A comparison of diagnostic methods in adolescent girls with and without symptoms of Chlamydia urogenital infection.

OBJECTIVE: To evaluate the clinical utility of various diagnostic tests, two enzyme immunoassays and a chemiluminescent DNA probe were compared with cell culture (with monoclonal antibody confirmation) for the diagnosis of endocervical Chlamydia trachomatis infection. DESIGN: The clinical performance of four diagnostic methods for Chlamydia trachomatis urogenital infections were compared, using specimens generated from consecutive pelvic examinations. SETTING: Subjects were recruited from an urban adolescent clinic that provides primary and referral care. PARTICIPANTS: A total of 479 adolescent female subjects were enrolled. The order of sample collection was randomized. Subjects were stratified according to whether they were asymptomatic (n = 228) or symptomatic (n = 251). MEASUREMENTS AND RESULTS: Discrepant analysis was performed when culture was negative and nonculture technique was positive. The subject was considered to have chlamydia if culture was positive, or if one or more nonculture techniques, with that test's confirmatory assay, were positive (consensus-positive). Prevalence of chlamydia was 11.0% in the asymptomatic, and 20.7% in the symptomatic, group. Overall, 32.5% of the infected subjects were asymptomatic. Sensitivity of diagnostic methods varied from 52% to 80% in the asymptomatic subjects, compared with 65% to 81% in symptomatic subjects. Culture sensitivity was 75% to 80%. The specificities of all tests were 96% or greater. Accuracy of nonculture methods varied from 89.5% (DNA probe, symptomatic subjects) to 96.9% (enzyme immunoassay asymptomatic subjects). CONCLUSIONS: There are significant differences in symptomatic subjects when evaluating accuracy of test outcome, using a consensus-positive criterion. Asymptomatic infections account for nearly one third of adolescent females infected with chlamydia. The prevalence of chlamydia urogenital infections are underestimated by any single diagnostic test, particularly in the asymptomatic patient.

Experience with side effects and health risks associated with Norplant implant use in adolescents.

Levonorgestrel implants (Norplant) have been recommended as a contraceptive method for teenage women. Our experience suggests that the use of Norplant implants in adolescents is associated with bleeding irregularities and modest weight gain. There is no effect on condom use or STD acquisition. Despite the bleeding irregularities, we documented high continuation rates, suggesting that with appropriate pre-insertion counseling, Norplant implants can be a successful contraceptive method for adolescent women.

PIP: An analysis of the experiences of 72 US adolescents (mean age, 15.5 years) suggests that Norplant implants are an appropriate contraceptive method for this population. All study participants had the implants inserted at a hospital-based adolescent clinic at least 1 year before chart review. The continuation rate was 97% at 12 months and 86% at 24 months. At insertion, 60 adolescents (83%) reported regular menstrual periods. At the various follow-up intervals (e.g., 3, 6, and 12 months), 12-18% had regular periods, 12-16% were amenorrheic, and the remainder had bleeding that was irregular in length and/or interval. Mean weight gains of 3, 4.5, and 5.8 pounds were recorded at 3, 6, and 12 months, respectively; however, there was no consistent trend and a substantial number of young women lost weight during the study period. Finally, there was no clear trend of increase or decrease after Norplant insertion in either condom use or rates of infection with sexually transmitted diseases (STDs). Pre-insertion counseling for adolescent Norplant acceptors should include preparation for menstrual irregularities and encouragement of condom use to prevent STD acquisition.

Depo-Provera in adolescents: effects of early second injection or prior oral contraception.

