Adolescent Health Care: A Practical Guide

Chapter 48

Gynecological Examination of the Adolescent Female

Merrill Weitzel

Jean S. Emans

A gynecological examination is an essential component of the health care of adolescent girls. This is especially important because the first pelvic examination can influence an adolescent's attitudes about reproductive health care for the rest of her life. Most adolescents are apprehensive about the examination of their genitalia, especially during a first examination. A sensitive approach to the adolescent's concerns and needs can aid in creating a positive and instructive experience.

Office Setting

The office setting is particularly important in creating a positive atmosphere for the adolescent girl. To create such an atmosphere a clinician should do the following:

1. Provide an office setting that is a comfortable and friendly. Support staff should be welcoming. A special seating area for teens with appropriate reading material is optima Privacy is a fundamental component for teens. An assessment of office procedures—such as weighing patients in the examination room, not in hallways—is key to meeting the needs of teens for privacy. Teens who wish to contact the office by telephone should have easy access to staff to schedule appointments and ask questions.
2. Special appointment times can be reserved for teens. Late afternoon or evening appointments may be more convenient for teens than morning times.
3. Practices limited to adolescents can have posters and pamphlets directed at the concerns of teens, such as smoking cessation, healthy nutrition, sexual decision-making, “how to say no,” birth control, sexually transmitted diseases (STDs), and human immunodeficiency virus (HIV) infection. Practices with patients of a wider age range usually opt for neutral decors but can still have pamphlets and materials displayed in areas “especially for teens” within the examination room. Computer “hot spots” with pertinent Web sites posted may be helpful.
4. Parents of adolescent patients should be included as much as possible in the history gathering and medical plan. However, the adolescent's need for medical privacy and confidentiality should be respected. An explicit statement (and in some practices a written statement) about confidentiality should be included early in the discussion because it will encourage more open discussion about risk behaviors. The limits of confidentiality (conditions that are life threatening or that require reporting by law) should also be discussed with the patient and her family.
5. During part of the gynecological assessment, the adolescent should be interviewed privately in a comfortable environment about risk behaviors and health-promoting behaviors. If at all possible, she should be fully clothed and seated eye-to-eye with the examiner for the first visit. Reassure her that what she communicates, regarding her reproductive health will be kept confidential. She should be made aware that the results of the examination will not be discussed with her parents or others without her permission but that you will encourage her to share her health concerns, medications prescribed, and management plans with her parents or caretakers.
6. Be aware of the fears and worries of the adolescent about the pelvic examination. These fears may be expressed as anxiety or occasionally as hostility. Ask the patient about her feelings concerning the examination and the worries or questions that she may have regarding her body. Many teens are worried about pain, discomfort, or embarrassment (“It will hurt” or “The doctor will judge me”), and need to be reassured about the tempo of the examination. The adolescent needs to feel in control of the tempo of each part of the examination.
7. Listening to rather than lecturing the adolescent is essential. The examination can be a critical time for health education and for helping the teen to value and protect her body. A virginal teen may be concerned about whether the examination will alter her hymen and should be reassured that the small speculum that is used was designed for girls who have not had intercourse. Girls who have used tampons are generally more comfortable with their bodies and can be particularly reassured as to the ease of the examination. Dispelling myths and respecting cultural preferences about pelvic examinations is important.
8. During each step of the examination, it is important to reassure the teen of her normality, as appropriate. The question, “Am I normal?” may be an underlying reason for any teen's visit. Other concerns may be “Do I have a STD?” or “Are my labia too big?”

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Indications for Gynecological Examinations

The indications for a complete or modified pelvic examination in an adolescent vary with the patient's complaint. For example, a 13-year-old girl who is not sexually active and who has a white vaginal discharge may be evaluated by obtaining one or two saline-moistened cotton-tipped applicator samples of the discharge and by examining the samples under the microscope for physiological discharge or Candida vaginitis. In contrast, a 16-year-old, sexually active girl who has had lower abdominal pain for 2 days and has a vaginal discharge deserves a complete pelvic examination. It is also important for clinicians to assess whether the answer can be obtained by the use of urine-based STD screening for Chlamydia trachomatis and/or Neisseria gonorrhea or by pelvic ultrasonography. For example, a girl with primary amenorrhea may be willing to allow only an external genital inspection; the internal genital structures can then be assessed by transabdominal ultrasonography.

