If dysmenorrhea persists despite an adequate trial of CHCs (>4 months), an alternative diagnosis, such as endometriosis, should be considered. When CHCs fail, a laparoscopy may be performed before advancing therapy to confirm the diagnosis and excise endometriotic lesions. Extended CHC therapy (84 days of active CHC followed by a 5to 7-day hormone-free interval) may control symptoms. Alternatives are depot medroxyprogesterone acetate (150 mg) every 2 months until symptoms are controlled, then every 3 months of levonorgestrel-releasing intrauterine system. Endometriosis may be treated with gonadotropin-releasing hormone agonists (nafarelin or leuprolide) and hormonal therapy, in older adolescents (>16 years of age) when symptom relief is required.
The median age of first intercourse in the United States is 17years for girls and 16 years for boys; this is similar to otherdeveloped countries. Although the age of coital initiation is similar among different socioeconomic groups, the prevalence ofadolescent childbearing is greatest in the lower socioeconomic strata. Risk factors for adolescent pregnancy include lower socioeconomic status, lower education, low self-esteem, lack of access to contraception, alcohol and drug use, and adverse earlylife experiences in the adolescent home. Approximately 900,000
U.S. females 12 to 19 years of age become pregnant each year. Inwomen younger than 20 years of age, there are 97 pregnancies,54 births, and 29 abortions per 1000. Increased use of contraceptives has reduced adolescent pregnancy by up to 35% since thepeak year of 1990. Adolescents who continue their pregnancyhave an increased incidence of preterm and very preterm births,low birth weight infants, infant neonatal admission, postneonatal mortality, child abuse, subsequent maternal unemployment, and poor maternal educational achievement. These risksare influenced by behavior and socioeconomic status, as well asinherent biologic risks within adolescents. Good prenatal care,nutrition, and social support improve pregnancy outcomes.
Pregnancy should be considered and ruled out in any adolescent presenting with secondary amenorrhea. Frequently pregnant adolescents delay seeking a diagnosis until several periods have been missed and initially may deny having intercourse. Early adolescents often present with other symptoms, such as vomiting, vague pains, or deteriorating behavior and may report normal periods. Because of the varied presentations of adolescent pregnancy, a thorough menstrual history should be obtained in all menstruating adolescents. Urine pregnancy tests are sensitive approximately 7 to 10 days after conception. Rape or incest should be ruled out in all cases of adolescent pregnancy.
When pregnancy is confirmed, immediate gestational dating is important to assist in planning. Options are to continue or terminate the pregnancy (if not beyond 20 to 24 weeks’ gestation). With the former, the adolescent may choose to parent the child or have the child adopted. Pregnant adolescents should be encouraged to involve their families to assist with decision making; parents may be more understanding than the adolescent expects.
Continuation of the Pregnancy
Adolescents who continue the pregnancy need early, consistent, and comprehensive prenatal care by a team of health care providers. Their socioeconomic situation should be evaluated in an effort to optimize the infant’s health and development. Although fewer than 5% of adolescents have their infants adopted, this option should be discussed. Pregnancy is the most common cause for females to drop out of school, so special attention should be given to keeping the adolescent in school during and after pregnancy.