PURPOSE: To examine the effects of an early second injection or prior use of oral contraceptive pills (OCP) on side effects of Depo-Provera during the early months of use in adolescents. METHODS: Thirty-six girls, gynecologic age 4.2 +/- 0.3 years, and body mass index (BMI) 23.2 +/- 0.8, received the currently recommended injection of 150 mg every three months. Twenty-seven girls (gynecologic age 3.9 +/- 0.5 years, BMI 24.0 +/- 0.8) received the second injection six weeks after the first injection. Fifteen girls (gynecologic age 5.0 +/- 0.5, BMI 25.4 +/- 1.3) switched directly from an OCP to Depo-Provera. The patients were periodically assessed by their care providers. RESULTS: Early administration of the second injection of Depo-Provera did not alter the bleeding episodes, onset of bleeding, or total days of bleeding (14.3 +/- 3.7 vs. 17.1 +/- 4.0, p = 0.62) during the three months interval following injection, compared with the standard second injection interval. Moreover, an excessive BMI gain (BMI increase 0.99 +/- 0.22 vs. 0.40 +/- 0.14, p = 0.03) was observed in these girls. Girls who switched directly from OCP showed no difference in the rate of BMI gain when compared to those not previously on OCP (BMI increase 0.38 +/- 0.3). Bleeding duration of these girls, however, was markedly reduced; the total number of days of bleeding was 5.7 +/- 1.9 (p = 0.0003) during the first three month interval, and 5.7 +/- 2.3 (p = 0.019) during the three month period following the second injection. This reduction did not persist beyond the first six months. CONCLUSIONS: Early second Depo-Provera injection does not alter the experience of menstrual abnormalities, and predisposes to greater weight gain; OCP use prior to Depo-Provera results in a decrease in the duration of bleeding with no change in the weight gain rate.

PIP: The capability of an early second injection or prior use of oral contraceptives (OCs) to improve satisfaction and long-term continuation of Depo-Provera in adolescents was investigated in a clinical trial involving 78 females 12-20 years of age (average, 15.9 years) recruited from a hospital-based adolescent health clinic. 36 subjects received injection of 150 mg of Depo-Provera every three months (Group 1), 27 received the second injection after only six weeks (Group 2), and 15 switched directly from OCs to the standard Depo-Provera regimen (Group 3). There was no difference between Groups 1 and 2 in terms of duration or frequency of menstrual bleeding; however, prior OC users experienced a significant reduction in the duration and intensity of bleeding in the first six months of Depo-Provera use (when estrogen was still present in the women's systems). Overall, 64% of study subjects reported less dysmenorrhea while on Depo-Provera. A slightly greater change in body mass index was observed among girls in Group 2 than in Groups 1 and 3; moreover, 70% of those in the early injection group reported increased appetite and weight gain compared to 39% of those on the standard schedule. The most commonly reported side effects included initial pain and soreness at the injection site (27%), decreased libido (56%), mood changes (31%), depression (26%), frequent headache (25%), fatigue (24%), and increase in acne (15%); there were no significant differences by group. 17 adolescents (22%) discontinued Depo-Provera, generally after two injections and due to bleeding irregularities or weight gain. 87% of adolescents who were prior OC users, 52% of those on the regular schedule, and 39% of those who received an early injection stated they were very satisfied with Depo-Provera. These findings indicate that early second Depo-Provera injection offers no advantages; use of OCs immediately prior to Depo-Provera should be further investigated, however, given its potential to minimize bleeding problems.

Adolescents' reasons for and experience after discontinuation of the long-acting contraceptives Depo-Provera and Norplant.

PURPOSE: The objectives of this study were to examine the reasons for discontinuation of the long-acting contraceptives Depo-Provera and Norplant in adolescents, and to assess the adolescents' experience after discontinuation of the methods. METHODS: A total of 35 adolescents [gynecologic age 4.7 +/- 0.3 years, and body mass index (BMI) 24.2 +/- 0.6] who discontinued Depo-Provera, and 31 adolescents (gynecologic age 3.4 +/- 0.3 years, BMI 24.1 +/- 0.9) who discontinued Norplant were periodically assessed during use of the methods and up to 12 months after discontinuation. RESULTS: The most common reasons for discontinuation of both Norplant (after 21.8 +/- 1.6 months of use) and Depo-Provera (9.2 + 0.9 months of use) were irregular menstrual bleeding (64%), weight gain (41%), and increased headaches (30%). Resumption of menstrual regularity and dysmenorrhea was noted sooner after discontinuation of Norplant, compared with Depo-Provera. The increase in BMI noted at discontinuation of Depo-Provera (1.1, P = .0005) and Norplant (1.3, P = .03) persisted up to 6 months after discontinuation of either method (0.6, P = .01 post-Depo-Provera discontinuation; and 0.9, P = 0.02 post-Norplant discontinuation). Only 62% of the adolescents reported no break in contraceptive practice. The condom was the most popular method (37%) after discontinuation of Depo-Provera, and oral contraceptive (39%) after discontinuation of Norplant. The cumulative conception proportion reached 0.93 at 12 months after discontinuation of Norplant, and was significantly higher (P = .01) compared with the cumulative proportion of conception after discontinuation of Depo-Provera (P = .50). CONCLUSIONS: Health care providers should aggressively manage physical problems associated with Depo-Provera and Norplant use, and expedite the transition to a new contraceptive method to minimize the high pregnancy rate observed after discontinuation of these methods in adolescents.

