A 22-year-old nulligravid woman comes to the office for her first gynecologic examination and to discuss contraception options. Menarche was at age 13. Her last menses was 2 weeks ago; periods occur every 30 days and last for 4 days. The patient has no dysuria, urinary frequency, vaginal discharge, postcoital spotting, or abdominal pain. She became sexually active a few months ago with her boyfriend; she is monogamous and currently uses condoms for contraception. The patient takes no medications and has no allergies. She does not use tobacco, alcohol, or illicit drugs. The patient has received all recommended vaccinations except for the human papillomavirus series. Her mother was diagnosed with ovarian cancer at age 46 and is currently undergoing chemotherapy. Vital signs are normal. Complete physical examination, including pelvic examination, shows no abnormalities. A urine pregnancy test is negative. In addition to her first Pap test, which of the following is the best recommendation for this patient?

Question

A 22-year-old nulligravid woman comes to the office for her first gynecologic examination and to discuss contraception options.  Menarche was at age 13.  Her last menses was 2 weeks ago; periods occur every 30 days and last for 4 days.  The patient has no dysuria, urinary frequency, vaginal discharge, postcoital spotting, or abdominal pain.  She became sexually active a few months ago with her boyfriend; she is monogamous and currently uses condoms for contraception.  The patient takes no medications and has no allergies.  She does not use tobacco, alcohol, or illicit drugs.  The patient has received all recommended vaccinations except for the human papillomavirus series.  Her mother was diagnosed with ovarian cancer at age 46 and is currently undergoing chemotherapy.  Vital signs are normal.  Complete physical examination, including pelvic examination, shows no abnormalities.  A urine pregnancy test is negative.  In addition to her first Pap test, which of the following is the best recommendation for this patient?

Quizplus · Accepted Answer

11ec25c8_d98b_fe9b_bc81_e9709d5bcdb4_MD0003_00 Chlamydia trachomatis and Neisseria gonorrhoeae are the 2 most common bacterial sexually transmitted infections and have a high prevalence in women age <25. However, these infections often have no symptoms. Due to the lack of symptoms (and subsequent lack of treatment) and high prevalence, patients are at risk of ascending infection (eg, pelvic inflammatory disease) that can result in long-term sequelae (eg, infertility, ectopic pregnancy) due to tubal scarring. Therefore, all sexually active women age <25 are recommended annual screening for C trachomatis and N gonorrhoeae, including those with low-risk sexual behavior (eg, monogamous, condom use) such as this patient. The nucleic acid amplification test (NAAT) is the gold standard for screening and diagnosis due to its high sensitivity and specificity. (Choice A) Cervical cancer screening most commonly begins at age 21 with cervical cytology (ie, Pap test). However, routine human papillomavirus (HPV) cotesting is not recommended in patients age <30 because most HPV infections are transient and spontaneously clear in younger patients. Unnecessary cotesting increases the risk of cervical procedures, which can lead to obstetric complications (eg, preterm birth). Instead, this patient should be offered the HPV vaccination series, which can be initiated at age <26, regardless of sexual activity. (Choice C) Clean-catch urinalysis is used to evaluate for cystitis in patients with symptoms (eg, dysuria, hematuria). This patient is asymptomatic, and screening for cystitis in asymptomatic patients is generally not recommended. (Choice E) Routine syphilis screening (eg, nontreponemal serology) is recommended in asymptomatic patients with a prior sexually transmitted infection, >1 sexual partner in the last 6 months, high-risk populations (eg, men who have sex with men), and pregnant patients due to the risk of congenital syphilis. This patient does not meet the criteria for testing (ie, no symptoms of syphilis [eg, chancre, maculopapular rash]) or routine screening. (Choice F) Wet mount microscopy evaluates for bacterial vaginosis, candidiasis, and trichomoniasis, all of which typically present with vaginal discharge. In contrast, this asymptomatic patient would likely have normal vaginal flora on microscopy, making this test unnecessary. Educational objective: All sexually active women age <25 are recommended annual screening for Chlamydia trachomatis and Neisseria gonorrhoeae due to high rates of asymptomatic infection and risk of long-term sequelae (eg, infertility). Nucleic acid amplification testing is the gold standard testing method. References: Update to CDC's treatment guidelines for gonococcal infection, 2020. (http://www.ncbi.nlm.nih.gov/pubmed/33332296) Sexually transmitted diseases treatment guidelines, 2015. (http://www.ncbi.nlm.nih.gov/pubmed/26042815) Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae-2014. (http://www.ncbi.nlm.nih.gov/pubmed/24622331)

A 22-Year-Old Nulligravid Woman Comes to the Office for Her