Adolescent Gynecology

Steven Collins, M.D.

Facilitator Role of the Health Care ProWe need to encourage our parents to be good role

vider

models, to really have open discussions with their

children at age appropriate levels.






Promote parent-child interchange about sexuality

Encourage parents to be good role models
Encourage open discussion at age-appropriate levels
Provide quality education through pamphlets, one on one
counseling, being involved in community programs

Life skills training, role playing and motivational interviewing

Normal Menstrual Cycle Parameters

Menstrual cycle parameters. Remember that menarche




is around 12.5 years of age. That 90% of females reach

90% of females have had menarche by sexual maturity rating

menarche by the completion of sexual maturity rating of






Median age on onset 12.7 years

4. Most cycles are about 28 days. With 3-7 days of flow

Cycle length is 21-35 days

3-7 days of flow (>8 days considered abnormal)
Normal blood loss is 30-40 mL (>80 abnormal)
Regular ovulatory cycles may not be established for up to 2
years after menarche.

with normal blood loss of 30-40 cc; anything greater than

80 cc is considered abnormal. The first couple of years
the periods can be very abnormal with a couple of
periods a month or a period not occurring for a month or
two. Anything that happens in the first couple of years is
probably just a variation with the exception of extreme
heavy or prolonged bleeding that may cause anemia
which at that point may need some intervention.

Physiologic Leukorrhea

Physiologic leukorrhea commonly occurs before menarche, and this is important to recognize so that we can




reassure and tell people not to worry about. It is fully

Usually described as copious, whitish mucoid discharge with

expected and to really make the diagnosis is to do a wet

no odor or irritation

Commonly precedes menarche 3-6 months

mount or even a Gram stain of the vaginal secretions and

Diagnosis made by wet mount with epithelial cells without

evidence of inflammation, absence of infections

Treatment consists of symptomatic care.

see the epithelial cells. There may be some bacteria

around but certainly not any white cells or clue cells or
other abnormal findings. We really just need to continue
to reinforce that there is nothing wrong, this is normal and
it is the first sign that menarche is on the way, usually
within three to six months.

Genital Discharge
When we see people with genital discharge, we really do

Detailed sexual history including:

need to take a very detailed sexual history including

menarche

menarche, tampon and/or condom use. Unfortunately,

tampon and/or condom use

early adolescents often will give you an answer like, "I

gravidity/pregnancies caused and outcome - contraceptive methods - number of partners - prior infections

description of discharge e.g. pruritic, odorous, quantity,

onset, color, consistency

don't know. I never look." You need to know gravidity or

pregnancies and what happened with those pregnancies.
Contraceptive methods used. Number of partners. Prior
infections and also a description of what the discharge
looks like, smells like, etc.

Genital Discharge--Physical Exam

The physical exam is very important with a good external

exam including the inguinal region as well as the pubic
hair area. Remember to look for bugs. We also want to





Good external exam including inguinal region and pubic hair

do a good abdominal exam and take vaginal samples as

Abdominal exam

appropriate. In a prepubescent child or someone with a

Vaginal samples

very small hymenal opening, then a vaginal swab is okay.

Blind vaginal swabs appropriate in young girls (12 to 13)

if virginal and exam consistent

Speculum exam preferred in older girls and those who

In someone who is sexually active, it is preferable that we

go ahead and do a pelvic exam with a speculum so that
you can have an endocervical sample.

are sexually active to examine and sample the cervix

Genital Discharge--Lab Samples

As far as lab sampling, the vaginal pool is appropriate for

wet mount. For sexually active males, leukocyte esterase




urine dipstick is an excellent screening tool. It's very, very

For sexually active, urine leukocyte esterase dipstick in males

sensitive with 99% plus sensitivity for picking up pus

for screening purposes

Vaginal pool for wet mount

basically which is then an indication that you need to do

For sexually active, urethral/endocervical cultures for N.

gonorrhea and C. trachomatis

Other cultures, e.g. Herpes, as appropriate

cultures. For the sexual active, you want to do urethral or

endocervical cultures for Neisseria gonorrhea and
Chlamydia and then of course other cultures as appropriate based on the physical exam.

Neisseria Gonorrhea
Gonorrhea in males can be diagnosed with a Gram stain

for white cells that contain the small Gram-negative

diagnostic for urethral sample in males; it is only suggestive in

intracellular diplococci. In males that is diagnostic. In

females

Gram stain with gram negative intracellular diplococci is

females you need to do a culture, because other bacteria

Good standard for diagnosis is culture, usually Thayer-Martin

media in a facultative anaerobic environment

Penicillin resistance increasing (both beta-lactamase and

chromosomally mediated)




can interfere with the reading of the Gram stain and be

confusing. So all health departments require, for female
diagnosis, that a culture be completed and the gold
standard is the culture. There are excellent transport
medias and the little culturette tubes can be easily taken

Can be concurrent with other STD's such as chlamydia

to the laboratory and then at that point is when they are

Complications

put in the facultative anaerobic environment. Penicillin

Pelvic Inflammatory Disease (main sequelae is infertility)

resistance is increasing so most people have switched to

Disseminated disease

not using penicillin for gonorrhea treatment.

