 60 days, 12 months, lifetime


• Previous vaginal infections or STIs


• Current exposures to STIs


• Papanicolaou (Pap) test date and results


• Contraceptive history


image Current method—type, duration, frequency of use, problems and satisfaction


image Past methods—type, duration, frequency of use, problems and satisfaction


• Obstetric history, as appropriate


• Review of systems: Urinary, gastrointestinal, endocrine, dermatologic, general health, growth, stressors, medications, allergies, and substance use



Physical Examination


A girl’s first gynecologic examination can influence her attitude toward future gynecologic care. When a gynecologic examination is performed, the child or adolescent should maintain a feeling of being in control. It is important that the provider take the time to establish rapport, preserve modesty, give choices, and obtain consent to examine. It is also important that the parent understands what the examination entails and why it is necessary.


The adolescent should be given as many choices as possible; if she would like someone else in the room with her; the position of the table; use of a hand mirror to observe; and when possible, the timing of the examination. This requires flexibility and time from the care provider, but demonstrates respect for the adolescent.



Prepubertal Child


There are a variety of positions in which to examine the vulva, vestibule, and lower vagina of a prepubescent girl. Lying on a table, supine, with feet together and knees out (“frog legged”) is generally the most comfortable for patients and provides ease of examination and obtaining of cultures if necessary. Another alternative is sitting up in the parent’s lap with feet and knees frog legged. Putting the parent on the examination table with feet in the stirrups and the child on his or her lap with feet to the outside of the parent’s legs is another alternative. If examination of the entire vagina is necessary, putting the child in knee-chest position on the examination table is the best position for noninvasive, internal examination of the vulva and vagina.


Examine or note the following:



• Breasts, abdomen, and inguinal area


• Presence and distribution of pubic hair


• Presence and distribution of body hair: Face, chest, back, abdomen, legs, arms


• Skin lesions


• State of hygiene


• Anus for cleanliness, excoriation, or erythema


• Sexual maturity rating (SMR) or Tanner staging (see Chapter 8 and Fig. 8-3)


• Genital examination with gentle traction on the labia majora


• Size of clitoris (approximately 3 × 3 mm prepubertal)


• Signs of estrogenization (prepubertal vaginal mucosa—moist, thin, and red; postpubertal vaginal mucosa—moist and dull pink)


• The hymen is normally smooth and continuous.


image Described as crescent shaped, annular, or redundant (Fig. 35-6)

image Presence of notches or tags—normal variation (Sugar and Graham, 2006)

image Presence of hymenal ridge—usually without sequela (Sugar and Graham, 2006)

image Imperforate hymen

image Periurethral bands

image

FIGURE 35-6 Types of hymens, photographed through a colposcope. A, Crescentic hymen. B, Annular hymen. C, Redundant hymen with crescent appearance after retraction.


(From Emans SJ: Vulvovaginal problems in the prepubertal child. In Emans SJ, Laufer MR, Goldstein DP, editors: Pediatric and adolescent gynecology, ed 5, Philadelphia, 2005, Lippincott Williams & Wilkins.)


The significance of the diameter of the hymenal opening as a diagnostic finding is debated. Both transverse and anteroposterior diameters are dependent on age, relaxation, method of examination, and type of hymen. In general, the older and more relaxed the child, the larger the opening. It is also larger with retraction and in the knee-chest position. In the 3- to 6-year-old, a range of normal findings for the transverse diameter is 1 to 6 mm and for the anteroposterior diameter, 1 to 7 mm. Obesity in young children is associated with hymenal openings larger than average for age (e.g., a 2-year-old with a 4-mm opening when average is 2 mm).



Adolescent




• Inspect the skin for acne.


• Examine the breasts; note Tanner stage.


• Palpate the thyroid.


• Inspect hair distribution on face, chest, back, arms, legs, and abdomen.


• Inspect the external genitalia and determine the Tanner stage.


• Vaginal examination alone may be adequate to assess for irregular bleeding, severe dysmenorrhea, vaginal discharge, and amenorrhea. However, a speculum and a bimanual examination may be necessary based on symptoms and history.



Diagnostic Studies


The routine care of the child and adolescent without gynecologic complaints does not require diagnostic studies.


