Adolescents comprise a unique subset of obstetric-gynecologic patients. This time of life involves a variety of changes and decisions, many of which center on awareness and expression of sexuality and individuality. There is, therefore, a great need for education, advice, and guidance regarding reproductive health, as well as the many others issues facing these emerging young adults. Despite these facts and their increased health risks, adolescents have the lowest rate of physician office visits of any age group. Adolescents who do seek health care often face the obstacles of lack of confidentiality, inability to pay, inconvenient service location and hours, and difficulty with compliance and follow-up care. Growth acceleration accompanies the first signs of puberty, which include breast budding (ages 9-11) followed by pubarche. Menarche occurs during the deceleration phase of growth at an average of 12.8 years in North America. Regular ovulation is typically established approximately twenty cycles later. Absence of thelarche by age thirteen or menarche by age 15 should be considered abnormal and warrants further investigation. The average duration of puberty is four years. The issue of confidentiality has previously been identified as a barrier to some adolescents seeking health care. The establishment of a trusting health care provider reduces this barrier and opens the opportunity for health education and counseling. The clinician providing health care for adolescents is obligated to be non-judgmental and to anticipate the need for privacy, confidentiality, and involvement in decision making. Adolescents should be encouraged to involve parents in their care. However confidentiality must be maintained. The adolescent's relationship with the clinician should be independent of that of the parents, and this should be clear to both her and her parents. This allows the adolescent to undergo examination, discussions and counseling with the same confidentiality that is afforded the parent or the adult patient. Women who are sexually active or over the age of 18 should have annual pelvic examinations and pap smears.

* age 18 or older

* suspected STD

* suspected pregnancy

* abnormal bleeding

* pubertal aberrancy

* sexual abuse

* abdominal or pelvic pain The purpose of cytologic screening is to help identify those individuals with intraepithelial lesions that may be treated at an early pre-invasive precursor stage. Screening for sexually transmitted diseases, including Neisseria Gonorrhea and Chlamydia trachomatis, should also be performed in adolescents who are sexually active.

Most adolescents will be cooperative with a simple step-by-step explanation of the pelvic examination by the practitioner.

Reluctance or refusal of the adolescent to comply with a pelvic examination should not result in discontinuation of services. Most adolescents will be cooperative with a simple step-by-step explanation of the pelvic examination by the practitioner. The presence of a companion should be offered to the adolescent patient. However, this should be done discretely so that she can have privacy if she prefers.

The most common complaints of the adolescent gynecologic patient are menstrual abnormalities and vaginal discharge. Other complaints many include irregular menses, dysmenorrhea , pelvic pain, and breast development problems. Many times the adolescent may have somatic complaints that allow an opportunity for discussion of other concerns, such as fear of pregnancy or sexually transmitted diseases, sexual abuse, or the need for contraception.

Sexually Transmitted Diseases:

A survey of adolescents revealed that most teenagers are aware of the risks of acquiring sexually transmitted diseases. Ninety percent of teens in a Centers for Disease Control study also knew about sexual transmission of human immune virus (HIV). Nevertheless, sexually transmitted diseases remain a problem affecting 2.5 million adolescents. Chlyamidia trachomatis and Neisseria Gonorrhea are reported to range up to 17% and 3% per year respectively in sexually active teens. The rate of human papilloma virus (HPV) infection continues to increase dramatically in the sexually activ population, especially in adolescents. Rates have been documented to reach up to 10% of these teens. Pelvic inflammatory disease (PID) is ten times more likely to develop in an adolescent than in an adult female. Up to 20% of the adolescent patients with PID will develop a tubo-ovarian abscess and thus diminish future fertility. Of even more concern, the number of cases of AIDS among thirteen to twenty-four years old increased by 43% between November of 1990 and November of 1992.

The sexual behavior patterns of many adolescents underscore the need for education and prevention programs. As a provider of adolescent health care, one should be aware of the community services and resources available to these young women and their partners.

Contraception:

By age 19, 75% of females and 86% of males report being sexually active. Twenty-six percent of unmarried females have experienced sexual intercourse by age fifteen. The pregnancy rate for women age fifteen to nineteen is higher in the United States than in any other developed country. During the last decade, 12% of all women ages fifteen to nineteen have become pregnant each year. The challenge remains to reach and educate those adolescents who are at highest risk of pregnancy a d do not use effective contraception.

The choice of contraception should be based on the individual needs of the patient. While oral contraceptives (OC's) provide the highest degree of protection against pregnancy, they do not offer the best protection against sexually transmitted diseases. The use of condoms, in addition to oral contraceptives, should be promoted to the sexually active adolescent who is at risk of acquiring or transmitting a sexually transmitted disease.

The adolescent's fears of complications related to the use of oral contraceptives can be reduced through appropriate education. Risks, benefits, and potential side effects, such as weight gain, nausea, breakthrough bleeding and lack of withdrawal bleeding, should be discussed with the adolescent prior to prescribing an oral contraceptive.

Pregnancy:

Thirty-nine percent of all pregnancies in women under the age of twenty are electively terminated in the United States. Adolescents tend to deny or delay confirmation of pregnancy. As a result, more mid-trimester abortions are performed in this group. When the pregnant adolescent does seek health care, her questions should be answered and she should be informed of her options, including adoption, foster care, parenting and abortion.

Pregnant adolescents and their infants are at risk because of socio economic disadvantages, limited job opportunities, lack of access to health care, and repeat pregnancies. Limited or no prenatal care may contribute to poor perinatal outcome in babies born to these young mothers.

Nutritional problems may range from anorexia to obesity. Intervention, including education and food supple mentation, can help to ensure ad equate development for both mother and fetus. The diet of the pregnant adolescent should contain 2700 calories per day after the first trimesten In addition, the pregnant adolescent requires 1600 mg. each of calcium and phosphorus per day. Substance abuse from alcohol to cocaine is more common than we would like to think among adolescents. Eighty-nine per ent of tenth graders have had exposure to alcohol and 8% have tried cocaine at least once. These patient's must be educated regarding the potential and long-term harmful effects of substance abuse to themselves as well as their unborn baby.

Sexual Abuse:

It has been estimated that up to 38% of all females under the age of eighteen have been involved in nonvoluntary sexual activity. These may include incest, "date rape", and other forms of sexual assault.

Signs that should alert health care providers to the possibility of abuse may include:

* recurrent abortions or pregnancies

* prostitution

* recurrent STD's

* substance abuse

* school truancy

* runaways

* recurrent urinary tract infections

* perineal warts

* psychosomatic symptoms

The needs of the victim of sexual abuse include medical attention for testing and treatment of sexually transmitted diseases, prevention of pregnancy, as well as evidentiary examination in sexual assault cases with the availability of trained counselors.

The Adolescent Obstetric-Gynecologic Patient, ACOG

Technical Bulletin, #145 September 1990.

Adolescent Acquaintance Rape. ACOG committee

Opinion #122, May 1993

Adolescents Right to Refuse Long-Term Contraception.

ACOG Committee Opinion #139. June 1994.

Condom Availability for Adolescents. ACOG

Committee Opinion #154, April, 1995.

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