Perihepatitis (Fitz-High-Curtis syndrome)

Bartholin's gland abscess

Certainly gonorrhea can occur concurrently with other

STDs like Chlamydia, and when you are treating for
gonorrhea you need to cover for Chlamydia also. There
is also perihepatitis or Fitz-High-Curtis syndrome where
you can see through a laparoscopic view the fibrous
bands and the inflammation that can occur in the liver.

Gonorrhea Treatment
Treatment of uncomplicated gonorrhea, not including






Ceftriaxone 125 mg IM x 1 or

perihepatitis or the disseminated gonorrhea. You do need

Cefixime 400 mg orally x 1 or

to cover for Chlamydia either with doxycycline or

Ciprofloxacin 500 mg orally x 1 or

azithromycin. At our center, we personally like the second

Ofloxacin 400 mg orally x 1

PLUS




choice of cefixime because it is an oral dose. We can

watch them take it. It doesn't inflict pain.

Doxycycline 100 mg BID orally x 7 days or

Azithromycin I gm orally x I

Chlamydia Trachomatis
Chlamydia. This is the most common bacterial sexually







Most common bacterial STD

transmitted disease. It is a very common cause of

Most common cause of urethritis in males

urethritis in males, and it is very commonly asymptomatic

Commonly asymptomatic in males and females

in both males and females, probably more likely to be

Intracellular in columnar epithelial cells

Gold standard for diagnosis and the only test allowed for
sexual abuse cases is culture but this is expensive and may
not be readily available

asymptomatic in males. It is an intracellular organism

found in the columnar epithelial cells. Therefore, if you
are diagnosing by culture, you really have to use a good
technique with cyto brush and get in the endocervix and
"roto-rooter" out some cells. Don't just barely dab any-

urethra at least 2.5-3 cm and "roto-rooter" as you come

Must know sensitivity and specificity for each test available in

in. We went to PCR which is very sensitive. In some

clinical setting.

centers when you compare PCR to cultures, there

Complications

actually isn't a whole lot of difference in cost. The

thing. If you do a urethral slide, you've got to get down the

direct fluorescent antibody(DFA), enzyme immunoassay (EIA).

Other methods include polymerase chain reaction (PCR),

endocervix will often have a clear to whitish discharge

Same as gonorrhea

Treatment

Doxycycline 100 mg orally BID x ? days or -

that is present with Chlamydia.

The gold standard for the diagnosis of Chlamydia,

Azithromycin 1 gm orally once

especially in sexual abuse cases is culture. There are

Follow up for gonorrhea and chlamydia Test of cure not

several other methods such as direct fluorescent anti-

necessary but may want to consider rescreen due to

body (DFA) and enzyme immunoassay (EIA).

possible reinfection risks

HIV, RPR as indicated

Treatment is doxycycline or azithromycin. For the

followup of both gonorrhea and Chlamydia, it is important
and we always ask people to please rescreen for syphilis
and HIV at the same time with a repeat somewhere down
the line, hopefully two to six months later.

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Trichomonas Vaginalis
Trichomonas vaginalis is a flagellated protozoa. Once




you've seen a lot of Trichomonas you can almost diag-

Not always sexually transmitted, may be spread by fomite but

nose it without a wet mount or culture because of this

be cautious of abuse in prepubertal children

Flagellated protozoa

bubbly green discharge that you see in the vagina. The

Yellow-green, frothy malodorous discharge in females, usually

asymptomatic in males

Punctate hemorrhages and swollen papillae often described

as a "strawberry cervix"

bubbles come from that little flagella flipping around. It is

like a mixer in there mixing the air with the discharge. It
is not always sexually transmitted. It can be fomite
spread. But in prepubescent children, sexual abuse must
be the diagnosis until proven otherwise. Also, the cervix

punctate hemorrhages and swollen papillae that can

Culture (Diamond's) is available to increase positive find rate

occur with Trichomonas. The flagellated organism can be

but is expensive

can be described as a "strawberry cervix" because of

wet prep, along with increase white cells

Diagnosis usually made by seeing flagellated organisms on

multi-flagellated. The Diamond's culture is available. It is

Treatment

very time consuming and therefore a very expensive test.

