for learning directives

1. CONTRACEPTION
CHAPTER 143

2. Contraception- also known as birth
control
It aims to prevent pregnancy and tries to stop this
happening by:
A. Keeping the egg and sperm cells apart
B. Stopping egg cell production
C. Stopping the combined sperm and egg or fertilized
egg in attaching to the lining of the womb.

3. FACTS ABOUT CONTRACEPTION:
According to World Health Organization in 2004, Adolescent fertility and
pregnancy prevention is one of the most important health-care issues in the
twenty-first century.
More than 15 million girls between the ages of 15 and 19 give birth every year
worldwide and in an additional 5 million have abortions
Although the full extent of the unmet need for contraception is hard to gauge
there is clearly a great need for increased adolescent reproductive and sexual
health education.

4. FACTS ABOUT CONTRACEPTION:
The untoward consequences of sexual activity in adolescent that includes
unwanted pregnancies and sexually transmitted diseases are at high rates.
Adolescent tend to experiment and do not seek reproductive healthcare when
they are sexually active.
That is why it is appropriate to have an early intervention and education to
prevent sexually transmitted infections or diseases and unintended
pregnancies in adolescent.

5. Contraceptive
Effectiveness
There are many methods in contraception:
1. The more effective methods: less than 1
pregnancy per 100 women in one year
• Implants
• Vasectomy – use another method for the
first 3 months to be sure of effectivity
• Tubal occlusion
• Intra uterine device or IUD

6. Contraceptive
Effectiveness
2. 4-7 pregnancies per 100 women in one year:
• Injectable – get repeat injections on time
• Pill – take a pill everyday
• Patch and ring – keep in place and change on
time
• 3. Less effective methods: more than 13
pregnancies per 100 women in one year (Tier 3)
• Male condom
• Sponge
• Withdrawal
• Spermicides

7. Contraceptive
Effectiveness
• Diaphragm-these methods should be used
correctly every time you have sex
• Fertility awareness-based methods such as
calendar and getting the temperature will
use condoms or abstain on fertile days.

8. Contraceptive
Counseling

9. Goal of Counseling w/ Adolescents
1. Understand adolescent experiences, preferences, perceptions, &
misperceptions about pregnancy & use of contraceptives
2. Help adolescents put unprotected intercourse risk in a personal
perspective
3. Educate adolescents about the various methods available using
information that is medically accurate, balanced, & provided in a
nonjudgmental manner
4. Help adolescents choose a safe & effective method that can either
be provided on site or be easily obtained through prescription or by
referral

10. Long-acting
Reversible
Contraception
● Safe and effective option for
adolescents including those
who have not been
pregnant or given birth
● Example: IUDS and
implants
Necessary Concepts
to Address:
● How effective the method is
● How long the method works
● What behaviors are required for
correct & consistent use
● What side effects may be seen
● Any noncontraceptive benefits of
the method
● What signs or symptoms of
complications should prompt a
return visit

11. Adolescents Chooses a Method
● clear plans on correct &
consistent use of chosen
method & strategies for
appropriate follow-up
● Help adolescent
consider potential
barriers to correct &
consistent use and
develop strategies to
deal with each barrier
● Assess if they
understood the
information discussed &
may confirm by asking
the teen to repeat back
key concepts

13. U.S. Selected Practice Recommendations
for Contraceptive Use
● provides guidance for providers regarding:
○ when to start contraception
○ how to be certain the woman is not pregnant at
contraception initiation
○ what examinations and tests are recommended
before initiating contraception
○ Most women do not require any exams or tests
before initiating contraception

14. Providers should:
● offer confidential services to adolescents & observe all relevant
state laws and legal obligations (e.g., notification or reporting of
sexual abuse)
● encourage adolescents to involve parents/guardians in their
healthcare decisions, while giving parents clear information on their
teen’s right to confidentiality, privacy, and informed consent
● All services should be provided in a youth-friendly manner
● Resources are available that describe ways to ensure a teen-
friendly reproductive health visit

15. Long-Acting Reversible
Contraception

16. • 4 levonorgestrel (LNG) IUDs (Liletta, Kyleena, Mirena,
and Skyla)
• copper (Cu) IUD, and
• etonogestrel subdermal implant

18. Intrauterine Devices
•small, flexible,
plastic objects
•differ in size, shape,
and the presence or
absence of
pharmacologically
active substances

19. IUDs that are currently approved by the
Food and Drug Administration (FDA)
• CuT380A (Paragard)
• enhanced by the copper ions released into the uterine cavity
• enhanced by the copper ions released into the uterine cavity
• effective for at least 10 yr
• 4 LNG IUDs (Liletta, Kyleena, Mirena, and Skyla)
• thickening of cervical mucus and inhibiting sperm survival to
suppressing the endometrium
• effective for at least 3 and 5 years

21. Note!
• All IUDs have typical-use failure rates of <1%

22. Common misconceptions of IUDs
•infections,
• infertility
•not safe for teens or nulliparous women

23. Implants
• inhibit ovulation
• acts on the uterus to
cause an atrophic
endometrium and
thicken cervical mucus to
block sperm penetration
• use failure rate is also
<1%

24. Implants
• no pelvic exam is required for
insertion
• trained provider can quickly place
or remove the implant in the
upper arm under local anesthesia
• Common side effects include:
• amenorrhea,
• irregular bleeding, or
infrequent bleeding, and
• prolonged or frequent
bleeding.

25. OTHER PROGESTIN-
ONLY METHODS

26. Progestin-only contraceptive methods
◦ Include:
◦ levonorgestrel (LNG) IUDs
◦ Implant
◦ injectable and progestin-only pills
◦ They do not contain estrogen.
◦ May be useful for teens with contraindications to estrogen.
◦ Generally safe for use in teens (category 1 or 2).

