Introduction

Child and Adolescent Gynecology was established to give young girls and female adolescents up to 19 years specialized gynecological care. This medical specialty is in answer to the need for specific medical care for all types of gynecological disorders in girls and female adolescents, as well as for the need for more physicians specializing in such disorders during this phase of life.²

The Child and Adolescent Committee of the Cuban Society of Obstetrics and Gynecology was set up in 1995. In July 1996, the Cuban National Maternal-Child Division approved the General Guidelines for the Development of Child and Adolescent Gynecology. This laid the foundation for the introduction and implementation of this specialty in the country.²

According to reports from the Pan-American Health Organization, more than half the world’s population is under 25 years of age, and the adolescent population between 10 and 19 years of age is expected to grow to approximately 1,200 million by the year 2020.³

In addition, Cuban demographers have identified an increased fecundity rate among young women in Cuba⁴-mainly in the 15-19 age group. Therefore, we believe that, fecundity in adolescence is a major health issue and actions should be taken .⁴ This aspect becomes most important when approached from the viewpoint of Reproductive Health-a concept recently introduced in the work of physicians.

Reproductive health is a state of complete physical, mental, and social well-being, and not only the absence of illness . It comprises all aspects of the reproductive system’s structure, functions and processes . Reproductive Health, as a concept, was first introduced in 1994, at the World Conference on Population and Development, in Cairo-although for some time it had been thought about and put into practice. The aim of Reproductive Health is to ensure a safe and satisfactory sexual life for all, as well as full access to safe, affordable, and acceptable fecundity regulation methods.^5,6

Adolescence, with all its particularities, is a challenge in today’s world. This acknowledgement, and its demographic, cultural, psychosocial, and economic significance, means specialists need to devote more time to it.^7,8 Furthermore, since adolescence is a phase of life in which unusual situations take place that can have long lasting impact on the individual’s life, personality, and orientation; and in which a new stage of learning begins;⁹ the study of reproductive health focusing on this period of life-a complex and transcendental age-is central for the development of specific actions aimed at managing the most vulnerable aspects of it.

The integrality of health actions, systematic and continuous work, and the communication we can establish with adolescent patients who come to our offices and clinics, play an essential role in their informative and formative development.¹⁰ Our main aim is prevention work regarding pregnancy (through contraception), abortion, and genital infections, among others. In this process, the participation of family members has proven vital for effectively tackling problems.

Based on these facts, we have conducted this study, to present our experiences working with female adolescents, as well as some achievements regarding aspects of these patients’ reproductive health, during almost four years of work in our primary care Child and Adolescent Gynecological Service.

Methods

A descriptive cross-sectional study was conducted of 212 female adolescents between the ages of 11 and 19 years who were seen at the Child and Adolescent Gynecological Service, in the Plaza Municipality, since its creation on September 1, 1996 until August 1, 2000.

As stated above, the clinical records of these adolescents were made using the corresponding official form (Appendix 1), which gathers information about main complaints, some sexuality characteristics- we have focused mainly on contraception, privacy during sexual relations, the time elapsed between meeting their partners and having the first sexual relations, and the main motivations for getting involved in sex. We also gathered data on contraception, including knowledge about the contraceptive method to be used, the use of other contraceptives, the time they had been using it, and discontinuation of treatment.

In patients with leucorrhea or cervicitis, we verified diagnosis and assessed evolution using conventional treatments.

In the patient’s clinical records we also included the participation or non-participation of family members and family doctors. We used the collected data to accomplish our objectives.

In our interview with each patient, we explored the main personal characteristics that we planned to include in our study, according to our objectives. Despite the participation of family members, we allowed time for a private interview in each case.

During our personal interview with each patient, and after we had filled out their clinical record and listened to their problems and assessed their self confidence, expectations and level of knowledge, we provided each patient with ample comprehensible verbal and illustrated information on the anatomical and physiological aspects of the reproductive system, as well as on sexually transmitted infections, abortion, and other topics of interest in relation with adolescent sexual and reproductive health. Patients were also allowed to explore examination instruments and contraceptives with their hands, as an additional teaching aid.

Finally, we met with the adolescents and their family members, using participatory communication techniques, based on our knowledge of their learning needs, and aimed at providing appropriate orientation and treatment consistent with each patient’s main complaint. On subsequent doctor’s visits we assessed evolution and effectiveness, attendance, proper follow-up treatment of infectious diseases, and use of contraceptives.

Family participation was very useful, especially the mother’s. The mothers revealed that in many cases there was a lack of good relations and guidance between the adolescent and her parents.

