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There are developmental transitions adults attain, conceived as stages of the family life cycle. In this chapter, we describe behavioral issues for adolescents, young adults, middle age and older women using this framework. We discuss expected behavioral issues normally occurring as part of the life cycle, as well as problematic ones requiring medical surveillance or intervention.

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The task of adolescence is to find one's own beliefs, moving from childhood to adulthood physically and in relationships. A number of events can occur during this time that will require the sensitive attention of the primary care physician, but numerous studies have suggested that confidentiality must be maintained for the physician to be trusted and helpful to an adolescent.

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Approach to the Gynecologic Examination

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Many women fear a pelvic examination, especially when they are undergoing it for the first time. Little research has been done on what strategies are best in performing a pelvic examination, but several techniques have been found to be helpful in clinical practice.

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Before performing the examination, clinicians should ask women if they have ever had a pelvic examination. In addition, they should take a complete sexual history, and specifically inquire about a history of sexual abuse or sexual dysfunction such as dyspareunia, vaginismus, and disorders of sexual desire. Problems with sexual desire can sometimes be related to underlying conditions such as hypothyroidism or depression. During the pelvic examination, potential causes of dyspareunia and vaginismus such as vaginal lesions, infection, and dryness or atrophy can be ruled out.

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It is useful for the clinician to describe exactly what is being done before and during the examination; providing more information about the reproductive organs may also be helpful. When the examiner is male, it is appropriate for a nurse or chaperone to be present.

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Other techniques include appropriate draping, using a warm speculum, using the narrowest speculum that will allow adequate visualization of the cervix, being as gentle as possible and encouraging the patient to use relaxation techniques including deep breathing and mental imagery. Deep breathing is suggested when the patient feels uncomfortable, and mental imagery (encouraging the patient to form and talk about a mental image) can be used to help further relax the pelvic muscles, and may be particularly useful for young women and for those who have been victims of sexual abuse. In addition, elevating the head will facilitate eye contact and may make it easier for some women to relax. In situations where a patient has suffered extreme abuse; anxiety, posttraumatic stress disorder (PTSD), or even dissociation may occur and a onetime dose of a benzodiazepine may be required.

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Research has shown that the experience of the first pelvic examination strongly influences attitudes about subsequent examinations; therefore, it is important for clinicians to make the first pelvic examination as positive an experience as possible. In a study describing experiences of the ...

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