Original Report| Volume 32, ISSUE 5, P520-524, October 2019

Documentation of Sexual and Menstrual Histories for Adolescent Patients in the Inpatient Setting


      Study Objective

      In this study, we aimed to determine the frequency of menstrual history and sexual history documentation in the inpatient setting.

      Design, Setting, and Participants

      A retrospective chart review was conducted for 307 female patients ages 11-18 years admitted from the emergency department at a single institution within a 7-month period. These charts were reviewed for documentation of menstrual and sexual history.

      Interventions and Main Outcome Measures

      Rates of menstrual and sexual history documentation were compared according to patient age, chief complaint, admitting specialty, and medical complexity.


      Sexual history documentation was noted in 158 (45.9%) of the 344 reviewed charts. Sexual history documentation rates were higher for patients with mental health symptoms (62.9%; 61 of 98 charts; P = .02) and lower for patients admitted to surgical services (30.6%; 19 of 62 charts; P = .04). At least 1 aspect of menses was documented in 113 (32.8%) of the 344 reviewed charts. Last menstrual period was the most commonly documented aspect of menstrual history, appearing in 100 (29.1%) of the 344 reviewed charts. Menarche (4.4%; 15/344), menses frequency (7.0%; 24/344), menses duration (2.6%; 9/344), flow quantity (4.9%; 17/344), and dysmenorrhea (4.4%; 15/344) were rarely documented, regardless of chief complaint or admitting service. Menstrual history documentation rates were significantly higher for patients requiring a gynecology consultation (73.3%; 11 of 15 charts; P < .01).


      Menstrual and sexual history documentation rates for adolescent patients requiring inpatient admission were low, with fewer than half of patients having a documented menstrual or sexual history.

      Key Words

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        • ACOG committee opinion no
        651: Menstruation in girls and adolescents: using the menstrual cycle as a vital sign.
        Obstet Gynecol. 2015; 126: e143
        • Golden N.H.
        • Carlson J.L.
        The pathophysiology of amenorrhea in the adolescent.
        Ann N Y Acad Sci. 2008; 1135: 163
        • Wimberly Y.H.
        • Hogben M.
        • Moore-Ruffin J.
        • et al.
        Sexual history-taking among primary care physicians.
        J Natl Med Assoc. 2006; 98: 1924
        • Diclemente R.J.
        • Wingood G.M.
        • Sionean C.
        • et al.
        Association of adolescents’ history of sexually transmitted disease (STD) and their current high-risk behavior and STD status: a case for intensifying clinic-based prevention efforts.
        Sex Transm Dis. 2002; 29: 503
      1. ACOG practice bulletin no. 152: emergency contraception.
        Obstet Gynecol. 2015; 126: e1
        • Gray M.E.
        • Shenoi S.V.
        • Dillingham R.
        Pre-exposure prophylaxis as HIV prevention in high risk adolescents.
        J Pediatr Pediatr Med. 2018; 2: 5
        • Hay P.E.
        • Kerry S.R.
        • Normansell R.
        • et al.
        Which sexually active young female students are most at risk of pelvic inflammatory disease? A prospective study.
        Sex Transm Infect. 2016; 92: 63
        • Bodurtha Smith A.J.
        • Holzman S.B.
        • Manesh R.S.
        • et al.
        Gonococcal conjunctivitis: a case report of an unusual mode of transmission.
        J Pediatr Adolesc Gynecol. 2017; 30: 501
        • Javanbakht M.
        • Gorbach P.
        • Stirland A.
        • et al.
        Prevalence and correlates of rectal chlamydia and gonorrhea among female clients at sexually transmitted disease clinics.
        Sex Transm Dis. 2012; 39: 917
        • O’Halloran C.
        • Winn A.
        Case 3: persistent pharyngitis in a 14-year-old girl.
        Pediatr Rev. 2018; 39: 213
        • Silber T.J.
        • Controni G.
        Clinical spectrum of pharyngeal gonorrhea in children and adolescents: a report of sixteen patients.
        J Adolesc Health Care. 1983; 4: 51
        • Andrade S.E.
        • Raebel M.A.
        • Morse A.N.
        • et al.
        Use of prescription medications with a potential for fetal harm among pregnant women.
        Pharmacoepidemiol Drug Saf. 2006; 15: 546
        • ACOG committee opinion no
        723 summary: guidelines for diagnostic imaging during pregnancy and lactation.
        Obstetr Gynecol. 2017; 130: 933
        • Boekeloo B.O.
        • Schamus L.A.
        • Cheng T.L.
        • et al.
        Young adolescents’ comfort with discussion about sexual problems with their physician.
        Arch Pediatr Adolesc Med. 1996; 150: 1146
        • Goyal M.K.
        • Witt R.
        • Hayes K.L.
        • et al.
        Clinician adherence to recommendations for screening of adolescents for sexual activity and sexually transmitted infection/human immunodeficiency virus.
        J Pediatr. 2014; 165: 343
        • Tomlin K.
        • Mirea L.
        • Williamson A.
        Pediatric and gynecologic rates of documentation of last menstrual period in female adolescents.
        J Pediatr Adolesc Gynecol. 2018; 31: 346
        • McShane M.
        • Perucho J.
        • Olsakowski M.
        • et al.
        Menstrual history-taking at annual well visits for adolescent girls.
        J Pediatr Adolesc Gynecol. 2018; 31: 566
        • Goyal M.
        • McCutcheon M.
        • Hayes K.
        • et al.
        Sexual history documentation in adolescent emergency department patients.
        Pediatrics. 2011; 128: 86
        • Powell-Bowns M.
        • Wilson M.S.
        • Mustafa A.
        Documentation of pregnancy status, gynaecological history, date of last menstrual period and contraception use in emergency surgical admissions: time for a change in practice?.
        World J Surg. 2015; 39: 2849
        • Zannoni L.
        • Giorgi M.
        • Spagnolo E.
        • et al.
        Dysmenorrhea, absenteeism from school, and symptoms suspicious for endometriosis in adolescents.
        J Pediatr Adolesc Gynecol. 2014; 27: 258
        • Klein J.R.
        • Litt I.F.
        Epidemiology of adolescent dysmenorrhea.
        Pediatrics. 1981; 68: 661
        • Kim H.K.
        • Kim H.S.
        • Kim S.J.
        Association of anxiety, depression, and somatization with menstrual problems among north korean women defectors in South Korea.
        Psychiatry Investig. 2017; 14: 727
        • Liu X.
        • Yang Y.
        • Yuan P.
        • et al.
        A study of the relationship between mental health and menstrual abnormalities in female middle school students from postearthquake Wenchuan.
        Biosci Trends. 2010; 4: 4
        • Takechi K.
        • Yoshioka Y.
        • Kawazoe H.
        • et al.
        Psychiatric patients with antipsychotic drug-induced hyperprolactinemia and menstruation disorders.
        Biol Pharm Bull. 2017; 40: 1775
        • Hillard P.J.A.
        Puberty, menarche, and the menstrual cycle: What do we know, and what do we teach?.
        J Pediatr Adolesc Gynecol. 2018; 31: 331
        • Talib H.J.
        • Karjane N.
        • Teelin K.
        • et al.
        Resident education curriculum in pediatric and adolescent gynecology: the short curriculum 2.0.
        J Pediatr Adolesc Gynecol. 2018; 31: 71