Update on Adolescent
Healthcare – Sexual Health
June 5, 2015
Karen L. Teelin MD, MSEd, FAAP
Assistant Professor of Pediatrics
Adolescent Medicine Specialist
Objectives
•
•
•
•
Teen pregnancy update
Teen contraception update
STIs in Adolescents
Issues relating to LGBTQ adolescents
Teen Pregnancy
• Complex issue influenced by culture,
poverty, and barriers to health care and
education
 Effective family planning has personal,
familial, and societal benefits
– Teen pregnancy perpetuates cycles of
poverty
– Teen pregnancy cost US taxpayers
$9.4 billion in 2011 (CDC)
Teen Pregnancy in the US
• Rates are at historic lows
– 26.5 births per 1000 teen women in 2013
• > 273,000 babies born to teen moms (CDC)
• But teen pregnancy still much more
common in the US than in other
industrialized countries
• Reported rates of adolescent sexual activity
are the same in US vs other industrialized
countries
– So why are our teen pregnancy rates higher?
Teen Pregnancy Rates 2008-2011, per
1000
U.S.
Singapore
Netherlands
Switzerland
0
10
20
30
40
Sedgh, Gilda, et al. “Adolescent Pregnancy, Birth, and Abortion Rates Across Countries: Levels and Recent
trends”, Journal Of Adolescent Health 56 (2015) 223-230.
50
60
Teen Pregnancy Rates
Worldwide, 2000
American and
European teenagers
are sexually active
at similar rates, but
the American
pregnancy rate is
much higher.
Per 1000
ARSHEP slide
Teen Birth Rate (age 15-19, per 1000
females, 2008)
Teen Birth Rate (per 1,000 Females 15-19)
Switzerland
Japan
Netherlands
Sweden
Denmark
Italy (2005)
Finland
Norway
Germany
France
Greece
Spain
Canada (2007)
Portugal
Austrailia
United Kingdom
United States
4.3
5.1
5.2
5.9
6
6.8
American teenage birthrate is:
4 times France’s rate
10 times Switzerland’s rates
8.6
9.3
9.8
10.2
12
13.6
14.1
15.9
17.1
26.7
41.5
0
5
10
15
20
25
30
35
40
45
US Teen Pregnancy Rates Much
Higher than Dutch Peers
Pregnancy, birth and abortion rates in the US and
Netherlands per 1,000 females ages 15-19
80
70
60
50
U.S. TEENS
40
DUTCH TEENS
30
20
10
0
PREGNANCY
ABORTION
BIRTH
Kost et al. 2010; van Lee et al. 2009
Dutch Teens More Likely to Use
Hormonal and Dual Methods
Percent of Dutch and US Adolescents 15-19 Using Condoms, Oral
Contraception and Dual Methods at First Intercourse
100
80
U.S. TEENS
60
DUTCH TEENS
40
20
0
BOYS USING
CONDOMS
GIRLS USING PILL
GIRLS' DUAL USE:
CONDOM & PILL
Abma et al,2010, Ferguson et al, 2008
Flaws with Abstinence Only (No Sex)
Paradigm
• Despite investment of federal funds, not shown to be
effective*
– Adherence over time is low**
• AAP recommends that pediatricians not rely on abstinence
counseling alone ***
• Makes sex between teens hard to discuss when it does
happen
• Gives limited tools for navigating relationships other than
marriage
• Provides a code, not empowerment
• Does not help kids clarify their values and live consistently
Source: ARSHEP
*Kirby, D. (2001). Emerging Answers: Research Findings on Programs to Reduce Teen Pregnancy. The National
Campaign to Prevent Teen Pregnancy
** Bruckner H, et al. J Adolesc Health. 2005; 36(4):271-78, and Pinkerton SD et al. Health Educ Behav. 2001.
***AAP Policy Statement, Contraception for Adolescents. 2014.
YRBSS 2013
• 46.8 % of 9-12th graders reported ever
having had sex
– 64% of 12th graders, 68% of black males
• 15% reported 4 or more partners
• 5.6% reported first intercourse before age
13
• Condom was the most commonly used
form of contraception.
Contraception
 Risks associated with contraception are
overestimated.
 No form of contraception is riskier than
pregnancy.
 Noncontraceptive health benefits of
contraception may be underestimated.