The following studies can be helpful as diagnostic tools. Specific studies and techniques are discussed with each diagnosis. Collection of specimens must be done with care. Techniques that are helpful include using a small amount of saline as a vaginal wash, using a soft plastic eyedropper or feeding tube, or using a moistened cotton swab.



• Wet mounts of vaginal secretions


• Saline for microscopic examination to look for white blood cells (WBCs), clue cells, trichomonads, and bacteria


• 10% potassium hydroxide (KOH) for whiff test and microscopic examination to look for yeast (branching hyphae and spores) (Fig. 35-7)


• pH of vaginal mucus (neutral in prepubescent; less than 4.5 once pubertal)


• Urine-based nucleic acid amplification test (NAAT), cultures, and/or serologic blood tests for STIs


• Other tests as indicated including pregnancy test by urine or serum, BiGGY agar culture (suspected yeast infection), or ultrasound


image

FIGURE 35-7 Drawings of vaginal smears showing A, Trichomonas; B, clue cells of bacterial vaginosis; C, leukorrhea; D, CandidaA, B, and C are saline preparations; D is a potassium hydroxide (KOH) preparation.


(From Emans SJ: Vulvovaginal problems in the prepubertal child. In Emans SJ, Laufer MR, Goldstein DP, editors: Pediatric and adolescent gynecology, ed 5, Philadelphia, 2005, Lippincott Williams & Wilkins.)



Cervical Cancer Screening


The American Cancer Society recommends that cervical cancer screening with Pap testing should begin approximately 3 years after a young woman has initiated vaginal intercourse and no later than 21 years old. After the initiation of cervical screening, the young woman should have annual Pap testing with conventional cytology or every 2 years with liquid-based cytology. However, the ACOG (2010a) released its latest committee opinion on screening, evaluation, and management of cervical cancer in adolescents in August 2010. The college recommends not starting Pap testing until 21 years of age unless the adolescent is sexually active and immunocompromised. As part of this publication, ACOG gives guidelines on how to follow up with young women who have had abnormal cervical cytology prior to this latest practice change (see ACOG, 2010a, for complete recommendations).


The rationale for this recommendation is the increasing understanding of the natural history of HPV infections, the causative agent of most cervical cancer. The Centers for Disease Control and Prevention (CDC) (2009) reports the overall prevalence of high-risk HPV at 23%. For adolescents the rate is 29%, whereas, for women in their twenties the rate has decreased to 13%. There is evidence that the majority of low-grade HPV lesions regress spontaneously and the risk of a young woman having a high-grade lesion leading to cervical cancer is extremely rare. Therefore, Pap annual testing led to overdiagnosis of cervical pathologic conditions and unnecessary interventions.



image Management Strategies



Anticipatory Guidance, Counseling, and Education


Anticipatory guidance related to gynecologic issues is important to both the child or adolescent and parents. Attention to appropriate genital hygiene can help prevent some potential childhood problems. The transition to puberty and establishment of menses is eased with appropriate education and counseling beforehand. With the advent of puberty and the increasing interest in sexuality, a great deal of guidance is needed to help the adolescent and her parents through these transitions. See Chapters 8 and 18 for further discussion of these topics.


Counseling and education related to normal gynecologic conditions and disorders of the gynecologic system need to be tailored to the child or adolescent and the parents. See Chapter 18 for more information on sexuality counseling. Confidentiality is a matter to be established with both the parents and the adolescent. Some states have specific laws that allow providers to treat adolescents for obstetric and family planning conditions without parental knowledge or consent.



Adolescent Pregnancy Prevention


There are several common goals in adolescent pregnancy prevention. These goals can be achieved by supporting a positive or protective environment, connecting the adolescent to an intervention program, and providing appropriate health care services. Prevention goals include the following:



• Maintain sexual health and promote sexual responsibility.


• Assist adolescents to make informed choices, recognizing educational, social, and economic effect of choices.


• Encourage abstinence and delay onset of intercourse.


• Provide contraceptive counseling and selection of a contraceptive device for any adolescent who has recently experienced a spontaneous abortion, as part of third-trimester health teaching before delivery, or at the time of an elective termination of pregnancy.


