Approach to the Physical Examination

An infant or very young child can be examined most easily while she is semirecumbent on her mother’s lap with her hips flexed and abducted. Put lateral and downward pressure on the labia majora so that you can visualize the introitus, hymen, and lower third of the vagina (Fig. 18–1). An alternative, equally effective technique is to hold the labia majora gently between your thumbs and forefingers and gently draw them forward (Figs. 18–2 and 18–3).

FIGURE 18–1 Lateral retraction of the labia majora while a prepubertal girl lies in a frog-legged position.

FIGURE 18–2 Forward retraction of the labia majora facilitates inspection of the hymenal area in this prepubertal child. An annular hymen is easily seen.

FIGURE 18–3 A mucocolpos, easily seen with lateral retraction of the labia majora.

A child who is age 2 years or older can also be examined in the knee-chest position. The child holds her bottom in the air with her knees 10 to 15 cm (about 4 to 6 inches) apart, allowing her stomach to sag against her thighs. Have an assistant or parent gently retract the labia majora on one side laterally and upward while you do likewise on the other side. This positioning facilitates the inspection of the external genitalia and causes the pubococcygeus muscle to relax, allowing the vagina to fall open. You can visualize the entire length of the vagina and frequently identify the cervix. Use the otoscope (without a speculum) to provide magnification and good illumination along the length of the vagina. Do not allow the otoscope to touch the external genitalia or to enter the vagina.

Examination of external genitalia

Examination of the external genitalia should include a systematic inspection of the clitoris, urethra, labia majora, labia minora, perihymenal tissues, hymen, posterior fourchette, and perineal body. Document the hymenal configuration and confirm its patency.

Variations in normal hymenal configuration have been well described (Figs. 18-4 to 18-6). Fimbriated hymens are characterized by redundant folds of hymenal tissue with scalloped rims that circumscribe the vaginal introitus. Annular or circumferential hymens are smooth, uniform skirts of hymenal tissue that completely surround the vaginal introitus. Posterior rim or crescentic hymens appear as smooth folds of tissue arranged from 2 o’clock through 11 o’clock around the introitus, with minimal or no hymenal tissue present inferiorly under the urethra.

FIGURE 18–4 Posterior rim hymen.

(From Pokorny S: Physical examination of the reproductive systems of female children and adolescents. Curr Probl Obstet Gynecol Fertil 8:202, 1990.)

FIGURE 18–5 Circumferential hymen.

(From Pokorny S: Physical examination of the reproductive systems of female children and adolescents. Curr Probl Obstet Gynecol Fertil 8:202, 1990.)

FIGURE 18–6 Fimbriated hymen.

(From Pokorny S: Physical examination of the reproductive systems of female children and adolescents. Curr Probl Obstet Gynecol Fertil 8:202, 1990.)

The hymenal orifice at the introitus varies in size and placement, the variations being directly influenced by the configuration of the hymenal tissue. You should be able to identify microperforate hymen, imperforate hymen, and cribriform hymen. The orifice of a microperforate hymen can be difficult to identify, but gentle probing directly beneath the urethra with a small moist swab helps locate the opening. The unestrogenized hymen is a very sensitive structure, thus care should be taken with any manipulation. Transverse hymenal bands and tags have been reported in 3% to 4% of girls and can be identified at the time of the newborn examination.

The diameter of the hymenal opening into the vagina varies with a child’s level of relaxation during the examination, age, the stage of pubertal development, and the configuration of the hymen. There is overlap in diameters recorded for varying age groups. Between ages 5 and 10 years, however, the upper normal limit of the transverse diameter of the hymenal orifice (in millimeters) should not exceed the child’s age in years. In a child in whom the transverse diameter is larger than expected for the age, you should question the possibility of a prior penetrating injury or prior instrumentation of the vagina.

Periurethral bands are observed in approximately 50% of prepubertal girls. These bands are bilateral in 91%, creating false pockets on either side of the urethral meatus.