Prescribing contraception
•
•
•
•
•
•
Provide confidential counseling
Pelvic exam not required
Basic H&P, including blood pressure
Reasonably rule out pregnancy
STI testing as indicated
Emergency contraception if unprotected sex in
the last 5 days
• Recommend LARC methods
• Provide condoms and stress the importance of
their use. (Dual method)
Adolescents with disabilities or chronic
medical problems
• Remember to discuss sexuality and
contraception for kids with CF, intellectual
disability, IBD, cancer.
• May need menstrual suppression.
• May be more likely to be victimized.
• May be taking teratogenic medications.
• Pregnancy may be more risky for these
adolescents as c/w typical adolescent.
If you have questions about whether
your patient is eligible for
contraception…
CDC Medical Eligibility Criteria
– www.cdc.gov/reproductivehealth/unintende
dpregnancy/USMEC.htm
History & Physical
• Most healthy teens have no contraindications
• In typical healthy adolescents: two contraindications to
exogenous estrogen
– Migraine with aura
– Personal history of blood clot
• Also include:
–
–
–
–
Review of current medications
Menstrual history
Psychosocial ROS (HEADS FIRST)
Blood pressure and general physical exam
• Pelvic exam not required
– Family history, esp FH of blood clots
Menstrual History
• Age at menarche
• Date of LMP, PMP
• Normal and on time?
• Duration
• Regularity, spotting
• How many pads or tampons
per day?
• Dysmenorrhea (Cramps,
back pain, vomiting,
diarrhea) and impact on
school / activities
Sexual History
• Sex with boys, girls, or both
• Points of contact
• Age at first sex, number of
partners
• Pregnancy history
• History of STIs
• Concerns about fertility
• History of unwanted, survival,
and/or coerced sex
• Last sexual contact and
relation to LMP
– If unprotected heterosexual
sexual intercourse within the
last five days, offer emergency
contraception
Emergency Contraception (EC)
• Use within 5 days (120 hours) of unprotected
sexual intercourse
• WHO: There are no situations in which “the
risks of using EC outweigh the benefits” (2004)
• NOTE: EC is different from a medical abortion
– Medical abortion is prescribed by ob/gyn
– Medical abortion uses Mifepristone and
Misoprostol
Emergency contraception
1. Levonorgestrel 1.5 mg(Plan B or Next Choice)
2. Ulipristal acetate 30 mg (Ella)
Progesterone receptor modulator / antiprogestin
More effective than levonorgestrel 5-7 days after unprotected intercourse
Careful about using in combination with cOCPs
3. Copper Intrauterine Device (Paraguard)
Also provides highly effective contraception for 10 years
4. Four Lo/Ovral contraceptive pills
1 mg Norgestrel works as emergency contraception
Contains estrogen - pt may have nausea, increased risk of blood clot
Emergency Contraception: 1.5 mg
Levonorgestrel
Take within 120 hours of unprotected sex
Sooner is better
Highly effective, but not 100%
Women who receive it in advance of need are more
likely to use it (Raine, 2000)
 Prevents ovulation for 4-10 days
 Will not disrupt or harm an existing pregnancy
 Consider discussing with male patients
Methods: Overview
How Often
Average 1st Year
Failure Rate
Lowest Failure
Rate
Male Condom
Every sex
18%
2%
Pills
Every day
9%
0.3%
Patch
Every week
9%
0.3%
Vaginal Ring
Every month
9%
0.3%
Injection
(DepoProvera)
Every 3 months
6%
0.2%
Copper IUD
(Paraguard)
Every 10 years
0.8%
Hormone IUD
(Mirena, Skyla)
Every 5 years
0.2%
Arm Implant
(Nexplanon)
Every 3 years
0.05%
Tubal Ligation
Forever
0.5%
LARCS = Long Acting Reversible
Contraception
• The most effective three methods are the LARC
methods – Over 99% effective
– Levonorgestrel intrauterine device (IUD) (Mirena or Skyla)
– Copper IUD (Paraguard)
– Implant (Nexplanon)
• Considered first line for adolescents (AAP 2014, Committee
on Adolescence)
• Most cost-effective forms of contraception
LARCS: Contraceptive CHOICE Project
(Tessa Madden, Jeffrey Peipert)
• 1404 teenage girls
• 72% chose an IUD or
implant
• Significantly lower
pregnancy, birth, and
abortion rates
• Continuation rates
higher for LARC
methods
• Also note: IUDs do NOT
increase the risk of PID
(except in the first 30
days after placement)
and do not cause
infertility!
