Gynecological Clinical Examination of the Adolescent
The gynecological examination of an adolescent has a triple objective: (a) clinical assessment; (b) diagnosis and therapy, and (c) establishment of an interpersonal relationship as the basis for support to teenaged girls who may be facing deeply emotional problems related to puberty, sexuality and fertility.

A gynecological examination is never routine. The clinician must be prepared to spend time, listening to the adolescent’s concerns and gathering information on the personal and family background. A consultation will be simple and interactive with a healthy, well-informed teenager who is coming for birth control advice or simple menstrual dysfunction. However, with a teen showing, for instance, serious chronic pathology or intersexuality, or who has been sexually abused, the consultation will be difficult, critical and fraught with consequences – all the more so since these situations are not often spoken of.

In any case, the examination principles remain identical: (a) it must be preceded by a full medical assessment; (b) it must be conducted once the patient has been given a thorough explanation of the examination and its objectives and has consented; (c) the least invasive examination that will be sufficient should be performed; (d) examinations should not be omitted solely because of the age of the patient, and (e) the physician will need to recognize cultural issues and respect them.

For an adolescent who is not sexually active, the examination is identical to that of a child. Endoscopy and pelvic examination are not systematically performed.

The vulva is estrogenized, the vagina measures 8–10 cm in length and there are physiologic secretions. Upon rectal examination the uterus is often laterally oriented to the left. Vaginal examination is possible if the teen is relaxed and her hymen is yielding. A small speculum may be used if necessary.

For a sexually active patient, vaginal examination, speculum examination and, if necessary, samples are required to look for potential genital infections.

Breast examination is part of the gynecological examination. At the beginning of development the breast is tender. The breast bud can be palpated before being seen; it appears as a small, hard mound beneath an enlarged areola.

Physiologic breast development is sometimes unequal in its early stage. There may be a 3- to 12-month difference between the beginning of development in each breast. The breast reaches its fully developed size in 2–4 years, but this period may vary. During the development phase, the breast is often firm upon palpation but rarely sensitive. Skin marks are frequent. They are red when they first appear and turn progressively white after a few months. They have no pathological meaning.

Once the examination is over, the physician should sit down with the adolescent to discuss potential therapy with the help, if necessary, of an anatomical chart. Parents or caregivers should stay in the waiting room during the examination. Information will be related to them by the adolescent herself or by the physician with her agreement and in her presence. She may ask that some elements of the examination remain confidential and her wish must be respected. A relationship of trust between physician and adolescent is absolutely necessary in the case of a long-term treatment, especially concerning chronic diseases.

References

1. Cowell CA: The gynecologic examination of infants, children and young adolescents. Pediatr Clin North Am 1981;28:247–266.
2. Emans J: Office evaluation of the child and adolescent; in Emans J, Laufer MM, Goldstein DP (eds): Pediatric and Adolescent Gynecology. Philadelphia, Lippincott, 1998.
3. Rey-Stocker I: Principes généraux d’examen gynécologique; in Salomon-Bernard Y, Thibaud E, Rappaport R (eds): Gynécologie médico-chirurgicale de l’enfant et de l’adiolescente. Paris, Doin, 1992, pp 63–75.
4. Sane K, Pescovitz OH: The clitoral index: A determination of clitoral size in normal girls and in girls with abnormal sexual development. J Pediatr 1992;120:264–266.
5. Pokorny SF, Kozinetz CA: Configuration and other anatomic details of the prepubertal hymen. Adolesc Pediatr Gynecol 1988;1:97–103.
6. Gardner JJ: Descriptive study of genitalia variation in healthy, non-abused premenarchal girls. J Pediatr 1992;120:251–257.
7. McCann J, Voris J, Simon M, Wells R: Comparison of genital examination techniques in prepubertal girls. Pediatrics 1990;85:182–187.