Gynecologic Emergencies: Management of Adolescent Patients in the ED

Identification and Management of Adolescent Gynecologic Emergencies in the Emergency Department

Below is a free preview. Log in or subscribe for full access. Or, get a free sample article ED Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion:
Please provide a valid email address.

*NEW* Quick Search this issue!

Table of Contents
About This Issue

The differential diagnosis for adolescent gynecologic complaints can be broad, and these cases are often complicated by psychosocial factors, confidentiality concerns, and the need to recognize abuse and sexual assault. This issue provides recommendations for the evaluation and management of obstetric and gynecologic emergencies. You will learn:

Obstetric and gynecologic causes of abdominal pain, pelvic pain, and abnormal uterine bleeding, including anatomic, infectious, and endocrine etiologies

Key aspects of history-taking for adolescent patients with gynecologic emergencies

When an external genitourinary examination or a pelvic examination is warranted

When a single hCG test is sufficient, and when serial testing is necessary

Recommendations for when laboratory screening (eg, a coagulation panel, endocrine workup, nucleic acid amplification testing, or urinalysis) and imaging studies are needed

Appropriate management for adolescent patients with an ectopic pregnancy, abnormal uterine bleeding, a Bartholin cyst or abscess, adnexal torsion, or an ovarian cyst or mass

Recommendations for management of adolescent patients with a sexually transmitted disease or pelvic inflammatory disease, as well as those who have experienced trauma or are a survivor of sexual assault

General guidelines regarding confidentiality issues associated with adolescent sexual health services

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology and Pathophysiology
  6. Epidemiology
  7. Differential Diagnosis
    1. Obstetric and Gynecologic Causes of Abdominal and Pelvic Pain
      1. Obstetric Causes of Abdominal Pain, Pelvic Pain, and Vaginal Bleeding
        • Ectopic Pregnancy
        • Molar Pregnancy
        • Benign Vaginal Bleeding in Pregnancy
        • Spontaneous Abortion
        • Septic Abortion
      2. Gynecologic Causes of Abdominal and Pelvic Pain
        • Adnexal Torsion
        • Adnexal Cyst/Mass
        • Anatomic Abnormalities
        • Bartholin Gland Cyst/Abscess
        • Infections
        • Endocrine Etiologies
        • Foreign Body
    2. Abnormal Uterine Bleeding
      1. Endocrine Etiologies
      2. Bleeding Disorders
      3. Medications
      4. Systemic Disease
      5. Masses
      6. Trauma
  8. Prehospital Care
  9. Emergency Department Evaluation
    1. History
    2. Physical Examination
      1. External Genitourinary Examination
      2. Pelvic Examination
  10. Diagnostic Studies
    1. Laboratory Testing
      1. Pregnancy
      2. Abnormal Uterine Bleeding
      3. Sexually Transmitted Infections
    2. Imaging Studies
      1. Ultrasound
        • Obstetric Ultrasound
        • Gynecologic Ultrasound
      2. Computed Tomography
      3. Magnetic Resonance Imaging
  11. Treatment
    1. Pregnancy
    2. Abnormal Uterine Bleeding
    3. Bartholin Cyst or Abscess
    4. Adnexal Torsion
    5. Ovarian Cyst or Mass
    6. Sexually Transmitted Infection and Pelvic Inflammatory Disease
      1. Treatment of Sexually Transmitted Infections
      2. Treatment of Pelvic Inflammatory Disease
    7. Trauma
    8. Sexual Assault
      1. Reporting and Forensic Examination
      2. Treatment and Testing After Sexual Assault
  12. Special Circumstances
    1. Consent and Confidentiality
    2. Patients With Special Healthcare Needs
  13. Controversies and Cutting Edge
  14. Disposition
  15. Summary
  16. Risk Management Pitfalls in the Management of Adolescent Patients With Gynecological Emergencies
  17. Time- and Cost-Effective Strategies
  18. Case Conclusions
  19. Clinical Pathway for Emergency Department Management of Abnormal Uterine Bleeding in Adolescent Patients
  20. Tables and Figures
    1. Table 1. Differential Diagnosis of Obstetric/Gynecologic-Related Abdominal and Pelvic Pain
    2. Table 2. Differential Diagnosis of Abnormal Uterine Bleeding
    3. Table 3. Treatment of Sexually Transmitted Infection and Pelvic Inflammatory Disease
    4. Table 4. Prophylaxis After Sexual Assault
    5. Figure 1. Obstetric Point-of-Care Ultrasound
    6. Figure 2. Molar Pregnancy on Ultrasound
    7. Figure 3. Ovarian Torsion on Ultrasound
    8. Figure 4. Bartholin Gland Cyst or Abscess Incision and Drainage
  21. References