CHOICE Project, St Louis MO
Rate per 1000 teens
CHOICE participants
US teens
Pregnancy
34.0
158.5
Birth
19.4
94.0
Abortion
9.7
41.5
IUDs
•T-shaped device
• Inserted into the uterus
during a pelvic exam
•Used extensively
worldwide
•Strings become soft and
usually cannot be felt by
partner
Hormonal IUD: Mirena or Skyla
– Last for 5 years (3 years for Skyla)
– Progesterone-only (levonorgestrel), mostly in
the uterus
– Inhibits sperm motility and thickens cervical
mucus
– May have irregular bleeding, especially first 3-6
months
– After the first 6 months, periods are usually
lighter and shorter. 20% of women become
amenorrheic.
Copper IUD: Paraguard
• No hormones
• Last 10 years
• May have some spotting at first, and periods
may be heavier or more painful for the first 36 months
• Afterward menses return to baseline
• Can be used for emergency contraception
• Copper ions are toxic to sperm
Nexplanon
•
Single small rod containing etonorgestrel
•
Placed under the skin of the nondominant arm,
between biceps and triceps
•
Highly effective contraception for 3 yrs
•
Placement (or removal) takes about 5 minutes and
is done in the office
–
Procedure is easy to learn and all pediatricians
should consider getting trained
•
May have irregular bleeding (28%) or amenorrhea
•
Other adverse effects: headache, acne, weight
gain (11.6%)
•
Thought to have less impact on BMD than Depo,
but this has not been well studied
DMPA (Depo-Provera)
• IM injection, Progesterone-only
• Given every 12 - 14 weeks
• Benefits:
–
–
–
–
Private, “forgettable” (to a point)
Treats dysmenorrhea and menorrhagia
Reduces the risk of endometrial ca
Safe during lactation
• Adverse effects:
– Irregular bleeding and spotting
• Usually resolves/improves over time
• After a year, about half of users are amenorrheic
– Weight gain
Depo Provera and Bone Mineral
Density
• Loss of BMD, or failure of accrual, during use
– Similar to breast feeding
– BMD recovers after use of Depo
– However, not recommended for girls with eating
disorders, on long term steroids, etc
– All patients should exercise and obtain adequate
calcium(1300 mg/d) and vitamin D (600 IU/d)
Combined hormonal contraception
• Pill – daily
• Patch –change weekly
• Ring – stays in for 3 weeks
• Contraindications to exogenous estrogen:
– Personal history of blood clot or known thrombophilia
• Includes first 6 wks postpartum
– Migraine with aura or focal neuro sx
– Uncontrolled hypertension
– Other: hepatic dysfunction, complicated valvular heart disease
– For younger teens, consider the effect on final height
– Note that smoking is NOT a contraindication in teenagers
Benefits of combined hormonal contraception:
•
•
•
•
•
Reduces bleeding, reduces anemia
Controls cycles
Treats dysmenorrhea and endometriosis
Improves acne and hirsutism
Reduces risk of endometrial cancer and
ovarian cancer (RR ovarian cancer ↓ 20% for
every 5 yr use)
Combined hormonal contraception Myths
• Neither weight gain nor mood changes have
been reliably linked to use of combined
hormonal contraception. (See AAP technical
report on contraception, 2014.)
Combined Hormonal Contraception Drug Interactions
– COCPS decrease the effectiveness of Lamictal
– Other anticonvulsants and antiretrovirals
decrease effectiveness of cOCPs
– No evidence that antibiotics decrease birth
control pill effectiveness, except rifampin
Combined hormonal contraception –
adverse effects
• May worsen migraine headaches
• May have transient nausea, breast
tenderness, or irregular bleeding
Combined hormonal contraception
and blood clots
• Pregnancy and delivery associated VTE:
– 29 per 10,000 woman years*
• Contraception associated VTE : (Average)
– 4-8 per 10,000 woman years* (6/10,000)
• VTE in non pregnant, non contraception user
– 1-3 per 10,000 woman years**
Based on international study with over 33,000
participants
*Dinger et al, Cardiovascular Risk Associated with Use of an
Etonogestrel-Containing Vaginal Ring, Obstetrics and
Gynecology, Oct 2013.