27. Progestins
◦ thicken cervical mucus to block sperm entry into the uterine cavity as well as induce an
atrophic endometrium leading to either amenorrhea or less menstrual blood loss;
◦ the implant and injectable additionally suppress ovulation
◦ Teens should be provided anticipatory counseling regarding bleeding irregularities that may
normally occur in the 1st 3-6 months of hormonal contraception use.

28. DEPO-PROVERA
◦ depot medroxyprogesterone acetate (DMPA, Depo-Provera)
◦ An injectable progestin
◦ a Tier 2 contraceptive method available as a deep intramuscular (IM) injection (150 mg), or as a
subcutaneous (SC) injection (104 mg) with typical-use failure rates of 4%.

29. ◦ must be readministered every 3 months (13 wk) and act to inhibit ovulation
◦ Common concerns: bleeding changes, bone effects, and weight gain
◦ After 1 yr of use, 50% of DMPA users develop amenorrhea (an added advantage for teens with
heavy menstrual bleeding, dysmenorrhea, anemias, or blood dyscrasias, or for those with
impairments that make hygiene difficult)

30. PROGESTIN-ONLY PILLS
◦ Progestin-only oral contraceptive pills (POPs)
◦ Available for the adolescent in whom the use of estrogen is potentially harmful, such those with
active liver disease, replaced cardiac valves, or hypercoagulable states.
◦ Quickly effective after 2 days of initiation in thickening cervical mucus, but are less reliable in
inhibiting ovulation
◦ Effects: short-lived

31. ◦ If a pill is >3 hr late from normal time, an unintended pregnancy may occur.
◦ POPs have a typical-use failure rate of 7%
◦ Bleeding irregularities include: amenorrhea and breakthrough bleeding.

32. Emergency
Contraception

33. • Emergency contraception refers to methods of
contraception that can be used to prevent pregnancy
after sexual intercourse. –WHO
• Can be used up to 120 hours/ 5 days after unprotected
intercourse or contraceptive failure.
• Unprotected intercourse mid-cycle carries a pregnancy
risk of 20–30%.
• At other times during the cycle, the risk is 2–4%.

34. Table 143.4 Possible Indications for Emergency Contraception
High Risk Sexual Activity
No contraception during intercourse
Rape
Coitus interruptus
Intoxication (alcohol, drugs)
Contraception Failures
Condom breaking, spillage, leaks, removal by male (purposeful)
Dislodgement, breaking of diaphragm, female condom, cervical cap
Expulsion of IUD
Spermicide failure to melt before coitus
Delayed or Missed Contraception
2 consecutive missed days of combined oral contraceptive
1 missed day of progestin only oral contraceptives
> 2-week late injection of depot medroxyprogesterone
≥ 2 day late start of vaginal ring or patch cycle
Other
Exposure to teratogens in absence of contraception

35. Copper IUD
https://www.mayoclinic.org/tests-procedures/paragard/about/pac-20391270
• CuT380A (Paragard)
• FDA approved.
• >99% effective if used within 5
days of unprotected sex.
• A T-shaped plastic frame that's
inserted into the uterus.
• Copper wire produces an
inflammatory reaction that is toxic
to sperm and eggs (ova),
preventing pregnancy..

36. Copper IUD Available Since Years Effective Use and FDA Approval Possible side effects
Copper IUD (Paragard) 1988 10 years
Approved only in
parous women, but
available to all women
regardless of parity.
Can be used as
Emergency
Contraception when
inserted within 5 days.
Abnormal menstrual
bleeding.
Higher frequency or
intensity of cramps/
pain.
https://www.kff.org/womens-health-policy/fact-sheet/intrauterine-devices-iuds-access-for-women-in-the us/#:~:text=The%20copper%20IUD%20is%20a,in%20the%20US%20since%201988.

37. Ulipristal Acetate
• Was FDA approved in 2010.
• Used up to 5 days after unprotected
sex.
• Few studies have shown it to be more
effective than levonorgestrel at and
beyond 72 hours.
• Start or resume hormonal
contraception no sooner than 5 days
after.

38. Levonorgestrel
• Was approved in 2013 as an OTC
option for all women of
childbearing potential.
• Uncommon Side effects:
Nausea and vomiting
• More effective than Yuzpe Method

39. Dual Protection
- It is a contraceptive use that protect against
Sexually transmitted infections/ HIV as well as
pregnancy
- Dual protection= protection against STI/HIV +
prevents pregnancy

40. CONDOMS
• Prevents sperm from being deposited in the
vagina.
• No major side effects
• ADVANTAGES:
• Low price
• No prescription needed
• Little need for advance planning
• Effectiveness in preventing transmission of STIs (HIV &
HPV)
• Cases of HIV increased the use of Condoms at last sexual intercourse among
adolescence (Highschool) from 46.2% during 1991 to 56.9% in 2015

41. MALE LATEX CONDOMS
• Most effective dual protection
• Should be used with an effective contraceptive method for
adolescents such as LARC.
• LARC- Long Acting Reversible Contraceptives
• Ex. copper Paragard IUD, the hormonal (progesterone) Mirena IUD,
and the hormonal contraceptive implant (effective for 10, 5 and 3
years, respectively)
FEMALE CONDOM
• Available OTC in single-size disposable units
• 2nd choice over male latex condom because of the complexity of
properly using the device.
• High typical-use failure rate of 21%
• Lack of human studies demonstrating effectiveness against STI
• Requires intensive education and hands-on practice to use it
effectively