Appropriate health care services are important in preventing adolescent pregnancy. This care should include confidentiality with minimal or no financial barriers; easy availability (e.g., timed for easy access, on site at school, or easy transportation to site); and a full range of contraceptive services for male and female adolescents (see section on contraception for specific methods).


Common components of successful intervention programs identified by Dryfoos (1998) are listed in Box 35-1. The National Campaign to Prevent Teen Pregnancy (2008) has also outlined actions that parents can take to help protect against pregnancy (Box 35-2).



BOX 35-1 Common Components of Successful Adolescent Pregnancy Intervention Programs




• Intensive individualized attention


• Early identification of at-risk children


• Early intervention to prevent high-risk behavior


• Youth empowerment


• Social skills training


• Parental involvement and training in parenting


• Community-wide multiagency collaborative approaches



BOX 35-2 What Parents Can Do to Protect Against Pregnancy




• Be clear about your sexual values and attitudes.


• Talk with your children early and often about sex, and be specific.


• Supervise and monitor your children and adolescents.


• Know their friends and families.


• Discourage early, frequent, and steady dating.


• Discourage dating of older persons.


• Encourage education and future goals.


• Know what your kids are watching, reading, and listening to.


• Build a strong, close relationship from an early age.



Contraception



Contraceptive Counseling and Education


Significant and specific knowledge is required for pediatric providers to offer reproductive health and contraceptive services to adolescents. An in-depth discussion is beyond the scope of this text; however, excellent management references are available. The authors recommend Contraceptive Technology by Hatcher and colleagues (2007), A Clinical Guide for Contraception by Speroff and Darney (2010), and Gupta and associates (2008).


Contraceptive counseling needs to be individualized and at the adolescent’s developmental level. It is also important not to overwhelm the patient with too much information at one time. Ascertain what methods she knows about or is thinking about using. Frequently the provider needs to dispel misconceptions about risks related to various methods and educate on the menstrual and health benefits. It may take more than one visit to find a compatible contraceptive method. However, the adolescent should not leave the office without understanding the risk of pregnancy and STIs and HIV with unprotected sex. She should have education about and a prescription for emergency contraception (EC) and know that condoms are a must for safer sex.


Factors identified as predictive of failure or success with contraception are listed in Box 35-3. Antecedent risk factors to unintentional pregnancy are listed in Box 35-4.



BOX 35-3 Factors Predicting Success or Failure With Contraception




• Age. Adolescents 15 years old and younger are at highest risk for pregnancy because 35% report using no method of contraception at their first episode of intercourse. In comparison, only 17% of females 19 years or older report using no method (Abma et al, 2004).


• Noncompliance with the first method chosen (previous method failure).


• Not acquiring a method of contraception at the first reproductive health visit.


• Frequency of family planning visits in the preceding 12 months. Increased compliance with clinic attendance appears to correlate with effective contraceptive use by client.


• Coital frequency. Adolescent females who have sexual intercourse more than six times per month are at greater risk of becoming pregnant.


• Length of time between first coitus and initiation of birth control use. The longer adolescents delay seeking services for contraception, the less likely they are to use a highly reliable method consistently and correctly.



BOX 35-4 Risk Factors for Unintentional Pregnancy




• Early onset of sexual activity, especially before 15 years old


• Early onset of substance use, including cigarettes, alcohol, and illicit drugs


• Lesbian or bisexual; these females are as likely to have sex with males as heterosexuals, but their pregnancy rate is more than doubled (Meininger and Remafedi, 2008)


• Low educational expectation


• Low perception of life options


• Poor grades and academic achievement


• Behavior problems, including truancy and delinquency


• Negative peer influence


• Poor contraceptive compliance or failure with a contraceptive device


• Nonintact families (those without both biologic mother and father present)


• Depression


• Cultural values that favor adolescent pregnancy


• Prior history of sexual or physical abuse or violence at home (Cox, 2008)



Initial Screening to Assess for Appropriate Contraception



History


For the most part adolescent women are healthy with no contraindications for hormonal contraceptive methods. However, it is important to get a personal history related to cardiovascular and peripheral vascular disease, diabetes, headaches, liver and gallbladder disease, and current medications (including prescription, over-the-counter [OTC], herbal, and dietary supplements). The World Health Organization (WHO), using evidence-based methodology, has developed medical eligibility criteria for starting contraceptive methods (2009). The authors recommend using the WHO website to access the most recent updates.



