Clinical Review

Your age-based guide to comprehensive well-woman care

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Menses, an important "vital sign." Once menstruation begins, evaluating menstrual cycle characteristics is important. Patterns that may require evaluation include2:

  • no menses within 3 years of thelarche
  • no menses by age 13 with no sign of pubertal development
  • no menses by age 14 with signs of hirsutism
  • no menses by age 14 with indications of an eating disorder
  • no menses by age 15
  • history of regular menses that are now markedly irregular
  • menses occur more frequently than 21 days or less frequently than every 45 days
  • menses occur 90 days apart for one cycle
  • menstrual bleeding that lasts more than 7 days
  • frequent tampon/pad changes (more than 1 tampon/pad every 1 to 2 hours).

BMI predicts future disease. Overweight and obesity are important risk factors for diabetes mellitus, hyperlipidemia, hypertension, and various cancers. Eating disorders are common among adolescents and often occur in association with other mental health problems.

Non–sexually active teens and children

Gynecologic examination typically involves inspection of the genitalia and not instrumentation of the vagina. A careful explanation of the proposed examination is important. Ask young adolescents who they would like to have in the examination room with them. A hand mirror can be used to involve the patient in the genitalia inspection. If it's necessary to obtain magnification, use a hand lens, an otoscope without the speculum, or a colposcope. Record the configuration of the hymen, if present. If indicated, examination of the genitalia while the patient is in the knee-chest position often provides a good view of the vagina and sometimes the cervix, without instrumentation.

Sexually active teens

Effective contraception, including the use of emergency contraceptives, is an important health focus for sexually active teens. Vaginal speculum examination and bimanual gyn exam are not required prior to prescribing hormonal contraceptives to teens. Based on a review of the evidence and expert opinion,3 the current recommendation is that prior to prescribing a hormonal contraceptive, a medical history and blood pressure measurement are the only requirements; breast examination and a gyn exam (vaginal speculum and bimanual gyn exam) are not necessary. Testing for chlamydia and gonorrhea can be performed using a urine sample. A cervical cytology examination is not necessary until age 21 unless the patient is in a high-risk group, such as immunosuppressed or HIV-infected teens.

The young woman: 19–39 years

Focus on reproductive issues. Contraception, pregnancy, and cervical cancer screening are common reasons for visits among women in this age group. Gynecologic problems can include polycystic ovary syndrome (PCOS), endometriosis, fibroids, infertility, pelvic pain, vulvovaginal pain syndromes, vaginitis, adnexal masses, and STDs, including pelvic inflammatory diseases.

Offer effective contraception

Long-acting reversible contraceptives (LARCs) are the most clinically and cost-effective forms of reversible contraception. There are three LARC methods available in the United States: 1) the copper T380A intrauterine device (IUD; Paragard), 2) the levonorgestrel-releasing intrauterine system (Mirena), and 3) the single-rod etonogestrel implant (Implanon, Explanon).

The use of IUDs among American women has increased from about 2.4% of contracepting women of reproductive age in 2002 to 8.5% in 2009.4 In Norway and France, contracepting women of reproductive age use IUDs at a rate of 27% and 23%, respectively.5 Typical-use pregnancy rates for LARCs are lower and continuation rates are higher than observed with oral contraceptives (OCs).

In an economic analysis, the cost of LARCs was lower than almost all other forms of reversible contraception over a 5-year interval.6 When financial and access barriers are removed, most women starting a contraceptive will use a LARC, if offered.7

Be aware of STDs

STDs are common in this age group. In the United States, chlamydial genital infections reach a peak in women 18 to 25 years old, with a prevalence of about 4%.8

Counsel her about exercise and weight loss

Approximately 60% of women older than age 20 are overweight or obese.9 The rise in obesity is a key contributing factor to an increase in many diseases, including gestational diabetes, type 2 diabetes mellitus, and hypertension. Successful efforts to reduce the prevalence of obesity through diet and exercise could markedly improve population health.

Don't overlook autoimmune conditions

Many autoimmune diseases reach a peak incidence between ages 19 and 39, and, except for ankylosing spondylitis, are more of a concern for women than men. Systemic lupus erythematosus, lymphocytic thyroiditis, and rheumatoid arthritis occur much more frequently in women than in men, with ratios in the range of 7:1 observed during this age interval.

Keep her immunity up to date

Immunizations recommended in this age group include:

  • one Tdap (tetanus toxoid, diphtheria, and pertussis)
  • tetanus every 10 years
  • influenza annually
  • varicella if no evidence of immunity
  • HPV for those aged 26 years or younger.


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