Most professional organizations suggest that cervical cancer screening be initiated at 21 years of age or 3 years after the onset of sexual activity, whichever occurs first. Girls receiving episodic care or who are immunosuppressed (e.g., HIV infection) should be screened earlier. The American College of Obstetricians and Gynecologists recommends annual Pap tests in women younger than 30 years after initiation of screening. An adolescent who is not sexually active can begin routine gynecological care whenever she feels comfortable, with the hope that by the age of 18 to 21 years she will have initiated routine care. However, the age of 18 to 21 years should be seen as a general guideline, and the wishes and background of the patient should be respected. It should be stressed that adolescents should have routine health guidance initiated before becoming sexually active. The American College of Obstetricians and Gynecologists recommends that the first visit for health guidance, screening, and preventive services should take place approximately at 13 to 15 years of age. It is an ideal time to provide education about preventive care needs, including the need for STD testing in sexually active females. Providers should separate the provision of contraceptive services and STD screening from requirements of cervical cancer screening. Pelvic examinations should not be a barrier to the prescription of oral contraception and other effective hormonal methods. In addition, patients and parents need to understand that there is still a need for preventive health care other than Pap testing. It is important for patients (and their parents) to realize that a pelvic examination and a Pap test are not the same. Most importantly, the first pelvic examination should be an educational and positive experience. Indications for modified or complete pelvic examinations therefore include the following:

1. Sexually active (vaginal intercourse) (within 3 years)
2. Symptoms of vaginal or uterine infection
3. Menstrual disorders including amenorrhea, dysfunctional uterine bleeding, severe dysmenorrhea, or mild-to-moderate dysmenorrhea unresponsive to therapy
4. Undiagnosed lower abdominal pain
5. Sexual assault (modified to collect the appropriate information and samples)
6. Suspected pelvic mass
7. Request by the adolescent

Obtaining The History

The history should include a gynecological assessment, general health history, review of systems, and information on risk behaviors. The HEADSS framework can be used; it focuses onHome, Education/career plans, Activities, Drugs/alcohol/tobacco, Depression, Suicidality, Sexuality, and Safety. These questions can be asked through a clinical interview, a written questionnaire, or a computer-aided questionnaire. Most of the visit should be devoted to seeing the teenager alone, because her presenting complaint is often different from her parents' concerns. However, it is essential to understand the concerns and the family history of the parent or parents. Mothers often attribute symptoms of their daughters to diagnoses that they themselves have had, such as ovarian cysts or other gynecological problems within the family. Although some medical conditions (e.g., polycystic ovary syndrome, endometriosis) clearly can occur within families, many other conditions are not related to the complaint that brings the teen to the clinician.

It is essential to know what the parent told the patient regarding the reason for the visit and whether the examination was explained. If the parent discussed the examination with the patient, it is important to gather information on how it was explained. Some patients are told, “Don't worry, you don't need an examination,” and others are told about the full speculum examination when potentially they only need one or two cotton-tipped applicator samples. It is also important to know what and how the parent has explained about menstrual periods, sexuality, and other issues to the young adolescent.

The younger teen may feel more comfortable if most of the history is obtained with parent or parents in the room. A few moments of privacy are all that is needed to obtain pertinent negatives about risk behaviors. It is often best to begin the interview by asking the adolescent why they have come to the office for an evaluation that day. It is imperative to address the chief complaint and to relate the gynecological examination (modified or complete) to that concern. Reasons for the visit may include pelvic pain, vaginal discharge, a menstrual disorder, or a possible pregnancy. A presenting complaint such as irregular menses may actually lead to a diagnosis of pregnancy; in such cases, the patient may be denying the possibility of pregnancy, or a menstrual complaint may be the only way for her to access medical care. Dysmenorrhea may mask a “hidden agenda” for obtaining oral contraceptives. The sexual history should be part of the structured questioning: “Have you ever had sexual intercourse?” “How old were you when you first had sex?” “Tell me about your partners.” “Are you sexually active with men? Women? Both?” “How many partners have you had?” “Have you ever been pregnant?” “Have you ever had a STD?” “Have you ever been forced to have sexual intercourse?” “Have you ever used condoms?” “If yes, how often?” It is important that these questions be preceded by the comment, “I ask all my patients these questions.”

