This is a 14 year old female who is brought to the Teen Health Clinic by her mother with a chief complaint of "missed periods" for 2 months. She experienced menarche at age 13. She believes her menses have been "more or less" regular but she has never kept track. She cannot remember the exact date of her last menstrual period. She states that when she has her menses, she has pain that is occasionally bad enough that she misses school. Her mother reports that her daughter has not had a period in at least two months and she wants you to test her for pregnancy and screen her for any sexually transmitted diseases (STD). She vehemently denies any sexual activity. She states that she feels perfectly fine and refuses to have a pelvic exam performed.

PMH: Unremarkable. No history of bleeding disorders. No current medications.

FH: Mother experienced menarche at age 13. No FH of bleeding disorders, gynecological tumors or other gynecological problems.

ROS: Unremarkable

Exam: VS are normal. Height and weight are 75th percentile for age. She is a well developed, adolescent female, in no acute distress. Non-hirsute. HEENT exam is normal. You ask her mother to step outside for the pelvic exam. While she is outside, you continue your questioning. She admits that she is sexually active. She uses condoms "sometimes" but her boyfriend doesn't like them. She states that she couldn't possibly have an STD because her boyfriend is "not that kind of person." She asks if you could give her some type of birth control and keep the conversation a secret from her mother. You explain carefully the need for a thorough gynecological exam and how the exam will be done. After talking with you a while, she agrees to have the pelvic and STD screen. She declines an HIV test.

Breasts: Tanner stage 4. Pelvis: Pubic hair tanner stage 3. Genitalia: Normal outward appearance. No malodor or discharge at the introitus. No vesicles, ulcers, or other lesions. Speculum/Pelvic Exam: Normal-appearing, nulliparous cervix. A Pap smear is performed and cervical swabs are obtained. No cervical motion tenderness is present. Non-gravid sized uterus palpable, without masses. Bilateral ovaries non-enlarged. No adnexal tenderness. The rest of her exam is normal.

Labs: UCG (-), WBC 7.0, Hg 13.8, Hct 40%, Plt 200, serum iron 100ug/dL, ferritin 80 ng/mL, RPR (-). A wet mount and KOH test are negative for yeast infection, bacterial vaginosis, or trichomonas. The GC and chlamydia assays are negative.

Clinical Course: After discussing contraceptive options with the patient, she decides on the combined oral contraceptive pill. She is counseled on monitoring her menses. Before she leaves, you warn her about HIV and STDs, and encourage condom use.

One month later, you get a call from her mother who is upset when she sees her medical insurance statement which shows an itemized expense list which contains a pregnancy test, a gonorrhea culture, and a prescription claim for birth control pills. She demands an explanation.

When dealing with the adolescent patient, it is important to remember that the adolescent is the patient, even if she is accompanied by a parent, usually the mother. At this stage of development, many adolescents are struggling to assume an adult identity and the patient may resent being talked about in her presence as though she wasn't there. She may have concerns that are different from an adult. An adolescent will likely be anxious about the gynecological exam. She may be afraid that it will be painful, and will likely be embarrassed about undressing (1). In allaying such fears, it would be helpful to direct the majority of the initial discussion toward the adolescent and to explain the exam completely. Speaking to the mother alone is useful for obtaining family history that may be pertinent and for uncovering any concerns that she may have. The patient may be suspicious of your private conversations with her mother. Often, the patient can be reassured by telling her what was discussed. Patients in this age range are often modest about the changes taking place in their bodies, and it is often best to leave it up to the girl whether she wants her mother present during the exam. It is important to speak to the patient alone at some point because she may have information that she is reluctant to reveal in the presence of her mother.

When attempting to solicit information about her menstrual cycles, it is best to ask specific questions regarding the frequency of menstrual flow, length of menses, and the amount of blood lost. Do not accept without question the patient's assurance that her periods are "normal" or "regular". When assessing the amount of blood lost, the patient should be asked how long it takes to soak through a tampon or pad, if she ever has to awaken in the night to change a pad, or if she has to use both methods at once. It is not enough to simply note how many pads or tampons the patient uses in a day because she may change pads as soon as one is soiled, wait until it is soaked, or change it according to her class schedule which dictates when she can make it to the restroom.