PIP: The authors present their findings from the study of adolescents' reasons for discontinuing the use of Norplant and Depo-Provera. Their experiences after method discontinuation were also assessed. 35 adolescents of mean gynecologic age 4.7 years and body mass index (BMI) 24.2 who discontinued Depo-Provera, and 31 adolescents of mean gynecologic age 3.4 years and BMI 24.1 who discontinued Norplant were periodically assessed during use of the methods and up to 12 months after discontinuation. The most common reasons for discontinuation of both Norplant and Depo-Provera after mean periods of 21.8 and 9.2 months use, respectively, were irregular menstrual bleeding (64%), weight gain (41%), and increased headaches (30%). The resumption of menstrual regularity and dysmenorrhea was noted sooner after discontinuation of Norplant, compared to Depo-Provera. The increase in BMI noted at the discontinuation of Depo-Provera persisted up to 6 months after discontinuation of either method. 62% of adolescents reported no break in contraceptive practice. The condom was the most popular method (37%) after discontinuation of Depo-Provera, and oral contraceptives (39%) after discontinuation of Norplant. The authors conclude that health care providers should aggressively manage physical problems associated with Depo-Provera and Norplant use, and expedite the transition to new contraceptive methods in an effort to minimize the high pregnancy rates observed after discontinuation of these methods in adolescents.

Adolescent girls' understanding of Papanicolaou smear results.

STUDY OBJECTIVE: Human papillomavirus (HPV) urogenital infections are common in sexually active adolescents. Previous research has indicated that adolescent girls do not reliably report histories of HPV infection. This study examined whether asking an adolescent girl if she had ever had an abnormal Papanicolaou (PAP) smear was a good screening question for evidence of HPV urogenital infection. DESIGN: The responses to the question about abnormal PAP smears, were compared with their charts for documented abnormal PAP smear, HPV infection, and sexually transmitted infection. SETTING: An urban, hospital-based adolescent clinic. PARTICIPANTS: Fifty adolescent girls (mean age, 14.8 years). MAIN OUTCOME MEASURES: Degree of agreement (kappa statistic). RESULTS: Using a kappa statistic, reported history of an abnormal PAP smear had "fair" agreement with documented dysplasia on PAP smear and "moderate" agreement with documented HPV infection (i.e., either condyloma on PAP smear or genital warts noted on examination). This reported history of an abnormal PAP smear agreed better with documented HPV infection than with documented dysplasia on PAP smear. CONCLUSIONS: There appears to be considerable confusion among adolescent girls regarding their PAP smear results. Care providers need to be sensitive to this when they are collecting historical information and when they are diagnosing HPV infection or an abnormal PAP smear.

Adolescents' knowledge of human papillomavirus and cervical dysplasia.

STUDY OBJECTIVE: This study examined adolescents' knowledge of human papillomavirus (HPV) and cervical dysplasia (CD). Factors associated with knowledge and self-reported change in health-related behaviors were identified. DESIGN: Interviews were conducted at an average of 2.5 years following the diagnosis of HPV/CD. Medical charts were reviewed. SETTING: The study was conducted at a university-based adolescent dysplasia clinic. PARTICIPANTS: Fifty females, ages 15-23 participated in the study: 88% African-American, 12% Caucasian. RESULTS: On average, participants responded correctly to 86% of the questions regarding HPV/CD. However, the following key points were routinely missed: 52% did not know cigarette smoking increased the risk for cervical cancer; 42% believed that HPV/CD was always symptomatic; and 22% did not know condoms decreased the transmission of HPV. According to participants, their health care provider explained the diagnosis and treatment of HPV/CD using words they understood "some" or "most of the time." Higher academic skills significantly correlated with greater knowledge of HPV/CD. Forty-one percent of participants with a smoking history reportedly increased their smoking since the diagnosis, and only 40% used condoms "most of the time." However, 90% had maintained or increased their frequency of Pap tests. CONCLUSIONS: Adolescent girls had knowledge of most factors related to HPV/CD, but many did not understand the risks of cigarette smoking and failure to use condoms. To improve understanding and compliance, health care providers should tailor educational strategies to the functional level of adolescents.