Metronidazole 2 gm orally once

screening for concomitant infections such as syphilis

and HIV

In our center, we pick up about 50% more Trichomonas

for diagnosis than only doing wet mount and that includes
staff physicians as well as medical technologists. Treatment for Trichomonas is metronidazole 2 gm orally taken
at once. The way we usually prescribe it is to take it with
a cracker. You can either use the 250 mg tablets which
are cheaper or the 500 mg tablets and then depending on
which one you are using, I have them take one tablet
every five minutes or one tablet every few minutes along
with a cracker in between to help calm their stomach.
Again, be aware of looking for syphilis and HIV.

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Bacterial Vaginosis
Bacterial vaginosis is also not necessarily a sexually




Not necessarily sexually transmitted

transmitted disease but in those people who are sexually

Associated with Gardnerella vaginalis, anaerobic organisms

active it most commonly is. It is associated with

and Mycoplasma hominis with an absence of normal

Gardnerella and other organisms with the absence of the

hydrogen-producing lactobacilli

Three of four criteria must be present for diagnosis of bacterial

vaginosis:
-

usual lactobacilli. Three of the four criteria presented up

here must be present. The positive whiff test is when you
take the vaginal secretions and add 10% KOH, which
releases a very fishy foul smelling odor. When you sniff
the tube, hold the tube and wave your hand over it. It's a

vaginal discharge

little like Chinese mustard. It has that same effect if it's a

Vaginal pH >4.5

real good one. What shows on the slides are clue cells

Positive whiff test

and the way I describe clue cells is if you remember what

Gray-white, thin, homogeneous, non-inflammatory

Clue cells on wet prep

the normal epithelial cell looked like, it kind of looks like

Treatment for bacterial vaginosis

a fried egg with the nucleus being the yolk. A clue cell is

Metronidazole 500 mg BID x 7 days or

Clindamycin cream (2%) one applicator intravaginally at

bedtime for 7 nights or

a fried egg with too much pepper on it.

Treatment for bacterial vaginosis is metronidazole 500

mg twice a day for seven days or one of the gels or

Metronidazole gel (0.75%), one applicator intravaginally

creams. I personally am trying to push that we use

qhs x 5 days

clindamycin treatment in our center. I think that we should

reserve metronidazole for Trichomonas because there
really is nothing else that works against Trichomonas at
this point and I really hate to think about a resistant
Trichomonas infection.

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Human Papilloma Virus (HPV)

Human papilloma virus. This is the virus that causes






Most prevalent STD in US

genital warts. It is the most prevalent sexually transmitted

Causes genital warts

disease in the United States. This should be nice and

May be detected on Pap smear in asymptomatic patients

Treatment and follow up changing

smooth and everywhere you see the little bump is

basically a growth of the virus.

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Pelvic Inflammatory Disease (PID)

Pelvic inflammatory disease. Abdominal pain, cervical

Diagnostic criteria

motion tenderness and adnexal tenderness and then one

MUST HAVE abdominal pain, cervical motion tenderness

or more of the following things that are listed in your

and adnexal tenderness

PLUS one or more of the following:
- Temperature 38 degrees C. or higher

handout. We consider every adolescent high risk, the

recommendation is you admit everybody primarily for
compliance and education. There is a lot to deal with
when someone comes down with PID, with the family,

- Leukocytosis of 10,000 WBC/mm3 or more

with the contraception and all the other issues. This can

- Purulent material from culdocentesis

be a very devastating diagnosis and unfortunately

- Pelvic abscess or inflammatory complex on bimanual

sometimes it is the first clue the family has that their child

exam or sonography

is sexually active.

- Elevated ESR or CRP

- Evidence of gonococcal or chlamydial cervicitis

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Treatment of PID


Consider all adolescents for inpatient treatment due to risk of

noncompliance

Along with antibiotic treatment, education and assessment of

the adolescent's social situation is essential

Strongly encourage contraception during hospitalization, if

needed. Continue OCP's during hospitalization if currently
prescribed

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Contraception
Contraception. Most adolescents seek professional

consultation for contraception six to 12 months after

months after initiating sexual activity

Most adolescents seek professional consultation 6 to 12

initiating sexual activity. Of course, there are various

Various forms

forms of contraception including abstinence, which still is

Abstinence is still the only safe sex

Withdrawal or coitus interruptus
Barrier methods (not used well by teens)

the only safe sex method. Then of course the barrier

methods that are used. None of the methods are used
terribly well by teenagers.

Condoms, foam. diaphragm with jelly, cervical cap

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Oral Contraceptive Pills

For females the most common form of birth control is oral

Benefits

contraception. There are many benefits. The ones that

Decreased risk of endometrial and ovarian cancer

are catching a lot of attention nowadays are the acne

Lowered incidence of benign breast disease

improvement and decreased hirsutism.