Menarche is the onset of menstruation in girls. As the hypothalamic-pituitary-gonadal (HPG) axis matures during puberty, the hypothalamus begins pulsatile secretion of gonadotropin releasing hormone (GnRH). GnRH stimulates the pulsatile secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) from the pituitary, approximately every 90-120 minutes. In turn, LH stimulates the theca cells of the ovary to secrete androstenedione, testosterone, and estradiol. FSH increases the number of granulosa cells in the ovarian follicle and promotes the conversion of androstenedione to estradiol in the granulosa cells. Estradiol promotes the formation of uterine endometrial glandular cells and stroma. Menarche occurs when estrogen levels are sufficient to stimulate proliferation of the uterine endometrium. Estradiol also stimulates the development of the follicle and its levels increase in puberty until ovulatory cycles are established. The rising estradiol levels positively feedback to stimulate an LH surge, prompting ovulation. Following menarche, plasma estradiol levels range from 50-200 pg/ml during the follicular phase, while progesterone levels range from 200-2500 ng/dl (average 750) during the luteal phase (2).

Menarche in North American girls occurs at a mean age of 12.7 years, with a range of 10-16 years, and occurs an average of 2 years after the onset of breast development (2,3). The majority of cycles within the first 2 years after menarche are anovulatory, and there tends to be great variance in cycle interval, duration of flow, and amount of blood loss. Cycle intervals may be as long as 6 months and continue to be irregular for the first 15 cycles (2,4,5,6).

Dysfunctional Uterine Bleeding

In a normal cycle, an average of approximately 35 mL blood is lost (range 20-60 mL) (7). The amount of blood loss is difficult to estimate by sight. A good guideline may be to consider 8 pads or 12 tampons, well soaked, as the upper limit of normal; however even these estimates are user-dependent and may not correlate well with actual blood loss. The normal duration of flow is 3-7 days, with >7 days considered prolonged. A normal cycle interval ranges from 21-35 days, with less than 21 or more than 35 days considered abnormal (8).

Until ovulatory cycles are established in the adolescent, endometrial proliferation occurs without progesterone regulation. The endometrium grows until the level of estrogen cannot sustain it, resulting in endometrial sloughing. In the adolescent, this results in cycles that are irregularly regular until regular ovulation is established. Although cycle lengths will vary, they tend to stay within the normal range. The time to develop ovulatory cycles is dependent on the age at which menarche occurs. When the ages of menarche were <12.0 years, 12.0-12.9, and 13.0 years or greater, it took, respectively, 1, 3, and 4.5 years to attain 50% ovulatory cycles (9). The same study demonstrated that it may take 6-7 years to attain 90% or greater ovulatory cycles. Most importantly, although most menstrual cycles in early adolescence are anovulatory, truly abnormal bleeding is rare.

Classification of Abnormal Uterine Bleeding in the adolescent (8):

Menorrhagia (hypermenorrhea): Prolonged (more than 7 days) or excessive (>80 ml) of uterine bleeding occurring at regular intervals.

Polymenorrhea: Regular episodes of uterine bleeding occurring at intervals of <21 days.

Metrorrhagia: Uterine bleeding occurring at irregular intervals with variable amount of flow.

Menometrorrhagia: Irregular and frequent bleeding, which may be excessive in amount and/or prolonged in duration.

Oligomenorrhea: Irregular bleeding episodes occurring at intervals of 35 days to 6 months.

Amenorrhea: No menses for at least 6 months.

Intermenstrual bleeding: Bleeding episodes occurring between regular menstrual periods.

Postcoital bleeding: Bleeding occurring after sexual intercourse.

Hypomenorrhea: Decreased amount of uterine bleeding occurring at regular intervals.

Dysfunctional uterine bleeding: Excessive uterine bleeding with no demonstrable organic cause.

The most common cause of excess irregular bleeding in the adolescent is dysfunctional uterine bleeding (DUB), comprising 50% to 97% of causes (10,11,12). The most common etiology of DUB is anovulatory cycles, but this can only be diagnosed after all organic causes have been ruled out. Included in the differential for an adolescent who presents with excessive uterine bleeding are: Pregnancy, spontaneous abortion, trauma, foreign bodies in the vagina, complications of contraceptive devices or hormones, infection, coagulation defects, platelet abnormalities, leukemia, drugs or medications, polycystic ovary disease, or endocrine disorders such as hypo/hyperthyroidism, Addison's or Cushing's disease. Although polyps, myomas, tumors, or endometriosis may be included in the differential, in contrast to the mature woman, diseases of the uterus are rarely the cause for irregular uterine bleeding in adolescents (10,11,12).