Relationship between perceived parental monitoring and young adolescent girls' sexual and substance use behaviors.

STUDY OBJECTIVE: The purpose of the study was to examine the independent effects of perceived parental monitoring on sexual experience, contraceptive, and substance use. DESIGN, SETTING, AND PARTICIPANTS: Adolescent females at an urban-based adolescent clinic (N = 174; 41% sexually experienced) rated the extent to which they were directly and indirectly monitored by their parents. MAIN OUTCOME MEASURES: These perceptions were compared with reported contraceptive use as well as substance use. Direct parental monitoring was best described using two dimensions: direct monitoring and direct monitoring when with peers. RESULTS: Direct monitoring was found to be associated with the use of hormonal birth control methods at last intercourse. Direct parental monitoring when with peers was found to be associated with less use of alcohol and cigarettes. CONCLUSIONS: These data suggest that parental monitoring is a relevant factor for primary care physicians to explore during treatment.

Methods for managing pelvic examination anxiety: individual differences and relaxation techniques.

Many adolescent girls anticipate pelvic examinations with anxiety. Providing information about the examination procedure is not sufficient to help all girls cope with their anxiety. An assessment of the adolescent's coping style allows the care provider to tailor the educational process to the individual adolescent. Once the care provider has become proficient in relaxation techniques, they can be used along with education. This article reviews coping styles and relaxation techniques that can be integrated into practice.

Adolescents' agreement to test for HIV when different testing methods are offered.

Offering rapid HIV testing improves rates of testing in adults, but little is known about whether offering adolescents a choice of testing methods increases rates of testing. The aims of the study were to determine rates of HIV testing in adolescents when different testing methods were offered and explore factors associated with agreement to be tested for HIV. Participants (n= 200, sexually experienced 13-22 year olds) were recruited from an urban adolescent clinic, completed a 99-item theory-based survey and were offered their choice of venipuncture, rapid fingerstick or rapid oral fluid HIV testing. Approximately half (49.5%) agreed to HIV testing. Male gender, parental completion of high school, intention to test for HIV if offered by clinician and higher perceived likelihood of current HIV infection were independently associated with agreement to test. Combining new strategies, such as opt-out testing, with routine testing may be needed to improve rates of adolescent HIV testing.

Acceptability of human papillomavirus self testing in female adolescents.

OBJECTIVES: To develop scales assessing acceptability of human papillomavirus (HPV) testing in adolescents, to compare acceptability of self to clinician testing, and to identify adolescent characteristics associated with acceptability. METHODS: Female adolescents 14-21 years of age attending a hospital based teen health centre self collected vaginal samples and a clinician, using a speculum, collected cervicovaginal samples for HPV DNA. Acceptability of and preferences for self and clinician testing were assessed at baseline and 2 week visits. RESULTS: The mean age of the 121 participants was 17.8 years and 82% were black. The acceptability scales demonstrated good internal consistency, reliability, test-retest reliability, and factorial validity. Scores were significantly lower for self testing than clinician testing on the acceptability scale and three subscales measuring trust of the test result, confidence in one's ability to collect a specimen, and perceived effects of testing (p < 0.01). Of those who reported a preference, 73% preferred clinician to self testing. Acceptability scores for both self and clinician testing increased significantly pre-examination to post-examination (p < 0.01). Multivariable analyses demonstrated that race was independently associated with pre-examination and post-examination acceptability of self testing, and that sexual behaviours and gynaecological experiences were associated with specific acceptability subscales. CONCLUSIONS: This sample of adolescents found clinician testing for HPV to be more acceptable than self testing and preferred clinician to self testing. If self testing for HPV is offered in the future, clinicians should not assume that adolescent patients will prefer self testing. Instead, they should educate adolescents about available testing options and discuss any concerns regarding self collection technique or accuracy of test results.