Tips on what to cover in an initial teen exam

What do you cover when you conduct a teen’s first gynecologic exam? Understand that an adolescent’s initial visit may not necessarily include a pelvic examination or a Pap test, but that it should cover a wide spectrum of issues facing a young woman of reproductive age.

The Washington, DC-based American College of Obstetricians and Gynecologists (ACOG) has developed a confidential questionnaire based on the Chicago-based American Medical Association Guidelines for Adolescent Preventive Services (GAPS), a comprehensive set of recommendations for teen preventive health services. (See the resources below for information.)

The ACOG questionnaire provides a quick overview of several subjects, including such issues as depression and substance abuse, says Paige Hertweck, MD, immediate past chair of ACOG’s Committee on Adolescent Health Care and associate professor in the department of obstetrics, gynecology, and women’s health at the University of Louisville (KY) School of Medicine.

"In my office, it is given to the patient to fill out after her blood pressure and weight are checked, and before the patient goes into the exam room with the family member," she notes. "That way, I can review the information and discuss any problems during the confidential portion of the exam."

Hertweck also gives out the questionnaire at follow-up visits to see if any of the situations have changed for her patients. Such information can help determine if the teen needs contraception, if she has become sexually active, or needs a referral for counseling if she is dealing with a substance abuse problem.

Am I normal?’

A teen’s first question during her first gynecologic exam may well be, "Am I normal?" says Hertweck. At this time, talk about pubertal development and get an overview of the patient’s menstrual cycle, she adds.

Ask a first-time teen patient about her cycle: its frequency, duration, and flow, advises Melanie Gold, DO, associate professor of pediatrics at the University of Pittsburgh School of Medicine and associate professor at the University of Pittsburgh Graduate School of Public Health. Discuss cramps and the impact they have on daily activities, she notes.

Sexual orientation is another subject for discussion: Ask the patient if she is attracted to "guys or girls, or both or neither, or she’s not sure yet," she suggests. Do not assume that the patient is sexually active; however, if she is, then take a sexual history, she states.

Perform a general physical exam, and assess pubertal staging, Gold suggests. Do a physical examination of the breasts; note when there is asymmetry or masses. Help the teen to understand what is normal, and encourage her to feel comfortable in touching her breasts, not necessarily for cancer detection, but "just for knowing what is normal for her," she says.

When performing the genital exam, include a general discussion on hygiene and discourage douching for this purpose, Gold advises. As you move through the external exam of the genital area, explain what you are checking and offer to have the patient use a hand mirror to see the area, says Gold. Most teen patients may not be comfortable in using a mirror at the time of the exam, but encourage them to do so later at home, she states.

Gold performs the genital exam with the patient’s feet up in the stirrups just to have them become comfortable with the examination position. This way, the patient is more comfortable when a speculum is used in a later visit.

The initial gynecologic exam should cover primary health issues such as depression, eating disorders, and substance abuse, because patients may not have a primary care provider, she says. Assess whether the patient has another source of primary care; and if she doesn’t, include them in the visit, she advises.

"I think the first thing is that the purpose of the visit is not for the pelvic exam," Gold states. "The purpose of the visit is to address a spectrum of reproductive health issues that a teen may have."

Resources

  • Review and download free materials developed under the American Medical Association’s Guidelines for Adolescent Preventive Services (GAPS) at the association’s web site, www.ama-assn.org. Click on "Physicians and Medical Students," "Public Health," "Adolescent Health," and "Clinical Preventive Services," to access the GAPS material. Downloadable material includes a younger adolescent questionnaire, a middle/older adolescent questionnaire, and a parent/guardian questionnaire, all in English and Spanish versions.
  • The American College of Obstetricians and Gynecologists’ (ACOG) Tool Kit for Teen Care, designed by the ACOG Committee on Adolescent Health Care, includes an adolescent visit questionnaire and adolescent visit record; tools for adolescent assessment, including laminated cards with the stages of pubertal development, blood pressure readings, and body mass index calculations; educational materials and fact sheets for teens and their parents; and tips for creating an adolescent-friendly office environment. The tool kit (Item AA415) is $45 for ACOG members and $55 for nonmembers, plus an $8.95 shipping/handling fee. Credit card orders may be made on-line at the ACOG store web site, http://sales.acog.org, telephoned to (800) 762-2264, ext. 315, or (304) 725-8410, ext. 339; or faxed to (800) 525-5562 (United States and Canada) and (304) 728-2171 (international.) Orders also may be mailed to ACOG Distribution Center, P.O. Box 4500, Kearneysville, WV 25430-4500. Several of the fact sheets in the Tool Kit are available free at the Medem web site (www.medem.com), a web resource developed by several leading professional medical organizations. Type in "Tool Kit for Teen Care" in the search box at the home page; the search engine will display the fact sheets.