42. OTHER BARRIER METHODS
DIAPHRAGM, CERVICAL CAP AND SPONGE
- Few side effects but less used by teenagers
- Cervical cap and Sponge have low failure rates in
nulliparous woman
- Diaphragm has similar rates among nulliparous and
parous woman.
- Adolescents object to messiness of the jelly or
insertion of diaphragm interrupting spontaneity of
sex and discomfort about touching their genitals
Typical use failure rate: Exceeds 14%

43. OTHER CONTRACEPTIVE METHODS
• Spermicides
• Withdrawal
• Fertility Awareness Based Methods
• Lactational Amenorrhea Method

44. Spermicides
Agents containing nonoxynol-9
• -foams, jellies, creams, films, effervescent vaginal
suppositories
• Placed in the vaginal cavity before intercourse and
reinserted before each subsequent ejaculation to
be effective
SIDE EFFECTS
• Contact vaginitis
• Vaginal and cervical mucosal damage
• Impact on HIV transmission unknown
TYPICAL USE FAILURE RATE – 21%

45. Fertility Awareness-Based Methods
• Pregnancy risk underestimated in adolescents
• 60% of teens use withdrawal
TYPICAL FAILURE RATE- 20%
Withdrawal
Method based on regular ovulatory cycles
• Standard Days method
• Basal body temperature method
• Billings method
Should be used with caution

46. Lactational Amenorrhea Methos
Highly effective and temporary method
Criteria
a.no return of menses
b. the infant is <6 months old
c. Exclusively breastfeeding

47. ADOLESCENT
CHAPTER 1 4 4
PREGNANCY

48. EPIDEMIOLOGY

49. • Despite these data, the United States continues to lead other
industrialized countries in having high rates of adolescent pregnancy,
with >700,000 pregnancies per year.
• National Survey of Family Growth (NSFG) 2006–2010
• Less than one third of 15-19 years old FEMALES
EPIDEMIOLOGY

50. 1. More teens are delaying the onset of sexual intercourse.
2. They are using some form of contraception when they begin to have sexual
intercourse
3. They are using long-lasting contraceptive agents such as injections, implants,
and intrauterine devices
3 FACTORS:

51. • Most pregnancies among U.S. adolescents are UNINTENDED
• 88% of births to teenagers 15-17 years old
• Pregnancy rate includes actual births, abortions, and best estimates
of fetal loss per 1,000 adolescents in that age-group
• Abortion rate among adolescents 15-19 years old: 14.3 per 1,000
females and accounted for 16.2% of all abortions in
• 1999–2008: abortion rate decreased by 20.7%
• 2004–2008: 5.8%
EPIDEMIOLOGY

52. • In industrialized countries with policies supporting access to protection against
pregnancy and sexually transmitted infections, older adolescents are more likely
to use hormonal contraceptives and condoms, resulting in a lowered risk of
unplanned pregnancy
ETIOLOGY

53. • In nonindustrialized countries, laws permitting marriage of young and
mid-teens, poverty, and limited female education are associated with
increased adolescent pregnancy rates.
ETIOLOGY

54. CLINICAL MANIFESTATIONS
• Some teens are reluctant to divulge concerns
of pregnancy
• PREGNANCY is still the most common
diagnosis when adolescents present with
secondary amenorrhea.

55. DIAGNOSIS

56. • On physical examination, the findings of an enlarged uterus, cervical
cyanosis (Chadwick sign), a soft uterus (Hegar sign), or a soft cervix
(Goodell sign) are highly suggestive of an intrauterine pregnancy. A
confirmatory pregnancy test is always recommended, either
qualitative or quantitative
DIAGNOSIS

57. • Modern qualitative urinary detection methods are
efficient at detecting pregnancy
• Beta subunit of human chorionic gonadotropin
(hCG)
• 98% detection
• 3-4 days after implantation
• Consequently, each negative test should be
repeated in 1-4 weeks if there is a heightened
suspicion of pregnancy.
• The most sensitive pregnancy detection test is a
serum quantitative βhCG radioimmunoassay, with
reliable results within 7 days after fertilization.
DIAGNOSIS

58. • Pelvic or vaginal ultrasound: detecting and dating a pregnancy
• Pelvic ultrasound will detect a gestational sac at about 5-6 weeks and
vaginal ultrasound at 4.5-5 weeks.
• This tool may also be used to distinguish diagnostically between
intrauterine and ectopic pregnancies.
DIAGNOSIS

59. Pregnancy Counseling And
Initial Management

60. Once the diagnosis of pregnancy is made…

61. It should not be assumed that the pregnancy
was unintended.
• Options include:
• A. releasing the child to an adoptive family
• B. electively terminating the pregnancy
• C. raising the child herself with the help of family,
Father of the baby, friends and other social
Resources.

62. • Options should be presented in a supportive, informative,
nonjudgemental fashion; for some young women, they may need to
be discussed over several visits.

63. • Other issues are how to inform and involve the patient’s parents and
the father of the infant
• Insuring continuation of the young mother’s education;
discontinuation of tobacco, alcohol, illicit drug use
• Discontinuance and avoidance of any medications that may be
teratogenic
• Examples are: folic acid, calcium, iron supp; proper nutrition; and
testing for STIs.

64. Discussion…

65. Risk factors for teenage pregnancy
• Poverty
• Parents with low level of education
• Growing up in a single-parent family
• Fewer opportunities in their community for positive youth
involvement
• Neighborhood physical disorder
• Foster care
• Poor performance in school

66. Importance of prevention
• In 2010, teen pregnancy and childbirth accounted for at least $9.4
billion in costs to U.S taxpayers for increased healthcare and foster
care
• increased incarceration rates among children of teen parents, and lost
tax revenue because of lower educational attainment and income
among teen mothers.

