Adolescent sexual and reproductive health in the Emergency Department: A podcast and blog post

This post endeavors to answer some key questions that we face in the Emergency Department when it comes to caring for adolescents with sexual and reproductive health concerns. It was inspired by a recent publication from the Pediatric Emergency Care Applied Research Network (PECARN) Adolescent Sexual Health Working Group. PECARN is a network that performs multicenter research related to the emergency care of children. The Adolescent Sexual Health Working Group is focused on researching topics of interest around sexual and reproductive health in the ED. I recently had the pleasure of interviewing three of the study authors and recorded our conversations, then created a podcast episode that hit on some of the highlights of their incredible work. James Gray helped me put this blog post together that delves into some of the topics in a bit more in depth fashion. After listening to the podcast the podcast, reading the linked article, and reading this post I hope that you will be able to do the following:

• Better understand the critical issues facing adolescents with sexual and reproductive health concerns that need active research in the Emergency Department
• Learn about how we maintain confidentiality for our adolescent patients
• Describe the key parts of a sexual history
• Describe which patients should get symptomatic and asymptomatic STI screening, and note how we should collect these tests
• Note the indications for chlamydia and gonorrhea treatment in the ED
• Define expedited partner therapy
• Discuss whether we need to do a pelvic exam in the Emergency Department
• Discuss the indications for emergency contraception

PEM Currents: The Pediatric Emergency Medicine Podcast

Gastroesophegeal Reflux and Gastritis – PEM Currents: The Pediatric Emergency Medicine Podcast

In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, I explore the complexities of gastroesophageal reflux (GER) and gastritis in children and adolescents. I’ll make the important distinction between gastritis – which is diagnosed only via endoscopy – and dyspepsia, the term best used to describe the symptoms many patients experience. I’ll dive […]

1. Gastroesophegeal Reflux and Gastritis 27:00
2. ECPR 07:35
3. Syphilis 09:25
4. Cervical Spine Injuries
5. Febrile Seizures 27:22

The MP3 file of this episide

What was this study about?

This is a Delphi study aiming to describe a research agenda for sexual and reproductive health in the emergency department. Delphi studies are consensus statements reached after an iterative process where a convergence of opinion (or point of diminishing return) is met.

The study highlighted 24 research priorities for sexual health in the ED. The top 10 research questions identified were:

• How can we optimize referral and follow‐up care for reproductive or sexual health needs among adolescents treated in the ED?
• How can we optimize evidence‐based care for adolescents with genitourinary complaints in the ED?
• Which sexual risk–reduction interventions (e.g., STI, HIV, pregnancy prevention) are cost‐effective in the ED setting?
• How can we disseminate and implement effective sexual health interventions in the ED?
• How do we optimize STI screening for the asymptomatic adolescents across different ED settings?
• How can we facilitate implementation and dissemination of best STI screening practices?
• How can we optimize HIV screening for the asymptomatic adolescent ED population across different ED settings?
• What is the feasibility and acceptability of providing partner‐based interventions (e.g., expedited partner therapy, notification) when adolescents are diagnosed with an STI in the ED?
• How can we most effectively identify females with recent unprotected intercourse to discuss pregnancy intentions and need for pregnancy prophylaxis (e.g., emergency contraception)?
• What are the short‐ and long‐term effects of evidence‐based sexual health interventions on key outcomes (e.g., HIV/STI identification, prevention of unintended pregnancy, ED visits for care)?

How can our actions in the ED help improve the health of adolescents?

Because many adolescents use the ED as their primary site of contact with physicians, we can really make a difference in their long term health outcomes. Providing counseling, screening, testing, and treatment are all within the scope of ED clinicians.

How can we maintain confidentiality for adolescents in the ED?

There are differences among state law and institutional policies regarding confidentiality. An overview of state laws regarding adolescent health confidentiality by state is available here at the Guttmacher Institute.

There are two distinct parts of the encounter where maintaining confidentiality is challenging

1. During the ED visit 
2. After the visit, due to billing and insurance practices

Steps to maximizing confidentiality during the visit:

• Educate physician and other staff about confidentiality laws
• Post signs notifying adolescents and families of the right to confidential care
• Interview the adolescent patient alone (no friends, no parents, no siblings)

Steps to maximizing confidentiality after the visit:

• Avoid obvious references to sexual health in the discharge instructions and visit diagnoses 
• Some electronic health records allow for confidential information to be saved separately, minimizing the risk of a breach of confidentiality
• Obtain a confidential phone number from the adolescent to deliver test results

What are the key parts of a sexual history?

