Annual pelvic examination in the sexually active adolescent female: what are we doing and why are we doing it?

Acceptability of human papillomavirus self testing in female adolescents

OBJECTIVES

To develop scales assessing acceptability of human papillomavirus (HPV) testing in adolescents, to compare acceptability of self to clinician testing, and to identify adolescent characteristics associated with acceptability.

METHODS

Female adolescents 14-21 years of age attending a hospital based teen health centre self collected vaginal samples and a clinician, using a speculum, collected cervicovaginal samples for HPV DNA. Acceptability of and preferences for self and clinician testing were assessed at baseline and 2 week visits.

RESULTS

The mean age of the 121 participants was 17.8 years and 82% were black. The acceptability scales demonstrated good internal consistency, reliability, test-retest reliability, and factorial validity. Scores were significantly lower for self testing than clinician testing on the acceptability scale and three subscales measuring trust of the test result, confidence in one's ability to collect a specimen, and perceived effects of testing (p < 0.01). Of those who reported a preference, 73% preferred clinician to self testing. Acceptability scores for both self and clinician testing increased significantly pre-examination to post-examination (p < 0.01). Multivariable analyses demonstrated that race was independently associated with pre-examination and post-examination acceptability of self testing, and that sexual behaviours and gynaecological experiences were associated with specific acceptability subscales.

CONCLUSIONS

This sample of adolescents found clinician testing for HPV to be more acceptable than self testing and preferred clinician to self testing. If self testing for HPV is offered in the future, clinicians should not assume that adolescent patients will prefer self testing. Instead, they should educate adolescents about available testing options and discuss any concerns regarding self collection technique or accuracy of test results.

Coercive sexual experiences and subsequent human papillomavirus infection and squamous intraepithelial lesions in adolescent and young adult women

PURPOSE

The purpose of this study was to examine the associations between coercive sexual experiences and subsequent human papillomavirus (HPV) infection and/or squamous intraepithelial lesion (SIL) in adolescent and young adult women, and to determine whether risk behaviors mediate and sociodemographic factors moderate any observed associations.

METHODS

Data were obtained from a longitudinal cohort study of female university students (N = 608). chi2 and Wilcoxon rank-sum tests were used to determine associations between history of a coercive sexual experience and subsequent risk behaviors, and between risk behaviors and HPV or SIL. Logistic regression models were used to determine whether a coercive sexual experience was associated with HPV or SIL and whether the association was mediated by risk behaviors and/or moderated by sociodemographic factors.

RESULTS

Twenty-two percent of participants reported a prior coercive sexual experience. Report of a prior coercive sexual experience was associated with a higher lifetime number of sexual partners (p < .0001), which in turn was associated with subsequent HPV infection (p < .0001) and SIL (p < .0001). In logistic regression models, coercive sexual experience was associated significantly with HPV (odds ratio [OR], 1.84; 95% confidence interval [CI], 1.19-2.84) and at a marginal significance level with SIL (OR, 1.90; 95% CI, .97-3.70). When the number of sexual partners was included in the first model, the association between coercive sexual experience and HPV infection became nonsignificant and the beta coefficient decreased by 49%. Race and age did not appear to moderate the association between coercive sexual experience and HPV.

CONCLUSIONS

The number of sexual partners is an important mechanism through which adolescent and young adult women who report a coercive sexual experience acquire HPV.

Comparison of Adolescent and Young Adult Self-Collected and Clinician-Collected Samples for Human Papillomavirus

OBJECTIVE

To examine the concordance between self-collected and clinician-collected samples for human papillomavirus (HPV) DNA.

METHODS

Sexually active adolescent and young adult women aged 14-21 years (N = 101) were enrolled in a prospective cohort study of HPV testing. Participants self-collected vaginal samples for HPV DNA, and clinicians collected cervicovaginal samples for HPV DNA and a cervical cytology specimen. We determined concordance between the results of self- and clinician-collected specimens using a kappa statistic and McNemar's test.