67. Adolescent Fathers
• Poorer educational achievement than their age-matched peers.
• They are more likely than other peers to have been involved with
illegal activities and with the use of illegal substances. Adult men
who father the children of teen mothers are poorer and
educationally less advanced than their age-matched peers and
tend to be 2-3 yr older than the mother; any combination of age
differences may exist.
• Sensitively and appropriately including the male partner in
discussions of family planning, contraception, and pregnancy
options may be a useful strategy in improving outcomes for all

68. MEDICAL COMPLICATIONS OF MOTHERS AND
BABIES
• The miscarriage/stillbirth risk for adolescents is estimated at 15–20%
• In the United States, elective pregnancy termination rates peaked
from 1985–1988 at 41–46%, decreasing since then to approximately
30% in 2008.
• Teen mothers have low rates of age-related chronic disease (diabetes
or hypertension) that might affect the outcomes of a pregnancy.
• However, compared with 20-39 yr old mothers, teens have higher
incidences of low birthweight infants, preterm infants, neonatal
deaths, passage of moderate to heavy fetal meconium during
parturition, and infant deaths within 1 yr after birth

69. • Teen mothers also have higher rates of anemia, pregnancy-associated
hypertension, and eclampsia, with the youngest teens having rates of
pregnancy-associated hypertension higher than the rates of women in their
20s and 30s
• The youngest teens also have a higher incidence of poor weight gain (<16
lb) during their pregnancy. This correlates with a decrease in the
birthweights of their infants.
• Sexually active teens have higher rates of STIs than older sexually active
women

70. • There is some evidence that teenage women have the highest rates of
violence during pregnancy of any group.
• Violence has been associated with injuries and death as well as
preterm births, low birthweight, bleeding, substance abuse, and late
entrance into prenatal care.
• An analysis of the Pregnancy Mortality Surveillance System indicates
that in the United States 1991–1999, homicide was the 2nd leading
cause of injury-related deaths in pregnant and postpartum women

71. Ectopic Pregnancy
• occurs in 1–2% of conceptions and is more common in women with a
previous history of an ectopic pregnancy, pelvic inflammatory disease,
prior appendicitis, infertility, in utero exposure to diethylstilbestrol,
and possibly an IUD
• Tubal pregnancy
• Cervical motion and adnexal tenderness (and adnexal mass) may be
present

72. Transvaginal sonography
• diagnostic test of choice to detect an ectopic pregnancy and reveals an adnexal
mass and no uterine pregnancy
• Measurement of sensitive quantitative serum βhCG levels together with
transvaginal sonography has value in diagnosing an ectopic pregnancy.
• If the initial βhCG is above the discriminatory zone (level at which one expects an
intrauterine pregnancy) but on transvaginal sonography there is no intrauterine
pregnancy, there may be an ectopic pregnancy or an abnormal uterine
pregnancy
• In addition, if the βhCG is below the discriminatory level (usually <3000 mIU/mL)
with no definitive diagnosis by sonography, serial βhCG testing should be
performed every 48 hr. In a normal uterine pregnancy, βhCG levels should
increase approximately 50% every 48 hr; declining levels may suggest a
miscarriage or an ectopic pregnancy

73. • Treatment of unstable or advanced patients is usually by laparoscopic
surgery or by laparotomy
• Stable patients with an unruptured ectopic pregnancy may be
treated with single-dose, or more often multidose, methotrexate to
induce abortion
• Contraindications to methotrexate in a stable patient include size of
the ectopic mass (>3.5 cm) and embryonic cardiac motion

74. • Prematurity and low birthweight increase the perinatal morbidity and
mortality for infants of teen mothers.
• One study showed that risk of homicide is 9-10 times higher if a child
born to a teen mother is not the mother’s firstborn compared with
the risk to a firstborn of a woman age 25 yr or older.

75. After childbirth
• depressive symptoms may occur in as many as 50% of teen mothers.
Depression seems to be greater with additional social stressors and
with decreased social supports. Support from the infant’s father and
the teen’s mother seems to be especially important in preventing
depression.

76. Psychosocial Outcomes/Risks for Mother and Child
• Educational issues
• Only about 50% of teen mothers receive a high school diploma by age 22
• Approximately 90% of women who do not give birth during adolescence
graduate from high school
• As an outcome, maternal lack of education limits the income of many of
these young families
• As for the child of teenage mother, he/she is more likely to have lower
school achievement and to drop out of high school, have more health
problems, and face unemployment as a young adult.

77. Psychosocial Outcomes/Risks for Mother and Child
• Substance use
• Higher pregnancy rate for those teenager girls who abuse drugs, alcohol,
and tobacco products.
• They tend to stop it during their pregnancy
• BUT they continue to use again about 6 months postpartum
• Results to complicated parenting and the possibility of the teenage mom’s return
to school

78. Psychosocial Outcomes/Risks for Mother and Child
• Repeat Pregnancy
• Early repeat pregnancy (< 2 years)
• 2nd infant is at higher risk of poor outcome than the 1st birth due to later
onset of prenatal care
• Mothers who are at risk of early repeat pregnancy:
• Those who do not initiate long-acting contraceptives after index birth
• Those who do not return to school within 6 months of index birth
• Those with mood disorders
• Those who are receiving major childcare assistance from the adolescent’s
mother
• Those who are married and/or living with the infant’s father
• Those having peers who were adolescent parents
• Those who are no longer involved with the baby’s father and who meet a new BF

79. Psychosocial Outcomes/Risks for Mother and Child
• Children born to teen mothers
• Many children born to teen mothers have behavioral problems that may
be seen as early as the preschool period
• 33% drop out of school early
• 25% become adolescent parents
• 16% if male, are incarcerated
• These poor outcomes are usually caused by:
• Poverty
• Parental learning difficulties
• Negative parenting styles
• Maternal depression
• Parental immaturity
• Poor modeling
• Social stress