In the emergency department, gynecologic complaints are common presentations for adolescent girls, who may present with abdominal pain, pelvic pain, vaginal discharge, and vaginal bleeding. The differential diagnosis for these presentations is broad, and further complicated by psychosocial factors, confidentiality concerns, and the need to recognize abuse and sexual assault. This issue provides recommendations for the evaluation and management of obstetric and gynecologic emergencies including infectious, anatomic, and endocrine etiologies. Offering adolescents evidence-based guidance and treatment for sexually transmitted infection and avoiding unwanted pregnancy can help to mitigate the high-risk behavior that can affect their wellness and future fertility.


Case Presentations

A 15-year-old girl presents to the ED with vaginal bleeding that has persisted for 1 month. Over the last few days, she has had to change pads every hour. The patient says she feels fatigued and is unable to go to school. Her vital signs are: blood pressure, 110/70 mm Hg; heart rate, 110 beats/min; respiratory rate, 16 breaths/min; and oxygen saturation, 100% on room air. On examination, she appears pale and fatigued. She has a systolic flow murmur with clear lungs, and her abdomen is soft and nontender. What labs should you order? Are imaging studies warranted and, if so, which would be best? Does this patient need a transfusion? Should she be admitted or can she be treated as an outpatient?

You are then called to the resuscitation room for a 17-year-old girl who was found unresponsive at home. On examination, she is ill-appearing, lethargic, has cool distal extremities, normal heart sounds, and clear lungs, and her abdomen is soft but tender in the left lower quadrant. Her vital signs are: blood pressure, 80/40 mm Hg; heart rate, 130 beats/min; respiratory rate, 25 breaths/min; and oxygen saturation, 95% on room air. What are the immediate first steps in managing this patient? What testing is needed for evaluation and management? What is the appropriate disposition?

Later in your shift, a 16-year-old girl presents to the ED with abdominal pain and vaginal discharge. She tells you that she recently started having sexual intercourse with her boyfriend and does not want her mother to know. On examination, she is well-appearing and has tenderness to the lower abdomen. Her vital signs are: blood pressure, 120/80 mm Hg; heart rate, 70 beats/min; respiratory rate, 15 breaths/min; and oxygen saturation, 100% on room air. What labs should you send for this patient? Should you treat her empirically with antibiotics? If you decide to treat her, what antibiotic regimen should you give? What is the law regarding confidentiality for this patient and how should you counsel her?



Adolescent patients comprise approximately 15% of all emergency department (ED) visits, accounting for nearly 15 million ED visits annually.1,2 Teenagers who seek care in the ED tend to engage in high-risk behaviors, including risky sexual activity and substance use; they may also have mental health issues, which can place them at higher risk for health issues, comorbidities, and high-risk behaviors.2 Pregnant adolescents account for an estimated 1% to 5% of pediatric ED visits, and this number is on the rise.3 Teens are less likely to seek care due to concerns about confidentiality, scheduling, transportation, cost, and embarrassment.4 When they do seek care, they are more likely to present to the ED than to a primary care provider. To better serve this high-risk population, it is important for emergency clinicians to be knowledgeable about adolescent reproductive health needs.