Physical Examination




• Height and weight; body mass index (BMI)


• Blood pressure


• Thyroid examination


• Breast examination, including Tanner staging


• Auscultation of heart and lungs


• Abdominal examination


• Pelvic examination (not a requirement to start oral contraceptive pills [OCPs])



Diagnostic Studies




• Pap smear if indicated by current guidelines


• NAAT on urine or cultures for GC and chlamydia


• Wet mounts when indicated by presence of abnormal vaginal discharge


• Complete blood count (CBC) or hemoglobin or hematocrit and rubella titer as indicated


• Syphilis serology with known STI, particularly condylomas or genital ulcers and if residing in endemic areas


• HIV



Hormonal Methods of Contraception (Coitus-Independent Methods)



Oral Contraceptive Pills



Types of Preparations

Two basic preparations are available: a combination formulation (COC) that contains estrogen (less than 50 mcg) and progestin in a low dose, and a progestin-only minipill. Most women in the U.S. use the combination formulation, in either monophasic or triphasic formats. Progestin-only pills (POPs) are prescribed for women in whom estrogens are contraindicated (e.g., lactating women or women with medical contraindications to estrogen). Generally they are not the first choice for nonlactating adolescents because of irregular bleeding and higher failure rates. Mechanism of action, theoretic and use effectiveness, benefits, disadvantages, and side effects are listed in Table 35-1. The initial use of an OCP requires special attention to dosing, preparation, timing, patient education, and follow-up.



TABLE 35-1 Hormonal Methods of Contraception: Mechanism of Action, Theoretic and Use Effectiveness, Benefits, Disadvantages, Side Effects, Failure and Efficacy

image image


Dosing

Initial dosing for a combination OCP should be at 30 to 35 mcg estrogen, with low progestin potency per tablet. Most providers have one or two OCPs that are favorites for first-time use in women without special conditions. There are 20-mcg combination OCPs available, should an ultra-low dose estrogen formulation be desired. The selection of an OCP can also be individualized based on menstrual characteristics or patient sensitivity. For example, a client with a history of cystic acne can be tried on an OCP in which the progestins are desogestrel or norgestrel, or on Ortho Tri-Cyclen or Estrostep, the only OCPs with U.S. Food and Drug Administration (FDA) approval for use in acne. For clients with hirsutism or polycystic ovary syndrome (PCOS), a low androgenic potency pill is used, such as Ortho-Cyclen, Desogen, or Ovcon-35. For clients who miss pills, using a monophasic 30- to 35-mcg pill provides more protection against escape ovulation than a 20-mcg estrogen, progestin only, or triphasic pill. Adolescents who demonstrate estrogen sensitivity can be tried on a more androgenic pill, such as Lo/Ovral, Nordette, or Loestrin or a 20-mcg preparation, such as Alesse.



Preparation

Given the vast selection of products available to the health care provider, Hatcher and colleagues (2007) developed a four-step flow chart to assist clinicians in choosing a combined OCP with low-dosage estrogen (Box 35-5).



BOX 35-5 Steps in Choosing a Combined Oral Contraceptive With Low-Dose Estrogen




1. Does the adolescent have a contraindication to estrogen use?


2. If yes, consider the use of a progestin-only formulation.


3. If the client can use estrogen, the provider can select from among numerous products, considering the following:


• The number of micrograms of estrogen in the preparation

• Availability of the pill on formulary

• Ease of understanding the packaging of the pill

• Price of the pill to the adolescent and possibly the clinic

• Previous adverse event or experience the adolescent may have had with a specific preparation

4. Consider other clinical factors, such as acne, nausea or vomiting, spotting or breakthrough bleeding, and absence of withdrawal bleeding.



Timing

Ideally, OCPs should not be started until the adolescent has had three to six regular periods after menarche, but sexually active or other high-risk teens can be put on OCPs even before menarche. OCPs can be started 3 to 4 weeks postpartum (if breastfeeding, POPs) or after a first-trimester therapeutic abortion (Hatcher et al, 2007; Nelson and Neinstein, 2008).