The appearance of the labia and perihymenal tissues may suggest that the child has been exposed to endogenous (or possibly exogenous) estrogen. The labia and perihymenal tissues of an unestrogenized prepubertal girl are poorly developed and appear red. Labial agglutination (Fig. 18–7) and chronic skin changes, such as increased pigmentation, may suggest a chronic inflammatory process. Document the presence of a purulent discharge, smegma, or leukorrhea. A thicker, lesser fusion of the posterior aspect of the labia minora may suggest excessive androgen stimulation due to congenital adrenal hyperplasia, especially if the labial fusion is associated with clitoral enlargement. If clitoromegaly is present, measure the clitoris glans in both transverse and longitudinal diameters. Normal values for clitoral size at various ages and stages of sexual development are available in pediatric gynecologic references.

FIGURE 18–7 Labial agglutination. The arrow points to the line of fusion between the labia minora.

Indications for vaginoscopy

Instrumentation of the vagina is rarely required in the evaluation of prepubertal girls. Indications for vaginoscopy include undiagnosed vaginal bleeding, refractory vaginal discharge, and suspicion of intravaginal foreign body. Before beginning vaginoscopy, show the child all the instruments, and let her touch them (Fig. 18–8). If you intend to obtain cytologic and bacteriologic specimens during vaginoscopy, use only water as a lubricant. Cystoscopes, hysteroscopes, and anoscopes have all been used for vaginoscopy.

FIGURE 18–8 Welch Allyn pediatric anoscope may be used as a vaginoscope.

Office vaginoscopy can be carried out successfully when the child understands what is to be done and trusts you. Because the vagina of a prepubertal girl is a short (4 to 5 cm), nonpliant cylinder that can be traumatized easily, place any instrument gently. The hymenal membrane is particularly sensitive. Applying 2% lidocaine jelly to the introitus may help make the examination less uncomfortable. If the child is tense and the hymenal opening does not relax, postpone vaginoscopy until the child is less anxious and better able to cooperate. A child should never be forcibly restrained during such an examination. On rare occasions, the gynecologic examination of a very young or very anxious child may best be carried out with anesthesia or conscious sedation.

Bacteriologic cultures

Bacteriologic cultures, when required, should be obtained from the prepubertal child’s vagina. Vulvar sampling is not sufficient. It is not necessary to sample the endocervical canal, as you would in adults because sexually transmitted infections in this age group involve the vagina, not the cervix.

Key Point

Even the seemingly simple task of obtaining a culture specimen from the vagina can be difficult because the prepubertal vaginal mucosa, being hypoestrogenic, is easily abraded.

It is important to premoisten culture swabs with nonbacteriostatic saline solution or sterile water. Use appropriately sized swabs for culturing, always choosing the smallest swab available (Fig. 18–9). Prior to collecting bacteriologic or viral specimens from the prepubertal child’s vagina, it may be prudent to discuss your needs with your local laboratory or microbiologist because the availability of testing methods will vary among facilities. Diagnostic modalities could range from culture, microscopy, antigen detection tests, nucleic acid detection test, or serology. The sensitivity and specificity of tests will vary according to the specimen type and the organism assayed. So seek an expert opinion first to ensure that you do the most appropriate test because children do not like vaginal sampling.

FIGURE 18–9 A Calgiswab (top) or a plastic eyedropper (bottom) can be used to obtain bacteriologic specimens from the prepubertal vagina.

Vaginal specimens may be obtained while the child is either in the knee-chest position or in the supine position, whichever effects greatest relaxation of the hymenal orifice, allowing the swab to be passed into the vagina without touching the sensitive hymenal membrane. Some clinicians report success with the use of vaginal irrigation specimens for culture. A malleable plastic sterile eyedropper or butterfly catheter tubing, encased in a red rubber catheter and with the needle removed, has been used to flush the vagina with sterile nonbacteriostatic saline solution or sterile water.