The history should include the following:

1. Menstrual history
2. Age at menarche
3. Duration of menses and interval between periods; intermenstrual staining
4. Amount of flow and any recent changes in amount of flow (this is often best accomplished by asking

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whether the patient uses tampons or pads and how often during the day she needs to change).

1. Date of last menstrual period
2. Dysmenorrhea—if present, severity and extent of missed school or activities
3. Premenstrual symptoms
4. History and type of vaginal discharge
5. Sexual history
6. Relationships, sexual contact, number and age of partners (men, women, or both), age at first sexual intercourse
7. Contraceptive methods used: Condoms ever? Frequency of use? (“all the time?” “never miss?”) Use at last intercourse? Previous use of hormonal contraceptive—benefits, problems
8. Prior STDs: Gonorrhea, chlamydia, syphilis, herpes, warts, HIV, pelvic inflammatory disease
9. Prior pregnancies (number and outcome of each—abortion, term, ectopic, miscarriage), and fertility concerns. Trying to get pregnant now?
10. Pap smear screening: Ever had a Pap test? When was the last Pap performed? Ever had an abnormal Pap smear? Colposcopy?
11. If the patient is sexually active, ask whether her partner treats her well and whether she has ever been in a situation where she felt unsafe, felt coerced to have sex, or was hit or slapped
12. Family history
13. Family history of gynecological problems (e.g., polycystic ovary syndrome, endometriosis)
14. Blood clotting disorders or stroke
15. Breast cancer or gynecological cancer (cervical, ovarian, uterine)

Gynecological Examination Equipment

Materials needed for the gynecological examination include the following:

1. Examination table with ankle supports: Oven mittens or other cloth holders placed over the metal supports increase foot comfort
2. Gowns, sheets
3. Light source (speculum light or lamp)
4. Specula: Metal—Pederson or Huffman (also sometimes called a Huffman-Graves speculum)—or plastic (medium and small), with or without self-contained light source
5. Gonorrhea culture medium or nonculture gonorrhea test (can also be done on urine)
6. Chlamydiascreening tests (e.g., NAATS) (can also be done on urine)
7. Spatula and cytobrush (or cytobroom) for Pap test
8. Cotton swabs and either tubes or slides for wet mounts
9. Ten percent potassium hydroxide (KOH) and saline for wet mounts, pH paper
10. Pap slide containers and fixative, or kits for ThinPrep or other Pap systems
11. Water-soluble lubricating jelly
12. Warm water source
13. Nonsterile gloves
14. Handheld mirror (use is optional and up to the patient)
15. Tissues
16. Tampons and sanitary napkins
17. Rapid pregnancy test kits

Pelvic Examination

A pelvic examination is generally performed annually for sexually active adolescents starting approximately three years after the initiation of sexual intercourse. The adolescent should be made to feel that she is in control and can stop the examination at any point to ask questions or, if need be, stop the examination entirely. A handheld mirror to permit viewing of her genitalia is helpful for some adolescents. The clinician should acknowledge that adolescent girls may feel nervous, particularly at the first examination. Explain that it takes only 2 or 3 minutes to perform the examination. Adolescents should be given the choice of whether to have their mother or another person (e.g., sister, aunt) stay in the room as support. The young adolescent may request that her mother stay with her during the pelvic examination; most older patients prefer that their mothers stay in the waiting room. The patient's wishes should be respected. Generally, male providers use a female chaperone for pelvic examinations. Female providers in some settings always use chaperones, and in other settings the use is considered optional. Many patients actually prefer to have only the provider in the room.

