Is There Anything That Should Be Included in a Female Adolescent Review of Systems?

Number 811 (Replaces Committee Opinion Number 598, May 2014)

Commission on Adolescent Health Care

This Committee Stance was developed by the American College of Obstetricians and Gynecologists' Committee on Adolescent Health Care in collaboration with committee members Rachael L. Polis, Practice, MPH and Steph Due east. Lee, DNP.

Abstract: The primary goal of the initial reproductive health visit is to provide preventive health care services, educational data, and guidance, in addition to problem-focused intendance. The initial reproductive health visit should take place between the ages of thirteen and 15 years. The scope of the initial visit will depend on the patient's concerns, medical history, physical and emotional development, and the level of intendance the patient is receiving from other health care professionals. All adolescents should have the opportunity to talk over health issues with a wellness intendance professional one-on-one, considering they may feel uncomfortable talking about these issues in the presence of a parent or guardian, sibling, or intimate partner. Addressing confidentiality concerns is imperative considering adolescents in need of health care services are more than probable to forego care if in that location are concerns about confidentiality. Laws regarding confidentiality of care to minors vary by country, and wellness intendance professionals should exist knowledgeable about electric current laws for their practise. Taking care to constitute secure lines of communication can build trust with the patient and guardian, support continuity of care, ensure adherence to legal statutes, and subtract barriers to services. Obstetrician–gynecologists accept the opportunity to serve as educators of parents and guardians about reproductive health issues. Preparing the role environs to include boyish-friendly and age-advisable reading materials, intake forms, and educational visual aids tin can make the full general office infinite more inclusive and accessible. Resources should be provided for both the adolescent patient and the parent or guardian, if possible, at the conclusion of the visit. This Committee Stance has been updated to include gender neutral terminology throughout the document, counseling topics with straight links to helpful resources, screening tools with direct links, addition of gender and sexuality discussion, and inclusion of trauma-informed intendance.

Recommendations and Conclusions

The American Higher of Obstetricians and Gynecologists makes the following recommendations and conclusions:

The initial reproductive health visit should take place between the ages of 13 and 15 years.
Creating an adolescent-friendly environment is important to make the patient feel comfortable and to establish a skilful human relationship for continued care.
Office staff should exist trained to be sensitive to the needs of the adolescent regarding contact and communication, interaction with parents or guardians, and front office procedures.
Training should include increasing condolement with problems regarding adolescent sexuality, respectfully addressing gender and sexual diverseness, and beingness aware of other potential barriers, such equally language access (access to linguistic communication interpretation and also age-appropriate and youth culture-advisable language), negotiating parent or guardian participation in the visit, and confidentiality.
At the initial visit, adolescents should be made aware of the limitations of confidentiality including bug related to country-specific mandatory reporting and insurance billing, notifications to parents and guardians through electronic health records (EHRs) and patient portals, and legal requirements of parental notification related to specific services (eg, ballgame).
During the initial consultation with the patient and parent or guardian, the obstetrician–gynecologist should inform them that the visit usually does not require an internal pelvic test, unless indicated by symptoms, and that cervical cancer screening begins at postadolescence.
All adolescents should have the opportunity to discuss health issues with a health intendance professional one-on-one, because they may feel uncomfortable talking near these issues in the presence of a parent or guardian, sibling, or intimate partner.
Before completing an examination, the obstetrician–gynecologist should counsel the patient nigh what to look for the physical examination portion of the visit, identify if there are patient concerns, and enquire about the patient'southward level of comfort. In some cases, a concrete examination might be performed at a separate visit.
At the completion of the physical examination, the health care professional should address physical findings, diagnosis, and potential treatment options. In one case a treatment plan has been mutually decided upon, the adolescent is encouraged to include the parent or guardian in the management plan.

This Committee Opinion has been updated to include gender neutral terminology throughout the document, counseling topics with direct links to helpful resource, screening tools with straight links, addition of gender and sexuality word, and inclusion of trauma-informed care. If a gynecologist is uncomfortable providing reproductive health intendance and contraception to adolescents, the professional person should refer the patient to a different reproductive health intendance professional person who is comfortable working with these patients. Obstetrician–gynecologists have the duty to refer patients in a timely mode to other wellness care professionals if they exercise non feel that they tin provide the standard reproductive services that their patients request 1.