Bimanual rectoabdominal examination is indicated in any prepubertal girl who presents with undiagnosed vaginal bleeding or in whom an intravaginal foreign body or a pelvic mass is suspected. As mentioned previously, the vagina in prepubertal girls is short, nonpliant, and easily abraded. You can obtain more information if you perform a rectoabdominal examination with the child in a supine, frog-legged position. A bimanual examination should enable you to identify the small uterus as a midline structure. Ovaries are abdominal organs in prepubertal girls; therefore, they should not be normally palpable on a bimanual examination.

Obtaining the History

A complete gynecologic history can indicate whether gynecologic disease is present. Document the age of onset and progress of pubertal change (thelarche, adrenarche; see Chapter 16). The mother’s age at menarche is often a good predictor of when her daughter will experience her first menstrual period. Menarche commonly occurs 2 years after thelarche, when breast development reaches Tanner stage 4.

Menses can be characterized in terms of duration of flow, amount of flow, and interval between menses (Fig. 18–10). The normal duration of flow varies from 3 to 7 days. Persistence of menses for longer than 10 days warrants evaluation. When asking about the cycle interval, make sure that the days of menstrual flow are included in the estimate. Day 1 of the menstrual cycle is the first day of the menstrual flow. A range of 25 to 35 days should be accepted as falling within the range of normal; shorter or longer intervals may require evaluation and treatment. Cycles can remain anovulatory for 2 to 4 years after menarche. Therefore, early cycle irregularity may reflect immaturity of the hypothalamic-pituitary-ovarian axis rather than gynecologic disease.

FIGURE 18–10 The menstrual calendar is a useful tool for prospectively recording menses.

(Courtesy of Dr. JEH Spence, Ottawa Civic Hospital, Ottawa, Ontario, Canada.)

It is often difficult to obtain a reliable impression of the amount of flow. The reported number of menstrual pads or tampons used per day is unreliable because a fastidious girl may change pads or tampons when they are only slightly soiled. Asking about symptoms such as low energy, fatigue, and dizziness may help identify the girl who is anemic secondary to menorrhagia.

Normally, the physiologic vaginal discharge varies in consistency and amount throughout the menstrual cycle, in response to the cyclic production of estrogen and progestin. Before menarche and the establishment of ovulatory cycles, the mucoid discharge may be copious as a result of unopposed estrogen stimulation, and this excessive production of mucus may, in turn, cause vulvar irritation. Taking the time to talk about the discharge and explaining that the secretions come from the endocervical glands in response to normal cyclic ovarian hormone production may help allay unspoken anxieties in both the girl and her parents. Frequently, patients and parents mistakenly perceive such physiologic discharge as indicating infection or pelvic inflammatory disease.

You must ask any adolescent girl about sexual practices because many are sexually active at an early age, and issues of sexual orientation can arise in this age group. Be sure to frame the questions in an open and specific manner. You may simply ask, “Some of my patients of your age are in a sexual relationship. Are you?” If the patient’s answer is affirmative, ask, “Is your partner a boy or girl?” If the patient is sexually active, ask the following:

You can form an impression about the girl’s susceptibility to risk-taking behavior by asking how many boyfriends she has had over the past year and with how many of them she has had sexual intercourse. These questions will set the stage for a frank discussion about substance abuse, interpersonal violence, sexually transmitted diseases, safe sex, homosexuality, and the patient’s own sexual experiences. She may want to discuss these issues with you but may be uncomfortable about initiating the discussion. It is important to delve into issues that may also make you a little uncomfortable. Information pamphlets on human sexuality, sexually transmitted diseases, healthy relationships, and contraception should be available in any clinical setting where adolescent patients are treated.

Approach to the Pelvic Examination

Many young girls are shy and nervous about an impending pelvic examination. Unfortunately, in preparing her daughter for the visit, a mother who is herself uncomfortable about pelvic examinations may have transmitted these anxieties to her daughter.

Give the patient the privacy to disrobe, provide her with a gown, and be sure she is appropriately draped throughout the examination. A chaperone should be present at every intimate examination.