We used the binomial test as the statistical method to compare proportions in the assessment of cases with leucorrhea or cervicitis. In this way we were able to verify whether the proportion of patients cured was significantly different from that of those who weren’t cured, considering the total number.

Data was noted in the clinical records. We used the counting stick method for calculations, and results were given in percentage. We included our results in tables and figures below to allow for better understanding .

Results

Figure 1 shows the main reasons for seeking help. They include contraception orientation (48.5%), followed by leucorrhea or cervicitis (40.0%) and request for induced abortion or menstrual regulation (22.1%). We wish to highlight that in many cases there was more than one reason. (Figure 1).

Table 1 shows some outstanding aspects of these patients’ sexuality and reproductive health. As we can see, 87.3% of them reported to have always had unprotected sex, 86.4% had no privacy or were afraid of getting caught. Most of them had their first sexual relation within the first month of their relationship (68.9%). Regarding the motivation for engaging in sex, most of them reported to have felt pressured by their partners (35.8%) or that they wanted to do what their friends were doing (29.7%)-an aspect where genre issues are present.

Table 1. - Some sexuality characteristics

Contraceptive Protection During Sexual Relations	No.	%
With Protection	27	12.7
Without Protection	185	87.3
TOTAL	212	100.0

Privacy during Sexual Relations	No.	%
No Privacy	184	86.4
Privacy	28	13.2
TOTAL	212	100.0

Time Between Meeting Partner and Having First Sexual Relation	No.	%
One Month	146	68.9
Two Months	49	23.1
Three Months and More	17	8.0
TOTAL	212	100.0

Motivation for Engaging in Sex	No.	%
Physical Attraction	38	17.9
Love	35	16.5
Partner Pressure	76	35.8
Peer pressure	63	29.7
TOTAL	212	100.0

Source: Clinical Records

Table 2 shows that the majority of patients did not know what contraceptive they were going to use (74.0%). In the second half of this table we can see that hormonal contraceptives were more commonly used (49.3%), especially oral hormonal contraceptives (45 patients, 30.0%). Figure 1 shows that although 103 patients came to us in search of a contraceptive method, we succeeded in giving contraceptives to 150 of the total. It is important to point out that the majority of patients remained on the contraceptive we gave them, and that only 10.7% of them discontinued use, 11 of them (7.3%) due to adverse side effects.

Table 2. - Aspects about contraception

Contraceptive to be Used	No.	%
Does Not Specify	111	74.0
Specifies	39	26.0
TOTAL	150	100.0

Contraceptive Used	No.	%
Hormonal	74	49.3
Intrauterine Devices	39	26.0
Condom	37	24.7
TOTAL	150	100.0

Time Using Contraceptive	No.	%
1 Year	27	18.0
1-2 Years	45	30.0
3-4 Years	62	41.3
Discontinued Use	16	10.7
TOTAL	150	100.0

Figure 2 shows that cases with leucorrhea or cervicitis accounted for 40% of the reasons for seeing the doctor (55.2% with leucorrhea, and 44.8% with cervicitis). Among cases with leucorrhea, there was a high incidence of Gardnerella vaginalis infection (19 cases, 40.4%) and genital warts (11 cases). There were two patients with secondary syphilis. All patients were treated and cured. One of the patients with cervicitis, was referred to a cervical disorder specialist, and diagnosed with a CIN II. This patient is still being followed up. We used the binomial test for proportion comparisons. The proportion of patients cured of leucorrhea or cervicitis in relation with the total number diagnosed with these disorders showed a statistically significant difference.

Table 3 shows that the majority of patients came to consultation accompanied by their mothers (58.9%). There was poor participation of the sexual partner in consultations (only 4.7%), as of the fathers (2.3%). The participation of family doctors was also small (16.5%), although the majority of cases were referred to us by them.

Table 3. - Participation of relatives and family doctors in consultations

Family/Relatives	No.	%
Mother	125	58.9
Father	5	2.3
No one	50	23.6
Partner	10	4.7
Others	22	10.4
Total	212	100.0

Family Doctor	No.	%
Participated	35	16.5
Did Not Participate	117	83.5
Total	212	100.0

Source: Clinical Records

Discussion

The analysis of the tables in our study shows that female adolescents use our services mainly due to situations linked to early engagement in sex and its consequences. It demonstrates that the group is vulnerable to reproductive health risks.¹¹

