Article Figures & Data
Tables
Service Recommendation Agency Grade* STI counseling High intensity 3–9 Hours of counseling conducted over multiple sessions and in groups USPSTF B Brief/short Single session or intervention lasting <30 minutes USPSTF I Cervical cancer screening (cytology) Do not screen before age 21 USPSTF D HPV testing Do not use for screening in those younger than 30 USPSTF D HPV vaccination Before onset of sexual activity at age 11 to 12 years, no earlier than age 9 years, in both females and males ACIP A Folic acid supplementation 400–800 μg of folate for all women of reproductive age to prevent neural tube defects USPSTF A ↵* Grade of recommendations is based on USPSTF definitions: A = high certainty of substantial benefit/offer or provide service; B = high or moderate certainty of moderate or substantial benefit/offer or provide service; C = likely only a small benefit for most individuals without signs or symptoms/may provide service to selected patients based on individual circumstances; D = moderate or high certainty of no benefit or harms outweigh benefits/recommend against service; I = evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.
Data taken from U.S. Preventive Services Task Force1⇓–3 and the Centers for Disease Control and Prevention.4
ACIP, Advisory Committee on Immunization Practices; HPV, human papillomavirus; STI, sexually transmitted infection; USPSTF, U.S. Preventive Services Task Force.
- Table 2. Summary of U.S. Preventive Services Task Force (USPSTF) Screening Recommendations for Sexually Transmitted Infections (STIs) in Adolescent Women
STI Screening Low risk High risk Pregnant Chlamydia A A B* Gonorrhea B B B* HIV C A A Herpes D D D Syphilis D A A Hepatitis B D D A HPV D D D Grade of recommendations are based on USPSTF definitions: A = high certainty of substantial benefit/offer or provide service; B = high or moderate certainty of moderate or substantial benefit/offer or provide service; C = likely only a small benefit for most individuals without signs or symptoms/may provide service to selected patients based on individual circumstances; D = moderate or high certainty of no benefit or harms outweigh benefits/recommend against service.
↵* Screen during the first and third trimesters.
Urge adolescents to use LARC methods such as the IUD, contraceptive implant, or DMPA.
Provide COCs, DMPA, and condoms without requiring a complete gynecological exam. Pap smears are not recommended until age 21.
Develop clear office policies on confidentiality for adolescent patients, and share these policies with patients, parents, and staff.
Provide free condoms to adolescents.
Use advance provision of EC for adolescents (with refills).
When prescribing OCPs, prescribe at least 3 months' worth of pills, and consider prescribing an entire year's supply.
Include troubleshooting with adolescents when discussing contraception choices (eg, “How will you remember to take your pill every day? Can you set a reminder on your cell phone?”)
Provide hands-on teaching with condoms and facilitate role-playing to help adolescents improve negotiating skills.
COC, combined oral contraceptives; DMPA, contraceptive injection; EC, emergency contraception; IUD, intrauterine device; LARC, long-acting reversible contraceptive; OCP, oral contraceptive pill.
Acyclic or cyclic pelvic pain, often with radiation to back or lower extremities Dysmenorrhea Abnormal uterine bleeding and associated cramping Deep dyspareunia Gastrointestinal symptoms- abdominal pain, nausea, diarrhea, constipation Symptoms are usually severe enough that the adolescent has missed school or other activities. Many of these patients have previously presented to an emergency department or another physician because of the pain. Chronic pelvic pain Adhesions Tubal occlusion Increased risk of ectopic pregnancy Infertility Recommendation Level of Evidence Transvaginal ultrasound is the imaging modality of choice in the initial evaluation of pelvic pain. A OCPs do not improve regression rates of ovarian cysts and should not be used for this purpose. A Initial treatment of endometriosis includes OCPs and NSAIDS. Patients will do better with a monophasic pill with a higher estrogen content (30–35 μg). A Dysmenorrhea should be managed with NSAIDs and OCPs. If symptoms do not improve, a work-up for secondary dysmenorrhea should be considered. A OCP, oral contraceptive pill; NSAID, nonsteroidal anti-inflammatory drug.
Causes Incidence Clinical Findings Treatment Structural/anatomical abnormalities Mullerian agenesis 1/4,000 to 1/10,000 Amenorrhea with normal external genitalia, but absent upper genital tract Support, counseling Rare; increasingly worsening cyclical pelvic pain (if rudimentary uterus present) Surgical removal of remnant Inability to have intercourse Surgical creation of neovagina Androgen insensitivity 1/60,000 Amenorrhea with normal external genitalia, vaginal “dimple,” absent uterus and cervix, testes in abdominal cavity or inguinal canal Support, counseling Possible surgical creation of neovagina Removal of testes (age 20) Imperforate hymen 1/1000 Amenorrhea with cyclic abdominal pain, hematocolpos, hematometra, hemoperitoneum Surgical removal of the hymenal tissue Bluish and bulging hymen Primary hypogonadism Gonadal dysgenesis Varies depending on etiology Varies depending on etiology Varies depending on etiology Premature ovarian failure 10% to 28% of women with primary amenorrhea History of ovarian injury (surgical, chemotherapy, radiation therapy), autoimmune disease, or chromosomal disorder Support, counseling, risk reduction for osteoporosis and cardiovascular disease Estrogen replacement Fertility assistance HPA axis dysfunction Functional hypothalamic amenorrhea Most common form of amenorrhea in adolescence Low levels of estrogen, LH, and FSH Correct underlying cause of hypothalamic dysfunction Anorexia nervosa, excessive exercise, excessive stress Promote bone mineral density OCPs Kallman syndrome Rare genetic disorder Amenorrhea, lack of pubertal development, anosmia Hormone replacement therapy, BMD monitoring Hyperprolactinemia Cause of 1% of primary and 15% of secondary amenorrhea Elevated prolactin level, hypothyroidism, antipsychotic medication use MRI of pituitary fossa for refractory or excessive prolactin level (>100 ng/mL) Galactorrhea is rare Bromocriptine Multifactorial PCOS Oligomenorrhea, hirsutism, acne, obesity, insulin resistance Weight loss, exercise, OCPs for menstrual regulation, insulin sensitizing medication (eg, metformin) to treat hyperinsulinemia Data from Refs. 42⇓–44.
BMD, bone mineral density; FSH, follicle-stimulating hormone; HPA, hypothalamic-pituitary axis; LH, luteinizing hormone; MRI, magnetic resonance imaging; OCP, oral contraceptive pill; PCOS, polycystic ovarian syndrome.
- Table 8. Clinician Resources on State-Specific Laws About Adolescent Reproductive Health Care
Website Resources www.guttmacher.org Specific information on state policies on minor consent laws, access to reproductive health services, and parental rights www.prch.org Physicians for reproductive health and choice has developed cards on minors' access to reproductive health services for 13 states www.cahl.org The center for adolescent health and the law has for purchase a summary of state minor consent laws