Always precede a pelvic examination with a general physical examination. This more familiar examination gives your patient time to become comfortable with you and helps relieve some anxiety. Appraise and stage the secondary sexual characteristics and look for evidence of an underlying endocrinopathy. Breast and pubic hair development can be staged according to the Tanner classification (see Chapter 3). Note the presence of axillary hair or of adult sweat odor. Thyroid gland enlargement, galactorrhea, and signs of androgen excess, such as acne, oiliness of the skin, and hirsutism, are all important findings. In the course of the general physical examination, you can give the patient much useful information about the changes that she may be noticing in her body.

Tailor the pelvic examination to the presenting complaint and the stage of pubertal development. Inspection of the genitalia alone offers much information. Systematically examine the clitoris, labia majora, labia minora, perihymenal tissues, hymen, posterior fourchette, and perineal body. While looking at the labia, assess whether the mucosal appearance and secretions are in keeping with exposure to estrogen. Thickening of the perihymenal tissues and increased development of the mons, labia majora, and labia minora suggest an estrogen effect. The configuration and patency of the hymen can be documented by inspection alone. Note the presence of leukorrhea or of secretions at the introitus. The presence of obvious secretions at the introitus provides indirect evidence that a normal cervix is present and that there is no obstruction between the cervix and perineum.

When first examining a young girl who is not sexually active, it is best not to attempt instrumentation of the vagina. As noted earlier, evaluation with the child in the knee-chest position allows visualization of the entire length of the vagina and inspection of the cervix. Culturing the vagina is much easier in adolescents because the estrogenized mucosa is thick and less easily traumatized. Swabbing, therefore, does not produce the same abrasive discomfort as in a nonestrogenized prepubertal girl.

Bimanual examination of the pelvis in the adolescent girl who is not sexually active is best carried out by a rectoabdominal examination with the girl in the supine frog-legged position. The rectoabdominal examination is generally perceived as less threatening by young girls who are not sexually active. A single-finger vaginal examination can produce enough patient anxiety and discomfort to preclude obtaining any useful information about the internal genitalia.

Pelvic examination of the sexually active adolescent requires instrumentation of the vagina. A complete gynecologic assessment may include both a Papanicolaou (Pap) smear and culture of the endocervical canal for sexually transmitted diseases. Currently, it is recommended that a cytologic screening of the cervix begin within 3 years of becoming sexually active or at age 21 years.

Various specula are available to facilitate the examination (Fig. 18–11). The Pederson and Huffman specula are best in pediatric practice because they are much narrower than the Graves speculum, a more appropriate instrument for the examination of multiparous women. Before performing a speculum examination, show the patient the instrument and explain how you will use it. It is easiest to examine adolescent girls when they are placed in the lithotomy position and properly positioned at the end of the examination table. Take the time to encourage the patient to breathe quietly and deeply during the examination and to relax the abdomen and buttocks. The patient should allow her knees to fall loosely open, effecting a further relaxation of the perineal muscles. Warm the speculum under warm (not hot) water; use only water for lubrication to facilitate insertion of the speculum into the vagina. Before inserting the speculum, gently retract the labia laterally with a gloved hand, bringing the hymenal opening into view and preventing inadvertent pinching of the labia when you insert the speculum.

FIGURE 18–11 A variety of vaginal specula should be available so that an appropriately sized instrument is always used. Left to right: Huffman, Pederson, and Graves specula.

As you insert the speculum, exert gentle pressure posteriorly, because any anterior pressure compresses the sensitive urethra. Next, open the blades of the speculum to bring the cervix into view. Gently swab away the mucus covering the exocervix, and inspect the cervix for any plaques, areas of whiteness, ulcers, or polyps. Nabothian cysts are not abnormal findings (Fig. 18–12). Note the transitional zone at the junction of the columnar and squamous epithelia (Fig. 18–13). It is the transitional zone that must be sampled when you obtain a Pap smear. In adolescents, it is not uncommon to see red-looking columnar epithelium on the exocervix. Do not mistake this finding as an indication of cervicitis.

FIGURE 18–12 Cervix visualized with the aid of a speculum. The arrow points to a benign nabothian cyst.

FIGURE 18–13 Photomicrograph of the cervix showing the cervical os and columnar epithelium (top), the transitional zone (arrow), and squamous epithelium (bottom).