In an interview study of emergency physicians and nurses, the following barriers to providing gynecologic and obstetric healthcare to teens were described: parental presence, difficulty building rapport in the ED setting, lack of knowledge about long-term contraception, lack of knowledge about confidentiality laws, and differences in language, gender, and religious or cultural beliefs.5 Additionally, clinicians can have knowledge gaps and discomfort in managing adolescent health.6,7 For example, Balamuth et al surveyed pediatric emergency clinicians and found an overall low level of knowledge about pelvic inflammatory disease (PID).8 One study of pediatric residents found that only 63% reported that teen pregnancy was adequately covered during residency.7 Many pediatric EDs are staffed largely by clinicians who have had minimal training in obstetrics.

This issue of Pediatric Emergency Medicine Practice reviews the gynecologic etiologies of abdominal/pelvic pain and vaginal bleeding, as well as first-trimester obstetric etiologies and complications in adolescent patients. The evaluation and management of these medical and surgical emergencies are discussed, along with the psychosocial and confidentiality issues pertaining to adolescents. For more information on the ED evaluation and management of common genital emergencies in girls, see the October 2018 issue of Pediatric Emergency Medicine Practice, “Diagnosing and Managing Common Genital Emergencies in Pediatric Girls.”


Critical Appraisal of the Literature

A literature search was performed in PubMed and the Cochrane Database of Systematic Reviews for articles and studies from 1992 to 2017 using the following search terms: adolescent pregnancy, vaginal bleeding, pediatric emergency department, ectopic pregnancy, pelvic inflammatory disease, adolescent gynecologic emergencies, pelvic pain, sexual assault, ovarian torsion, and confidentiality. The reference lists of the articles found were reviewed for additional relevant publications, and 76 articles were chosen for inclusion. The majority of the articles are review articles, in addition to retrospective and prospective studies.

Unfortunately, there is a dearth of emergency medicine clinical practice guidelines focusing on adolescent care. The guidelines cited in this issue are based on adult studies, but the recommendations can be extrapolated safely to adolescents as well. These include the United States Centers for Disease Control and Prevention (CDC) Sexually Transmitted Disease (STD) treatment guidelines9 and clinical practice guidelines on ectopic pregnancy.10


Risk Management Pitfalls in the Management of Adolescent Patients With Gynecological Emergencies

1. “The patient said she had never had sex before, so I didn’t do a pregnancy test.”

Adolescents often do not disclose sexual activity, due to concerns about confidentiality. Emergency clinicians should have a low threshold for pregnancy and STI testing in adolescent girls, regardless of the history provided by the patient.

5. “The girl came in with vaginal discharge after intercourse with a partner reporting an STI, so I tested her for gonorrhea and chlamydia. I told her to call back in 2 days for results.”

Studies have shown that adolescents have poor follow-up and can be difficult to contact after presentation to the ED. If there is clinical concern for an STI, treat empirically for both gonorrhea and chlamydia in the ED; do not wait for test results.

9. “I found out the patient was pregnant, so I updated her mom about my plan to transfer her to a hospital with obstetric services.”

Clinicians are prohibited by law from disclosing pregnancy to parents/guardians without the patient’s consent, unless there is concern that the patient will harm herself or someone else. Adolescents aged > 12 years can seek sexual health services for contraception, pregnancy care, STI treatment, and sexual assault care, as well as mental health and substance use services without parental consent. Laws vary by state, so emergency clinicians should be familiar with confidentiality regulations where they practice


Tables and Figures

Differential Diagnosis of Obstetric/Gynecologic-Related Abdominal and Pelvic Pain


