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Kara is a 15-year-old African American teen who is 2 weeks postpartum and has come today for birth control. Her body mass index (BMI) today is 32. The young man who fathered her child is no longer part of her life, but she has begun a new relationship with another young man. Her pregnancy resulted because of inconsistent oral contraceptive use, and she clearly is at risk for a repeat pregnancy because of the new relationship. For a variety of reasons, she has chosen to use depot medroxyprogesterone acetate (DMPA). Recent studies have revealed that it is not only possible to tailor DMPA prescribing practices to individual teen characteristics, but it may be medically indicated because of possible effects on future health.

Sierra is an 18-year-old teen and the mother of a 1-year-old son. She has been in the foster care system for several years. Her parents were unable to maintain a functional family due to drugs and violence. Though she is in contact with her mother, her mother is not able to provide her with any emotional or financial support. This is not an unfamiliar scenario in an obstetrical and gynecological practice that provides care for teens. Medically, Sierra’s care has been rather unremarkable. Her prenatal, childbirth, and postpartum experiences were without any untoward events. She has come consistently for gynecological care. Today’s visit is for an IUD placement because she has sometimes forgotten her birth control pills and she does not want another pregnancy. School attendance with a newborn was much more difficult than Sierra imagined it would be, so she finished high school with a graduate equivalency diploma (GED). She currently lives in a shelter provided by a local teen family support program, and with their help has found a job in a fast-food establishment and day care for her son. Sierra is about to ‘‘age-out’’ of the social service system. A significant number of teen mothers are in Sierra’s position. They have managed to finish high school or obtain a GED. They are working at lowpaying jobs that do not provide a living wage or benefits. They are barely managing to pay rent and child care. Medical providers are often at a loss as to how to help these young women, who have demonstrated they are competent academically, responsibly caring for their children and motivated to get a better job and become financially independent. The One Family Scholars (OFS) program is a unique not-for-profit organization created by Paul and Phyllis Fireman and family to end family homelessness in Massachusetts. The program provides college scholarships coupled with career development and leadership training for low-income and formerly homeless mothers. With financial aid and the support of an ‘‘extended family’’ to help them achieve their academic goals, the Scholars have the opportunity to forge a permanent path out of poverty. Ethnically

Major advances in the prevention of cervical cancer have been made this year. On average there are about 9710 new cases of cervical cancer in the United States each year and 3700 deaths attributed to it. The lethality of cervical cancer is even greater worldwide where it is the second most common cancer in women causing over 470000 new cases each year and 233000 deaths. The discrepancy is largely due to the decreased availability of affordable screening and treatment in many countries. The vaccine Gardasil manufactured by Merck Pharmaceuticals was approved by the Food and Drug Administration (FDA) using a priority review process early in June of this year. By the end of June the Center for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) had issued recommendations that Gardasil be routinely given to girls when they are 11-12 years old. The ACIP recommendation also allows for the vaccination of girls beginning at 9 years at the discretion of the physician or healthcare provider. In addition the recommendation includes girls and women ages 13-26 years old because they will benefit from the protection although the best protection is achieved before the onset of sexual activity. (excerpt)

Mariya is 17 and presents for an office visit requesting birth control. She represents a majority of teens in that she began having sexual intercourse before requesting birth control. Most young women (79%) wait a month or more after their first intercourse to see a health care provider with the median wait being 22 months after first intercourse. She and her boyfriend have used condoms--sometimes--and a recent late period rather frightened both of them. He is her first sexual partner. Until recently there would have been no question that Mariya would have a pelvic exam which included a Pap test and STD screening for gonorrhea and chlamydia before being prescribed birth control; however a better understanding of the pathogenesis and natural history of the human papillomavirus (HPV) and abnormal cervical cytology has resulted in different recommendations. The American Cancer Society (ACS) now recommends that cervical cancer screening begin approximately 3 years after the onset of vaginal intercourse and no later than age 21 years. These new guidelines are the results of a consensus of a national panel of experts who reviewed evidence and concluded that there is little risk of missing an important cervical lesion within three to five years of exposure to HPV. (excerpt)

