Initiation of gynecologic care in healthy young women.
Make it a policy to take the gynecologic history with the patient without the parent being present, starting at the age of 14 years or earlier, on an individualized basis. Asking the parent to leave the room as a part of routine practice makes this discussion far easier.
Start your consultation by asking specific questions about the girl's menstrual period. Oftentimes, their periods are irregular, painful, or heavier/longer than they think is normal. If this is the case, it is appropriate to refer your patient to a gynecologist. Also refer your patient if she expresses an interest in seeing a gynecologist for any reason.
Ask about boyfriends, sexual activity, and birth control. Often, girls do not want their parents to know about their sexual activity. I recommend you tell parents that you routinely recommend referral to a gynecologist at a certain age to address menstrual issues. This is an easy way to bring up the subject without making the patient or parent feel uncomfortable.
As a general pediatrician, you can manage this type of patient if you feel comfortable with discussion and management of problematic periods, birth control, and sexual activity. You also should be comfortable with counseling your patients on sexually transmitted disease (STD) prevention and other preventive tools, such as the human papillomavirus (HPV) vaccine.
I want pediatricians to routinely discuss the HPV vaccine with their patients and parents. The HPV vaccine is ideally given to young women before they are sexually active, as early as age 9 years. By the time most girls see a gynecologist for the first time, they are already sexually active and have already been exposed to HPV.
Pediatricians can help by encouraging parents to vaccinate their 9- to 13-yearolds. This discussion also should be taking place with parents of boys.
I realize that there is a wide range in how pediatricians practice. Some feel completely comfortable with gynecologic care in this age group and will perform gynecologic exams, STD testing, and prescribe birth control if necessary. Others might have the discussion and then refer if an exam or prescription for birth control is required. Others may not even feel comfortable having the discussion. So I think gynecologic referral of a patient in this age group is based on the comfort level of the pediatrician.
If you do refer to a gynecologist, you can help prepare a girl by letting her know what to expect. For example, if a girl is being sent for evaluation of vaginal discharge, the patient needs to understand that she is going to have an internal examination with a speculum. I have seen several young women for evaluation of this problem who were surprised that I had to examine them. Discharge cannot be appropriately evaluated simply by talking to the patient. So you can alleviate a lot of anxiety by explaining the exam to the patient ahead of time.
On the other hand, not every young woman needs to be examined during her first gynecologist visit. If her initial appointment is a discussion regarding menstrual cycles or birth control, I often just take a history to establish rapport with the patient. I often want to do this in private, without a parent, so that I can comfortably ask questions about personal issues such as sexual activity. It is very helpful if you can prepare the parent ahead of time that this private discussion will need to take place.
Several physician organizations provide recommendations and other guidance for management of these patients. The American Academy of Pediatrics provides relevant resources for pediatricians. For example, in September 2010, it published a Clinical Report on Gynecologic Examination for Adolescents in the Pediatric Office Setting (http://aappolicy.aappublications.org/cgi/content/full/pediatrics; 126/3/583).
You also might consider consulting with colleagues, including an ob.gyn. or a pediatrician who is fellowship trained in adolescent pediatrics.
JENNIFER MILOSAVLJEVIC, M.D.
DR. MILOSAVLJEVIC is an ob.gyn. with Women's Health Services at Henry Ford Hospital in Detroit. Dr. Milosavljevic said she did not have any relevant disclosures.
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|Title Annotation:||SUBSPECIALIST CONSULT|
|Date:||Mar 1, 2011|
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