A common clinical problem seen by physicians is the adolescent who presents with irregular intervals of bleeding that is normal in duration and amount of flow. For most of these adolescents, reassurance and observation are usually sufficient. The adolescent should be encouraged to keep a record of duration of menses, cycle interval, and amount of bleeding. Bleeding that is outside of normal parameters requires further evaluation (13). Signs of chronic disease, polycystic ovary disease, endocrine abnormalities, or blood dyscrasias, if present, should be evident in the physical exam with corresponding symptoms obtained in the history. The evaluation of abnormal uterine bleeding in the adolescent also requires a thorough gynecological exam. If the bleeding is active, the site of bleeding should be determined, as occasionally rectal or urethral bleeding may be mistaken for menstrual spotting. A speculum exam should be performed to inspect for signs of infection, trauma, foreign bodies, or evidence of contraceptive devices. Cervical cultures, a wet mount, and a Pap smear are obtained as necessary. Vaginal irrigation may be used to obtain these samples in the patient who will not tolerate a speculum exam. A bimanual pelvic exam is used to check for cervical motion tenderness, adnexal tenderness, and masses. A single-finger digital palpation is adequate for most adolescents, but if the hymenal orifice is still too small for a single-digit exam, a rectoabdominal bimanual palpation may be done instead. Initial laboratory evaluation should include a CBC, coagulation studies, serum iron and ferritin, and urine or blood HCG. The following studies should be added if clinically indicated: thyroid studies, prolactin level, glucose, STD screen, hormone levels to evaluate for hirsutism or polycystic ovary disease (DHEAS, testosterone, 17-OH progesterone, LH, FSH). A pelvic ultrasound, endometrial biopsy, or pituitary CT may be added if warranted. Surgical interventions, such as a hysteroscopy and D&C are diagnostic methods of last resort (13).

After organic, systemic, and iatrogenic causes are ruled out, the abnormal bleeding may be diagnosed as dysfunctional uterine bleeding (8). Most adolescents with irregular bleeding in the first two years following menarche do not require long term management (10). If the bleeding interferes with the patient's daily activities or is severe enough to cause anemia, treatment is recommended. If anovulation is the suspected etiology, the initial hormonal intervention should be progestin therapy to initiate a secretory change of the endometrium and produce a controlled withdrawal bleed. Progestin stops endometrial growth and organizes endometrial sloughing so that menses will occur following progestin withdrawal, rather than at random times. Failure to bleed with progestin withdrawal warrants further workup. Estrogen treatment causes the regrowth of endometrium over raw, denuded areas where previous bleeding occurred. It is often clinically useful in controlling acute bleeding episodes, but progestin therapy is also required if the etiology of the bleed is anovulation. Combination estrogen/progestin oral contraceptives are the treatment of choice in adolescents, and also serve the dual benefit of preventing pregnancy if the adolescent is sexually active (8).

Dysmenorrhea

Dysmenorrhea is defined as cramping pain in the lower abdomen that occurs in conjunction with menstruation. If the pain is due to pelvic pathology or alterations in normal pelvic anatomy, the pain is classified as secondary dysmenorrhea, whereas primary dysmenorrhea occurs in the absence of any known pelvic pathology. Secondary dysmenorrhea is uncommon in adolescents, but primary dysmenorrhea is the most common gynecologic problem in young women, with reported rates as high as 75-90% (14,15,16). The incidence increases with sexual maturity, with one study reporting a 38% incidence at Tanner stage 3, increasing to 66% at Tanner stage 5. Dysmenorrhea also increases with chronological age from 39% in 12 year olds to 72% in 17 year olds. 14% of girls in one study frequently missed school because of menstrual pain, and of those with severe dysmenorrhea, 50% reported missing school (17).

Symptoms of primary dysmenorrhea are usually noted beginning 1-3 years after menarche. It is more commonly seen in girls who have established ovulatory cycles. Pain that begins within 6 months or 3 years after menarche is more indicative of secondary dysmenorrhea. Patients typically report intermittent, cramping suprapubic pain that may radiate to the lower back or thighs. The pain may begin a few days before menstruation and continue for as long as 7 days following the start of flow. More commonly, the pain begins a few hours after the start of menstruation, and lasts 24-48 hours. The pain is often accompanied by systemic symptoms including nausea and vomiting, fatigue, diarrhea, lightheadedness, and headaches. Often, there is a family history of dysmenorrhea, and the physical exam is completely normal (18).

Due to the nature of the symptoms and the timing of the pain coincident with menses, a focused history and physical exam is usually sufficient to rule out non-gynecologic conditions of lower abdominal pain such as appendicitis, urinary tract infections, or inflammatory bowel disease. Secondary causes of pelvic pain must be ruled out. As with all women of child-bearing age, pregnancy must be excluded, along with the possibility of ectopic pregnancy. Premenstrual syndrome (PMS) will also occur cyclically with menses, but is usually associated with breast tenderness and abdominal bloating rather than abdominal cramping. A history of infection or previous abortion or surgery may indicate pelvic inflammatory disease (PID) or adhesions from inflammation and scarring. Any sexually active adolescent should have a speculum exam with cultures taken for Chlamydia trachomatis and Neisseria gonorrhoeae, and have a Pap smear. A pelvic exam should detect any unusual masses, cervical motion tenderness typical of PID, or cervical stenosis. Secondary causes such as endometriosis, polyps, fibroids, or tumors are rare in adolescents, and a workup for these conditions are not usually indicated. In many instances, it is preferable to confirm the diagnosis through a therapeutic trial of NSAIDs (16).

