Caring for the gynecologic needs of the adolescent patient

Carri Holton, MSN, WHNP-BC, Department of Pediatric & Adolescent Gynecology at Children’s Hospital Colorado, gave a presentation on gynecologic care for adolescent patients at the NPWH 25th Annual Premier Women's Healthcare Conference in Houston, Texas, from September 29 to October 2.¹

Holton first outlined how health care providers can provide preventive health screenings and offer guidance to adolescents, teens, and parents in pediatric gynecology. Conditions such as pediatric vulvovaginitis, lichen sclerosis, genital injuries, labial adhesions, congenital anomalies in the reproductive system, menstrual suppression, tumors, premenstrual syndrome and premenstrual dysphoric disorder, and breast problems in youths are treated via pediatric gynecology, as is fertility preservation or hormone replacement.

During an office evaluation, there should be a welcoming environment for adolescent patients, according to Holton. Health care providers will require technical skills to complete hymen exams, single-digit exams, and smaller speculums. They will also need to have the patience to listen to adolescents and parents, along with learning the history of their patients.

Confidentiality was also discussed. Holton noted that adolescents must be made aware of instances when information is not confidential, such as suicidal or homicidal thoughts. Minor consent laws should be known, as many states allow minors to consent to family planning, pregnancy care, substance use related care, and outpatient mental health services. All states allow minors to consent to sexually transmitted infection testing.

When arranging and performing an adolescent exam, the decision should be between the adolescent and the provider, though there should be a chaperone present. Providers should explain all components of the exam to the patient and parent. Patients should be reassured that they are in control of their body and the exam can be stopped at any time.

When moving onto the next step, providers should ask permission to pull the sheet back. Holton reminded them to be explaining female anatomy with proper terms, educating parents and patients. Breasts and pubic hair should be examined for Tanner staging, and external genitalia should be examined for normal anatomy.

In the presentation, Holton discussed normal pubertal development along with abnormalities, and encouraged attendees to learn this information so that they may recognize signs of abnormal development. Providers need to first identify the cause then determine treatment. This could include hormone replacement therapy in cases of primary ovarian insufficiency.

Holton also outlined instances of physiologic anovulation—when slow maturation occurs in anovulatory cycles. This can lead to noncyclic, unpredictable, and inconsistent bleeding. In cases where bleeding is too much, adolescents should see an oncologist for testing, especially in cases of concerning history with bleeding disorders in the individual or family.

In cases of mild bleeding without anemia, providers should reassure patients, provide them with prophylactic iron supplementation, and offer hormonal contraceptives if desired. In moderate bleeding with anemia, providers should give patients combined oral contraceptives, micronized oral progesterone, depo Provera injection, levonorgestrel (LNg) intrauterine device (IUD), and iron supplementation.

Further treatments, along with hospitalization and blood transfusion, may be needed in cases of severe bleeding. In all cases, Holton stated that iron supplementation should be given.

Holton also discussed polycystic ovary syndrome (PCOS), reminding attendees that every case is different. Holton also noted that PCOS is not caused by ovarian cysts or being overweight, and that much is still unknown about PCOS. Diagnoses may be given as “irregular periods,” and can present as amenorrhea, oligomenorrhea, and chaotic periods.

Treatment for PCOS will vary based on concerns, as it can lead to metabolic concerns, acne, dermatologic concerns, and nutrition concerns. When these concerns arise, screenings should establish a rapport in the first visit. Repeated screenings should at first take place every 3 months, then every 3 to 12 months depending on the patient.

Holton lastly talked about dysmenorrhea and endometriosis. Dysmenorrhea is painful menstruation, often increasing risk of anxiety and depression. It can be managed with dietary, vitamin, and herbal treatments along with exercise and yoga, or with pharmacologic interventions.

Dysmenorrhea is often caused by endometriosis. Risk factors of endometriosis include earlier menarche, nulliparity, shorter menstrual cycles, childhood sexual and physical abuse, and more. To treat endometriosis, Holton recommended both surgical and medical treatments. Complementary and alternative therapies may also reduce symptoms.

Reference

1. Holton C. Gynecologic care for the adolescent patient: perspective from a PAG WHNP. Presented at: 25th Annual Premier Women's Healthcare Conference. Houston, Texas. September 29 to October 2, 2022.