RESULTS

Of the 51% of participants who were HPV positive, 53% had 1 type, 25% had 2 types, and 22% had 3 types or more; 25 different HPV types were identified. Self-collected samples detected more participants with HPV than clinician-collected samples (45% versus 42%, P =.65). When results were categorized into presence or absence of high-risk HPV types, agreement between self- and clinician-collected specimens was high (kappa 0.72) and the difference between test results was not significant (McNemar's P =.41). However, when all HPV types detected were considered, agreement was perfect in only 51% of those with 1 or more types of high-risk HPV type. There was no association between agreement and age or HPV type.

CONCLUSION

Self testing for HPV DNA may be sufficiently sensitive for the detection of high-risk HPV DNA among adolescent and young adult women in clinical settings.

How to perform a pelvic exam for the sexually active adolescent

The pelvic examination is a necessary health screening for sexually active female adolescents. This article describes how to perform a pelvic examination, including collecting specimens for sexually transmitted infections, wet mount evaluation, and the Papanicolaou test. Additional sections cover abnormal findings and special considerations.

Pap test results among low-income youth: prevalence of dysplasia and practice implications

OBJECTIVES

To describe Papanicolaou (Pap) test findings and identify prevalence and correlates of dysplastic cervical abnormalities in low-income adolescent females.

DESIGN AND SETTING

This cross-sectional study included a modified random sample of female students ages 16 to 25 years at 54 U.S. Job Corps centers.

PARTICIPANTS

5,734 female students enrolled in a federal job training program. Admission health records were reviewed and abstracted.

MAIN OUTCOME MEASURE

Pap test findings using the Bethesda classifications. Pap smear results indicating dysplasia (atypical squamous cells of undetermined significance [ASCUS] with dysplasia) or squamous intraepithelial lesions (low-grade squamous interepithelial lesions [LGSIL] or high-grade squamous intraepithelial lesions [HGSIL]). Participants with less severe findings were compared with those who needed follow-up.

RESULTS

For 71.4% of participants, no abnormalities were found. 15.6% had benign cellular changes, 9.2% had reactive changes, and 9.9% had epithelial cell abnormalities. Of those tested, 5.6% (+/- 0.8%) had dysplastic Pap smear findings, with 0.3% (n = 12) HGSIL. All groups were equally affected, with abnormalities not associated with race/ethnicity, age, geographic region, education level, size of city of residence, or receiving public assistance.

CONCLUSIONS

In this population, dysplastic Pap smear results were not uncommon. Findings indicate that Pap screening, alone or in combination with more sensitive tests, can identify cervical abnormalities, including HGSIL, that suggest a need for further evaluation or follow-up.

An update on human papillomavirus infection and Papanicolaou smears in adolescents

Human papillomavirus infection is one of the most common sexually transmitted infections in young women, and may lead to clinical sequelae such as anogenital condylomata and cervical squamous cell carcinoma. Recent data on the biology and natural history of HPV infection in adolescents will have important implications for the development of adolescent-specific protocols for cervical cancer screening and for follow-up of abnormal cytology.

Clinical breast and pelvic examination requirements for hormonal contraception: Current practice vs evidence

Clinical breast and pelvic examinations are commonly accepted practices prior to provision of hormonal contraception. Such examinations, however, may reduce access to highly effective contraceptive methods, and may therefore increase women's overall health risks. These unnecessary requirements also involve ethical considerations and unwittingly reinforce the widely held but incorrect perception that hormonal contraceptive methods are dangerous. This article reviews and summarizes the relevant medical literature and policy statements from major organizations active in the field of contraception. Consensus developed during the last decade supports a change in practice: hormonal contraception can safely be provided based on careful review of medical history and blood pressure measurement. For most women, no further evaluation is necessary. Pelvic and breast examinations and screening for cervical neoplasia and sexually transmitted infection, while important in their own right, do not provide information necessary for identifying women who should avoid hormonal contraceptives or who need further evaluation before making a decision about their use.