Most of the symptoms of primary dysmenorrhea are now thought to be due to the effects of endogenous prostaglandins, particularly PGF2alpha. The secretory endometrium contains high levels of PGF2alpha which are released when the endometrium is sloughed off during menstruation. These prostaglandins stimulate uterine contractility and painful cramping. The levels of PGF2alpha are highest in the first two days of menses, when symptoms are most severe, and have been shown to be elevated in women who complain of severe dysmenorrhea (16). NSAIDs are the treatment of choice for initial therapy of dysmenorrhea in adolescents. These drugs act to inhibit prostaglandin synthetase, and have reported efficacy rates of 64-100%. In contrast, aspirin and acetaminophen were not shown to be superior to placebo in double-blind studies (19,20). Unfortunately, many adolescents self-treat for dysmenorrhea without consulting an adult. Of those that are self-treating, many take ineffective medications (aspirin or acetaminophen) or use less than the recommended dosages. Therefore, it is important for physicians to inquire about dysmenorrhea during routine visits to ensure that patients are being treated appropriately. Oral contraceptives are a second treatment option for dysmenorrhea that is highly effective (90%) and also serves the dual benefit of birth control for sexually active adolescents. For the roughly 10% of those who do not respond to these options, other alternatives exist ranging from laparoscopic surgery to acupuncture (16).

Contraception

By their 18th birthday, 56% of female adolescents have had intercourse (21). Each year, more than 1 million females 15-19 years old become pregnant, with the vast majority of these pregnancies unintended (22). An effective strategy to reduce unintended pregnancies and sexually transmitted diseases is to provide teens with basic information about reproduction and contraception (21). Contraceptive options for adolescents must be tailored to their specific needs and concerns. Factors to consider in choosing a contraceptive for an adolescent include: ease of use, STD protection, cost, safety, and acceptability.

Combined oral contraceptives (COC): AKA "The Pill". These consist of a daily tablet containing a combination estrogen and progestin taken continuously for 3 weeks, with one week of placebo pills to allow menses. COCs inhibit the midcycle gonadotropin surge, thereby preventing ovulation. They also thicken the cervical mucus, making passage of sperm into the reproductive tract more difficult, and thin the lining of the endometrium, making it less favorable for implantation. They have a perfect use failure rate of 0.1% with a typical failure rate of 3% even when an occasional pill is missed (23). COCs have multiple noncontraceptive benefits which are not usually appreciated by adolescents, such as the reduction of endometrial and ovarian cancer. One benefit that many young women may appreciate is the recent FDA approval of one COC, OrthoTricyclen, for the treatment of acne. COCs may also be beneficial in young women who experience heavy, prolonged, or painful menses. This method does not require the cooperation of a partner, and does not interfere with spontaneity. Oral contraceptives, however, do not protect against STDs so teens should be encouraged to also use condoms. The patient must be motivated to take a pill every day in order for this method to be successful. Contraindications include: history of breast cancer, thromboembolic disease, pregnancy, undiagnosed abnormal uterine bleeding, smoking, heart disease or heart failure, CVA, or liver tumors. Older formulations of "The Pill" contributed to weight gain, but this is not seen with the newer pills on the market today. Teens who receive reassurance from their doctors that the new oral contraceptives will not cause them to gain weight are more likely to continue taking the pill long term (24).

Progestin only pill (POP): "Mini pill". This is a pill that is taken daily without any breaks. Its mechanism of action is similar to COCs. It thickens the cervical mucus and thins the endometrium to prevent implantation. Ovulation is suppressed only 60% of the time and the requirements for taking the POP are stricter. These pills must be taken at approximately the same time, every day. If a pill is delayed by more than 3 hours, the patient must be counseled to use a backup method of contraception for at least 48 hours. Perfect use failure rate is 0.5%, actual use 3-5%. POPs may cause irregular or breakthrough bleeding that may be stressful for the adolescent. In general, this method is not recommended as a first choice for most teens, but is useful for those with medical conditions where estrogen is contraindicated. It can also be used safely by nursing mothers (23).