Improvement in dysmenorrhea. ovarian cysts, bone density,

dysfunctional bleeding, anemia
Protective effect against PID
Decreased ectopic pregnancy -Acne improvement and
decrease hirsutism

17

Oral Contraceptive Pills

There are risks and disadvantages and the biggest one

Risks and disadvantages

is that it must be taken every day, of course. The ones

Must be taken every day

that we hear about the most are still nausea and vomiting

Nausea or vomiting

and fear of weight gain.

Headaches
Depression or other mood changes
Decreased libido
Cervical ectopia and increased risk of Chlamydia cervicitis
Thrombophlebitis, pulmonary emboli
Hepatocellular adenomas

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Depo-medroxyprogesterone Acetate
(Depo-Provera)

Other forms of birth control. Depo-medroxyprogesterone

acetate injection or Depo Provera has a lot of benefits.

The biggest one, to me, is that it is a highly effective

Benefits

method and all they have to do is come in every 12

- No estrogen

weeks to get their shot and it is just wonderful. We have

- Long term contraception

our teenagers come in, which gives us a week grace

- Low risk of ectopic pregnancy

period, if you will.

- No tell-tale signs of using contraception (vs. pill packs or

implants under skin)
- Highly effective method
- May decrease frequency of seizures

As far as risks and disadvantages, the biggest thing is

weight gain. Bone density decreases with prolonged use
of Depo Provera and that they have to come back in. It
would just be wonderful if you could make this happen via
satellite or something. But they do have to come in. The

Depo Provera

slide on the right, again, is strictly to point out that over

here we have Depo Provera and we are talking about

Risks and disadvantages

- Amenorrhea or irregular bleeding (some worry about being
pregnant because of no periods)

failure rates. Other methods are compared and it is right

over here and it is the absolute best you can do as far as
birth control.

- Weight gain
- Breast tenderness
- Bone density decrease with prolonged use
- Depression
- No immediate discontinuation
- Return visits every 12 weeks

19

Progestin Implants (Norplant)

Progestin implants, or Norplant, was en vogue for a very

Benefits

short time with adolescents and then lost vogue once

- No estrogen

Depo Provera came around. The nice thing was it was

- Long-term contraception (5 yr)

- Low risk of ectopic pregnancy
- Immediate reversibility

highly effective, long term, excellent birth control. Kids

are afraid of the procedure. It is a big unknown and it was
described as a procedure or a surgical technique. They
had to be scheduled specially to come in to get the

- Requires no further compliance after insertion until removal

Norplant inserted and you have to take them back out.

Risks and disadvantages

We haven't put a Norplant in for about three and a half

- Menstrual cycle disturbances, often excess bleeding

years and I think that is pretty much the experience with

- Weight gain

adolescents across the country. It still is used in older

- Breast tenderness

populations and again it is an excellent form of birth

- Interaction with anticonvulsants, which decreases effective-

control but not for teens.

ness to unacceptable rates

- Difficult removal
- High initial cost
- Fear of pain for insertion

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Compliance Issues


Increased compliance is associated with a perceived lack of

side effects, older age of the user, and satisfaction with the
selection of method

Many adolescents may discontinue birth control for the

following reasons:
Side effects-perceived or real
Lack of support by significant others (eg, parents, peers,
partners)
Lack of concern for self or the future
Ambivalence about becoming pregnant
Low self esteem
Desire to please others (ie, willing to become pregnant
because the boyfriend or grandparent wants a baby)
Inability to take a pill daily or to have access to care, such
as lack of transportation

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References

1.

Emans S J, Goldstein, DP. Pediatric and Adolescent

Gynecology, Third Edition. Boston: Little, Brown and
Company, 1990.

2.

Friedman SF, Fisher M, Schonberg SK. Comprehensive

Adolescent Health Care. St. Louis: Quality Medical Publishing, Inc., 1992.

3.

Hatcher RA, Stewart F, Trussell Jet al. Contraceptive

Technology, Sixteenth Edition, New York: Irvington Publishers, 1994.

4.

Holmann AD, Greydanus DE. Adolescent Medicine,

Second Edition. California: Appleton & Lange, 1989.

5.

Holmes KK, Mardh PA, Sparling PF, et. al. Sexually

Transmitted Diseases, Second Edition. New York: McGrawHill, Inc., 1990.

6.

McAnarney ER, Kreipe RE, Orr DP, Comerci GD. Textbook

of Adolescent Medicine. Philadelphia: W.B. Saunders
Company, 1992.

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