The main reasons for seeking consultation are contraception orientation, requests for induced abortion or menstrual regulation, leucorrhea, and cervicitis. If we take into consideration that reproductive health deals with three main issues, namely, contraception, abortion, and new contraceptives, as stated by Scavone,¹² and that women who undergo induced abortion are going against their reproductive health,¹³ we can understand the importance of visiting our service in this context, since they provide appropriate, conscious, and directed sexual education in each session, as well as specialized and differentiated-in most cases multidisciplinary-treatment. Peláez hit the nail on the head when he stated that the work of these services deals with practically all the chief components of reproductive health.⁵

It has been affirmed that access to good-quality health services, with appropriate supplies, has a significant impact on the users’ sexual and reproductive health.¹⁴

As we know, the changes posed by adolescence include the awakening of sexuality and the increase of sexual desire or sensations linked to it. This awakening, as well as how to integrate these feelings, behavior, and relations with their parents and other adults with minimum conflict and anxiety, pose a significant challenge for adolescents.¹⁵

As shown in our results, there are negative consequences for the normal development and evolution of sexuality from unprotected sex and lack of privacy.. These can be frustrating experiences and cause future sexual dysfunctions. Furthermore, the fact that the main motivation for engaging in sex was, in the majority of cases, pressure on behalf of their partner or peer pressure, reveals the presence of genre issues and sex-gender social relations. Males have been indirectly encouraged from generation to generation to have early sexual relations. This explains the need for participative sex education,^16-18 which we carried out in all cases.

In our results we have specifically referred to three of our service’s main achievements, besides education, formation, information, and participation-which are of vital importance in reproductive health, and make it possible to appraise our work.

The first one deals with contraception. Although there are no biomedical reasons to contraindicate particular contraceptives, several factors are taken into account when choosing the most appropriate. These factors include age, history of previous pregnancies, family environment, weak couple relations, and active sexual life, among others.¹⁹ Adolescents usually focus on the present, and tend not to plan ahead or foresee possible long term consequences of their actions. We found this to be true in our study. When the adolescents studied first came to our offices, they reported to have had unprotected sex, and many of them did not know what contraceptive to use. In adolescents, hormonal contraceptives are the second choice, after condoms.¹⁹ After explaining to them the characteristics, advantages and disadvantages of each contraceptive method, in our offices and participatory meetings, we tried, respecting the principle of “not imposing criteria, but instead providing alternatives,” to see that the use of hormonal contraception, especially oral ones, prevailed among our patients. Of them, only 10.6% had to discontinue treatment, mostly due to adverse side effects. If we take a look at the chief reasons for the doctor’s visit, we will see that initially there were 103 patients who came for contraception, and we succeeded in increasing this number to 150. Moreover, we will see that the fact that at the time of our study there were patients that had been using contraceptives for 1-3 years was because the majority of them requested a contraceptive and applied it during the period studied.

Another important achievement of our service was the diagnosis and evolution of cases with cervicitis or leucorrhea. These were the two main complaints, and the treatment of these disorders is an important factor in adolescent gynecological care, as we have already stated²⁰ As shown in our results, the majority of patients with leucorrhea (87.2%) or cervicitis (76.3%)were cured, with a statistically significant difference, as compared with the total of those who came with these disorders (p<0.05). The treatment used was the conventional one, which reveals that the main factor in the satisfactory evolution of these patients is their attendance at consultations and an appropriate follow-up. As we know, gynecological infections, are very closely related with sexually transmitted infections as well as with sexual habits and customs, which can become important risk factors^21,22 and can bring about consequences, such as an increase in the incidence of ectopic pregnancy, infertility, cervical cancer, and other disorders^22,23-all of them of great importance in reproductive health.

Finally, the third achievement of our service was the incorporation of family members, which occurred in more than half the cases (61.2%), including mothers and fathers.

The family is included among the social, cultural and economic factors that have an impact on sexual and reproductive health.²⁴ Although we sometimes requested private interviews with the adolescents, both adolescents and their family members participated actively in our consultations, as well as in the participative communication techniques applied. In these sessions we used personal experience techniques with all participants as the main representatives of the patients’ social environment. In many cases, contradictions among family members and their adolescents were found. However, we pursued our objective : communication as a social interaction process,^25-27 keeping in mind that communication and education are always complex processes when dealing with reproductive health issues, although they both must involve accurate and clear messages. ^26,28 This made it possible for us to clarify many aspects regarding our study participants’ sexual relations, contraception, genital infections, sexually transmitted infections, abortion, etc., which are considered major reproductive risk factors;²⁹ as well as their attitudes, beliefs, and risk perception. This made it possible for us to provide proper personalized orientation in each case.