Differential Diagnosis of Abnormal Uterine Bleeding




Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

  1. Ziv A, Boulet JR, Slap GB. Emergency department utilization by adolescents in the United States. Pediatrics. 1998;101(6):987-994. (Retrospective study; 3982 patients)
  2. Wilson KM, Klein JD. Adolescents who use the emergency department as their usual source of care. Arch Pediatr Adolesc Med. 2000;154(4):361-365. (Retrospective study; 6748 patients)
  3. Timm NL, McAneney C, Alpern E, et al. Is pediatric emergency department utilization by pregnant adolescents on the rise? Pediatr Emerg Care. 2012;28(4):307-309. (Retrospective study; 15,190 ED visits)
  4. Hock-Long L, Herceg-Baron R, Cassidy AM, et al. Access to adolescent reproductive health services: financial and structural barriers to care. Perspect Sex Reprod Health. 2003;35(3):144-147. (Review article)
  5. Miller MK, Mollen CJ, O’Malley D, et al. Providing adolescent sexual health care in the pediatric emergency department: views of health care providers. Pediatr Emerg Care. 2014;30(2):84-90. (Cross-sectional study; 29 patients)
  6. Miller MK, Pickett M, Leisner K, et al. Sexual health behaviors, preferences for care, and use of health services among adolescents in pediatric emergency departments. Pediatr Emerg Care. 2013;29(8):907-911. (Cross-sectional study; 306 patients)
  7. Emans SJ, Bravender T, Knight J, et al. Adolescent medicine training in pediatric residency programs: are we doing a good job? Pediatrics. 1998;102(3 Pt 1):588-595. (Prospective study; 155 patients)
  8. Balamuth F, Zhao H, Mollen C. Toward improving the diagnosis and the treatment of adolescent pelvic inflammatory disease in emergency departments: results of a brief, educational intervention. Pediatr Emerg Care. 2010;26(2):85-92. (Randomized controlled trial; 237 participants)
  9. Workowski KA, Bolan GA, Centers for Disease Control and Prevention, et al. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137. (CDC guidelines)
  10. Barnhart KT. Clinical practice. Ectopic pregnancy. N Engl J Med. 2009;361(4):379-387. (Review article)
  11. Chumlea WC, Schubert CM, Roche AF, et al. Age at menarche and racial comparisons in US girls. Pediatrics. 2003;111(1):110-113. (Retrospective study; 2510 patients)
  12. Fraser IS, Critchley HO, Broder M, et al. The FIGO recommendations on terminologies and definitions for normal and abnormal uterine bleeding. Semin Reprod Med. 2011;29(5):383-390. (Review article)
  13. Munro MG, Critchley HO, Fraser IS. The FIGO systems for nomenclature and classification of causes of abnormal uterine bleeding in the reproductive years: who needs them? Am J Obstet Gynecol. 2012;207(4):259-265. (Review article)
  14. Fraser IS, Critchley HO, Munro MG. Abnormal uterine bleeding: getting our terminology straight. Curr Opin Obstet Gynecol. 2007;19(6):591-595. (Review)
  15. Lee V, Tobin JM, Foley E. Relationship of cervical ectopy to chlamydia infection in young women. J Fam Plann Reprod Health Care. 2006;32(2):104-106. (Retrospective study; 231 patients)
  16. Brunham RC, Gottlieb SL, Paavonen J. Pelvic inflammatory disease. N Engl J Med. 2015;372(21):2039-2048. (Review article)
  17. Chernick L, Kharbanda EO, Santelli J, et al. Identifying adolescent females at high risk of pregnancy in a pediatric emergency department. J Adolesc Health. 2012;51(2):171-178. (Prospective study; 459 patients)
  18. Finer LB, Zolna MR. Unintended pregnancy in the United States: incidence and disparities, 2006. Contraception. 2011;84(5):478-485. (Retrospective study; registry data)
  19. Goldner TE, Lawson HW, Xia Z, et al. Surveillance for ectopic pregnancy--United States, 1970-1989. MMWR CDC Surveill Summ. 1993;42(6):73-85. (Retrospective study; registry data)
