Monica Sifuentes, MD
An 18-year-old female college student in good health comes in for a routine health maintenance visit during her spring break. She is unaccompanied by her parents and has no complaints, stating that she just needs a checkup. She enjoys college, passed all her fall and winter classes, and has some new friends. She denies tobacco use but says many of her friends smoke e-cigarettes. She occasionally drinks alcohol and has tried marijuana once. Although she is not currently sexually active, she is interested in discussing contraceptive options. Her last menstrual period, which occurred 2 weeks previously, was normal. She is taking no medications. Her physical examination is entirely normal.
1. What issues are important to discuss with adolescents at reproductive health maintenance visits?
2. What are the indications for a complete pelvic examination?
3. When is a Papanicolaou test indicated as a part of the reproductive health visit?
4. What methods of contraception are most successful in adolescent patients? What factors about each method should be considered?
5. What are the legal issues involved in prescribing contraception to minors in the absence of parental consent?
Adolescent visits to primary care physicians are relatively infrequent by the time teenagers reach puberty. At most, the healthy adolescent patient is seen once or twice during high school for preparticipation sports or camp physicals. If an adolescent is not involved in athletics or if activities in which the adolescent is involved do not require periodic assessments, such a teenager will rarely visit a health professional while in high school except for an acute illness. Therefore, it is extremely important to use any interaction with an adolescent as a unique opportunity to provide anticipatory guidance and health education, particularly reproductive health education. This chapter is largely devoted to a discussion of the reproductive health of adolescent females. However, the Evaluation section is divided into 2 sections, 1 for females and 1 for males. The reader is referred to Chapter 60 for more information on sexually transmitted infections.
Reproductive health is multidimensional and includes sexuality-related services, screening for communicable infections, anticipatory guidance, and counseling. Such services should be included as a part of the routine health maintenance examination for male and female adolescents for several reasons. The high incidence of sexually transmitted infections (STIs) in this age group, the risk of acquiring HIV, and the reality of an unplanned pregnancy make reproductive health issues increasingly important for teenagers and young adults. Additionally, adolescents rarely schedule appointments with primary care physicians prior to the initiation of coitus. Experimentation with drugs and alcohol at this time in their lives also contributes to early, unplanned sexual experiences (Box 58.1).
Aside from issues of sexual activity, the adolescent also may have questions about the progression through puberty. Normal variants in body habitus or certain physical characteristics can be a source of unnecessary anxiety for the uninformed teenager. Health education to alleviate these fears is ideal. The adolescent who is seen for a health maintenance examination should be allotted extra time so that topics such as puberty, abstinence, gender identity, sexual behaviors and activity, STIs, and contraception can be discussed. Additionally, during more acute, problem-oriented visits, the adolescent should be encouraged to voice any other concerns he or she may have. Depending on the nature of these issues, follow-up appointments can be scheduled.
Normal Secondary Sexual Development
Puberty begins during early adolescence with the development of secondary sexual characteristics. Because of the tremendous variation in the age, duration between pubertal stages, and somatic growth of adolescents, a sexual maturity rating (SMR [ie, Tanner stage]) is used to describe breast and pubic hair development in females and genital development and pubic hair growth in males (Figures 58.1, 58.2, and 58.3). The average age of menarche in the United States is 12.5 years, which for most females occurs during SMR 3 and 4. In contrast, spermarche occurs early in pubertal development in boys, at approximately 13 years of age, with little to no pubic hair development. Full fertility is generally achieved by age 15 years, or mid-adolescence, in most boys and girls.