Creating an Inclusive and Adolescent-Friendly Environment

Creating an adolescent-friendly surround is important to make the patient feel comfortable and to establish a skillful relationship for continued intendance Box 1. Preparing the office environment to include adolescent-friendly and historic period-appropriate reading materials, intake forms, and educational visual aids can make the general office infinite more inclusive and accessible. Providing a confidential questionnaire for the patient to complete near sexual history, social history (eg, drug or alcohol employ, or both), and contraceptive needs tin can assist to identify psychosocial needs; ideally, this can be done when patients are carve up from their parents or guardian. However, some patients may non exist comfortable sharing personal data in writing earlier meeting with a gynecologic care professional. A written questionnaire is i source of potential communication; some adolescents may prefer exact communication direct with the health care professional. Further designating and designing specific rooms to be boyish-friendly tin can allow the patient to explore reading material and brochures confidentially, out of view from other patients, parents, or guardians. The obstetrician–gynecologist should provide education with the use of models and visual diagrams to engage the patient.

Tips for Creating an Office Environment That Appeals to Adolescents

Nonpregnant adolescents might be intimidated by a reception area full of obstetric patients; therefore, consider seeing adolescent gynecology patients during a dedicated time.
Many adolescents and parents adopt later-schoolhouse appointments.
Make sure your reception expanse and examination rooms incorporate age-appropriate and culturally inclusive reading materials and audiovisual aids.
Consider having ane or two rooms where adolescents are seen and examined. Remove or de-emphasize materials and equipment (eg, colposcope) that may brand adolescents uncomfortable during their visit.
Designate a place for the parent(s) or guardian(s) to wait that is abroad from the examination room. Be sure that the boyish patient understands that the parent(s) or guardian(southward) is (are) not inside hearing range (eg, avoid letting them wait in the hall exterior the examination room).

Training for Role Staff

Office staff should exist trained to be sensitive to the needs of the boyish regarding contact and communication, interaction with parents or guardians, and front office procedures. Training should include increasing condolement with issues regarding adolescent sexuality, respectfully addressing gender and sexual diversity, and being aware of other potential barriers, such equally language access (access to language interpretation and also age-appropriate and youth culture-advisable language), negotiating parent or guardian participation in the visit, and confidentiality. Although initial reproductive health visits have the potential to be uncomfortable for all adolescents, they may be even more then for transgender and nonbinary patients because of assumptions about gender associated with the visit, lack of health care professional and staff cognition, and fear of bigotry 2. See Box 2 for bug to be addressed in staff training.

Preparing Staff

Confidentiality and Patient Autonomy

Addressing confidentiality concerns is imperative considering adolescents in need of health care services are more than likely to forego care if there are concerns about confidentiality 3. Laws regarding confidentiality of care to minors vary past land, and health care professionals should be knowledgeable about current laws for their practice 4. At the initial visit, adolescents should exist fabricated aware of the limitations of confidentiality, including issues related to state-specific mandatory reporting and insurance billing, notifications to parents and guardians through EHRs and patient portals, and legal requirements of parental notification related to specific services (eg, abortion) 4. Traditionally, minors may provide informed assent rather than consent for medical therapies. In contrast to informed consent, informed assent entails involving young patients in discussions and decisions most their care as appropriate for their developmental stage. This approach respects the developing independence and autonomy of minors past allowing them to be involved in their medical conclusion making, while acknowledging the need to obtain authorization to care for from their parents or guardians 5. Encounter ACOG Committee Opinion No. 803, Confidentiality in Adolescent Health Care, for more details on confidentiality in the provision of health intendance for adolescents 4.

Obstetrician–gynecologists and other wellness care professionals should develop a system for discussing the importance of confidential services with the patient and guardians, communication protocols for verifying patient release of information, and safeguards for EHR or insurance billing information breaches. Taking intendance to establish secure lines of communication can build trust with the patient and guardian, back up continuity of care, ensure adherence to legal statutes, and subtract barriers to services.

Solitary Fourth dimension

All adolescents should have the opportunity to hash out health issues with a health intendance professional one-on-one, because they may experience uncomfortable talking about these issues in the presence of a parent or guardian, sibling, or intimate partner iv. Recognizing that some of these issues are sensitive in nature, it may be appropriate for a nonparental support person to be in the room (eg, a friend), if a patient prefers. During time alone with the patient, the obstetrician–gynecologist can discuss issues such equally those included in Table 1. If a parent or guardian desires time lone with the obstetrician–gynecologist, this should be discussed with the boyish patient and should occur before the obstetrician–gynecologist spends time solitary with the patient, if possible, to reassure the adolescent patient that confidentiality volition be maintained.

The Initial Reproductive Health Visit

Gender Identity and Sexuality

The initial visit is a prime number opportunity for the obstetrician–gynecologist to build trust with the patient. Discussion of gender and sexuality should exist explored with open, nonjudgmental, and nonassuming questions. Request all patients routinely for their gender identity and gender pronouns normalizes the interaction and allows patients to disclose without being targeted; skillful do includes reciprocal disclosure (eg, "Hello, I am Dr. Singh and I utilise she/her pronouns. Is the name on your nautical chart what you would like me to telephone call you? What pronouns do you utilise?"). Obstetrician–gynecologists likewise can counsel patients about contraception for gender-affirming menstrual control or inquire about the adolescent's other gender affidavit concerns, such every bit mental health, bullying, family unit back up, or desire for hormone therapy.