  20. McWilliams GD, Hill MJ, Dietrich CS 3rd. Gynecologic emergencies. Surg Clin North Am. 2008;88(2):265-283. (Review article)
  21. Huancahuari N. Emergencies in early pregnancy. Emerg Med Clin North Am. 2012;30(4):837-847. (Review article)
  22. Gestational trophoblastic disease. In: Cunningham F, Leveno K, Bloom S, et al. eds. Williams Obstetrics. 23rd ed. New York: McGraw Hill Medical; 2010:257. (Textbook chapter)
  23. Sebire NJ. Histopathological diagnosis of hydatidiform mole: contemporary features and clinical implications. Fetal Pediatr Pathol. 2010;29(1):1-16. (Review article)
  24. Guthrie BD, Adler MD, Powell EC. Incidence and trends of pediatric ovarian torsion hospitalizations in the United States, 2000-2006. Pediatrics. 2010;125(3):532-538. (Retrospective study; 1232 patients)
  25. Samuels-Kalow M, Mollen C. Acute pelvic pain in the adolescent: a case report. Clin Pediatr Emerg Med. 2015;16(2):119-124. (Case report; 1 patient)
  26. Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann Emerg Med. 2001;38(2):156-159. (Retrospective study; 87 patients)
  27. Melcer Y, Sarig-Meth T, Maymon R, et al. Similar but different: a comparison of adnexal torsion in pediatric, adolescent, and pregnant and reproductive-age women. J Womens Health (Larchmt). 2016;25(4):391-396. (Retrospectivestudy; 227 patients)
  28. Paltiel HJ, Phelps A. US of the pediatric female pelvis. Radiology. 2014;270(3):644-657. (Review article)
  29. Koyama A, Dorfman DH, Forcier MM. Long-acting reversible contraception in the pediatric emergency department: clinical implications and common challenges. Pediatr Emerg Care. 2015;31(4):286-292. (Review article)
  30. Haamid F, Sass AE, Dietrich JE. Heavy menstrual bleeding in adolescents. J Pediatr Adolesc Gynecol. 2017;30(3):335-340. (Review article)
  31. Ford CA, Millstein SG, Halpern-Felsher BL, et al. Influence of physician confidentiality assurances on adolescents’ willingness to disclose information and seek future health care. A randomized controlled trial. JAMA. 1997;278(12):1029-1034. (Randomized controlled trial; 562 participants)
  32. Musacchio NS, Gehani S, Garofalo R. Emergency department management of adolescents with urinary complaints: missed opportunities. J Adolesc Health. 2009;44(1):81-83. (Retrospective study; 163 patients)
  33. Blake DR, Fletcher K, Joshi N, et al. Identification of symptoms that indicate a pelvic examination is necessary to exclude PID in adolescent women. J Pediatr Adolesc Gynecol. 2003;16(1):25-30. (Prospective study; 193 patients)
  34. Givens TG, Jackson CL, Kulick RM. Recognition and management of pregnant adolescents in the pediatric emergency department. Pediatr Emerg Care. 1994;10(5):253-255. (Retrospective study; 94 patients)
  35. James AH. Bleeding disorders in adolescents. Obstet Gynecol Clin North Am. 2009;36(1):153-162. (Review article)
  36. Brown J, Fleming R, Aristzabel J, et al. Does pelvic exam in the emergency department add useful information? West J Emerg Med. 2011;12(2):208-212. (Prospective study; 183 patients)
  37. Silva C, Sammel MD, Zhou L, et al. Human chorionic gonadotropin profile for women with ectopic pregnancy. Obstet Gynecol. 2006;107(3):605-610. (Cohort study; 200 patients)
  38. Causey AL, Seago K, Wahl NG, et al. Pregnant adolescents in the emergency department: diagnosed and not diagnosed. Am J Emerg Med. 1997;15(2):125-129. (Retrospective study; 271 patients)
  39. Goyal M, Hersh A, Luan X, et al. Frequency of pregnancy testing among adolescent emergency department visits. Acad Emerg Med. 2013;20(8):816-821. (Retrospective study; 11,531 ED visits)
  40. ACOG Committee Opinion No. 349, November 2006: Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Obstet Gynecol. 2006;108(5):1323-1328. (Committee Opinion)