Most teenage girls have very little accurate information about their reproductive systems. Vaginal health in particular seems to be an area where myths and misinformation abound. More than 20 years of adolescent gynecology practice has given me some insight as to the sources teens use for information about vaginal health. Media sources such as TV and magazine ads are extremely influential. The concept of feminine hygiene has been mostly created by those who manufacture and sell feminine hygiene products. They have capitalized on the idea of menstruation as an unclean process an idea promulgated by centuries of cultural practices that isolated women during menstruation and regarded menstrual blood as unclean or even dangerous. Though women in our society are no longer isolated or avoided during their menses many female relatives perpetuate this concept by encouraging their daughters and granddaughters that the vagina needs to be cleaned after sex after the menses or just routinely. Mothers and grandmothers are a very influential source in my experience. In the urban setting in particular many teenage girls have been raised by their grandmothers who are well-intentioned but who often pass on information that is outdated or mythical. Learning how to douche seems to be a rite of passage for many teenage girls and douche products abound. (excerpt)

Persistent pelvic pain in teens can be a challenging problem with multifactorial etiologies. Certainly because of the high incidence of sexually transmitted infections in this age group an infectious cause (pelvic inflammatory disease; PID) is a likely diagnosis. Somatization of mental health problems such as depression can be a contributing factor. Pain that has become chronic in reproductive age women is increasingly attributed to endometriosis. Between 71% and 87% of women of childbearing age who present with chronic pelvic pain have endometriosis. Myra is the 18-year-old single mother of an 8-month-old daughter. She lives with her daughter in a shelter for teen mothers. Since her daughters birth she has used oral contraceptives for birth control. For about 5 days Myra had some pelvic pain and irregular vaginal bleeding. Her examination was consistent with PID: positive for cervical discharge cervical motion tenderness tender uterus and adnexa. She was afebrile and wet mount had many white blood cells (WBCs). Her pregnancy test was negative. (excerpt)

It is well known that teens and young adults have the highest rates of sexually transmitted diseases (STDs), particularly gonorrhea and chlamydia. One might logically assume that this group would also be more frequently screened for STDs; however, this appears not to be the case. A study by the Centers for Disease Control (CDC) Division of STD Prevention in 2005, using data from the National Ambulatory Medical Care Survey, found that young women were not screened at 84.0% of 1.2 million asymptomatic preventive visits and were not tested for chlamydia at 78.3% of 0.6 million visits where they presented with signs or symptoms of chlamydia. These data indicate that the incidence of STDs is at best underestimated. In spite of this fact, CDC data have shown a rise in the STD rates over the past 2 years. Current prevention efforts focus on safe or safer sex, which has come to mean promoting abstinence or consistent condom use. Safe-sex education cannot be stressed enough; however, STD prevention efforts may be missing the connection between alcohol use and the risky behaviors directly associated with exposure to STDs. Recent studies of teens and young adults have shown that alcohol use is significantly associated with higher incidences of STDs. Among females, binge drinking was uniquely associated with risky sexual behaviors, such as receptive anal sex and multiple partners, and an STD diagnosis. Binge drinking is defined as 5 or more drinks in a row for males and 4 or more drinks in a row for females. It is recognized that alcohol-related problems do not start at the level of drinking that is legally defined as intoxication. Reductions in cognitive and psychomotor performance are found at low levels of alcohol consumption, which may lead to negative health consequences. Wechsler et al have found in the College Alcohol Study (CAS), which used 4 different data collection points over 14 years, that drinking among college students has remained consistently at 44% of students