DepoProvera: This is depot medroxyprogesterone acetate (DMPA) that is injected intramuscularly every 12 weeks. It works primarily by suppressing ovulation through a mechanism similar to the POPs. Its perfect use and actual use failure rate is 0.3%. Because the patient is required to return for a new injection every 12 weeks, it is still user-dependent, but the teen is freed from daily compliance worries. The major drawback of this method is that irregular bleeding or spotting has been reported in 25-50% of users in the first 6-12 months. However, most users eventually become amenorrheic. The patient should be properly counseled to expect these effects, and if she can get through the initial irregular bleeding, most teens find the lack of monthly menses appealing. This may be a disadvantage to those teens who rely on their periods as an indicator of pregnancy. This method is advantageous to certain handicapped adolescents and their caretakers. It provides both long-term birth control and the eventual freedom from messy menses (23).

Lunelle: This is a once-a-month injection of synthetic estrogen and progesterone (medroxyprogesterone acetate/estradiol cypionate). It provides the convenience of a once-monthly birth control method while minimizing the irregular bleeding that occurs with progestin-only contraceptives. The mechanism of action is similar to the COCs. The failure rate is currently estimated at 0.1 failures per 100 women-years. This method has only recently been approved for use. It requires that the patient return to their health care provider monthly for injections (25).

Ortho Evra, the first contraceptive patch, was introduced in 2002. It is placed on the skin of the buttocks, torso, or abdomen and releases a steady stream of estrogen and progestin (norelgestromin and ethinyl estradiol). A patch should be worn each week for 3 weeks in a row and changed every 7 days. The 4th week is patch-free to allow menses. The mechanism of action and side effect profile are similar to other hormonal contraceptives. Perfect use failure rate is 0.6%. The patch may be less effective in women >198 lbs compared to women with lower body weights. The risk of the patch falling off was <2% in clinical trials (26).

NuvaRing: The first hormonal vaginal contraceptive ring was approved by the FDA in 2001. NuvaRing is a small, flexible, transparent ring containing the hormones etonogestrel and ethinyl estradiol which are similar to the hormones in COCs. The ring is inserted into the vagina and provides a continuous low dose of estrogen and progestin for 3 weeks. It is removed in the fourth week to allow menses. A new ring is used each month. In clinical trials, pregnancy rates were 1-2% in one year of use. Side effects and contraindications are similar to COCs. Like all hormonal contraceptives, it does not protect against STDs or HIV (27).

Male latex condoms are the method of choice for adolescents, as they offer protection against both pregnancy and STDs. The male condom is the most common nonhormonal contraception used by adolescents aged 15-19 (28). Latex condoms have been shown to prevent the transmission of HIV, herpes, chlamydia, gonorrhea, cytomegalovirus, hepatitis B, trichomonas, and probably human papilloma virus (29). Perfect use failure rates range from 1-4%, with typical use failure rates of 10-21%. Teens should be instructed in the proper use of condoms. They should be advised to use spermicide, a water-based lubricant if needed, never a petroleum or oil based lubricant as these compromise the integrity of the condom, and to seek emergency contraception right away if the condom should break or slip. The most common deterrents to use are the interruption of intercourse required to put on the condom, the foresight required to purchase and keep the condom readily available, and the necessary cooperation of the male partner. Actual side effects, such as latex or spermicide allergies are not common (23).

Female condoms work as a barrier to sperm, similar to the male condom. It is a single-use, polyurethane pouch with a ring on one end that is inserted into the vagina to cover the cervix, and another open ring on the other end that remains outside the vagina. Perfect use failure rate is 3%, typical use failure is 15-25%. The advantages of this method are that it is the only female-controlled barrier method that offers protection against STDs comparable to the male condom, it is an alternative to females who have a latex allergy, and does not require male cooperation. Disadvantages include its higher cost ($3.00 per condom) and lesser availability, unusual appearance, and occasional crackling noise during intercourse or walking (23).

The diaphragm is a flexible rubber dome placed over the cervix and is used in conjunction with spermicidal jellies or foam. It may be inserted up to 6 hours prior to intercourse, but must be in place at least 30 minutes prior. It must be left in place for 6 hours after. The perfect use failure rate is 6% with a typical use failure of 20%. The diaphragm must be fitted by a physician and the patient must be able to insert and place it properly. It provides limited protection against some STDs but is not as effective as condoms. The initial cost of several hundred dollars may be discouraging to teens, but can be cost-saving in the long run if the patient is extremely active sexually. Disadvantages: Some teens are not comfortable touching their own genitals during insertion and removal. If positions are changed during sex, the diaphragm must be checked to make sure it is still in place. If the patient has a significant weight change, or becomes pregnant, she must be refitted. The diaphragm must be carefully inspected and cleaned between uses. There is a slight increase in urinary tract infections associated with diaphragm use, and if left in place >24 hours, there is a risk of toxic shock syndrome (23).