Box 58.1. Reproductive Health: Sexual Activity
Statistics on sexual activity among adolescents in the United States have changed over the last decade. Previously, it was reported that 1 in 4 females and 1 in 3 males had had sexual intercourse by 15 years of age. Currently, only 13% of teenagers have ever had vaginal intercourse by age 15, according to the Guttmacher Institute. Currently, most adolescents are waiting to initiate sexual activity; by their 19th birthday, 7 in 10 teenagers of either sex have had sexual intercourse. Contraceptive use at first premarital sexual encounter has increased to nearly 80% in adolescent females and 87% in adolescent males; however, unintended pregnancy and sexually transmitted infections (STIs) continue to be a major public health concern for this age group. Although the pregnancy rate among teenagers has dropped steadily over the past 10 years, each year nearly 850,000 adolescent females younger than 20 years become pregnant. Most of these pregnancies are unintended and occur premaritally, especially among certain racial and ethnic minority groups. The outcome of these pregnancies in 15- to 19-year-olds varies. An estimated 50% to 60% of these pregnancies result in live births, 30% end in abortion, and 10% to 15% are miscarried or stillborn.
Unprotected sexual activity among adolescents has several adverse health consequences, the most obvious being teenage pregnancy. Of the adolescents who continue their pregnancies, preterm birth (<37 weeks’ gestational age) and low birth weight (<2,500 g [5.5 lb]) are 2 of the most frequently reported neonatal complications. Long-term maternal psychosocial sequelae of adolescent pregnancy include undereducation/school failure, limited vocational training and skills, economic dependency on public assistance, subsequent births, social isolation, depression, and high rates of separation and divorce among teenage couples.
In addition to unintended pregnancy, the risk of contracting an STI, such as chlamydia, human papillomavirus, herpes, and HIV, is increased. In cases of pelvic inflammatory disease from gonorrhea or chlamydia, future problems with fertility and an increased risk of ectopic pregnancy can occur. Human papillomavirus, which is associated with the development of genital warts, cervical dysplasia, and cancer, accounts for approximately one-half of STIs diagnosed in adolescents and young adults. The prevalence rates of other STIs, such as chlamydia and gonorrhea, are still highest among 15- to 19-year-old females compared with older age groups in the United States. More alarming, however, is the relationship between AIDS in young adults aged 20 to 29 years and probable exposure to HIV during adolescence.
Many factors have been associated with the initiation of early coitus in adolescents. They include male sex; race/ethnicity; poverty; a large, single-parent family; previous teenage pregnancy in the household, whether of the mother or a sibling; poor academic achievement; discrepancy between the onset of physical puberty and cognitive development; peer group encouragement; and problem behaviors, such as drug use. Additionally, religious affiliation and cultural norms likely influence this decision. The role of hormonal changes during puberty and their influence on behavior remains unknown.
The adolescent with an intellectual disability that may or may not be associated with chronic illness requires special consideration in terms of reproductive health. With recent advances in medical therapy for conditions such as diabetes mellitus and sickle cell disease, many of these adolescents experience normal pubertal development and fertility. Like their healthy peers, some begin engaging in sexual intercourse at an early age. Unintended pregnancy and childbirth can exacerbate some chronic illnesses and can increase health risks significantly for both the adolescent and developing fetus. The genetic implications and specific patterns of inheritance of certain medical conditions must also be considered. Thus, attention to sexual issues is essential for the adolescent or young adult with chronic medical illness and/or intellectual disability.
Figure 58.1. Female pubic hair development. Sexual maturity rating 1: prepubertal, no pubic hair. Sexual maturity rating 2: straight hair is extending along the labia and between ratings 2 and 3, begins on the symphysis pubis. Sexual maturity rating 3: pubic hair is increased in quantity; is darker, coarser, and curlier; and is present in the typical female triangle. Sexual maturity rating 4: pubic hair is more dense, curled, and adult in distribution but is less abundant. Sexual maturity rating 5: abundant, adult-type pattern; hair may extend on the medial aspect of the thighs.
Figure 58.2. Female breast development. Sexual maturity rating 1: prepubertal, elevations of papilla only. Sexual maturity rating 2: breast buds appear, areola is slightly widened and projects as small mound. Sexual maturity rating 3: enlargement of the entire breast with no protrusion of the papilla or of the nipple. Sexual maturity rating 4: enlargement of the breast and projection of areola and papilla as a secondary mound. Sexual maturity rating 5: adult configuration of the breast with protrusion of the nipple, areola no longer projects separately from remainder of breast.