Before the examination begins, it is helpful to explain to the teen, while she is still fully clothed and seated, the various parts of the examination—general physical examination, inspection of the genitalia, speculum examination, and bimanual examination, indicating the reasons why each part is important for evaluating her medical complaint. It is also good, both in the early discussion and during the examination to talk about feelings related to the examination and ways to relax and feel in control, such as the use of imagery, deep breathing and other relaxation techniques, a mirror, a step-by-step format, or distraction from a family member. She should also be reassured that adequate drapes will be used. Each step is then explained again as the actual examination is done.

The steps are as follows:

1. Make sure that the patient has emptied her bladder before the examination.
2. Ask the patient to undress completely and put on a gown.
3. Perform a general examination including inspection of the skin (acne, hirsutism, acanthosis nigricans); palpation of the thyroid gland; and examination of the breasts, heart, abdomen, and inguinal area for lymphadenopathy.
4. Have the patient lie supine on the examination table, feet resting either in or on the ankle supports. Instruct the patient to slide her buttocks to the edge of the table. Elevating the head of the table 30 degrees is optional; it can provide the adolescent an increased sense of control and can make sliding down easier. The foot of the examination table should be turned away from a doorway. The drape or sheet should be positioned so that eye contact can be maintained with the patient.
5. Ask the patient to touch her knees to your hands, which are held out to the side. Do not try to pry her legs apart.
6. Inspect the external genitalia (Fig. 48.1).
7. Note pubic hair distribution and sexual maturity rating (Tanner stage).
8. Assess for signs of erythema, inflammation, nevi, warts, or other lesions over the perineum, thighs, mons, labia, and perianal region. After informing the patient that you are about to do so, place the palms of both hands adjacent to the labia majora and gently

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separate them to examine the external structures. Check the size of the clitoris, which is typically 2 to 4 mm wide; a width of 5 to 10 mm is considered a possible sign of virilization, and >10 mm indicates definite virilization.

• Skene glands: These are two small glands located just inside the urethra. They are usually not visible.
• Bartholin glands: These are two small mucussecreting glands located just outside the hymeneal ring at the 5 and 7 o'clock positions. They can become enlarged, infected, or both.

1. The hymen should be carefully inspected for estrogen effect (light pink, thickened), for congenital anomalies (septate, imperforate, microperforate), and for transections that might result from consensual or nonconsensual sexual intercourse. For girls who are being evaluated for prior sexual abuse or assault, a saline-moistened cotton-tipped applicator can be used to run the edge of the hymen to look for transections. With gentle retraction, the anterior vagina may be visible and again the estrogen effect can be observed—pink mucosa, white vaginal secretions.
2. Obtaining samples: For patients who need a vaginal smear done to assess estrogenization (amenorrhea) or who need wet mounts obtained to evaluate vaginal discharge, saline-moistened or dry cotton-tipped applicators can be used to obtain samples (see later discussion). This may be all that is needed to assess the particular gynecological complaint.
3. Speculum examination: The correct size of speculum should be selected, and the speculum should be warmed, if possible, before insertion. It should not be lubricated with anything other than water if a Pap test or other samples are to be taken (Fig. 48.2). If the hymeneal opening is small, a Huffman (Huffman-Graves) speculum (½ × 4½ in.) is used to visualize the cervix. For the sexually active teen, a Pederson speculum ( 7/8 × 4½ in.) or occasionally a Graves speculum (3/8 × 3¾ in.) is appropriate. A plastic speculum with an attached light source is also useful for facilitating the examination. Some examiners believe it is helpful to remove the speculum from its package and show it to the patient. Other experts believe that the value of showing the adolescent the speculum in advance is limited and that the adolescent may become more fearful of the examination. If you choose to show the adolescent the speculum, explain that although the speculum is long it is the exact length of the vagina and allows visualization of the cervix, which is the opening of the uterus located at the end of the vagina. In the virginal teenager a one-finger, gloved (water-moistened) examination demonstrates the size of the hymeneal opening and the location of the cervix and allows subsequent easy insertion of the speculum. To avoid surprising the patient during the speculum examination, touch the speculum to the thigh first and tell the patient that you are going to place the cool speculum into the vagina. The speculum should be inserted posteriorly in a downward direction to avoid the urethra (Fig. 48.3). Applying pressure to the inner thigh at the same time the speculum is inserted into the vagina may be helpful.
4. Observe the vaginal walls for signs of estrogenization, inflammation, or lesions.
5. Inspect the cervix. The stratified squamous epithelium of the external os is usually a dull pink color. There is often a more erythematous area of columnar epithelium surrounding the cervical os, called a cervical ectropion. The junction between the two types of mucosa is called the squamocolumnar junction,and it is particularly important that this area be sampled during the Pap test screening. This ectropion may persist throughout the adolescent years, especially in hormonal contraceptive users. Mucopurulent discharge from the cervix characterizes cervicitis, typical of infections with N. gonorrhea, trachomatis, and herpes virus. Small, pinpoint hemorrhagic spots on the cervix, so-called “strawberry” cervix, can occur rarely with Trichomonasinfections. The cervix should be examined for any lesions or polyps. Any abnormal growth on the cervix should be referred for further evaluation and colposcopy.
6. To assess signs and symptoms of vaginitis, swabs for wet mounts and pH can be obtained from the vagina and then placed in one or two drops of saline on one slide (forTrichomonas, white cells, or “clue cells”) and in one drop of 10% KOH (for pseudohyphae) on another slide. A swab should also be applied to pH paper; a pH <4.5 suggests normal physiological discharge or Candidainfection, and a pH >4.5 suggests bacterial vaginosis or Trichomonas infection.
7. If indicated, obtain a Pap test of the cervix. This should include at least a 360-degree rotation of the spatula in contact with the cervix, with care taken to sample the “transition zone” or squamocolumnar junction. Nylon cytobrushes are also commonly used in addition to the spatula, thereby ensuring the collection of cells from the endocervical canal.
8. Endocervical tests for STDs: Tests for gonorrhea and chlamydia include nucleic acid amplification tests