The contraceptive sponge was pulled off the market in 1995 for reasons unrelated to either safety or reliability, but it has become available again in 1999. The sponge is a doughnut-shaped polyurethane foam barrier containing a chemical spermicide. The sponge must be moistened with water and inserted into the vagina up to 24 hours prior to intercourse and may be left in place up to 30 hours. Perfect use failure rate is 10%. Typical use failure is 15-20% for nulliparous women, and has been reported as high as 40% in women who have had a child (30).

Spermicides come in a variety of forms (jellies, creams, foam, suppositories, tablets) that may be used alone or in conjunction with other methods. The most common active ingredients in spermicides are nonoxynol 9 or octoxynol, which acts to incapacitate sperm. In addition, these spermicides may have some bactericidal action. Spermicides must be inserted vaginally 10-30 minutes prior to intercourse and a new application is required for each act of intercourse. The perfect use failure rate is 6% with a typical use failure of 25%. Spermicides are often perceived by adolescents as messy and inconvenient, and continuation rates are low (23).

Contraceptive methods that are not appropriate for adolescents include the cervical cap and intrauterine devices (IUD). Sterilization is not appropriate as it is considered a permanent end to fertility. (31)

Intrauterine devices (IUD) and cervical caps are not recommended for teens so they will not be discussed here.

Physicians should ensure that adolescents are informed of the availability of emergency contraception. Teens need to be made aware of this option ahead of time due to the narrow window of time that treatment can be effectively applied. It should be stressed that postcoital methods should not be relied upon as the primary birth control method, and are primarily intended for emergencies. The most common method is the prescription of a larger than normal dose of oral contraceptive pills usually within 72 hours of intercourse. Depending on the time of the cycle in which it is taken, emergency contraceptive pills may inhibit ovulation, interfere with fertilization, or inhibit implantation of a fertilized egg. They should not be confused with abortifacients such as RU486 which are designed to end established pregnancies.

In general, the male condom is the most appropriate birth control method for adolescents. It is readily available over the counter, inexpensive, and protects against both pregnancy and STDs. Adolescents should be encouraged to use condoms, but a second method may be appropriate if condom use is less than perfect. Hormonal methods do not offer protection against STDs, but have low failure rates. The most common side effect of progestin-only methods is irregular bleeding. Many adolescents are not comfortable touching their own genitals, making internal barrier methods such as the diaphragm, the sponge, or the cervical cap less than ideal methods for many teens.

STD screening

The gold standard for the diagnosis of Neisseria gonorrhoeae and Chlamydia trachomatis has been culture. Endocervical specimens for culture are typically obtained from swabs taken during a speculum exam, with additional pharyngeal and rectal swabs obtained as necessary. Culture for C. trachomatis has sensitivities of 60-80% and specificities close to 100% for endocervical specimens (32). Culture for N. gonorrhoeae is 58-96% sensitive (33). A single endocervical culture will detect 85% of N. gonorrhoeae infections. A second culture will catch an additional 7-10% of infections (34). Culture methods have several limitations. They are slow, generally requiring 3-7 days for results. Only viable organisms can be detected and test results can be affected by storage and transport conditions.

Recently, several alternative tests for the detection of chlamydia or gonorrhea have been made available with acceptable sensitivities and specificities. Newer DNA amplification tests increase diagnosis when used in conjunction with other detection methods, and can be performed on both endocervical specimens and urine samples. Urine based testing provides a unique method of noninvasive screening, and is especially helpful in young adolescents who may be uncooperative with the pelvic exam. Polymerase Chain Reaction (PCR) and Ligase Chain Reaction (LCR) are two DNA amplification methods used today. For the detection of C. trachomatis in endocervical specimens, PCR is comparable to culture (sensitivity 79-99% and specificity 99-100%). In urine samples, the measured sensitivity was 96-100% with a specificity of 99-100% (32). LCR results have outperformed culture (Endocervical: sens 94% and spec 100%); (Urine: sens 96% and spec 100%) (35). For the detection of N. gonorrhoeae, LCR has been proven equally sensitive to culture methods using both endocervical swabs and urine specimens. Most studies have shown a sensitivity of >88% and specificity of 99-100% for LCR (34,36). Another alternative to culture is the DNA Probe assay, which may be performed alone (unamplified) or in conjunction with DNA amplification. DNA amplification is recommended for all urine samples. The unamplified DNA probe has a sensitivity and specificity essentially equivalent to culture for endocervical specimens, but a sensitivity of only 50% in urine that has not undergone amplification (34,37). Enzyme Immunoassay (EIA) and Direct Fluorescent Antibody (DFA) were developed as an alternative to culture. Both these methods are faster than culture and can detect nonviable as well as viable organisms; however, their sensitivities have been shown to be variable with the prevalence of the disease. They are useful screening tools in populations where the prevalence of infection is high (32,34).