**Lidegaard et al. BMJ 2010
Combined hormonal contraception: blood clots
• Risk of clot depends on dose of estrogen, the
type of progestin, and the delivery method
– Drosperinone 3x increase in risk of clot
• Most teens who develop a blood clot have 2 or
more risk factors*
• If a teen is going to develop a clot associated
with contraception, it usually happens within
the first three months and nearly always
within the first year.**
*Pillai, Prasanth et al. Contraception –related Venous Thromboemboism in a Pediatric
Institution. NASPAG 2013
**Sidney et al. Recent combined hormonal contraceptives and the risk of
thromboembolism and other cardiovascular events in new users. Contraception, 2013.
Pills
• Have been available for more than 50 years
• One of the best studied medications ever prescribed
• Dose of estrogen (ethinyl estradiol) ranges from 50 mcg to 10 mcg
– Teens should start with a 30 mcg pill
– Start with a monophasic formulation that contains the progestin
levonorgestrel or norgestimate (e.g. Lo/ovral, Cryselle, Low-0gestrel)
• If miss one, take as soon as you remember. If miss two, call.
• Various formulations including shortened placebo interval,
continuous cycling, containing iron, chewable, biphasic, triphasic
– Consider continuous cycling for girls with anemia, Von Willebrand,
severe dysmenorrhea
The Patch
Transdermal contraceptive patch:
Ortho Evra or Xulane
• Place on abdomen, upper torso, upper arm, or
buttocks
• Change weekly for 3 weeks
• Then 1 week patch-free
• Less effective for women who weigh > 198 lbs
• Occasional skin effects: hyperpigmentation,
irritation
• Possible slight increased risk for VTE as compared
with COCs
Vaginal Ring: NuvaRing
• Insert in the vagina and leave in for 3 weeks
• Remove for one week withdrawal bleed
• Contains enough medication for 35 days.
(Excellent method for extended use)
• Adolescents may need reassurance re insertion
• Partners cannot feel the ring
• Can remove for up to 3 hours
• Can use with tampon
Progesterone only pill
•
•
•
•
•
•
•
•
“Mini-pill”
Brand names: Micronor, Camilla
Norethindrone 0.35 mg daily
No placebo pills
Stringent adherence is necessary
Less effective than other methods
Can control bleeding and help with dysmenorrhea
May be a good option for selected adolescents, e.g.,
those who develop headaches on estrogen, or have
migraine with aura
Quick Start Algorithm
For pills, patch, ring, Depo
First day of LMP 5 or fewer days ago?
Yes
No
Urine Pregnancy Test Negative?
Yes
No
Advise that negative urine pregnancy
test cannot rule out conception from
acts of intercourse in the last two weeks
Last sexual intercourse 5 or
fewer days ago?
Yes
Offer Emergency Contraception
Initiate Method Today
No
Provide options counseling or
refer to someone who can
Return in 3-4 weeks
for follow-up and
repeat pregnancy
test
Summary
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•
•
•
•
•
•
•
•
Teen pregnancy is an important public health problem.
About half of American 9th-12th graders report sexual activity.
Prescribing contraception does not require a pelvic exam.
Emergency contraception is safe and effective and is not a
medical abortion.
Always recommend dual method contraception.
LARCS are long acting reversible contraceptives and include
IUDs (intrauterine devices) and subdermal implants. Last 3-5
years.
LARCS are first line contraceptives in teens because they work
much better than any other method. Continuation rates are
higher.
Screen for personal or family history history of VTE and
personal history of migraine with aura prior to prescribing
combined hormonal contraceptives.
Combined hormonal contraceptives include pills, the patch
(change weekly), and the vaginal ring (leave in for 3 weeks).
Sexually Transmitted Infections
•
•
•
•
•
•
•
STIs are a hidden epidemic
20 million new STIs reported to the CDC per yr*
54% of these occur in 15-24 year olds*
Most STIs are asymptomatic
Many cases go undiagnosed
Potential for severe sequelae
Routine screening is a national public health
priority
*Source: CDC fact sheet
Cases
• 1) A 16 year old sexually active girl presents to the
Emergency Department with dysuria. She has not had fever.