Melissa is age 17 and a high school senior. Her exam today is suspicious for a chlamydial infection. She has a cervicitis and a mucopurulent discharge. Four months ago she was treated for Chlamydia-PID. At that time she seemed reluctant to tell her boyfriend that she had a sexually transmitted infection though she knew she had no other partner. She said then "He will say I gave it to him." After a detailed explanation of the epidemiology and possible consequences for health she promised to see that he was treated. Today when asked if he was treated she has difficulty making eye contact and says in a low voice that she never told him. She denies that she is afraid to tell him but her downcast eyes and reluctance to make eye contact suggest otherwise. (excerpt)

the healthiest outcome is achieved by early identifiTeens, Periods, and Pregnancy cation of the pregnancy. Assurances of confidentiality and access to pregnancy testing are key factors in Jeanne is 16 and has been coming to you for care promoting early entry of a pregnant teen into the since she was a toddler. Her younger siblings see you healthcare system. also. With the diagnosis of an intrauterine pregnancy, it Today’s appointment she made herself because is important to confirm gestational age, begin options she is having “some trouble with her periods.” Since counseling, and determine when and how she will menarche at age 12 she has had monthly periods but tell her parents. two months ago she had a one-day period and missed Jeanne’s history is consistent with her estimated her period this past month. She had sex once at a gestational age of pregnancy. Many teens, however, party after having a few drinks. She is afraid she for reasons of fear, denial, or ignorance, may give a might be pregnant and remembers that you told her history that suggests they are very early pregnant when she was about 12 that you would respect her when in reality they are further along. Their true confidentiality about sensitive issues. gestational age may limit their options for pregnancy Irregular periods are common in adolescence; termination. Also the pelvic exam is an opportunity many teens do not ovulate monthly for a year or two to do a Pap test and cultures for gonorrhea and chlaafter their menarche. However, pregnancy is the most mydia. Though the rates of gonorrhea and chlamydia likely cause of “irregular” periods in a teen. It is wise have declined, the incidence is highest in teens and to suspect or at least rule out pregnancy when a teen young adults. Abnormal Pap tests, often associated has some irregular periods, especially if: with the Human Papilloma virus, are frequent among sexually active teens. HIV counseling and testing • use of drugs/alcohol is suspected should be considered. • there is some instability in the teen’s family life Jeanne needs options counseling, as do all teens. such as parents’ divorce or separation, remarriage, A teen needs to hear the “what ifs.” What if you death, or parent has a new partner carried the pregnancy to term? What if you had an • poor intrafamily communication abortion? What if you placed the baby for adoption? • family abuse of drugs/alcohol The pros and cons of each choice and the likely and • family history of mental illness, especially in a potential effects on her life/academic career/family parent should be clearly identified. Include her partner if • domestic violence possible. A referral for options counseling may be made to Indeed, her pregnancy test is positive, her uterus is a local social service agency, which can be identified enlarged and she is clearly anxious about what to do through the yellow pages of the telephone book, on and how to tell her parents. Certainly the healthiest the Internet, or through the State Department of state for Jeanne is a non-pregnant state, and fortuPublic Health. Some schools have programs that innately the teen pregnancy rate has declined over the clude a teen counselor. past decade. Studies indicate a decrease in sexual Telling her parents is another issue that needs to activity in teens1 and increased use of condoms with be addressed. Can she tell her parents? Will she do first intercourse.2 However, once a pregnancy has been conceived so? What does she anticipate their reaction will be?

Disturbing trends are revealed in the CDC Sexually Transmitted Disease Surveillance 2006. Rates of gonorrhea (GC), chlamydia (CT), and syphilis increased in 2006. Since the 15e24 age group bears the highest disease burden for GC and CT, this trend is worrisome and deserves some examination of possible causes. Gonorrhea rates increased in 2006 for the second consecutive year. As in previous years, the South had the highest GC rates of the four regions of the USA. For many years the GC rates in the South had been declining, but in 2006, the GC rates rose by 12.3%. In contrast, the GC rate in the Northeast declined by 21.2%. The trend is similar for African Americans. After ten years of declining rates of GC, in 2006, the GC rate for African Americans increased by 6.3%. While the rate of GC among African Americans has always been greater than that of Caucasians, recent trends demonstrate that the disparity has gotten smaller. For the second consecutive year gonorrhea rates among women are slightly higher than among men, which has not been the case historically. In 2006, the GC rates continued to be highest among adolescents and young adults. The highest rates were among 15e19 year old females. This age group of females also has the distinction of having the highest rates of CT. African American women are disproportionately affected, having rates of CT more than seven times that of Caucasian females. GC and CT are major causes of PID in young women. Since the rates of CT are so high in young women, CDC now recommends annual CT screening for all sexually active women under age 26. Repeat testing in 3 months is recommended because the re-infection rate is high. For this reason, it makes sense to treat partners for CT, which can be done even in services that routinely treat only females. If getting the male partner in for treatment is unsuccessful, a prescription for azithromycin 2 gm in the partner’s name can be given to the female patient. That represents a more serious effort to reduce CT rates.