Questions

1. Can a physician provide family planning services to a minor without parental knowledge? If an adolescent demands confidentiality, how can a physician prevent the transfer of billing/insurance information to reach parents?

2. What is the normal age range for menarche?

3. What are some common treatments for dysmenorrhea?

4. Name some things that should be discussed with a female adolescent during a physician visit?

5. What is the normal cycle length, amount of blood loss, and duration of flow in menses?

6. What is the most common side effect of progestin-only contraceptive methods?

7. If a speculum exam cannot be performed, or the patient refuses, how can screening for chlamydia and/or gonorrhea be accomplished?

References

1. Millstein SG, Adler NE, Irwin CE Jr. Sources of anxiety about pelvic examinations among adolescent females. J Adolesc Health Care 1984;5(2):105-111.

2. Lee PA. Chapter 5 - Normal Pubertal Development. In: Goldfarb AF (ed). Clinical Problems in Pediatric and Adolescent Gynecology. 1996, New York: Chapman & Hall, pp. 49-60.

3. Tanner JM. Trend toward earlier menarche in Long, Oslo, Copenhagen, the Netherlands, and Hungary. Nature 1973;243:95.

4. Dewhurst CJ, Cowell CA, Barrie LC. The regularity of early menstrual cycles. J Obstet Gynaecol Br Common 1971;78:1093.

5. Batrinos ML, Panitsa-Faflia C, Courcoutsakis N, et al. Incidence, type and etiology of menstrual disorders in the age group 12-19 years. Adolesc Pediatr Gynecol 1990;3:149.

6. Apter D, Vihko R. Serum pregnenolone, progesterone, 17-hydroxyprogesteone, testosterone, and 5a-dihydrotestosterone during female puberty. J Clin Endocrinol Metab 1977;45:1039-1048.

7. Goldfarb A. Chapter 6 - Dysfunctional Uterine Bleeding. In: Goldfarb AF (ed). Clinical Problems in Pediatric and Adolescent Gynecology. 1996, New York: Chapman & Hall, pp. 61-68.

8. Mishell Jr DR. Chapter 37 - Abnormal Uterine Bleeding. In: Stenchever MA, Droegemueller W, et al (eds). Comprehensive Gynecology, fourth edition. 2001, Philadelphia: Mosby, pp. 1079-1098.

9. Apter D, Vihko J. Hormonal pattern of adolescent menstrual cycles. Clin Endocrinol Metab 1983;57:82.

10. Demanest CB. When the teen has irregular periods. Patient Care 1984;181:154-163.

11. Pepe F, Iachello PM, Panella M. Dysfunctional uterine bleeding in adolescents. Clin Exp Obstet Gynecol 1987;14:182-184.

12. Giowani GP. Vaginal bleeding in adolescents. J Reprod Med 1984;29:417-420.

13. Richlin SS, Rock JA. Chapter 14 - Abnormal Uterine Bleeding. In: Carpenter SE, Rock JA (eds). Pediatric and Adolescent Gynecology, second edition. 2000, Philadelphia: William & Wilkins, pp. 207-224.

14. Alvin PE, Litt IF. Current status of the etiology and management of dysmenorrhea in adolescence. Pediatrics 1982;70:516-525.

15. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain, and irritable bowel syndrome in primary care practices. Obstet Gynecol 1996;87:55-58.

16. Coco AS. Primary Dysmenorrha. Am Fam Phys 1999;60:489-496.

17. Klein J, Litt J. Epidemiology of adolescent dysmenorrhea. Pediatrics 1981;68(5):661-664.

18. Dawood MY. Etiology and treatment of dysmenorrhea. Semin Reprod Endocrinol 1985;3:283-294.

19. Rosenwaks Z, Jones GS, Henzl MR, et al. Naproxen sodium, aspirin, and placebo in primary dysmenorrhea. Reduction of pain and blood levels in Prostaglandin F2alpha metabolite. Am J Obstet Gynecol 1989;140:592-598.

20. Janbo T, Lokken P, Nesheim BI. Effect of acetylsalicylic acid, paracetamol, and placebo on pain and blood loss in dysmenorrheic women. Eur J Clin Pharmacol 1978;14:413-416.

21. Sex and America's Teenagers. New York: Alan Guttemacher Institute, 1994.

22. Henshaw SK. Teenage abortion, birth and pregnancy statistics by state, 1988. Fam Plann Perspect 1993;25:122-126.

23. Slupik RI. Chapter 19 - Adolescent Contraception. In: Sanfilippo JS, Muram D, et al (eds). Pediatric and Adolescent Gynecology 2001, Philadelphia: W.B Saunders, pp. 305-317.