80. Psychosocial Outcomes/Risks for Mother and Child
• Children born to teen mothers
• These poor outcomes are usually caused by:
• Poverty
• Parental learning difficulties
• Negative parenting styles
• Maternal depression
• Parental immaturity
• Poor modeling
• Social stress
• Exposure to surrounding violence
• Conflicts with grandparents

81. Care of Adolescent Parents and Their Children
2012 American Academy
of Pediatrics Clinical
Guidelines: Care of
Adolescent Parents and
Their Children

82. Prevention of Teen Pregnancies
• Adolescent pregnancy is a multifaceted problem that requires multifactorial
solutions.
• Provision of contraception and education about fertility risk
• Family and community involvement are essential elements for teen
pregnancy prevention

83. Prevention of Teen Pregnancies

84. Prevention of Teen Pregnancies
• Abstinence-only sexual education - aims to teach adolescents to wait until
marriage to initiate sexual activity but, unfortunately, does not mention
contraception
• HIV and STI prevention and in the process prevent pregnancy
• Both abstinence and contraception
• Teenagers who participate in programs with comprehensive sex education
components generally have lower rates of pregnancy than those exposed
solely to abstinence-only programs or no sex education at all

85. THANK YOU!

86. ADOLESCENT SEXUAL
ASSAULT
CHAPTER 145

87. • Sexual assault is an act of violence that may or may not involve rape.
Rape, also an act of violence, is not an act of sex. Rape is historically
defined as coercive sexual intercourse involving physical force or
psychological manipulation of a female or a male.
• Recognizing that sexual intercourse is not a requirement for the
definition, the Department of Justice (DOJ) defines rape as “the
penetration, no matter how slight, of the vagina or anus with any body
part or object, or oral penetration by a sex organ of another person,
without the consent of the victim.”

88. EPIDEMIOLOGY
• Exact figures on the incidence of rape are unavailable because many
rapes are not reported.
• It is estimated that 1 in 5 women and 1 in 71 men will be raped in their
lifetime.
• Females exceed males as reported rape victims, but male rape may be
more underreported than female rape.
• In 2010 the DOJ National Crime

89. • In 2010 the DOJ National Crime Victimization Survey reported that the
annual rates of sexual victimization per 1,000 persons were 4.1 for ages
12-17 yr and 3.7 for 18-34 yr. Between 1995 and 2013 the rate of rape
and sexual assault was highest for adolescent females between ages 18
and 24 yr.
• The National Survey of Children's Exposure to Violence (NatSCEV 2014),
revealed that 12.9% of 14-17 yr olds experienced any sexual
victimization in the past year, 21.7% had experienced any sexual
victimization in their lifetime; and 4.2% experienced sexual assault in
the past year and 10.2% in their lifetime

90. • This survey also demonstrated how other experiences with violence
compound the risk for sexual victimization.
• Youth with a history of maltreatment by a caregiver were 4 times
more likely to experience sexual victimization and >4 times more
likely to experience sexual victimization if they had any witness to
violence.
• Among older adolescents age 18-24 yr, the rate of rape and sexual
assault was 1.2 times higher for those not enrolled in college than
those in college

91. Adolescents at High Risk of Rape Victimization
Male and Female Adolescents
• Drug and alcohol users
• Runaways
• Those with intellectual disability or developmental delay
• Street youths Transgender youth
• Youths with a parental history of sexual abuse
• Sex trafficking

92. Primarily Females
• Survivors of prior sexual assault
• Newcomers to a town or college
Primarily Males
• Those in institutionalized settings (detention centers, prison)
• Young male homosexuals

93. Types of Nonstranger Rape

94. Acquaintance Rape
• Most common form of rape for adolescents age 16-24 yr.
• Assailant may be a neighbor, classmate, or friend of the
family.
• Victims are more likely to delay seeking medical care, may
never report the crime (males > females), and are less likely
to proceed with criminal prosecution even after reporting
the incident(s).

95. Date Rape
• Assailant is in an intimate relationship with the victim.
• May be associated with intimate partner violence.
• Assailant may engage in more sexual activities than other
men his age and often has a history of aggressive behavior
toward women.

96. Sexual Abuse
• All sexual contact or exposure between an adult and a
minor, or when there is a significant age or developmental
difference between the youth.
• The assailant may be a relative, close family friend, or
someone of authority.

97. Types of Stranger
Rape

98. Sex Trafficking and Commercial Sexual
Exploitation of Children (CSEC)
i. Child 12 and 13 yr.
ii. Child maltreatment.

99. Drug-Facilitated Rape
i. Alcohol is the most common drug
associated with sexual victimization.

100. Gang Rape
i. Group of males rapes a solitary female victim.
ii. May be part of a ritualistic activity or rite of passage for
some male groups.
iii. fear retaliation or confrontation with assailants.

101. Date Rape
Is sexual violence perpetrated by a person in an intimate
relationship with the victim
These victims may be new to a specific environment

102. Drug-facilitated rape
• The opportunity for acquaintance and date rape may be greater with
individuals under the influence of alcohol
• date rape drugs such as γ-hydroxybutyric acid (GHB), flunitrazepam
(Rohypnol), and ketamine hydrochloride are the leading agents used for these
illegal purposes
• Acquaintance and date rape victims often experience long-term issues of
trust, self-blame, and guilt, resulting in lost confidence in judgment
concerning future relationships.

103. Male rape
i. same-sex rape of males.
ii. Issues of loss of control and powerlessness are particularly
bothersome for male rape victims,

104. Clinical Manifestations:
• The adolescent's acute presentation following a rape may
vary considerably, from histrionics to near-mute withdrawal.
Even if they do not appear afraid, most victims are extremely
fearful and very anxious about the incident, the rape report,
examination, and the entire process, including potential
repercussions.