Taking a Sexual History

Sexual history questions Box 3 can help guide the discussion on sexuality, sexual orientation, and sexual behavior. The obstetrician–gynecologist should hash out contraception and STIs associated with coital and noncoital sexual action half dozen. Discussing previous sexual activity and asking patient about plans for sex can provide an opportunity to share anticipatory guidance for the prevention of pregnancy, if desired, and STIs. It may be an appropriate and useful time to provide teaching about gynecologic beefcake, including the wide variations in what is typical and a review of the supporting beefcake (eg, pelvic flooring muscles).

Sexual History Questions to Ask Patients

Who exercise you find yourself attracted to sexually or romantically? (Boys? Girls? Both? No one? Non sure?)
Are you lot in a human relationship with anyone?
Are you having sex with anyone? If and so, what kind of sexual activity are you having?
- How many sexual partners accept yous had in the past iii months? In the last twelvemonth?
- Have you e'er been diagnosed with a sexually transmitted infection (STI)?
- How erstwhile were you the showtime fourth dimension you lot had sex (intercourse)?
- Have y'all e'er had sex with a person of your aforementioned sex?
- Are you having sex activity with someone who can get you lot pregnant?
- Do you lot employ anything to foreclose pregnancy?
- Practise you use anything to foreclose STIs? If yes, what practise you use?
- How often practise you and your partner(s) utilise a rubber when y'all accept sex?
- Do you employ sexual activity toys?
- Do you e'er feel pressured to have sexual practice or has anyone interfered with your birth control?
- Have y'all always had sex for money or drugs?
- Have you lot talked with your parents? How practice your parents feel about this?
Do you always participate in other sexual activities, such equally touching or oral or anal sex?
If you are not having sex, are you thinking about having sex activity in the future?
Practice you masturbate? Exercise yous employ something other than your hands?
Have you "sexted"? Sent or received explicit pictures?
When, if e'er, do you see yourself having children?

Timing, Scope, and Components of the Initial Visit

The initial reproductive health visit should have place between the ages of xiii and 15 years. The telescopic of the initial visit will depend on the patient's concerns, medical history, concrete and emotional development, and the level of care the patient is receiving from other wellness care professionals. As individuals transition from childhood into young adulthood, there are concrete, neurodevelopmental, psychological, and social developmental changes. From a developmental standpoint, these changes fit into iii stages of adolescent evolution, classified every bit early on, heart, and late adolescence Table ii. It is important to recognize that growth in one area of development might not stand for with the patient's chronological age; thus, anticipatory guidance should be offered based on a patient's private needs.

The Initial Reproductive Health Visit

The main goal of the initial reproductive wellness visit is to provide preventive wellness intendance services, educational information, and guidance, in addition to problem-focused intendance Table 1. Obstetrician–gynecologists should assess a patient'due south human papillomavirus (HPV) vaccination status, educate about the vaccine, and provide information technology, if appropriate. The visit allows patients and their parents or guardians the opportunity to visit the role, meet the obstetrician–gynecologist, alleviate fears, and develop trust. The obstetrician–gynecologist also can back up the adolescent patients by providing the opportunity for them to participate in their own wellness intendance decisions and by reassuring them that their concerns will be addressed in a confidential setting, when possible. These are the offset steps to help adolescent patients navigate their own health intendance. This may be the first time an adolescent has been asked to consider and participate in their ain health care and begin to transition their health care away from the parent or guardian and to develop patient autonomy.

If the patient is sexually active or considering becoming sexually active, the obstetrician–gynecologist should provide counseling on contraception options, including emergency contraception and long-acting reversible methods seven. Many adolescents are at risk of engaging in unhealthy and risky behaviors such as booze, substance use, texting while driving, and tobacco and electronic cigarette use; these issues should be identified and addressed. Many youths are exposed to dating violence 8. It is of import to screen for physical and sexual abuse, eating disorders, anxiety, and depression Tabular array 1. Screening for take chances-taking behaviors can be facilitated past using a questionnaire as an culling to direct interviewing; this can help guide which issues should be prioritized at the visit.

Adolescents with intellectual disabilities too require reproductive health care. Depending on the degree of disability or developmental filibuster, the obstetrician–gynecologist may need to engage in an in-depth discussion with the parent or guardian regarding menstruation, fertility, hygiene, options for menstrual manipulation and contraception, and how to keep the patient prophylactic nine.