1. Is the patient sexually active (ask, “have you ever had sex before?” and then ask clarifying questions)
2. The date of last sexual encounter (ask, “when was the last time you had sex?”). If they had unprotected sex in the last 5 days, emergency contraception can be offered.
3. Contraception and protection (ask, “are you using contraception, like the pill, or protection, like condoms? What kind?”). This can open a conversation about contraception, STI risks, etc.
4. Previous STI testing (ask, “have you ever been tested for things like HIV, gonorrhea, chlamydia before? When?”). This can help you identify patients who have not received recommended testing.

Who should get asymptomatic screening?

The CDC provides detailed guidance here. Some of this depends on local prevalence, so consider that when making decisions about who to test.

Sexually active females under 25

• Gonorrhea and chlamydia:  yearly
• HIV: once (yearly if high risk)

Sexually active males under 25:

• Gonorrhea and chlamydia: consider yearly if an area of high prevalence
• HIV: once (yearly if high risk)

What are the indications for treatment of gonorrhea and chlamydia in the ED?

Presumptive treatment should be based on the following factors:

1. Confidence in clinical diagnosis
2. Patient risk factors
3. Likelihood of follow up if testing is positive

Risk factors for women include:

• <25 with a new sexual partner
• A partner with concurrent partners
• A partner with an STI

It is reasonable to defer treatment until results are available for lower risk patients, especially if your ED has a strong culture around result follow up and subsequent treatment.

What is expedited partner therapy (EPT)?

EPT is the clinical practice of treating the sexual partners of a patient diagnosed with gonorrhea or chlamydia. It is allowable in 44 states, and explicitly prohibited only in South Carolina (in June 2019). The CDC summary on EPT can be found here.

What is the best way to collect specimens for gonorrhea, chlamydia, and HIV testing?

Currently, nucleic acid amplification tests performed on urine (or self-swabs or endocervical swabs in women) are used, with sensitivities between 91 and 93%. We are hoping to have a point-of-care test available soon, which would help greatly with antibiotic stewardship.

Who needs a speculum exam? Are there instances where a bimanual exam is sufficient?

Traditional teaching has been that any sexually active female with abdominal pain should get a bimanual exam to evaluate for cervical motion or adnexal tendnerness (supporting a diagnosis of pelvic inflammatory disease) and a speculum exam to evaluate for copious mucopurulent discharge or a friable cervix consistent with cervicitis (or even the “strawberry cervix” suggestive of Trichomonas, or HSV vesicles). People also worry about finding a foreign body. 

However, there was a study by Farrukh et al. that prospectively examined the value of the pelvic exam in patients aged 14-20 in the pediatric ED, and found that performing a pelvic exam rarely changed the diagnosis of cervicitis or PID when compared to history alone. Perhaps even more importantly, a pelvic exam is an uncomfortable experience for women in the ED, and can contribute to longer length-of-stay when compared to men. 

Are people providing contraception in the ED to teens? Is that something we should be doing?

In general, very few places are prescribing contraception in the ED, for a variety of reasons. There is evidence that female adolescents are receptive to learning about pregnancy, contraception, and sexual health in the ED. However, the idea of providing contraception and appropriate counseling has to fit in the ED model of care: it has to be quick and not time-intensive for the physician. 

What about emergency contraception?

A reminder that emergency contraception works mainly by inhibiting ovulation, and there is no evidence that either of the FDA-approved emergency contraceptive options work after fertilization. 

In general, we are successful at offering emergency contraception after sexual assault. However, we aren’t as successful at offering emergency contraception to teens who report unprotected intercourse in the days prior to presentation, even though most teens report not wanting to get pregnant.

References

Brown J, Fleming R, Aristzabel J, Gishta R. Does pelvic exam in the emergency department add useful information?. West J Emerg Med. 2011;12(2):208-212.

Farrukh S, Sivitz AB, Onogul B, Patel K, Tejani C. The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease. Ann Emerg Med. 2018 Dec;72(6):703-712.e1. doi: 10.1016/j.annemergmed.2018.05.004. Epub 2018 Jul 2. PMID: 30251627.

Linden JA, Grimmnitz B, Hagopian L, Breaud AH, Langlois BK, Nelson KP, Hart LL, Feldman JA, Brown J, Reid M, Desormeau E, Mitchell PM. Is the Pelvic Examination Still Crucial in Patients Presenting to the Emergency Department With Vaginal Bleeding or Abdominal Pain When an Intrauterine Pregnancy Is Identified on Ultrasonography? A Randomized Controlled Trial. Ann Emerg Med. 2017 Dec;70(6):825-834. doi: 10.1016/j.annemergmed.2017.07.487. Epub 2017 Sep 19. PMID: 28935285.

Miller MK, Chernick LS, Goyal MK, et al. A Research Agenda for Emergency Medicine-based Adolescent Sexual and Reproductive Health. Acad Emerg Med. 2019;26(12):1357-1368. doi:10.1111/acem.13809