Urine analysis is unremarkable. Urine culture is ordered.
What other test should be ordered?
• 2) An 18 year-old new mother presents at 6-wks
postpartum for IUD insertion. Purulent discharge is noted
at the cervical os. Samples are taken for NAAT tests, and
the insertion procedure is aborted.
• 3) A 16 yo presents with the chief complaint “my period
comes every two weeks”. After talking with her, you
ascertain that she has always had regular menses, but
recently she has intermenstrual spotting, particularly after
sexual intercourse.
Chlamydia Trachomatis
• Most commonly reported infectious disease in the US, and most
common bacterial sexually transmitted infection
– Estimated 2.8 million new chlamydial infections per yr in the US
• 30% in 15-19 year olds1
• 2,413 cases reported in Onondaga County in 20132
– Adolescents are disproportionately affected
• Biologic (cervical ectropion) & social factors
• 7% prevalence among sexually active 14-19 yo girls3
– 2.8% in suburban private practices; 20.8% in girls entering National Job Corps4
• Chlamydia screening is a national public health priority
– All sexually active girls under age 25 should be screened yearly5
– Screen more frequently in girls at high risk or with previous diagnosis
of Chlamydia
1. CDC
2. Onondaga County Health Dept
3. NHANES data, Forhan SE, et al. Pedaitrics, 2001
4. CDC, quoted in AAP Textbook of Adolescent Healthcare, p. 489
5. CDC, AAP, USPSTF guidelines
Chlamydia
• Gram-negative, obligate intracellular
bacterium
• May persist for months or years
• 1-3 week incubation period
• Infects the epithelium of the urogentical tract
or rectum
Chlamydia - Symptoms
• Commonly asymptomatic
• Boys: dysuria or penile discharge
– Less commonly pain or swelling in one or both
testicles
• Girls: dysuria, abnormal vaginal discharge or
abnormal vaginal bleeding
– May cause urethritis, cervicitis, endometritis,
salpingitis
• Rectal symptoms: pain, discharge, bleeding
Chlamydia Complications & Sequelae
•
•
•
•
•
•
•
•
•
PID
Perihepatitis (Fitz Hugh Curtis syndrome)
Ectopic pregnancy, PROM, spontaneous abortion
Tubal infertility
Chronic pelvic pain
Reactive arthritis (Reiter syndrome)
Epididymitis, prostatitis
Bartholin gland abscess
Neonatal conjunctivitis (5-12 days after birth) and
pneumonia (subacute, afebrile, 1-3 months of age)
Chlamydia Treatment
• 1 gm azithromycin orally x1, given in clinic
– Or: Doxycyline 100 mg PO BID x 7 d
– Alternative: Erythromycin 500 QID x 7d
• If you have a NAAT test for gonorrhea that is negative, then
you do not have to treat for gonorrhea concurrently
• See cdc.gov STD treatment guidelines
• Offer Expedited Partner Therapy (EPT) for partner
treatment
– Legal in NYS for heterosexual patients diagnosed with Chlamydia
only
• Patient should return in 3 months for a test of reinfection
– Recurrence is common: 54% of adolescents younger than 15 yo
and 30% of adolescents 15-19 yo
Neisseria Gonorrhea
• 2nd most commonly reported reportable
infection in the US
– >330,000 cases reported in 2012
• Adolescents account for 58.7% of cases
– Rate among blacks is 17 times the rate among whites
• Structural socioeconomic factors, sexual networks
• Gram negative intracellular diplococcus
• Infects the GU tract, rectum, oropharynx,
conjunctiva
• Incubation period 1-14 days
Gonorrhea
•
•
•
•
•
Most (75-90%) cases in women are asymptomatic
Many (10-40%) male cases are asymptomatic
Symptoms – similar to chlamydia except:
Rarely causes genital ulcers
Gonococcal Pharyngitis:
–
–
–
–
Usually asymptomatic
May cause pain or exudates
May look like mono or GAS
Self-limited (but should be treated if diagnosed)
Gonorrhea complications
• Complications – similar to chlamdyia, except:
• Neonatal conjunctivitis (2-5 days of life), may cause
blindness
• Disseminated gonococcal infection (3% of untreated cases)