24. American Academy of Pediatrics, Committee on Adolescence: Adolescent Pregnancy - Current Trends and Issues: 1998. Pediatrics 1999;103(2):516-519.

25. Kaunitz AM. Injectable long-acting contraceptives. Clin Ob Gyn 2001;44(1):73-91.

26. Zieman M, Guillebaud J, et al. Contraceptive efficacy and cycle control with the Ortho Evra/Evra transdermal system: the analysis of pooled data. Fertility & Sterility 2002;77(2)S13-S18.

27. http://www.nuvaring.com/

28. US Department of Health and Human Service: Secretary Shalala launches national strategy to prevent teen pregnancy: New state-by-state data show decline in teen birth rate. Human and Health Services News 1997;1-3.

29. ACOG Committee Opinion. Condom Availability for Adolescents. Number 154 -- April 1995. Committee on Adolescent Health Care. American College of Obstetricians and Gynecologists. Internat J Gynaecol Ob 1995;49(3):347-351.

30. Trussell J, Hatcher RA, Cates W, et al. Contraceptive failure in the United States: an update. Stud Fam Plann 1990;21:51.

31. Moore JG, DeCherney AH. Chapter 46 - Contraception and Sterilization. In: Hacker NF, Moore JG (eds). Essentials of Obstetrics and Gynecology, third edition. 1998, Philadelphia: WB Saunders, pp. 516-531.

32. Woods GL. Update on Laboratory Diagnosis of Sexually Transmitted Diseases. Clin Lab Med 1995;15(3):665-684.

33. Xu K, Glanton V, Johnson SR, et al. Detection of Neisseria gonorrhoeae infection by ligase chain reaction testing of urine among adolescent women with and without Chlamydia trachomatis infection. Sex Transm Dis 1998;25:533-538.

34. Droegemueller W. Chapter 22 - Infections of the Lower Genital Tract. In: Stenchever MA, Droegemueller W, et al (eds). Comprehensive Gynecology, fourth edition. 2001, Philadelphia: Mosby, pp. 641-705.

35. Quinn, TC. DNA Amplification Assays: A New Standard for Diagnosis of Chlamydia trachomatis infections. Ann Acad Med Singapore 1995;24:627-633.

36. Smith K, Ching S, Lee H, et al. Evaluation of ligase chain reaction for use with urine for identification of Neisseria gonorrhoeae in females attending a sexually transmitted disease clinic. J Clin Microbiol 1995;33:455-457.

37. Schwebke JR, Zajackowski ME. Comparison of DNA probe (Gen-Probe) with culture for the detection of Neisseria gonorrhoeae in an urban STD programme. Genitourinary Med 1996;72(2):108-110.

Answers to questions

1. In Hawaii, a minor who is at least 14 years of age may consent to receive contraceptive services, prenatal care, and STD/HIV/AIDS services. The physician may notify parents (with the consent of the patient), but parental consent or notification is not required. In fact, if an adolescent demands confidentiality, it becomes a difficult situation since it might not permissible for the physician to release information, even to parents. The wording of the statute is, "left up to the treating physician's discretion in consultation with the minor who received medical treatment", but the statute later states that the minor, "shall have the same legal capacity to act" as an adult, making their demand for confidentiality no different than that of an adult. Most insurance companies provide itemized claim information to the subscriber of the insurance policy (usually the parent). It is not possible to circumvent this in most instances. Thus, adolescents should be counseled that once they have used their parent's medical insurance, their parents will receive such information. They must consent to this release of information, or they must remove the medical insurance information so that an insurance claim is not submitted. They should also understand that they will receive a bill for all medical services, although their ability to pay it should not impede the delivery of medical services. In most instances, it may be appropriate to counsel the adolescent to share this information with their parents, and in many instances, they will consent once they understand all the issues. This requires provision of factual information to the adolescent and patience.

2. 10 to 16 year old, average 12.7.

3. NSAIDs are the treatment of choice in adolescents. Oral contraceptives may also be used.

4. Adolescents should be provided with information about their diagnosis, contraception, breast self-exam, STDs and AIDS. Instruction should be provided on how to track menses. Condom use should be encouraged in those who are sexually active.

5. 21-35 days between menses, 20-60 mL blood loss (avg 35 mL), 3-7 days of menstruation.

6. Irregular bleeding.

7. PCR or LCR (DNA methods) for chlamydia and gonorrhea assayed from a urine sample or vaginal fluid sample.