For many teenagers, the first visit to the gynecologist can be intimidating. The prospect of meeting a new doctor asking curious, deeply personal questions about sex and menstruation is daunting. And most likely, parents, older siblings, or friends warned them about the infamous pelvic exam.
The exact time when adolescent patients should start visiting a gynecologist depends on when a patient hits puberty. Family doctors and pediatricians can help teenagers transition by referring patients to a youth-friendly practice and clearing up some of the misunderstandings that arise during the first gynecological visit. Gynecologists on the other side of the referral can help patients transition by ensuring confidentiality and creating a safe space for young patients.
Medscape Medical News spoke to three adolescent health experts about when teenagers should be catered for their gynecological needs and how their doctors can help them make the transition.
Age-appropriate care
Dr. Anne-Marie Amies Oelschlager
“Most people have very limited information about their reproductive health,” said Anne-Marie Amies Oelschlager, MD, a pediatric gynecologist at Seattle Children’s, Seattle, Washington and a member of the American College of Obstetricians and Gynecologists (ACOG) Clinical Consensus Committee Gynecology.
ACOG official guidelines require that the first reproductive health visit be between the ages of 13 and 15. However, the exact age may vary depending on the specific needs of the patient.
For example, some patients start menstruating early, by the age of 9 or 10, said Mary Romano, MD, MPH, a pediatrician and specialist in adolescent medicine at Vanderbilt Children’s Hospital in Nashville, Tennessee. Pediatricians who find it uncomfortable to tell young patients about menstruation should refer the patient to a gynecologist, for whom such discussions are routine.
Dr. Mary Romano
If a patient does not have a menstrual cycle by the age of 14 or 15, this should also be treated by a family doctor or gynecologist, Romano added.
“The importance here is to address teen reproductive health from the age of 10 or 12 or the onset of puberty,” said Patricia Huguelet, MD, pediatric gynecologist at Children’s Hospital Colorado, Aurora, Colorado. During these early visits, the doctor can provide “predictive guidance”, advise the teen about what’s normal for menstruation, sex, and relationships, and address what isn’t, she said.
Dr. Patricia Huguelet
Ideally, patients who were labeled female at birth but now identify as male or non-binary will meet with a gynecologist early in the sex determination process and a gynecologist will continue to be part of the patient’s interdisciplinary treatment team , Romano, who advises LGBTQ + adolescents, consults as part of their practice, added. A gynecologist can assist these patients in a variety of ways, including helping those who are considering or using puberty blockers, and providing reproductive and health education to patients in a manner that takes into account the patient’s gender identity.
Patient recommendations
Some pediatricians and general practitioners may speak to their patients about topics such as the menstrual cycle and birth control. However, anyone who feels uncomfortable asking adolescent patients about their reproductive and sexual health should refer them to a gynecologist or specialist in adolescent medicine, Romano advised.
“The biggest benefit I’ve noticed is often [patients] come from a pediatrician or medical professional and often appreciate the opportunity to speak to a doctor they have never met about their personal issues, “Amies Oelschlager told Medscape Medical News.
Referring teens to a specialist who is either trained in adolescent medicine or has experience treating this age group has benefits, Romano said. Clinicians with this experience know that adolescents are not “mini-adults” but have unique developmental and medical problems. How to counsel and educate them poses unique challenges, she said.
For example, heavy menstrual bleeding is a major reason a patient – either an adult or a teenager – presents to a gynecologist, Huguelet said. But the pathology is very different for these two age groups. In patients between the ages of 30 and 40, polyps and fibroids are common problems associated with profuse bleeding. These disorders are rare in teenagers, while bleeding disorders are common, she said.
Most patients will continue to see their pediatrician and general practitioner for other issues. And in some areas, gynecologists can reinforce advice from pediatricians, such as encouraging patients to receive the HPV vaccine, said Amies Oelschlager.
Common misunderstandings
Family doctors can also help clear up common misconceptions teenagers – and their parents – have about gynecology. Some parents may believe that certain birth control methods cause cancer or infertility, have concerns about the HPV vaccine, or think hormone therapies are harmful, Amies Oelschlager said. But the biggest misconception concerns the infamous pelvic exam.
“Many patients assume that every time they go to the gynecologist they will have a pelvic exam,” she said. “When I say, ‘We don’t have to do this,’ they are so relieved.”
The guidelines have changed since the parents of today’s teenagers first went to the gynecologist. Many patients don’t need their first Pap smear until they are 25 years old after the American Cancer Society recently changed guidelines. (ACOG is considering taking the same stance, but still recommends starting screening at 21.) “Most patients don’t need a screening, even when it comes to sexual health and screening [for sexually transmitted infections]that goes without a test, “said Huguelet.
Confidentiality and Comfort
On the other side of the referral, gynecologists should follow several best practices to treat adolescent patients. Arguably the most important part of the first gynecological visit is giving patients the opportunity to have one-on-one meetings with the doctor without a parent in the room. During this time, the doctor should make it clear that what he is discussing is confidential and will not be shared with his or her parents or guardians, Huguelet said. Patients should also be able to have a friend or other non-parenting person in the room during this face-to-face conversation with the doctor, especially if the patient is uncomfortable, to discuss sensitive issues alone.
Young people are better looked after, reveal more and perceive that they are better looked after when the process is confidential, said Romano. However, there are limits to confidentiality that, as per ACOG guidelines for the first reproductive visit, physicians should also make clear to their patients. These restrictions may vary by state, depending on reporting issues, insurance billing, and legal requirements for patient reporting for certain services such as abortion.
The use of electronic medical records has brought additional challenges for private communication with adolescent patients, said Amies Oelschlager. In her practice, she tries to ensure that the young person is the one who has the access data for their records. If not, their office has the patient’s cell phone number to be sure to text or call.
“We firmly believe that adolescents should have access to reproductive health care, psychiatric care and treatment for addictions without notifying their parents,” said Amies Oelschlager.
Telemedicine visits can also be helpful for young people entering gynecology for the first time. And taking the time to develop a relationship with patients at the beginning of the visit, Huguelet said. By directing questions to the adolescent patients rather than their parents, Huguelet shows that she is there primarily to address the needs of the teenage boy.
ACOG has guidelines on other steps gynecological practices, including those visiting both adults and adolescents, can take to make their practices and visits more youth-friendly. These steps include asking patients about their preferred names and pronouns at the beginning of the visit or as part of the initial admission form, training office staff to familiarize themselves with issues relating to the patient’s adolescent sexuality and gender and sexual diversity, and providing space for adolescents who have to wait apart from obstetricians; and age-appropriate literature on hand so adolescents can learn more about reproductive health.
After that initial reproductive health visit, gynecologists and general practitioners should also work together to ensure that their patients’ overall health is considered, Huguelet said.
“Working together will always serve patients better in every area,” said Romano, “and this area is certainly no different.”
Amies Oelschlager, Romano and Huguelet have not disclosed any relevant financial relationships.
Jillian Mock is a freelance science writer based in New York City. She writes about health, climate change and the environment. Her work has appeared in many publications, including the New York Times, Audubon Magazine, and Scientific American.
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