The participation of family doctors in this type of health care is crucial, especially during the screening process and the selection of cases to be referred to reproductive health services. Their participation was not as great as we hoped for, although the majority of cases we received were referred by them. We must emphasize as well their role as educators and change-promoting agents, since vital elements of reproductive health such as early pregnancies, abortions, sexually transmitted infections, contraception, and all the problems linked with sex education, are continually present in their daily work.^6,30

Conclusions

APPENDIX 1

26 DE JULIO POLYCLINIC. PLAZA MUNICIPALITY

Adolescent Clinical Record No.: _______________
ID. Number: ____________

DOCTOR’S NAME: _________________________________________

Patient: ______________________________ Age: ______

Skin Color: _______ 1) White 2) Mestizo 3) Black 4) Oriental

Family Doctor’s Office: __________ Polyclinic: ____________ Municipality: ________

Educational Status : ______ 1) Primary 2) Secondary 3) Polytechnic
4) Pre-University 5) University 6) Other
Latest Diploma: _____________

Marital Status: _____ 1) Single 2) Married 3) Divorced 4) Common-Law Marriage

Cohabitants: _____ 1) Parents 2) Mother 3) Father 4) Relatives
5) Couple 6) Non-relatives 7) Alone

Parents’ Marital Status : ______ 1) Married
2) Divorced: a) With Steady partner b) With No Steady partner
3) Common-Law Marriage

Parents’ Labor Status: _____ 1) Both Work 2) Only One Works
3) None Works

Parents’ Educational Status: Mother: ____ Father: _____ Tutor: _____
1) Primary 2) Secondary 3) Polytechnic
4) Skilled Worker 5) Pre-University 6) University
7) 7) Does Not Know

Total Cohabitants : _______ Total Rooms : _______ Total Bedrooms: ______

Companion to Consultation: ____ 1) Parents 2) Mother 3) Alone
4) A Relative 5) A Friend 6) Family Doctor

Reason for the consultation:
__________________________________________
1) Leucorrhea 2) Amenorrhea 3)Menstrual Disorders 4) Family Planning
5) Cervical Disorders 6) Sexually Transmitted Infections 7) Mammary Disorders
8) Puberty Disorders 9) Gynecological Tumors 10) Pelvic Pain
11) Menstrual Regulation/Induced Abortion 12) Dysmenorrhea
13) Other

PRESENT ILLNESS

Menarche _________ First Sexual Rel. _______ First Pregnancy _______
Gynecological Age _______ Privacy ______
Time Between Meeting Partner and First Sexual Relation _______
Motivation for Engaging in Sex _______
Total Pregnancies ______ births ______ Abortions/Miscarriages ______
Menstrual Regulations _______
Ectopic Pregnancies ______ Date of Latest birth or Abortion/Miscarriage _____
Date of Latest Menstruation ________ Menstrual Formula _____
Do you know about any contraceptive method? 1) YES 2) NO 3) I DON’T KNOW
Have you ever used a contraceptive? 1) YES 2) NO 3) OCCASIONALLY
Which ? ________ For how long? ___________
Are you still using it? _______ 1) YES 2) NO 3) OCCASIONALLY
Why don’t you use it anymore?___________________________________________
Number of Sexual Partners _____ 1) None 2) 1-3 3) 3-6 4) More than 6
How have you learned about contraceptives? _______________
1) Friends 2) Boyfriend/Girlfriend 3) Siblings 4) Parents 5) School
6) Medical Centers 7) Mass Media 8) Other

PHYSICAL EXAMINATION
10-14 15-16 17-18 19
DATE
WEIGHT
HEIGHT
WEIGHT APPRAISAL

PHASES OF DEVELOPMENT (TANNER)

BREASTS PUBIC HAIR UNDERARM HAIR OSSEOUS MATURATION

Hair Distribution _________ 1) Present - Adult
2) Present - Puberty
3) Absent

BREAST EXAM:
ABDOMEN:

VULVA AND PERINEUM:

HYMEN :
VAGINA:
BI-MANUAL DIGITAL EXAM:

DIGITAL RECTAL EXAM:

SPECULUM:

SCHILLER TEST:

OTHER TESTS:

MAIN FINDINGS:

PRESUMPTIVE DIAGNOSIS:

STRATEGY:

EVOLUTION AND TREATMENT

Cuban Medical Research

CHILD AND ADOLESCENT GYNECOLOGICAL SERVICES IN PRIMARY CARE

Introduction

Objectives

General

Methods

Results

Discussion

Conclusions

References

APPENDIX 1

All rights reserved (c) 2002 - MEDICC - Medical Education Cooperation with Cuba - ISSN: 1527-3172