The benefits of breastfeeding to the health of infants and mothers have been well documented. A less quantifiable positive effect of breastfeeding is the increase in the mothers self-esteem and confidence as a mother if she has successfully initiated breastfeeding. This boost to self-esteem is particularly noticeable in the teen mom. A common characteristic of teens who either consciously or unconsciously choose to become pregnant is a sense of failure of never having achieved something worthwhile. Pregnancy and childbirth provides them with a sense of accomplishment but they absolutely beam with pride when they successfully initiate and persevere with breastfeeding their baby. (excerpt)

A teen's definition of sexual activity most often does not include oral or anal sex. Abstinence only programs vary widely as to how they define sexual behavior and may be contributing to misinformation about STD transmission. Unknown is the extent to which declining teen pregnancy rates are due to non-coital activities replacing vaginal intercourse.

After numerous gynecological examinations of teenage girls it becomes clear that they have little knowledge of their vaginal anatomy or any concept of vaginal health. Health education pertaining to reproductive organs is at best limited to pictures of the internal reproductive organs a reflection in part of ambivalence about sexuality. Little focus is on the vagina presumably because there might be more discussion about its function. Vaginitis is a very common reason for office visits by teens as well as adult women every year. Bacterial vaginosis (BV) vulvovaginal candidiasis (VVC) and Trichomoniasis (Trich) are the three most common types seen. Though only Trich is felt to be sexually transmitted BV and VVC are considered sexually-associated since they are usually seen in sexually active females. In prepubertal vaginitis not associated with sexual abuse the causative organisms are usually respiratory pathogens such as Group A beta hemolytic streptococci and H. influenzae or enteric organisms usually E. coli. (excerpt)

Sara is a 16-yr-old who was recently admitted to a hospital for treatment of severe PID. She had been experiencing abdominal pain for several weeks but was reluctant to seek treatment because she was afraid her parents would learn she had begun a sexual relationship. Unfortunately her pediatrician who had been her doctor for as long as she could remember had never clarified a policy of confidentiality with her. Often her mother came with her to medical appointments and her doctor never asked to see her alone. Sara didn’t know she had a right to confidential treatment. The failure of the health care system to provide her confidential care has resulted in increased medical costs pain for Sara and the increased risk that her future fertility may be impaired. Many times parents will bring their teen for a gynecological exam and they can be very helpful in providing both the teen’s and the family’s medical history. However honest answers from the teen are more likely if the parent is not present for the exam and sensitive questions about sexual activity violence and drug use are asked in private. (excerpt)

Thorny issues requiring difficult decisions are part of our personal and professional lives. Sometimes however patients present us with circumstances that make our obligation to the patient conflict with our moral obligation. Such were the circumstances of my experience with GD. She was a 16-year-old Hispanic teen and 6 weeks pregnant when I met her. Outwardly she was a picture of health like many of the teens we see. But GD carried a heavy burden. About 4 months prior to the visit she had been diagnosed with HIV and had told no one! Only the professionals who had tested and counseled her knew of the diagnosis. Because of fear she had resisted counseling efforts to help her disclose her HIV infection to her partner and his family. She had been living with them for about 4 months. This living situation was a source of support and she feared having no where to go if they rejected her. She was estranged from her family. The stigma of HIV is strong and there is much myth and misinformation surrounding transmission. She felt sure his family would ask her to leave their home. In addition GD feared her partners reaction might be violent. He was very angry when she had told him of her chlamydia infection about a month prior. She did not want to lose him. Circumstances were such that it was highly probable that GD had become infected by a previous partner. (excerpt)