Always obtain specimens in the following sequence:

5. Thinly smear the collected specimens on glass slides and immediately fix them with 95% ethyl alcohol. Alternatively, a broom may be used to obtain cytologic samples. This samples both the endocervix and exocervix simultaneously. When using the broom, the long central bristles are inserted into the cervical os until the lateral bristles touch the exocervix. The handle is then rolled 3 to 5 full rotations.

FIGURE 18–14 Equipment required to obtain a Papanicolaou smear consists of the Cytobrush and Ayre spatula (top) or broom (bottom).

FIGURE 18–15 Colposcope.

Liquid-based cytology is a newer method used by some cervical cytologic screening programs. This is a superior method to a conventional smear in that cells that are collected are placed in a liquid preservative, and a slide preparation is done in the laboratory. With this process, a better slide sample is obtained, improving specimen adequacy. A collection of cells in the liquid medium also allows for additional or repeat testing.

HPV testing is not currently used as an initial cervical cancer screening modality. HPV testing is used to triage women over age 30 years who have an ASCUS (abnormal cells of uncertain significance) Pap test and may have a role in the follow-up of women previously treated for squamous intraepithelial lesions.

When you collect specimens for sexually transmitted diseases, it is always important to be familiar with the swabs, transport systems, and types of testing offered by your local facility. Multisite testing, that is, pharynx, rectum, and urethra, may be necessary in some situations. When testing for Chlamydia trachomatis and Neisseria gonorrhoeae, the swab should be inserted into the endocervical canal and rotated 180° to ensure that columnar epithelial cells are collected. Exocervical samples are more appropriate when testing for herpes simplex virus.

When all necessary cytologic and bacteriologic specimens have been obtained, withdraw the speculum slowly, gently rotating the blades so you can visualize the mucosa along the entire length of the vagina. Once you have completed inspection of the vagina, perform a bimanual examination, using a standard lubricant jelly. In an adolescent girl, discretion should dictate whether you should perform a one- or two-finger vaginal examination. Examine the anterior, posterior, and lateral vaginal fornices. During this examination, you can delineate the position and size of the uterus and identify any adnexal fullness. Normally, moving the cervix in any direction should not produce discomfort. If the patient is uncomfortable with cervical motion, adnexal disease may be present.

After palpation of the vaginal fornices and side walls, use one hand on the lower abdomen to gently palpate and outline the uterus and adnexa. To palpate the uterus, use the fingers inserted into the vagina (vaginal fingers) to lift the uterus upward to the hand on the abdomen (abdominal hand), which is placed suprapubically. When palpating the uterus, assess its size, shape, position within the pelvis, and mobility. A nulliparous uterus is normally the size of a golf ball. When palpating the adnexa, place the vaginal fingers into the lateral vaginal fornix and gently sweep them along the posterior pelvic wall, sacrum, and side wall. Place the abdominal hand laterally, just above the iliac crest. Gently bring the vaginal and abdominal hands together, allowing the adnexa to slip through your fingers. A normal ovary is about the size of an almond. The ovary is normally tender to pressure, producing some mild visceral pain. When palpating the ovary, characterize its size, shape, consistency, location, mobility, and degree of tenderness.

After completing the abdominovaginal examination, perform a rectovaginal examination, with your index finger in the vagina and your middle finger in the rectum. This step allows you to assess the rectovaginal septum for thickening or nodularity.

During the pelvic examination, you may use a hand mirror to give the patient an anatomy lesson and to review the physiology of puberty and menstruation with her. You can discuss many anticipated developmental changes and common menstrual problems, giving her an opportunity to express concerns that she might not otherwise mention. Once the physical and pelvic assessments are complete and the patient has dressed, sit with her and review all of the findings. Most girls need to be reassured that they are normal healthy young women.