105. Interview and Physical Examination
To provide medical care for the teen and to collect and
document evidence of the assault when applicable
The clinician's responsibilities are to provide support, obtain
the history in a nonjudgmental manner, conduct a complete
examination without retraumatizing the victim, and collect
forensic evidence

106. • The history should be obtained by asking only open-
ended questions to obtain information about
• (1) what happened;
• 2) where it happened;
• (3) when it happened;
• (4) who did it

107. Laboratory data
• When adolescents present for medical care within 72-96 hr of a
sexual assault, aforensic evidence collection kit should be offered to
the patient
• Regardless of the adolescent’s decision
• Schedule follow-up evaluations

109. Treatment
• Prophylactic antimicrobials and contraception for STIS
( trichomoniasis, bacterial vaginosis, gonorrhea, and
chlamydial infection)
• Antimicrobial prophylaxis recommended for adolescent
victims
because of the risk of an STI and pelvic inflammatory diseases
• HIV postexposure prophylaxis (PEP) is considered if the
perpetrator is HIV-positive

110. Prevention
• Primary prevention
-education of preadolescents and adolescents on the issues of rape, healthy
relationships, internet dangers, and drug- and alcohol-facilitated rape
-should target both male and female at high schools or colleges
• Secondary prevention
-informing adolescents of the benefits of timely medical evaluations when rape has
occurred.
-ask adolescents about past experiences of forced and unwanted sexual behaviors

114. STIs
SEXUALLY
TRANSMITTED
INFECTIONS

115. Table of Contents
01
Etiology &
Epidemiology 04 Diagnosis
02
Pathogenesis
& Screening 05
Treatment &
Prevention
03 Common infections

116. Etiology &
Epidemiology

117. ETIOLOGY
Higher risk for STIs:
● Adolescents who has had oral, vaginal, or anal sexual intercourse
● Adolescents who initiate sex at a younger age
● Adolescents who are victims of sexual assault
● Youth residing in detention facilities
● Youth attending sexually transmitted disease (STD) clinics
● Young men having sex with men

118. ETIOLOGY
Higher risk for STIs:
● Youth who are injection drug users
● Sex with multiple concurrent partners or multiple sequential partners of
limited duration
● Failure to use barrier protection consistently and correctly
● Increased biologic susceptibility to infection

119. ETIOLOGY

120. EPIDEMIOLOGY
● STI prevalence varies by age, gender, and race/ethnicity.
● Adolescents and young adults <25 yr of age have the highest reported prevalence of
gonorrhea and chlamydia.
● In 2015, females age 20-24 yr had the highest reported chlamydia rate, followed by
females 15-19 yr of age.
● Non-Hispanic black females 20-24 yr of age had the highest chlamydia rate.
● Prevalence of chlamydia among the U.S. population was highest among African
Americans.

121. EPIDEMIOLOGY
● In 2015, 20-24 yr old females had the highest and 20-24 yr old males had the second
highest gonorrhea rates.
● Syphilis rates are increasing at an alarming rate, especially among males, accounting for
>90% of all primary and secondary cases.
● Of those male cases, men who have sex with men (MSM) account for 82% of male
cases when the gender of the sex partner is known.
● Males age 20-24 yr have the 2nd highest rate of primary and secondary syphilis.
● Pelvic inflammatory disease (PID) rates are highest among females age 15-24 compared
with older women.

122. EPIDEMIOLOGY
● In 2015, youth age 13-24 yr accounted for 22% of all new HIV diagnoses in the U.S., with
most (81%) occurring among gay and bisexual males.
● Only 10% of high school students have been tested for HIV.
● Among male students who had sexual contact with other males, only 21% have ever
been tested for HIV.
● Human papillomavirus (HPV) is the most frequently acquired STI in the U.S.
● Herpes simplex virus type 2 (HSV-2) is the most prevalent viral STI.
● Genital HSV-1 infections are increasing among young adults.

123. EPIDEMIOLOGY
● Youth who lack HSV-1 antibodies at sexual debut are more susceptible to acquiring a
genital HSV-1 infection and developing symptomatic disease from primary genital HSV-2
infection.
● Increasing oral sex among adolescents and young adults also has been suggested as a
contributing factor in the rise in genital HSV-1 infections.

124. EPIDEMIOLOGY

125. Pathogenesis

126. PATHOGENESIS
During puberty:
● Increased levels of estrogen
cause the vaginal epithelium to
thicken and cornify
● cellular glycogen content rise
● causing the vaginal pH to fall

127. PATHOGENESIS
Those changes will:
● increase the resistance
of the vaginal epithelium to
penetration by certain organisms
(including Neisseria
gonorrhoeae) and increase the
susceptibility to others (Candida
albicans and Trichomonas

128. PATHOGENESIS
● The transformation of the
vaginal cells leaves columnar
cells on the ectocervix, forming a
border of the 2 cell types on the
ectocervix, known as the
squamocolumnar junction.
● The appearance is referred to as
ectopy.

129. PATHOGENESIS
● With maturation, this tissue involutes.
● Prior to involution, it represents a
unique vulnerability to infection for
adolescent females.
● The association of early sexual debut
and younger gynecologic age with
increased risk of STIs supports this
explanation of the pathogenesis of
infection in young adolescents.

130. SCREENING

131. Early detection and treatment are primary
STI control strategies.

132. Some of the most common STIs in
adolescents, including HPV, HSV,
chlamydia, and gonorrhea, are usually
asymptomatic and if undetected can be
spread inadvertently by the infected host.