Figure 58.3. Male genital and pubic hair development. Sexual maturity rating 1: prepubertal, no pubic hair, genitalia unchanged from early childhood. Sexual maturity rating 2: light, downy hair develops laterally and later becomes dark; penis and testes may be slightly larger; scrotum becomes more textured. Sexual maturity rating 3: pubic hair is extended across pubis; testes and scrotum are further enlarged; penis is larger, especially in length. Sexual maturity rating 4: more abundant pubic hair with curling, genitalia resemble those of an adult, glans has become darker. Sexual maturity rating 5: adult quantity and pattern of pubic hair, with hair present along the inner borders of the thighs. The testes and scrotum are adult in size.
The history obtained at a reproductive health visit should include 2 parts: the medical history, which in females focuses primarily on the gynecologic history, and the psychosocial interview. Regardless of the type of visit scheduled, the physician should take a few moments at the beginning of the interview to address routine health maintenance issues with the adolescent (Box 58.2). For the female patient, the primary care physician should ask whether she has ever undergone a genital or pelvic examination. Additionally, current methods of contraceptive use, if any, should be reviewed (Box 58.3). If the adolescent female has just started taking oral contraceptives, compliance, common side effects, and a review of the more emergent complications of birth control pills is warranted, especially at an initial visit. The acronym ACHES (abdominal pain, chest pain, headaches, eye problems, severe leg pain) is useful to remember life-threatening reactions that can be associated with hormonal contraceptive use (Box 58.4), although these reactions are uncommon in otherwise healthy adolescent girls. If the adolescent is using another form of contraception, adherence to and satisfaction with the particular method should be reviewed along with the respective common side effects. The physician should specifically inquire if the adolescent desires to continue the same method of birth control or is interested in another method.
Box 58.2. What to Ask
For Males and Females
•How is the adolescent feeling overall?
•Has the adolescent had any recent illnesses or conditions that the health professional should know about?
•When was the last physical examination performed? Did it include a genital or pelvic examination?
•Is the adolescent sexually active?
—If so, are their sexual relationships with males, females, or both?
—When was the last episode of vaginal or anal intercourse?
—Was the last episode of sexual intercourse protected or unprotected?
—Does the adolescent have oral sex?
—How old was the adolescent when he or she they began having sexual relationships? Was it consensual? Coerced? Forced?
—How many sexual partners does the patient have currently? How many sexual partners has the patient had in his or her lifetime?
•Is there any history of or ongoing physical or sexual abuse?
•Has the adolescent or any of the adolescent’s partners ever been treated for a sexually transmitted infection or tested for HIV?
For Females Only
•What was the age at menarche?
•What was the date of the last menstrual period and the duration and amount of flow?
—Are any symptoms, such as cramping, bloating, or vomiting, associated with menses?
—Are any of these symptoms incapacitating? Do they cause the adolescent to miss school or work?
—Does the mother or do any siblings have similar problems? If so, how do they manage them, if at all?
Box 58.3. What to Ask
•Does the adolescent use condoms never, sometimes, or always?
•Is any other method of birth control also used?
•Is the adolescent female currently using oral contraceptives?
—If so, what particular type is she taking, and how long has she been using this method of contraception?
—How often does she miss taking the pill? What does she do when she fails to take the pill?
—Does she experience common minor side effects, such as breakthrough bleeding, headache, or nausea?
•Is the adolescent female using a long-acting progestin, such as Depo-Provera? If so, has she experienced irregular bleeding, weight gain, hair loss, headache, or acne?
•Is there another method of contraception that the adolescent has used or might be interested in discussing or starting, such as long-acting reversible contraception?
•What does the adolescent know about emergency contraception?
Box 58.4. Danger Signs Associated With Oral Contraceptive Use
A Abdominal pain (severe)
C Chest pain (severe) with shortness of breath
E Eye problems (visual loss or blur)
S Severe leg pain (calf and/or thigh)