Adolescent Contraception

Pregnancy is a leading cause of hospital admission among teenage women. By the end of high school, 50% of students have had sexual intercourse. Only 50% of teenagers use a contraceptive at first intercourse. Most adolescent pregnancies are unplanned and follow unprotected intercourse or ineffective use of a contraceptive method rather than failure of a contraceptive method. Women who first give birth at an early age have subsequent children more rapidly and experience greater marital instability and lower educational attainment than women who have their first children later in their lives. Babies born of teenage mothers are more likely to be small for dates, to be born prematurely, and to have low Apgar scores at birth, all factors associated with greater perinatal mortality. The chances of growing up in poverty, having school difficulties, trouble with the law, and child abuse are recognizably higher in children of teenage mothers.

The younger the adolescent girl, the less likely she is to request birth control from her physician. Therefore, it is important to talk openly and in a nonjudgmental manner with adolescent patients and offer them information concerning sexuality and contraception. During such discussions, you can present abstinence as a positive choice; however, if abstinence is not the adolescent’s choice, you must offer appropriate contraceptive options.

It is useful, when discussing various contraceptive methods, to have both concise information pamphlets and samples of the methods available for scrutiny—oral contraceptive pills (OCPs), intrauterine contraceptive devices, spermicidal creams, condoms, sponges, and diaphragms (Fig. 18–16).

FIGURE 18–16 Counseling about contraceptive choices is facilitated by a complete kit of available devices.

Female barrier methods are not an acceptable contraceptive choice for most adolescents. The diaphragm is a dome-shaped rubber cup with a flexible rim that is inserted together with a spermicide into the vagina before intercourse. Many adolescents feel uncomfortable with the internal manipulation this barrier method requires. The most common cause of diaphragm failure in adolescents is nonuse. Reported failure rates for diaphragms range from 160 to 320 pregnancies for every 1000 women during the first year of use.

Another similar option is the contraceptive sponge, made of collagen impregnated with the spermicide nonoxynol 9. Individual fitting is not required, as it is for diaphragms, because the sponge is available in one size only; however, it still requires insertion into the vagina. As with the diaphragm, this manipulation makes its use unacceptable to many adolescents. The reported failure rate for the contraceptive sponge is the same as for the diaphragm.

A better barrier option is the male condom; its failure rate is 150 pregnancies for every 1000 women during the first year of use. Unfortunately, it is often very difficult for a young girl to ask her partner to use a condom, underscoring the importance of discussing contraception with both adolescent boys and girls. The lubricated condom also provides protection against some sexually transmitted diseases. It is necessary to give unsolicited detailed instructions to the adolescent, who may be too shy or embarrassed to ask just how a condom is used properly.

Spermicides (foam, gel, films) are available without a prescription, but 160 to 320 of every 1000 women become pregnant within the first year of typical use of these products. Nonoxynol 9 is in many spermicide products, but there are now concerns that it may increase the risk of HIV transmission because it frequently induces vaginal irritation, which disrupts the integrity of the vaginal mucosa.

The female vaginal condom is available but should be deemed a method of protection against sexually transmitted diseases rather than a contraceptive method. The failure rate for the female condom is 210 pregnancies for every 1000 women during the first year of use.

The intrauterine contraceptive device (IUCD) has not been commonly used in the young adolescent patient. The copper containing IUCD is frequently poorly tolerated by nulliparous patients because it can aggravate preexisting menorrhagia and dysmenorrhea. This issue is now less problematic with the progestin-containing system (Mirena) being available. As a young patient may potentially be involved with several sexual partners over time and therefore be at risk for contracting a sexually transmitted infection, a careful risk assessment and exploration of alternative options must be done prior to placing an intrauterine device. The failure rate of the copper-containing IUCD is 8 pregnancies for every 1000 women during the first year of use. For the progestin-containing system, the failure rate is 1 pregnancy for every 1000 women during the first year of use.

The low-dose, combined oral contraceptive pill (OCP) administered either as a cyclic or continuous regime is an effective means of preventing an unintended pregnancy. Its failure rate is 80 pregnancies for every 1000 women during the first year of use. Frank discussion of the risks and noncontraceptive benefits of OCPs often helps allay patients’ concerns about its use. Healthy adolescents who are not overweight, or hypertensive, and who do not smoke have a low risk of developing life-threatening complications. The pill’s contraceptive effect is secondary to inhibiting ovulation, thinning of the endometrial lining, changes in the cervical mucus that render it impermeable to sperm and interference with fallopian tube motility.