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(NAATs), DNA probes, immunoassays, and cultures. Endocervical Chlamydia NAAT screening has higher sensitivity than urine screening, but urine screening is an excellent option if a pelvic examination is not being performed. The speculum is removed after the samples for STD tests are obtained.

8. Bimanual examination: The bimanual vaginal–abdominal examination involves the insertion of one or two gloved, lubricated fingers into the vagina while the other hand is placed on the abdomen. If this is her first bimanual examination, it is worthwhile to have the patient practice relaxing her abdominal muscles first: “Take a few deep breaths and blow it out.” Once her abdomen is relaxed, the bimanual examination can begin. Remind the patient that you will be examining her uterus and ovaries and to communicate any feelings of discomfort she may be experiencing during the examination. If it is not comfortable for the patient to tolerate a vaginal–abdominal examination or there are cultural preferences, then a rectal–abdominal examination, in the lithotomy position, usually will yield the needed information.

1. Palpation of the vagina and cervix: Check for lesions along the side walls and on the cervix and any tenderness on cervical motion.
2. Palpation of the uterus: Assess the size, the position of the uterus, and any masses or tenderness. Pushing backward on the cervix causes the uterus to move anteriorly, allowing for its palpation with the abdominal hand.
3. Gently explore the posterior fornix and the rectouterine pouch (pouch of Douglas) for masses, fullness, and tenderness.
4. Palpation of the adnexa: Assess for any masses, tenderness, or abnormalities of the ovaries or the adnexal area. To palpate these structures, insert the examining fingers into each lateral fornix, positioning them slightly posteriorly and high. Sweep the abdominal examining hand downward over the internal fingers. Normal ovaries are usually <3 cm long and are rubbery.

If there is a history of significant pelvic pain or an adnexal mass is felt, a rectovaginal–abdominal examination can help complete the evaluation of the adnexa or uterus and the rectum, anus, and posterior cul-de-sac. A rectovaginal–abdominal examination is performed with the index finger in the vagina, the middle finger in the rectum, and the other hand on the abdomen. The examination permits evaluation of the uterosacral ligaments and cul-de-sac as well as the mobility of the uterus. It is important to inform the patient that she may experience an urge to defecate: “You may feel like you are having a bowel movement, but you won't go. Your brain is just giving you a different message.” The rectovaginal septum should be thin and pliable, and the pelvic floor should be free of masses and tenderness. On indication, stool retrieved can be tested for occult blood.