  41. Emans SJ. Dysfunctional uterine bleeding. In: Emans SJ, Laufer MR. eds. Pediatric and Adolescent Gynecology. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2005:270. (Textbook chapter)
  42. Uppal A, Chou KJ. Screening adolescents for sexually transmitted infections in the pediatric emergency department. Pediatr Emerg Care. 2015;31(1):20-24. (Prospective study; 307 patients)
  43. Chernesky M, Jang D, Gilchrist J, et al. Head-to-head comparison of second-generation nucleic acid amplification tests for detection of Chlamydia trachomatis and Neisseria gonorrhoeae on urine samples from female subjects and self-collected vaginal swabs. J Clin Microbiol. 2014;52(7):2305-2310. (Prospective study; 575 patients)
  44. Demetriou E, Emans SJ, Masland RP Jr. Dysuria in adolescent girls: urinary tract infection or vaginitis? Pediatrics. 1982;70(2):299-301. (Prospective study; 53 patients)
  45. Huppert JS, Biro F, Lan D, et al. Urinary symptoms in adolescent females: STI or UTI? J Adolesc Health. 2007;40(5):418-424. (Cross-sectional study; 296 patients)
  46. Marin JR, Abo AM, Arroyo AC, et al. Pediatric emergency medicine point-of-care ultrasound: summary of the evidence. Crit Ultrasound J. 2016;8(1):16. (Review article)
  47. McRae A, Murray H, Edmonds M. Diagnostic accuracy and clinical utility of emergency department targeted ultrasonography in the evaluation of first-trimester pelvic pain and bleeding: a systematic review. CJEM. 2009;11(4):355-364. (Review article)
  48. Levy JA, Noble VE. Bedside ultrasound in pediatric emergency medicine. Pediatrics. 2008;121(5):e1404-e1412. (Review article)
  49. Thamburaj R, Sivitz A. Does the use of bedside pelvic ultrasound decrease length of stay in the emergency department? Pediatr Emerg Care. 2013;29(1):67-70. (Retrospective study; 330 patients)
  50. Crochet JR, Bastian LA, Chireau MV. Does this woman have an ectopic pregnancy? The rational clinical examination systematic review. JAMA. 2013;309(16):1722-1729. (Systematic review; 14 studies, 12,101 patients)
  51. Albayram F, Hamper UM. First-trimester obstetric emergencies: spectrum of sonographic findings. J Clin Ultrasound. 2002;30(3):161-177. (Review article)
  52. Moore C, Todd WM, O’Brien E, et al. Free fluid in Morison’s pouch on bedside ultrasound predicts need for operative intervention in suspected ectopic pregnancy. Acad Emerg Med. 2007;14(8):755-758. (Prospective study; 242 patients)
  53. McGee DM, Connolly SA, Young RH. Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 24-2003. A 10-year-old girl with recurrent bouts of abdominal pain. N Engl J Med. 2003;349(5):486-494. (Case Report; 1 patient)
  54. Wilkinson C, Sanderson A. Adnexal torsion -- a multimodality imaging review. Clin Radiol. 2012;67(5):476-483. (Review article)
  55. Pecchioli Y, Oyewumi L, Allen LM, et al. The utility of routine ultrasound in the diagnosis and management of adolescents with abnormal uterine bleeding. J Pediatr Adolesc Gynecol. 2017;30(2):239-242. (Retrospective study; 230 patients)
  56. Swenson DW, Lourenco AP, Beaudoin FL, et al. Ovarian torsion: case-control study comparing the sensitivity and specificity of ultrasonography and computed tomography for diagnosis in the emergency department. Eur J Radiol. 2014;83(4):733-738. (Retrospective study; 40 patients)
  57. Waseem M, Gernsheimer J, Perales O. Two adolescents with ectopic pregnancies: experience with methotrexate. Pediatr Emerg Care. 2006;22(7):497-499. (Case report; 2 patients)
  58. Fung Kee Fung K, Eason E, Crane J, et al. Prevention of Rh alloimmunization. J Obstet Gynaecol Can. 2003;25(9):765-773. (Clinical practice guidelines)
  59. Huguelet PS, Buyers EM, Lange-Liss JH, et al. Treatment of acute abnormal uterine bleeding in adolescents: what are providers doing in various specialties? J Pediatr Adolesc Gynecol. 2016;29(3):286-291. (Retrospective study;150 patients)