Examination

During the initial consultation with the patient and parent or guardian, the obstetrician–gynecologist should inform them that the visit usually does not crave an internal pelvic examination, unless indicated by symptoms (eg, abnormal bleeding, discharge, intestinal pain, or pelvic pain) and that cervical cancer screening begins postadolescence 10 11 12. Many adolescents and their parents and guardians are unaware of the difference between a Pap test and a pelvic examination 13; thus, the obstetrician–gynecologist should provide guidance most these procedures and why they may be advisable to perform at future visits.

If a concrete examination is indicated (eg, in symptomatic patients or to provide education about beefcake and hygiene), the obstetrician–gynecologist should ask adolescent patients if they would prefer this portion of the examination be performed with or without a parent or guardian present. The American Higher of Obstetricians and Gynecologists recommends that a chaperone be in the room during the physical examination, besides as during diagnostic studies such as transvaginal ultrasonography 14. Patients should accept autonomy regarding parent or guardian presence during examination, but a parent or guardian should not take the place of a chaperone 15. Patients should be counseled that they accept the right to refuse any examination.

Before completing an test, the obstetrician–gynecologist should counsel the patient nigh what to look for the physical test portion of the visit, place if there are patient concerns, and ask most the patient's level of comfort. In some cases, a physical examination might be performed at a separate visit. When a gynecologic test is performed, tanner staging of breast and pubic pilus evolution should be evaluated and documented. During an external pelvic examination, the obstetrician–gynecologist can offer the option for patients to hold a mirror to educate themselves about their anatomy. Gentle traction on the labia majora unremarkably allows for complete visualization of the hymen and vaginal orifice Figure ane. Selecting a speculum for the examination should exist adamant past the patient's pubertal status, hymenal opening, and sexual experience. Offering to show an adolescent patient the speculum earlier the examination may be a useful way to provide educational activity and reassurance. Typically, a narrow Pederson or Huffman speculum should be used. For patients with a history of trauma or gender dysphoria, a concrete examination, particularly a gynecologic exam, might trigger anxiety; using a trauma-informed model of intendance that is collaborative and patient-driven can make the test more than manageable 16.

The Initial Reproductive Health Visit

If patients are sexually agile, almanac screening for chlamydia and gonorrhea is recommended 17. Screening for STIs should be done in accordance with the Centers for Disease Control and Prevention'southward guidelines for "Sexually Transmitted Diseases (STDs) Treatment and Screening" at https://www.cdc.gov/std/handling/default.htm. When appropriate, the health intendance professional should consider screening with a urine sample or an oral, vaginal or anal swab. Self-collected swabs (versus samples taken by a wellness intendance professional) may be a reasonable alternative if preferred by the patient. The Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists recommend that patients aged 13–64 years exist tested for human immunodeficiency virus (HIV) at least once in their lifetime and annually thereafter based on factors related to risk 18. Trichomonas screening can be considered for patients receiving care in high prevalence settings (eg, an STI clinic), those with a high take chances for infection (eg, multiple sex partners, a history of STI), and with presenting concerns of vaginal discharge 17.

Direction and Follow-Up

At the completion of the physical test, the health intendance professional should address physical findings, diagnosis, and potential treatment options. Once a treatment program has been mutually decided upon, the adolescent is encouraged to include the parent or guardian in the management plan. It is disquisitional to assess what information tin can and cannot be shared with the parent or guardian. At the conclusion of the visit, the patient, parent or guardian, and obstetrician–gynecologist should hash out the findings and recommendations. Whatsoever remaining concerns tin can be addressed, and the parent or guardian tin can be offered guidance on adolescent development. Follow-up should exist individualized and determined by the patient's needs. Adolescents may do good from shut follow-upward for questions and support regarding adherence to contraception 19. Some adolescents will be seen on an almanac ground because their needs volition change with historic period; others who demand problem-solving care may require closer follow-up; discussing future visit expectations is appropriate. Obstetrician–gynecologists accept the opportunity to serve equally educators of parents and guardians about reproductive health issues. Resources should be provided for both the adolescent patient and the parent or guardian, if possible, at the conclusion of the visit.

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Source: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/10/the-initial-reproductive-health-visit

Is There Anything That Should Be Included in a Female Adolescent Review of Systems?

Recommendations and Conclusions

Creating an Inclusive and Adolescent-Friendly Environment

Tips for Creating an Office Environment That Appeals to Adolescents

Training for Role Staff

Preparing Staff

Confidentiality and Patient Autonomy

Solitary Fourth dimension

Gender Identity and Sexuality

Taking a Sexual History

Sexual History Questions to Ask Patients

Timing, Scope, and Components of the Initial Visit

Examination

Direction and Follow-Up

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