Because the adolescent girl is frequently an erratic, inconsistent user of the pill, breakthrough bleeding can be a problem. You can enhance compliance with use of the pill by discussing breakthrough bleeding with the patient and instructing her on how to avoid it. Unfortunately, if breakthrough bleeding becomes a problem, it often makes the patient discontinue using the pill altogether, underscoring the necessity of close follow-up of adolescent patients. If poor compliance with an oral regime is encountered, options such as the contraceptive transdermal patch (Evra) or the vaginal contraceptive ring (Nuvaring) are valuable alternatives to explore. The failure profiles with these methods are comparable to that of the OCP.

Advise the young patient that if she encounters problems with pill use, she should directly contact you or a well-trained nurse. Promoting such communication makes patients’ use of the OCP more consistent and enables most problems to be addressed easily. At each return visit, talk to the patient about what she is doing to prevent pregnancy, so that you can identify and correct improper and inconsistent contraceptive use. If she uses a contraceptive erratically, talking about unintended pregnancy and its impact on her life may help enhance her compliance.

All patients should be made aware of the existence of emergency postcoital contraception. First coital experiences are frequently unprotected. A condom may break or a diaphragm become displaced during intercourse; thus, postcoital methods have a place in the contraceptive armament. Formerly, the most commonly used regimen involved the use of a combination 50-μg pill, such as norgestrel–ethinyl estradiol (Ovral). Two tablets are given immediately to a patient who has had inadequately protected intercourse within the preceding 72 hours; the same dose is repeated 12 hours later. This regimen frequently produces marked nausea, despite routine premedication with an antiemetic. An emergency contraceptive formulation containing levonorgestrel (Plan B) is now most commonly used and is available to patients without prescription. It is associated with less nausea, is more effective in preventing pregnancy, and can be used up to 120 hours after unprotected intercourse. The levonorgestrel-containing emergency contraceptive prevents 95% of pregnancies when used within 24 hours of intercourse. Withdrawal bleeding, an indicator of treatment success, can be expected to occur within 21 days in 98% of women treated. Shortening of the cycle is seen in 20% of women. Women who do not have spontaneous bleeding 21 days after treatment should undergo serum pregnancy testing.

Long-acting injections of the progestin medroxyprogesterone acetate (Depo-Provera) have been recognized as an effective alternative means of providing contraception. The standard recommended dose is 150 mg every 90 days, given as a deep intramuscular injection. Ovulation is inhibited for 3 months after injection. This medication also produces atrophy of the endometrium and alters cervical mucus so it does not facilitate sperm transport. Complications related to this method include menstrual cycle disturbance varying from unpredictable breakthrough bleeding to amenorrhea, weight gain, and increased frequency of headaches. Studies of medroxyprogesterone have demonstrated a failure rate of 30 pregnancies for every 1000 women in the first year of use. The effect of this method on bone mineral density and the accrual of bone in young women is currently an area of concern and active research.

Progestin implants are not available in Canada at this time. In the United States, a 3-year, single rod implantable progestin system is available (Implanon). The rod contains etonogestrel as its active ingredient. This method inhibits ovulation, produces amenorrhea, and is highly effective.

Summary

The inclusion of gynecologic evaluation in every girl’s physical examination increases familiarity and comfort with this assessment for both you and the child. Performing the assessment on many children enables you to discriminate between normal anatomic variants and pathologic changes. As a young girl approaches puberty, this examination gives you an excellent opportunity to offer information about developmental changes and sexuality in a casual, nonthreatening manner. Describing the concerns about sexuality expressed to you by other children often induces a shy girl to reveal her own concerns or misconceptions. The gynecologic examination is not difficult. It should be carried out in an organized fashion with appropriately proportioned instruments and diagnostic tools readily at hand. The confidence and thoughtfulness with which you approach the assessment are apparent to both the child and the parent.