  60. Bennett AR, Gray SH. What to do when she’s bleeding through: the recognition, evaluation, and management of abnormal uterine bleeding in adolescents. Curr Opin Pediatr. 2014;26(4):413-419. (Review article)
  61. Kessous R, Aricha-Tamir B, Sheizaf B, et al. Clinical and microbiological characteristics of Bartholin gland abscesses. Obstet Gynecol. 2013;122(4):794-799. (Retrospective study; 219 patients)
  62. Marzano DA, Haefner HK. The Bartholin gland cyst: past, present, and future. J Low Genit Tract Dis. 2004;8(3):195-204. (Review article)
  63. Krivochenitser R, Bicker E, Whalen D, et al. Adolescent women with sexually transmitted infections: who gets lost to follow-up? J Emerg Med. 2014;47(5):507-512. (Retrospective study; 382 patients)
  64. Pattishall AE, Rahman SY, Jain S, et al. Empiric treatment of sexually transmitted infections in a pediatric emergency department: are we making the right decisions? Am J Emerg Med. 2012;30(8):1588-1590. (Prospective study;198 patients)
  65. Rhodes KV, Bisgaier J, Becker N, et al. Emergency care of urban women with sexually transmitted infections: time to address deficiencies. Sex Transm Dis. 2009;36(1):51-57. (Prospective study; 134 patients)
  66. Golden MR, Whittington WL, Handsfield HH, et al. Effect of expedited treatment of sex partners on recurrent or persistent gonorrhea or chlamydial infection. N Engl J Med. 2005;352(7):676-685. (Randomized controlled trial; 5252 participants)
  67. Goyal M, Hersh A, Luan X, et al. Are emergency departments appropriately treating adolescent pelvic inflammatory disease? JAMA Pediatr. 2013;167(7):672-673. (Retrospective study; 704,882 ED visits)
  68. Savaris RF, Teixeira LM, Torres TG, et al. Comparing ceftriaxone plus azithromycin or doxycycline for pelvic inflammatory disease: a randomized controlled trial. Obstet Gynecol. 2007;110(1):53-60. (Randomized controlled trial; 120 participants)
  69. Crawford-Jakubiak JE, Alderman EM, Leventhal JM, et al. Care of the adolescent after an acute sexual assault. Pediatrics. 2017;139(3). (Review article)
  70. Centers for Disease Control and Prevention. Hotlines and referrals. Accessed January 15, 2019. (CDC resources)
  71. (AGI) The Alan Guttmacher Institute. Minors’ access to contraceptive services. Accessed January 15, 2019. (Report)
  72. Sigman G, Silber TJ, English A, et al. Confidential health care for adolescents: position paper of the Society for Adolescent Medicine. J Adolesc Health. 1997;21(6):408-415. (Position statement)
  73. Srivaths LV, Dietrich JE, Yee DL, et al. Oral tranexamic acid versus combined oral contraceptives for adolescent heavy menstrual bleeding: a pilot study. J Pediatr Adolesc Gynecol. 2015;28(4):254-257. (Randomized controlledtrial; 17 participants)
  74. Davies J, Kadir RA. Heavy menstrual bleeding: an update on management. Thromb Res. 2017;151 Suppl 1:S70-S77. (Review article)
  75. Rein DB, Kassler WJ, Irwin KL, et al. Direct medical cost of pelvic inflammatory disease and its sequelae: decreasing, but still substantial. Obstet Gynecol. 2000;95(3):397-402. (Retrospective study; 3 years of claims data and national survey data)
  76. Trent M, Ellen JM, Frick KD. Estimating the direct costs of pelvic inflammatory disease in adolescents: a within-system analysis. Sex Transm Dis. 2011;38(4):326-328. (Retrospective study; 1 year of hospital charges)
Publication Information

Tatyana Vayngortin, MD; Shruti Kant, MD, FAAP

Peer Reviewed By

Geri Hewitt, MD; Beth W. Rackow, MD

Publication Date

February 1, 2019

Pub Med ID: 30676713

Get Permission

Content you might be interested in
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

Money-back Guarantee
Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.