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9. At the completion of the examination, offer the patient a box of tissues to be used to remove the lubrication from her perineum after you leave the room. Some patients may require assistance in sliding up the table before taking their feet out of the ankle supports. Instruct the patient to dress fully and return to the office for a discussion of your findings and plan. Before the practitioner leaves the room, the patient should be in a sitting position and draped.

During the postexamination discussion, the patient should be congratulated for her cooperation, and the importance of the findings of the examination (positive or negative), should be discussed in relation to her chief complaint. All questions should be answered, and any therapy and further tests required should be outlined. This is an important time for discussion of the adolescent's concerns about normal anatomy and physiology, contraception (including emergency contraception), and sexuality. Reinforce the positive experience of sharing her information with you as a demonstration of her ability to think about her sexual health and be responsible. During this discussion with the adolescent, it is important for the examiner to listen carefully, remembering that teenagers may not communicate all their concerns initially. At the conclusion of the discussion, the parent or partner can be invited to join the health care provider and the teenager. The parent can be informed of the results of the examination and the treatment plan. Any confidential information that is revealed to the parent should have been previously agreed upon with the teenager, so as to maintain trust. Parents should be encouraged to ask questions and to voice concerns.

Helping a teen through her first gynecological visit sets the stage for reproductive health care for a life-time. The gynecological visit is an ideal opportunity to provide education, listen to concerns, assess medical and psychosocial complaints, and promote a healthy future. The examination also allows the clinician an opportunity to impart to the teenager a positive attitude toward her body and to stress the importance of health maintenance.

Web Sites

For Teenagers and Parents

http://www.youngwomenshealth.org/pelvicinfo.html. Information about your first pelvic examination from Boston Children's Hospital.

http://www.goaskalice.columbia.edu/0643.html. From Columbia University for college students and older teens. Questions and answers about reproductive health and specifically here about pelvic examination.

http://www.sa.psu.edu/uhs/womenshealth/pelvicexam. cfm. From Penn State University Health Service, information about pelvic examination and Pap smears.

www.cdc.gov/std/hpv. Centers for Disease Control about sexually transmitted diseases and HPV.

http://teenadvice.about.com/cs/girlstuff/ht/pelvicexamht. htm. A Web site on the first pelvic examination developed in collaboration with The New York Times.

References and Additional Readings

American College of Obstetricians and Gynecologists. Cervical cancer screening in adolescents. ACOG Committee OpinionNo.300. Obstet Gynecol 2004;104(4):885.

Emans SJ, Laufer MR, Goldstein DP. Pediatric and adolescent gynecology, 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005.

Emans SJ, Woods ER, Allred EN, et al. Hymenal findings in adolescent women: impact of tampon use and consensual sexual activity. J Pediatr 1994;125:153.

Ford CA, Millstein SG, Halpern-Feilsher BL, et al. Influence of physician confidentiality assurances on adolescents' willingness to disclose information and seek future health care.JAMA 1997;278:1029.

Gray SH, Walzer TB. New strategies for cervical cancer screening in adolescents. Curr Opin Pediatr 2004;16: 344.

Kahn J, Chiou V, Allen J, et al. Beliefs about Pap smears and compliance with Pap smear follow-up in adolescents. Arch Pediatr Adolesc Med 1999;153:1046.

Larsen SB, Kragstrup J. Experiences of the first pelvic examination in a random sample of Danish teenagers. Acta Obstet Gynecol Scand 1995;74:137.

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

Saslow D, Runowicz CD, Solomon D, et al. American Cancer Society guideline for the early detection of cervical neoplasia and cancer. CA Cancer J Clin 2002;52:342.

Thrall JS, McCloskey L, Ettner SL, et al. Confidentiality and adolescents' use of providers for health information and for pelvic examinations. Arch Pediatr Adolesc Med 2000;154: 885.