– Tender small pustular skin lesions that become necrotic ulcers,
may be on palms and soles, purpuric, hemorrhagic, or vesicular
– Asymmetric arthralgias, migratory arthritis (wrists, ankles)
– Meningitis, endocarditis
– Source is usually asymptomatic cervical or pharyngeal infection
• Facilitates HIV transmission
Gonorrhea diagnosis
– Same as Chlamydia
– If NAAT is repeated within 2 weeks after
treatment, may get false positive
• Remember to test all sites of contact: NAAT
test of oropharyx and/or rectum
– Use the swab labeled for the cervix
Gonorrhea –
Emerging Antibiotic Resistance
• Neisseria gonorrhea historically acquired resistance to
sulfonamides, penicillin, and flouroquinolones
• Cephalosporins are the only remaining treatment
option
• But Ceftriaxone-resistant strains have been identified in
Japan (2009), France (2010), and Spain (2011)
• MICs in the US are increasing…Era of untreatable
gonorrhea may be coming
• Screening and appropriate treatment are essential
Pelvic Inflammatory Disease (PID)
• Common, polymicrobial ascending GU tract
infection with severe sequelea
• Caused by C. trachomatis, N gonorrhea,
Mycoplasma genitalium, anaerobes, others
• Low threshold for diagnosis and treatment
• Treat if EITHER of the two minimum criteria are
met:
– Uterine or adnexal tenderness (unilateral or bilateral)
– Cervical motion tenderness occurring in the absence
of any other explanation
PID
• Additional signs and symptoms (not necessary for
diagnosis)
–
–
–
–
Fever >38.3 (101)
Abnormal cervical or vaginal mucopurulent discharge
Increased ESR or CRP
Gonorrhea or Chlamydia test positive
• Treatment: Ceftriaxone 250 mg IM, AND
Azithromycin 1 gm PO weekly x 2 weeks, AND
Flagyl 500 mg PO BID x 14 days
– IV treatment: Cefoxitin + Doxy
– Alternative IV tx: Clinda + Gent
PID
• Additional signs and symptoms (not necessary for
diagnosis)
–
–
–
–
Fever >38.3 (101)
Abnormal cervical or vaginal mucopurulent discharge
Increased ESR or CRP
Gonorrhea or Chlamydia test positive
• Treatment: Ceftriaxone 250 mg IM, AND
Azithromycin 1 gm PO weekly x 2 weeks, AND
Flagyl 500 mg PO BID x 14 days
– IV treatment: Cefoxitin + Doxy
– Alternative IV tx: Clinda + Gent
HIV
• 50% of cases in US adolescents remain undiagnosed. Nearly 10,000 new
diagnoses per year in Americans between the ages of 13 and 24.
• Offer universal screening
– NY State law: Must offer to all patients at least 13 years old who have not
been previously offered an HIV test, with limited exceptions
• Screen high risk patients every 3-6 months
• Acute retroviral syndrome is often missed: (Pharyngitis, flu-like illness
with fever, chills, malaise, fatigue, cough)
– Low threshold for testing
• Diagnosis is a form of prevention
• Order: HIV antigen/ antibody screen
– Results available within an hour
– Includes p24 antigen, an early marker of HIV present soon after infection
(10-14 days)
• Post exposure prophylaxis (PEP) is avaiable
• Some patients may be good candidates for Pre-Exposure Prophylaxis
(PrEP)
Genital Ulcers
• Painless: Syphilis – often single lesions
• Painful: Herpes – often multiple lesions
• Painful and NOT herpes…consider:
– Chancroid (haemophilus ducreyi)- often multiple lesionsdeep, ragged ulcers, violaceous border
– CMV, EBV
– Behcet’s
– Vulvar aphthosis / Virginal ulcers / Lipshultz ulcers
• Lymphogranuloma venereum (chlamydia serovars L1-3)
•
•
•
•
Rare in this country
Occasional outbreaks, mostly in MSM
Single painless papule or shallow ulcer
In later stages causes severe symptoms
Other STIs
• Mycoplasma genitalium – common, no easy way to
diagnosis, but for cases of refractory PID or vaginal
discharge, treat for mycoplasma with moxifloxacin.
(See CDC.gov 2015 STD treatment guidelines)
• Human Papillomavirus: Very common, causes cancer
and warts, start PAP smear at age 21, HPV test is for
women over 30 undergoing cervical cancer screening.
