Committee Opinion
Number 626, March 2015


Committee on Adolescent Health Care
This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictating an exclusive course of treatment or procedure to be followed.


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The Transition From Pediatric to Adult Health Care: Preventive Care for Young Women Aged 18-26 Years

ABSTRACT: Young women (aged 18–26 years) are a heterogeneous population transitioning from adolescence into adulthood who may present with unique issues and challenges, including a potential gap in health care after pediatric health care. Obstetrician–gynecologists should note that these patients may need assistance in transitioning from a pediatrician to a provider of adult health care (an internist, family practitioner, or obstetrician–gynecologist), especially in the absence of a parent. Preventive counseling is crucial for helping young women anticipate changes and stressors and for easing their life transitions. A preventive health care visit offers the obstetrician–gynecologist an opportunity to screen for health issues and counsel the patient about a variety of health topics, some of which are particularly relevant to young women.


Preventive counseling is crucial for helping young women (aged 18–26 years) anticipate changes and stressors and for easing their life transitions. Obstetrician–gynecologists should note that these patients may need assistance in transitioning from a pediatrician to a provider of adult health care (an internist, family practitioner, or obstetrician–gynecologist), especially in the absence of a parent. Young women are a heterogeneous population transitioning from adolescence into adulthood who may present with unique issues and challenges, including a potential gap in health care after pediatric health care. Young women often view an obstetrician–gynecologist as their primary care provider (1). A preventive health care visit offers the obstetrician–gynecologist an opportunity to screen for health issues and counsel the patient about a variety of health topics, some of which are particularly relevant to young women. The American College of Obstetricians and Gynecologists publishes a more extensive review of well-woman care, available at http://acog.org/About-ACOG/ACOG-Departments/Annual-Womens-Health-Care/Well-Woman-Recommendations (2) and www.immunizationforwomen.org (3).

Interview and Screening Questions

Family and Friends

A clinician caring for a young woman should assess the patient’s living situation, including with whom the patient lives, how well she gets along with others at home, and whether she feels safe and secure. Often, questioning a patient about her friends’ high-risk behaviors (eg, alcohol consumption and drug use) can make the patient more receptive to answering the questions.

Education and Work

A clinician should assess whether the patient has any difficulty with school or work. Furthermore, the clinician should verify that the patient receives treatment or supportive services for learning disabilities or conditions that can affect learning and work performance, such as attention-deficit/hyperactivity disorder.

Appearance, Fitness, Nutrition, and Lifestyle

The patient should be asked if she has any concerns or questions about the shape or size of her body or the way she looks; if she wants to gain or lose weight; and if she has ever tried to lose weight or control her weight by vomiting, using diet pills or laxatives, or not eating for a day. The patient should be questioned about her dietary behaviors (eg, intake of fruits and vegetables, calcium, multivitamin with folic acid, iron, and dietary restrictions). Tools such as questionnaires can identify a patient at risk of an eating disorder (4).

Questions about what activities the patient engages in offer insight into her level of physical activity and enjoyment; too much time spent on electronics and social media can detract from being physically active. Young adult athletes should be asked about their use of performance-enhancing substances, including steroids (5). The clinician should ask the patient about her amount of sun exposure and use of sun protection and discuss the harmful effects of tanning.

Use of herbal and natural supplements should be assessed because some supplements can interfere with certain prescription medications (eg, St. John’s wort interferes with the efficacy of oral contraceptive pills) (6). The patient should be asked if she is considering any body modifications, such as body art, piercings, or tattoos. Discussion about long-term satisfaction and safety is appropriate at this time (7).

Sleep Disorders

Sleep disorders are common among young women and lack of sleep can lead to increased risk of diabetes, weight gain, heart disease, depression, driving accidents, and mistakes at school or work. The National Institutes of Health’s National Heart, Lung, and Blood Institute provides additional information and resources on sleep (www.nhlbi.nih.gov/health/health-topics/topics/sdd/howmuch.html) (8).

Safety, Weapons, and Violence

Injuries are the most common preventable cause of morbidity and mortality among young women. Questioning the patient about firearms (eg, whether there are any in the patient’s household) can open the discussion. Health care providers should be aware of state laws that affect these discussions. Additionally, clinicians should address the use of seat belts, use of helmets for sports and other activities, and the avoidance of texting or drinking while driving.

All patients should be asked about abuse, neglect, physical or sexual violence, and reproductive coercion (eg, sabotage of contraceptive methods, pregnancy coercion or pressure) (9). See RADAR: A Domestic Violence Intervention (www.instituteforsafefamilies.org/materials/m/radar) (10) for a useful mnemonic for asking screening questions. Clinicians should discuss safety and the risk of sexual assault. Questions about cyber safety are also important, and counseling patients about responsible use of the Internet is beneficial.

Reproductive Health History, Sexual History, and Contraception

The health care provider should discuss the patient’s sexual health, orientation, behaviors, and activity; the sex of her partner or partners; her number of lifetime partners; her sexual satisfaction; and her sexual function. It is important to discuss initiation of sexual activity with patients who are not yet sexually active. Discussion of a patient’s contraceptive needs should include emergency contraception, pregnancy prevention, and the prevention of sexually transmitted infections, as well as support for abstinence.

Preconception counseling should be provided for patients considering pregnancy or at risk of unintended pregnancy. Recommendations for screening for certain genetic disorders can be discussed when appropriate (11). When a pregnancy is identified in this age group, the patient should be provided with counseling appropriate to her needs, including the discussion of keeping the child once delivered, adoption of the child, or pregnancy termination.