133. Screening initiatives for chlamydial
infections have demonstrated reductions in
PID cases by up to 40%.

134. Federal and professional medical
organizations recommend annual
chlamydia screening for sexually active
females <25 yr old.

135. Comprehensive, confidential, reproductive
health services, including STI screening,
should be offered to all sexually
experienced adolescents.

136. COMMON
INFECTIONS AND
CLINICAL
MANIFESTATIONS
STI syndromes are generally
characterized by the location of
the manifestation or the type of
lesion. Certain constellations of
presenting symptoms suggest
the inclusion of a possible STI in
the differential diagnosis.

137. URETHRITIS
● Urethritis is an STI syndrome characterized by inflammation
of the urethra, usually caused by an infectious etiology.
● Approximately 30–50% of males are asymptomatic but may
have signs of discharge on diagnosis.
● Chlamydia trachomatis and N. gonorrhoeae are the most
commonly identified pathogens.
● Sensitive diagnostic C. trachomatis and N. gonorrhoeae tests
are available for the evaluation of urethritis.
● Noninfectious causes:
- Urethral trauma
- Foreign body
● Urinary tract infections (UTIs) are rare in males who have no
genitourinary medical history.

138. EPIDIDYMITIS
● Inflammation of the epididymis in adolescent males is most often
associated with an STI, most frequently C. trachomatis or N.
gonorrhoeae.
● The presentation of unilateral scrotal swelling and tenderness,
often accompanied by a hydrocele and palpable swelling of the
epididymis, associated with the history of urethral discharge,
constitute the presumptive diagnosis of epididymitis.
● Evaluation:
- Physical exam
- Gram stain of urethral secretions
- Urine leukocyte esterase test, or urine microscopy.
● A C. trachomatis and N. gonorrhoeae nucleic acid amplification test
(NAAT) should be performed

139. VAGINITIS
● A superficial infection of the vaginal mucosa frequently
presenting as a vaginal discharge, with or without vulvar
involvement.
● Bacterial vaginosis, vulvovaginal candidiasis, and
trichomoniasis are the predominant infections associated with
vaginal discharge.
● Bacterial vaginosis is not categorized as an STI, sexual activity
is associated with increased frequency of vaginosis.
● Vulvovaginal candidiasis, usually caused by C. albicans, can
trigger vulvar pruritus, pain, swelling, and redness and dysuria.

140. CERVICITIS
Cervicitis is an irritation or infection of the cervix which involves the deeper
structures in the mucous membrane of the cervix uteri. It makes the
cervix appears red and may produce a pus-like discharge. Patient is
frequently asymptomatic but present with complaints of irregular or
postcoital bleeding.
● The pathogens identified most frequently with cervicitis are C.
trachomatis and N. gonorrhoeae.
● Herpes Simplex Virus is a less common pathogen associated with
ulcerative and necrotic lesions on the cervix.
Two major diagnostic signs characterize Cervicitis:
(1) a purulent or mucopurulent endocervical exudate visible in the
endocervical canal or on an endocervical swab specimen called mucopurulent
cervicitis or cervicitis
(2) sustained endocervical bleeding easily induced by gentle passage of a cotton
swab through the cervical os, signifying friability.

141. PELVIC INFLAMMATORY DISEASE
Pelvic inflammatory disease (PID) is an infection of the female
reproductive organs. It encompasses a spectrum of inflammatory
disorders of the female upper genital tract, including
endometritis , salpingitis , tuboovarian abscess , and pelvic
peritonitis , usually in combination rather than as separate
entities
● N. gonorrhoeae and C. trachomatis predominate as the
involved pathogenic organisms in younger adolescents.
● PID (tuboovarian abscess) has rarely been reported in
virgins and is usually caused by E. coli and associated in
some patients with obesity and possible pooling of urine in
the vagina.

142. PELVIC INFLAMMATORY DISEASE
The clinical diagnosis of PID is based on the presence of at least 1 of the
minimal criteria:
● cervical motion tenderness
● uterine tenderness
● adnexal tenderness
➢ Healthcare providers should consider the possibility of PID in young, sexually
active females presenting with vaginal discharge or abdominal pain.
➢ The majority of females with PID have either mucopurulent cervical
discharge or evidence of white blood cells (WBCs) on a microscopic
evaluation of a vaginal fluid–saline preparation.

143. GENITAL ULCER SYNDROME
An ulcerative lesion in a mucosal area exposed to sexual contact is the unifying
characteristic of infections associated with these syndromes. These lesions are most
frequently seen on the penis and vulva but also occur on oral and rectal mucosa.
● HSV and Treponema pallidum (syphilis) are the most common organisms
associated with genital ulcer syndromes.
● Genital herpes is the most common ulcerative STI among adolescents, is a
chronic, lifelong viral infection.
● Two sexually transmitted HSV types have been identified, HSV-1 and HSV-2.
The majority of cases of recurrent genital herpes are caused by HSV-2. However,
among young women and MSM, an increasing proportion of anogenital herpes
has been HSV-1.
● Syphilis is a less common cause of genital ulcers in adolescents than in adults.
Lymphogranuloma venereum caused by C. trachomatis serovars L1-L3 is
uncommon, although outbreaks do occur in MSM.

144. A, Initial herpes infection showing multiple erosions with polycyclic outlines surrounded by an
erythematous halo and associated with intense pain.
B, Erosions surrounded by an erythematous halo.

146. GENITAL LESIONS AND ECTOPARASITES
Lesions that present as outgrowths on the surface of the epithelium and other
limited epidermal lesions are included under this categorization of syndromes.
HPV can cause genital warts and genital-cervical abnormalities that can lead to
cancer.

