A 14-year-old girl is brought to the office for a well-child examination. The patient's mother states that she is doing well in school and plays on the volleyball team. The patient sleeps 9 hours every night and often until noon on weekends. She drinks 2 glasses of 2% milk daily and her screen time is limited to 2 hours a day. She has no chronic medical conditions and takes no medications. At age 12, she received her first dose of human papillomavirus (HPV) vaccination, with another dose administered 6 months later. The patient underwent menarche at age 13, and her last menstrual period was 2 weeks ago. She has never been sexually active. The patient's mother has hypothyroidism, and her maternal grandmother recently died from complications of type 2 diabetes mellitus. Height and weight are at the 60th percentile. Blood pressure is 104/68 mm Hg and pulse is 60/min. Physical examination reveals an alert and engaged adolescent. Sexual maturity rating (Tanner) stage is 4. Cardiopulmonary examination is unremarkable. The abdomen is soft and nontender. The remainder of the examination is normal. Which of the following is the best next step in management of this patient?
In addition to routine screening (eg, depression, substance use) and health care maintenance, the adolescent well-child visit is an opportunity to discuss preventive health care measures. Because many adolescents become sexually active during or immediately after the pubertal transition, the adolescent visit should include contraceptive counseling and discussion of safe sex practices.
Contraceptive counseling ideally takes place before the first sexual encounter. Adolescents are unique in that they have multiple potential barriers to contraception including confidentiality concerns, limited knowledge of reproduction, and misconceptions about contraceptive options. By addressing these concerns, a trusting health care provider–patient relationship can develop and may lead to higher contraception initiation rates. As a result, contraceptive counseling and discussion of safe sex practices can reduce unintended pregnancy and sexually transmitted infection rates.
(Choice A) Annual Chlamydia trachomatis screening is indicated for all sexually active women age <25 due to the increased incidence of infection in this patient population. For this reason, dual contraception with condoms plus another contraceptive method is recommended for adolescents. This patient has never been sexually active, and therefore does not require screening.
(Choice C) Individuals age ≥15 require 3 doses of the human papillomavirus (HPV) vaccine to achieve immunity. In contrast, individuals age <15, such as this patient, require only 2 doses administered 6 months apart to achieve equivalent immunity. This difference is likely attributable to a less mature immune system, which promotes increased antibody production and subsequent immunity with fewer doses.
(Choice D) Hemoglobin A1c screening for type 2 diabetes mellitus is performed in individuals age >45. Earlier screening may be indicated in patients with risk factors (eg, obesity, affected first-degree relative). This patient is at low risk.
(Choice E) TSH levels are measured in patients with symptoms (eg, weight loss/gain, heat/cold intolerance) or concomitant disorders (eg, hypertension, dyslipidemia). This patient's sleep pattern is normal for adolescence and her family history is not a screening indication.
(Choice F) Breast self-examination is no longer recommended for breast cancer screening in any age group; it increases the rate of false-positive results and unnecessary procedures (eg, biopsy) and does not affect outcomes.
Educational objective:
The adolescent well-child visit should include contraceptive counseling and discussion of safe sex practices. Contraceptive counseling is an opportunity to develop a trusting health care provider–patient relationship and to decrease the rates of unintended pregnancies and sexually transmitted infections.