There are several ways in which OCPs can be initiated:



• Quick start—same day start in certain circumstances


image If within 72 hours of unprotected sex, use EC now and start OCPs the next day.

image If pregnancy can be ruled out or there was no unprotected sex since the last menses, may start same day and use backup (condoms) for 7 days or until menses starts. This is a preferable method for adolescents because it is less complicated and has a higher rate of continuation.

• Start first day of menses


• Start within 5 days after menses and use backup (condoms) for 7 days


• First Sunday after menses started and use backup (condoms) for 7 days


Another timing issue is the pattern of COC use. The majority of pill packs come with 28-day cycling: 21 days of active tablets and 7 days of placebo tablets, with the woman having a monthly withdrawal bleed during the placebo week. For years, providers have recommended various patterns of monophasic COC use to prevent withdrawal bleeds. Women can skip the placebo week of their pill packs for one, two, or three cycles to decrease the number of withdrawal bleeds per year. This is particularly helpful in women with endometriosis, menorrhagia, severe dysmenorrhea, and menstrual migraines. In 2003 extended-cycle COCs came on the market, packaged with 84 active pills and 7 inactive pills, giving women only four withdrawal bleeds per year.



Patient Education



• Provide clear instructions on how to start OCPs.


• Emphasize correct and consistent use of the OCP.


• Take the pill every day in the order presented in the pill pack—no matter what your body is doing or what your friends say.


• How to make up missed or forgotten pills and the use of a backup method


image One missed pill—take as soon as possible (ASAP) and take next pill as usual.

image Two missed pills—take one pill ASAP and one pill in 12 hours. Then continue with the remainder of the pack and use backup for 7 days. Additionally, offer emergency contraception (EC) if pills missed in first week of pack.

image If more than two pills are missed—take EC and restart OCPs the next day and use backup for the next 7 days. If declines EC, skip missed pills and continue the rest of the pack and use backup until next menses (Hatcher et al, 2007.)

• Explain common side effects and the need to call if questions or concerns arise.


• Stress the importance of dual methods for protection from STIs and HIV.


• All adolescents should use condoms along with any other method used for contraception.


• All adolescents should have a prescription for EC and understand how to use them.



Follow-up Management

Provide an emergency follow-up number and instruct the client on indications for calling. Schedule a return appointment. The return visit gives the health care provider an opportunity to assess the physiologic effects of the OCP and the adolescent’s acceptance and use of this particular contraceptive method.


Adolescents tend to be acutely aware of and sensitive to body changes and processes. As a result they may incorrectly interpret physical signs, exaggerate the effects of OCPs on their bodies, and discontinue the OCP use without consulting their health care provider. At the follow-up visit, the provider should reemphasize the noncontraceptive benefits of the OCP, have the client discuss concerns about the OCPs, discuss the lower risks of OCPs compared with those of pregnancy, and review and reclarify directions and side effects.


Interview the client for STI exposure, compliance, satisfaction with medication, and perceived side effects. The use of the mnemonic ACHES (Box 35-6) can help guide assessment questions, and can be used carefully to help the teenager understand more clearly the risks of OCPs without unduly concerning her.



BOX 35-6 The Mnemonic ACHES Used to Teach and Assess for Risks of Oral Contraceptive Pills




• Abdominal pain. Have you experienced abdominal pain (severe)?


• Chest pain. Have you noticed chest pain (severe), cough, or shortness of breath?


• Headaches. Do you have headaches (severe), dizziness, weakness, or numbness?


• Eye problems. Have you had a change in vision (loss or blurring) or other eye problems or speech problems?


• Severe leg pain. Have you had any severe leg pain, especially in the calf or thigh?


Physical examination parameters during the return visit include weight and blood pressure measurements and any laboratory follow-up.



Other Methods of Hormonal Contraception


Hormonal contraception can also be delivered in other preparations. Three of these methods are listed in Box 35-7.