HPV is vaccine-preventable.
• Scabies: Itchy! Treat with permethrin 5% and
environmental disinfection
• Lice: Itchy rash with visible lice or nits. Treat with
permethrin 1% and environmental disinfection
Routine Screening
Chlamydia
Gonorrhea
Girls
Boys
AAP: All sexually active ≤25 yrs
CDC: : All sexually active ≤25
yrs
USPSTF: All sexually active ≤24
yrs
AAP: Screen MSM and screen those
at increased risk
CDC: Screen MSM. Insufficient
evidence for routine screening.
Consider screening in settings with
increased prevalence, e.g. adolescent
clinics
USPSTF: Insufficient evidence to
recommend routine screening
AAP: All sexually active <25 yrs
CDC: All sexually active <25 yrs
USPSTF: All sexually active if
increased risk for infection
AAP: Consider screening on basis of
individual and population-based risk
factors
CDC: Screen MSM, anyone with
contact in the last 60 days
USPSTF. Insufficient evidence
Increased risk: Prior history of STI, new or multiple partners, inconsistent condom use, drug use,
survival sex, early onset of sexual intercourse, drug use, residence in community with high rate of
gonorrhea infection
Back to the cases
• 1) A 16 year old sexually active girl presents to the
Emergency Department with dysuria. She has not had fever.
Urine analysis is unremarkable. Urine culture is ordered.
What other test should be ordered?
• 2) An 18 year-old new mother presents at 6-wks
postpartum for IUD insertion. Purulent discharge is noted
at the cervical os. Samples are taken for NAAT tests, and
the insertion procedure is aborted.
• 3) A 16 yo presents with the chief complaint “my period
comes every two weeks”. After talking with her, you
ascertain that she has always had regular menses, but
recently she has intermenstrual spotting, particularly after
sexual intercourse.
LGBTQ Issues
• Lesbian, gay, bisexual, transgender, or
questining
Screening in Special Populations
• Boys having sex with boys / MSM
– Chlamydia and gonorrhea at least yearly: Screen genital and
extra genital sites (pharynx, rectum)
• Extra genital sites are more likely to be asymptomatic, so screening
is necessary
– HIV test at least annually, q3-6 months for high risk
– RPR
– HBV screening. (HBsAg and anti-HBs or anti-HBc)
– HCV screening if also uses or previously used illicit IV drugs, or
if HIV positive.
• Girls having sex with girls / WSW – same screening
recommendations as for heterosexuals
Why discuss LGBTQ issues?
• Up to 15% of youth self-identify as LGBTQ
• Youth LGBTQ community is marginalized
• LGBTQ youth have increased health risks
– Don’t assume high risk behavior or mental health concerns
• Providing LGBTQ youth-competent care is a skill
– Many of us were not trained and do not have the life
experiences that would make us aware of these issues
– Even for those who are LGBT or Q, training is important
because this is a diverse community with varying needs

2014
Sexual
Attraction
Biological
Sex
Sexual
Orientation
Paradigm of
Sexuality
Sexual
Behavior
Gender
Identity/
Expression

2014
LGBTQ and Adolescence
• Components of sexuality are overlapping, fluid, and
evolving during adolescence
• Adolescence is a time of physical, emotional,
intellectual, and sexual change and exploration
• Sexual orientation may emerge during adolescence
• Gender identity issues may emerge during adolescence
Definitions
• LGBTQ - lesbian, gay, bisexual, transgender, or questioning
• Gender identity = internal sense of one’s own gender
– Gender identity is different from gender expression (external
manifestation of gender) and separate from sexual orientation
(who you are attracted to)
• Transgender refers to inner sense of gender that is
different from biologic / natal / assigned gender
– Gender dysphoria refers to a marked incongruence between natal
gender and one’s experienced or expressed gender, and is
associated with a strong desire to be of the other gender or an
insistence that he or she is the other gender.

2014
More definitions
• Sexual orientation
– Pattern of romantic or sexual attractions. Describes the gender of the
persons to whom one is attracted
– An internally applied label. Applies to gay and straight adolescents
• Coming-out
– Process of acknowledging to oneself and then to others one’s sexual
orientation
– Applies to gay and straight adolescents – anytime you mention a
spouse or partner, or talk about a movie star you find attractive
– A lifelong process – for gender minorities, often involves correcting
others’ assumptions

2014
Asking
• Are your partners girls, boys, or both?