147. GENITAL LESIONS AND ECTOPARASITES
Genital HPV types are classified according to their association with cervical cancer.
Infections with low-risk types, such as HPV types 6 and 11 , can cause benign or low-grade changes in cells of
the cervix, genital warts, and recurrent respiratory papillomatosis.
High-risk HPV types can cause cervical, anal, vulvar, vaginal, and head and neck cancers. High-risk HPV
types 16 and 18 are detected in approximately 70% of cervical cancers
Persistent infection increases the risk of cervical cancer. Molluscum contagiosum and condyloma latum
associated with secondary syphilis complete the classification of genital lesion syndromes.
As a result of the close physical contact during sexual contact, common ectoparasitic infestations of the pubic
area occur as pediculosis pubis or the papular lesions of scabies.
.

148. HIV AND HEPATITIS B
HIV and hepatitis B virus (HBV) present as asymptomatic, unexpected occurrences in most
infected adolescents.
High vaccination coverage rate among infants and adolescents have resulted in substantial
declines in acute HBV incidence among U.S.-born adolescents.
Risk factors identified in the history or routine screening during prenatal care are much more
likely to result in suspicion of infection, leading to the appropriate laboratory screening, than
are clinical manifestations in this age-group

149. Dia
Diagnosi
s

150. ● When eliciting a sexual health history, discussions should be appropriate for
the patient's developmental level.
● Dyspareunia is a consistent symptom in adolescents with PID .
-Providers must ask about oral or anal sexual activity to determine sites for
specimen collection.
● Urethritis should be objectively documented by evidence of inflammation or
infectious etiology.
DIAGNOSIS

151. ● Inflammation can be documented by:
- (a) observing urethral mucopurulent discharge,
(b) ≥2 WBCs per high-power field on microscopic examination of Gram
stain urethral secretions,
(c) urine microscopic findings of ≥10 WBCs per high-power field of first-
void urine specimen, or
(d) a positive urine leukocyte esterase test of a first-void specimen.
DIAGNOSIS

152. ● An essential component of the diagnostic evaluation of vaginal, cervical,
or urethral discharge is a chlamydia and gonorrhea NAAT.
- Female vaginal swab specimens and male first-void urine are
considered the optimal specimen types.
● Evaluation of adolescent females with vaginitis includes laboratory data.
- Traditionally, the cause of vaginal symptoms was determined by pH and
microscopic examination of the discharge.
DIAGNOSIS

154. ● Clinical laboratory–based vaginitis tests are also available.
- The Affirm VPIII (Becton Dickenson, San Jose, CA) is a moderate-
complexity nucleic acid probe test that evaluates for T. vaginalis , G.
vaginalis , and C. albicans and has a sensitivity of 63% and specificity
>99.9%, with results available in 45 min.
- Some gonorrhea and chlamydia NAATs also offer an assay for T.
vaginalis testing of female specimens tested for N. gonorrhoeae and C.
trachomatis , considered the gold standard for Trichomonas testing.
DIAGNOSIS

158. ● Cell culture and polymerase chain reaction (PCR) are the preferred HSV tests.
● The Tzanck test is insensitive and nonspecific and should not be considered
reliable.
● Accurate type-specific HSV serologic assays are based on the HSV-specific
glycoproteins G2 (HSV-2) and G1 (HSV-1).
● Type-specific HSV serologic assays might be useful in the following scenarios:
(1) recurrent genital symptoms or atypical symptoms with negative HSV
cultures;
(2) a clinical diagnosis of genital herpes without laboratory confirmation; and
(3) a patient with a partner with genital herpes, especially if considering
suppressive antiviral therapy to prevent transmission.
DIAGNOSIS

159. ● For syphilis testing , nontreponemal tests, such as the rapid plasma reagin
(RPR) or Venereal Disease Research Laboratories (VDRL), and treponemal
testing, such as fluorescent treponemal antibody absorbed tests, the T.
pallidum passive particle agglutination (TP-PA) assay, and various enzyme
and chemiluminescence immunoassays (EIA/CIA), are recommended.
● A positive treponemal EIA or CIA test can identify both previously treated
and untreated or incompletely treated syphilis.
DIAGNOSIS

161. ● Rapid HIV testing with results available in 10-20 min can be useful when the
likelihood of adolescents returning for their results is low.
● Clinical studies have demonstrated that the rapid HIV test performance is
comparable to those of EIAs.
DIAGNOSIS

162. Treatment
and
Prevention

163. TREATMENT
● Diagnosis and therapy are often carried out within the context of a confidential relationship
between the physician and the patient.
● Therefore, the need to report certain STIs to health department authorities should be
clarified at the outset.
● A health department’s role is to ensure that treatment and case finding have been
accomplished and that sexual partners have been notified of their STI exposure, and will
therefore not violate confidentiality.
● Expedited partner therapy (EPT) - the clinical practice of treating sex partners of patients
diagnosed with chlamydia or gonorrhea, by providing prescriptions or medications to the
patient to take to the partner without the healthcare provider first examining the partner, is a
strategy to reduce further transmission of infection.

168. —cont’d

169. ● Sexuality education
○ Healthcare providers should integrate sexuality education into clinical practice with children from
early childhood through adolescence.
○ Adolescents should be counseled regarding sexual behaviors associated with risk of STI
acquisition and educated using evidence-based prevention strategies, which include a discussion
of abstinence and other risk reduction strategies, such as consistent and correct condom use.
● High-intensity behavioral counseling is recommended by the U.S. Preventive Services Task Force
○ The HPV vaccine (Gardasil 9) is recommended for 11 and 12 yr old males and females as
routine immunization.
○ Catch-up vaccination is recommended for females age 13-26 and for males age 13-21 who
have not yet received or completed the vaccine series; males age 22 through 26 may be
vaccinated.
PREVENTION