All My Children

Needless to say, no adolescent (or any older woman) is excited about having a pelvic exam, especially if there is discomfort in this area to start with. It is important that whoever does the exam explain step-by-step what is going to happen and then talk her through it while it is being done. She should be reassured that it is normal to feel nervous and awkward and that while the exam is not particularly comfortable, it shouldn’t be extremely painful either. Both patient and parent should understand that a pelvic exam does not terminate a girl’s virginity. Sexual morality is not violated by a medical procedure whose purpose is to help assess, diagnose, and treat a physical problem.

A young girl should feel free to tell her physician when and where it hurts and know that the exam will be modified if she is having a lot of pain. Many teenagers feel more comfortable if the exam is done by a physician they know and trust, regardless of gender, while others specifically prefer that it be done by a female health-care provider. In either case, the examiner should be accompanied by a female attendant.

Normally during a pelvic exam, the external genitals are briefly inspected, and then a speculum (the “duckbill” instrument) is gently inserted. A narrow speculum should be available for younger patients, and this should pass through the hymen (the ring of soft tissue just inside the labia at the entrance to the vagina) without tearing it. The vaginal walls will be checked, and a Pap smear is normally done. During a Pap smear, some cells are gently obtained from the cervix and then transferred to a slide. The cells are examined microscopically for evidence that might indicate that a sexually transmitted disease, a cancer, or a precancerous condition is present. Tests for specific sexually transmitted diseases may also be done. Then the examiner will insert one or two fingers into the vagina while the other hand gently presses on the lower abdomen. Much information can be obtained from this simple maneuver, including the size of the uterus and ovaries and the location and intensity of any tenderness. A rectal examination may also be done at this time.

Some additional tests may be done during a basic physical exam. These could include:

• Vision and hearing screening
• Urinalysis
• Blood tests, especially: a blood count to check for anemia (especially in girls); cholesterol and other circulating fat molecules (called lipids) if there is history of elevated cholesterol or heart attack before age fifty-five in one or more family members
• A screening test for tuberculosis may be put on the arm. A temporary local reaction (a firm bump at the injection site) within two or three days indicates a past exposure to tuberculosis. If this occurs, further evaluation will be necessary to determine the appropriate course of action.

1. • A tetanus and diphtheria (Td) booster should be given ten years following the last injection, which in most cases will have been at four or five years of age. Thus Td is typically given at a fourteen- or fifteen-year-old checkup, unless an injury prior to this age required an earlier booster. Remind your adolescent that this is normally repeated every ten years for the rest of his life. A booster may be given after five years if he sustains a wound that results from a puncture, crush injury, burn, or frostbite, or one that is contaminated with dirt, feces, or saliva. In addition, some physicians give a tetanus booster if five years have elapsed since the last one and the adolescent is going on a wilderness expedition or to a foreign country where vaccine might not be available.
   • Measles/mumps/rubella (MMR) vaccine should be given if your child has had only one injection thus far. It is unwise to count on a single immunization during infancy to protect against these infections throughout adolescence and adulthood. (Many colleges now require proof of two doses of MMR prior to entrance.)
   • Hepatitis B vaccine should be given if the series has not been complete already. Parents who are aware that this infection is transmitted primarily through sexual contact and intravenous drug use may feel it is unnecessary to subject their son or daughter to a three-dose vaccine. (”My kid won’t do those things—why does he need these shots?”) But a significant proportion of hepatitis B cases occur among people who are notinvolved in any risky behavior and who have no clear-cut exposure history. Since this infection can potentially be lethal or cause significant chronic illness, the vaccine is a good investment.
   • If your adolescent has never had chicken pox (varicella) and has not been previously immunized against it, vaccination against this virus would be advisable, especially because infections in teenagers and adults tend to be more severe than in younger children. Prior to the thirteenth birthday, only one dose of varicella vaccine is needed, while after age thirteen two doses should be given four to eight weeks apart. Varicella vaccine may be given at the same time as an MMR and/or Td injection.

A number of immunization updates are usually given during the adolescent years:

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