• Are you attracted to girls, boys, both, or neither?
• Do you have any questions or concerns about your
gender?

2014
How do young children reveal their
transgender identity?
• 1. Bathroom behavior. “Does your little girl pee standing
up?”
• 2. Swimsuit aversion. (Most trans kids absolutely will not
wear the bathing suit of their anatomical sex.)
• 3. Underwear selection. “Does your son want the girl cut
underwear with flowers on them?”
• 4. A strong desire to play with toys typically assigned to
the opposite sex.
• If all four of the above behaviors line up, the child may be
transgender
• However, the majority of gender-variant kids are not
transgender. They are just gender nonconforming.
Transgender Care
• Refer to specialist (Endocrine or Adolescent)
• Diagnosis Gender Dysphoria
– Not gender identity disorder
• Specialist will require:
– Mental health letter
• Goldberg Counseling Center
– Informed consents (parental signatures) required
• Note that medicines often not covered by insurance

2014
Summary LGBTQ issues
• Ask patients about the gender of their sexual partners
• Don’t assume a heterosexual or cisgender identity
• Screen boys having sex with boys more frequently, screen
sites of contact, and include RPR
• Adolescents with gender dysphoria can be referred to
adolescent medicine or endocrinology. They will need
parental consent and a mental health letter

2014
Questions?

2014
Quiz
• 1. Which of the following are considered
contraindications to prescribing estrogen in a
healthy teenager?
a)
b)
c)
d)
(a)
(b)
(c)
(d)
Smoking
History of sexually transmitted infection
Migraine with aura
History of DVT
(a) And (d)
(b) and (d)
(a) and (c)
(c) and (d)
Quiz
• 2. Emergency contraception with
levonorgestrel may be effective up to how
long after unprotected intercourse?
A.
B.
C.
D.
E.
1 day
2 days
3 days
4 days
5 days
Quiz
• 3. Which of the following are considered first line
contraception methods for teenagers?
i.
ii.
iii.
iv.
v.
A)
B)
C)
D)
Mirena (levonorgestrel) IUD
Paraguard (copper) IUD
Nexplanon (etonorgestrel) subdermal implant
Oral contraceptive pills
Vaginal ring (NuvaRing)
i., ii., and iii.
i. and iv.
iii., iv., and v.
iv. and v.
Quiz
4. Which of the following could be symptoms of a
sexually transmitted infection?
I.
II.
III.
IV.
Irregular vaginal bleeding
Dysuria
RUQ pain
Rectal bleeding
a.
b.
c.
d.
I and II only
II and III only
I, II, and III only
All of the above
Quiz
• 5. Which of the following patients should be screened /
tested for chlamydia?
a.
b.
c.
d.
e.
A 14 yo girl who has never been tested before. She has
been sexually active with one partner with condom use
and has no complaints.
A 15 yo girl who was treated for chlamydia 3 months ago
and has no current symptoms and no new partner.
A 16 yo sexually active boy with dysuria but no penile
discharge.
An 18 yo girl with vaginal discharge and bleeding after
intercourse who had a negative chlamydia test 3 months
ago.
All of the above.
3. Quiz
• 6. According to the CDC recommendations
and NYS law, who should be offered HIV
screening?
a. All patients at least 13 years old who have not
had a prior test, with limited exceptions
b. Only sexually active patients at least 16 years old
c. Only patients with symptoms of opportunistic
infections
d. Only patients who have been diagnosed with
other STIs or who have risk factors
Quiz
7. You are seeing a 15-year-old girl for a health supervision visit. She
reports being sexually active, but she denies vaginal discharge,
dysuria, or abdominal pain. She reports occasional use of condoms,
and she has had several sexual partners, but she has never had a
sexually transmitted infection. You wish to screen her for the
presence of chlamydial infection and gonorrhea. Which of the
following statements regarding laboratory testing for these agents it
true?
a.
b.
c.
d.
e.
Urine analysis is a good screening test.
Chlamydia culture has poor specificity.
Nucleic acid amplification tests are highly sensitive if performed on
vaginal samples.
Gram stain of vaginal secretions is sensitive but not specific.
No laboratory testing is indicated because she has no symptoms.
Thank you