BOX 35-7 Other Methods of Hormonal Contraception



Contraceptive Patch


The contraceptive patch (Ortho Evra) is a 20-cm2 transdermal adhesive patch consisting of progestin (17-deacetylnorgestimate) and ethinyl estradiol placed on the trunk, buttock, or arm once a week for 3 weeks and removed for 1 week to allow for a withdrawal bleed. The advantage of the patch is that it does not require the user to remember a daily oral contraceptive pill (OCP). Disadvantages include the visibility of the patch, which precludes privacy of method, and the need to remember to replace the patch when indicated. The patch also has decreased efficacy in women who weigh more than 198 pounds (90 kg). It costs about the same as OCPs (except for generic forms) and has the same precautions and side effects as OCPs. There is some evidence that the patch may have an increased risk of nonfatal venous thromboembolism (VTE) over OCPs in some women. Careful screening of VTE risk is recommended.



Vaginal Ring


The vaginal contraceptive ring (NuvaRing) is a self-administered contraceptive, consisting of a soft, flexible, 2-inch transparent plastic ring with a hole in the middle. It is 0.125 inch thick and is impregnated with estrogen and progestin. It is inserted vaginally once a month on or before the fifth day of menses, left in place for 3 weeks, removed for 1 week to allow for a withdrawal bleed, and then a new ring inserted. Placement over the cervix is not necessary. As long as it is in contact with the vagina, it is working. The failure rate is the same as OCPs: typical use 8%, and perfect use 0.3%. Advantages include that it is coitus independent, does not involve the use of messy creams or gels, and is only dealt with once a month. It does not provide protection against sexually transmitted infections (STIs); there is some initial breakthrough bleeding, and the user must be comfortable inserting and removing the device and be able to adhere to the usage schedule.



Subdermal Implant Contraception


Implanon is currently the only implanted form of progestin-only contraception on the market in the U.S. Implanon is a one-rod, 3-year subdermal implant that has a newer form of progestin (etonogestrel). The method of action is the same as other progestin-only methods. The advantage of an implant is that it provides long-acting contraception. Disadvantages include surgical insertion and removal procedures and side effects, such as irregular bleeding, weight gain, and acne. It is a more successful method for mature adolescents committed to long-term contraception.



Injectable Contraception: Medroxyprogesterone Acetate (Depo-Provera)



Protocol for Initial Use

Always evaluate for pregnancy before giving the initial dose. A single 150-mg injection inhibits ovulation for 13 weeks. Dosage adjustment for body weight is not necessary. It is preferable to deliver the initial injection before day 5 of the menstrual cycle to minimize pregnancy potential. Injections are usually given at 12-week intervals. If more than 13 weeks have transpired between injections, evaluate for pregnancy before giving the injection. Mechanism of action, theoretic and use effectiveness, benefits, and disadvantages are listed in Table 35-1.



Patients Appropriate for Medroxyprogesterone Acetate

Medroxyprogesterone acetate is a contraceptive method of choice for patients with the following characteristics:



• Seeking a long-term, reversible, highly reliable, private method of contraception


• Those for whom use of estrogen is contraindicated (e.g., patients with a previous thromboembolic episode, lupus, sickle cell anemia)


• Those with seizure disorders—improves control (Speroff and Darney, 2005)


• Those with poor compliance using other contraceptive methods


• Those with menstrual hygiene issues, such as individuals who are mentally retarded, because medroxyprogesterone acetate often causes amenorrhea after two injections



Postcoital Hormonal Contraception or Emergency Contraception



Preparation

EC is designed to be used after unprotected intercourse to prevent an unwanted pregnancy. Plan B was the only FDA-approved oral emergency contraceptive marketed in the U.S. and is approved for purchase without a prescription for women older than 18 years. Plan B is a two-tablet progestin-only method that should be taken within 72 hours of unprotected intercourse for the highest efficacy. The dosage is either one tablet taken immediately with the second tablet taken in 12 hours or both tablets taken at one time. The FDA has approved a second emergency contraceptive (Ella) that can be taken up to 5 days after unprotected intercourse. Ella requires a prescription in all cases. Regular OCPs (combination) may also be used at recommended dosages; this regimen is referred to as the Yuzpe method. POPs are another alternative (see Hatcher et al, 2007, for specifics). There are no contraindications to EC for progestin-only formulations.

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Jul 24, 2016 | Posted by in PEDIATRICS | Comments Off on Gynecologic Disorders

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