To be maximally effective, the human papillomavirus vaccine should be administered during the target age range (ages 11–12 years) or before the onset of sexual activity; catch-up vaccination is recommended up to age 26 years (12). A patient’s risk of sexually transmitted infections should be screened by a clinician with direct questions about types of sexual behaviors (eg, oral, vaginal, or anal sexual contact) and the concurrent use of alcohol or drugs (13). Assessment and education about the proper use of male condoms can be addressed.

Substance Use and Abuse

The patient should be questioned directly about her use of cigarettes and other tobacco products; alcohol, including binge drinking; and other drugs, including designer and performance-enhancing drugs and stimulants prescribed for attention-deficit/hyperactivity disorder. Substance abuse screening can be performed with specific instruments such as the CRAFFT screening tool (www.ceasar-boston.org/CRAFFT/pdf/CRAFFT_English.pdf) (14). Other screening instruments can be found at the Substance Abuse and Mental Health Services Administration’s web site (www.samhsa.gov).

Mental Health

Although many screening tests are available, the following two basic questions can predict the need for a more in-depth depression screening tool: 1) over the past 2 weeks, have you ever felt down, depressed, or hopeless? and 2) have you felt little interest or pleasure in doing things? (15). Self-injurious behaviors, such as cutting and burning, although not typically suicide attempts, indicate a degree of psychologic distress and should be addressed at the time of the physical examination.

Physical Examination

All patients should have their vital signs (including blood pressure) checked, as well as weight and height measurements to calculate body mass index. Vision and hearing screening should be done if the patient has any related symptoms. Lipid screening may be considered based on family history. Presence of acne, hirsutism, acanthosis nigricans, or other skin changes should be noted.

For this age group, the American College of Obstetricians and Gynecologists recommends performing clinical breast examinations every 1–3 years beginning at age 20 years and that clinicians educate patients about breast self-awareness (16). Whether or not to perform a complete pelvic examination at the time of the periodic health examination for an asymptomatic patient should be a shared decision after a discussion between the patient and her health care provider. Cervical cancer screening should begin at age 21 years, and screening should be performed every 3 years through age 29 years (17). Additional options are available for women 30 years and older.

Preventive counseling may be summarized at the conclusion of the visit. Congratulating the patient on all reported positive health behaviors is as important as counseling her on areas of concern.

References

  1. Callahan ST, Cooper WO. Changes in ambulatory health care use during the transition to young adulthood. J Adolesc Health 2010;46:407–13. [PubMed] [Full Text]
  2. Well-woman care: assessments and recommendations. Washington, DC: American College of Obstetricians and Gynecologists; 2013. Available at: acog.org/~/media/Departments/Annual%20Womens%20Health%20Care/PrimaryAndPreventiveCare.pdf?dmc=1&ts=20130511T2104247568. Retrieved September 9, 2014.
  3. American College of Obstetricians and Gynecologists. Immunization for women. Available at: http://www.immunizationforwomen.org. Retrieved September 9, 2014.
  4. Morgan JF, Reid F, Lacey JH. The SCOFF questionnaire: assessment of a new screening tool for eating disorders. BMJ 1999;319:1467–8. [PubMed] [Full Text]
  5. Performance enhancing anabolic steroid abuse in women. Committee Opinion No. 484. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:016–8. [PubMed] [Obstetrics & Gynecology]
  6. Johne A, Brockmoller J, Bauer S, Maurer A, Langheinrich M, Roots I. Pharmacokinetic interaction of digoxin with an herbal extract from St John’s wort (Hypericum perforatum). Clin Pharmacol Ther 1999;66:338–45. [PubMed]
  7. Carroll ST, Riffenburgh RH, Roberts TA, Myhre EB. Tattoos and body piercings as indicators of adolescent risk-taking behaviors. Pediatrics 2002;109:1021–7. [PubMed] [Full Text]
  8. National Heart, Lung, and Blood Institute. How much sleep is enough? Available at: http://www.nhlbi.nih.gov/health/health-topics/topics/sdd/howmuch.html. Retrieved September 9, 2014.
  9. Reproductive and sexual coercion. Committee Opinion No. 554. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;121:411–5. [PubMed] [Obstetrics & Gynecology]
  10. Jaeger JR. RADAR: a domestic violence intervention for women. The Family Violence Clinical Network. Philadelphia (PA): Institute for Safe Families; 2005. Available at: http://www.instituteforsafefamilies.org/materials/m/radar. Retrieved September 9, 2014.
  11. Preconception and prenatal carrier screening for genetic diseases in individuals of Eastern European Jewish descent. ACOG Committee Opinion No. 442. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;114:950–3. [PubMed] [Obstetrics & Gynecology]
  12. Human papillomavirus vaccination. Committee Opinion No. 588. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;123:712–8. [PubMed] [Obstetrics & Gynecology]
  13. Addressing health risks of noncoital sexual activity. Committee Opinion No. 582. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:1378–83. [PubMed] [Obstetrics & Gynecology]
  14. Center for Adolescent Substance Abuse Research (CeASAR). The CRAFFT screening interview. Boston (MA): Children’s Hospital Boston; 2009. Available at: http://www.ceasar-boston.org/CRAFFT/pdf/CRAFFT_English.pdf. Retrieved September 9, 2014.
  15. Screening for depression in adults: U.S. preventive services task force recommendation statement. U.S. Preventive Services Task Force. Ann Intern Med 2009;151:784–92. [PubMed] [Full Text]
  16. Breast cancer screening. Practice Bulletin No. 122. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:372–82. [PubMed] [Obstetrics & Gynecology]
  17. Screening for cervical cancer. Practice Bulletin No. 131. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:1222–38. [PubMed] [Obstetrics & Gynecology]

Copyright March 2015 by the American College of Obstetricians and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington, DC 20090-6920. All rights reserved.

ISSN 1074-861X

The transition from pediatric to adult health care: preventive care for young women aged 18–26 years. Committee Opinion No. 626. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:752–4.

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