New developments in diagnosis and management of adolescents with sexually transmitted disease

The battle against the epidemic of sexually transmitted infections continues but the clinician has new diagnostic and therapeutic weapons. This manuscript reviews new technologies, as well as novel applications of newer methodologies, such as utilization of amplified DNA techniques for urine specimens or patient-collected specimens. Newest treatment recommendations are also reviewed.

Adolescents and sexually transmitted diseases

Pediatricians with busy practices have limited time to spend with each patient. But because much of adolescent morbidity and mortality is related to behavioral issues, time and energy are crucial to providing effective counseling and care to adolescents. Many barriers to provision of services to adolescents exist, including time, space, décor, office hours, office fees, and support personnel. Despite these barriers to care of adolescents and, in particular, sexually active adolescents, the need for pediatricians to provide these services is clear. Services include anticipatory guidance and counseling about developing sexuality and sexual behaviors, as well as management of health consequences of sexual behavior. Primary care providers have an opportunity to assist adolescents to develop mature and healthy sexual relationships. This necessitates a full understanding of each patient's unique situation, listening to adolescents' concerns, and honest and straightforward discussion of sensitive information. Beginning the process of discussion of sexuality and relationships early in the pediatric years may help adolescents and their parents to develop healthy sexual attitudes and behaviors.

Adolescent gynecology in the office setting

As stated by the Committee on Adolescence of the AAP, All pediatricians who choose to see teenagers should be able to provide counseling about sexual behavior, education on contraceptive methods and prevention of sexually transmitted diseases, and assistance with access to family planning services, preferably in the office or, if necessary, by referral. Expansion of skills and office capabilities to provide routine reproductive health care for adolescents, including pelvic examinations, annual Pap tests, diagnoses of pregnancy, diagnoses and treatment of sexually transmitted diseases, and the prescription of contraceptives, is also encouraged. Pediatricians who have longstanding relationships with their patients, and who are admired and trusted are ideal for providing this care.

A study of 10,296 pediatric and adolescent Papanicolaou smear diagnoses in northern New England

OBJECTIVE

This study analyzes pediatric and adolescent Papanicolaou (Pap) smear diagnoses to determine the prevalence rates of squamous intraepithelial lesion (SIL) as well as infectious and reactive processes in this age group.

DESIGN

A total of 10 296 Pap smear diagnoses from patients 10 to 19 years of age collected over a 1-year period and classified according to the Bethesda system were reviewed. This population was almost exclusively white, the majority residing in rural or suburban areas of Maine, New Hampshire, and Vermont. The percentage of abnormal smear results was then compared with data generated for older age subsets.

RESULTS

The following diagnoses were made on 10 296 Pap smears from patients 10 to 19 years of age: 7208 (70.01%) normal; 1689 (16.4%) benign cellular change; 1004 (9.75%) atypical squamous cells of undetermined significance; 388 (3.77%) squamous intraepithelial lesion (SIL); and 7 (0.06%) atypical glandular cells of undetermined significance. A total of 1503 (14.6%) of smears showed infectious processes. Compared with the results of adult Pap smears collected over the same time period, the age 20 to 29 subset with 27 067 Pap smears and the age 30+ subset with 42 617 Pap smears showed 11.79% and 8.43% infectious processes and 3.49% and 1.27% SIL, respectively. Therefore, the highest rate of infectious processes and SIL was found in the subset of patients age 10 to 19 years.

CONCLUSIONS

Because the development of SIL and hence cervical cancer is causally related to sexually transmitted human papilloma virus (HPV) infection, this high rate of abnormal Pap smear results of both an infectious and precancerous nature in this population may reflect a high level of sexual activity among adolescent girls. These data reinforce the importance of implementing early cervical Pap smear screening in the sexually active pediatric and adolescent population.