396 Obstetrics and Gynecology Board Review •••
❍ Describe the two FDA-approved vaccines shown to be effective at preventing HPV infection.
(1) A quadrivalent HPV vaccine that protects against HPV infections due to HPV genotypes 6, 11, 16, and
- This vaccine is effective at providing protection against cervical cancer and vulvar, vaginal, and cervical
dysplasia, as well as genital warts caused by these strains.
(2) A bivalent HPV vaccine that protects against HPV infections due to HPV genotypes 16 and 18. This vaccine
is protective against cervical cancer and vulvar, vaginal, and cervical dysplasia, but not offer protection against
genital warts infection.
❍ How should the HPV vaccine be administered?
Given intramuscularly as three separate 0.5 mL doses. All doses should be given within 6 months of the first dose.
Dose #1, give at chosen date; dose #2, give 1 to 2 months after the first dose; dose #3, give 6 months after the
first dose.
❍ Who should receive the HPV vaccine?
The vaccine is approved for girls and women aged 9 to 26 years old. The vaccine is also approved for boys and
men aged 9 to 26 years old; however, routine vaccination for boys and men is not yet recommended. The vaccine
is most effective if given before the onset of sexual activity. After initiation of intercourse, the vaccine may still be
given; however, the vaccine will not protect against genotypes of HPV that a person has already been exposed to.
While the HPV vaccine is categorized as a class B drug, more research is needed regarding the administration of
the vaccine during pregnancy. Women who are known to be pregnant should not be vaccinated. Lactating women
may be vaccinated.
❍ What is the most common gynecologic complaint among adolescents?
Dysmenorrhea is the most common complaint among adolescent girls. It is also the leading cause of repeated
short-term absences from school in this age group.
❍ What is the most common cause of dysmenorrhea in adolescents?
Most cases of dysmenorrhea in adolescents have no underlying pelvic pathology, and are thought to be due to the
uterine release of prostaglandins during menstruation. The remaining 10% have an underlying pathology, which is
most commonly endometriosis. Other causes are obstructing Müllerian anomalies and pelvic inflammatory disease.
❍ What is the usual presentation of endometriosis in adolescents?
Pelvic pain is the primary reason adolescents with endometriosis seek medical attention. This presents as an
acquired, progressive dysmenorrhea, usually with both cyclic and acyclic components.
❍ Describe the appearance of endometriotic lesions on laparoscopy, in an adolescent.
Endometriotic lesions in adolescents are usually red, clear, or white, in contrast to the powder-burn lesions
commonly seen in adults.
❍ What are the treatment guidelines for endometriosis in adolescents?
(1) NSAIDs and continuous combination hormone therapy is considered first-line treatment.
(2) Gonadotropin-releasing hormone (GnRH) agonists with add-back is reserved for failure of hormonal
treatment, because of concern over its potential to retard bone growth.
(3) Surgery should be used to preserve fertility.
(4) A multidisciplinary pain management service should be provided, including support groups.