Episode 9.9 Pediatric & Adolescent Gynecology Essentials

Join Howard and Janeen Arbuckle for this discussion of pediatric and adolescent gynecology essentials. Pediatric and adolescent gynecology is a newer discipline bringing specialized care to young women with unique gynecologic needs, with a focus on counseling, education, and age-appropriate interventions.

• Abnormal uterine bleeding in adolescents is rarely caused by structural problems (unlike in adults) and typically relates to immaturity of the hypothalamic-pituitary-ovarian axis
• Hematologic workup should be considered for adolescents with heavy menstrual bleeding as this may be the first time their clotting system is challenged
• Hormonal therapies are safe to use once menarche has occurred, with no impact on bone growth
• Long-acting reversible contraceptives offer superior pregnancy prevention (1 in 10,000 for implants vs 8 in 100 for typical pill use) but require thoughtful counseling
• Private interviews with adolescent patients create trust while preparing them for independent healthcare navigation
• Tranexamic acid is effective for heavy menstrual bleeding in adolescents but pill size and frequency can limit compliance
• Most ovarian cysts in adolescents represent normal physiologic function and rarely require intervention
• Preservation of reproductive organs should be prioritized in adolescent surgery, including leaving ovaries after torsion when possible
• Vaginal bleeding in pre-pubertal girls requires assessment for secondary sexual characteristics to distinguish precocious puberty from other causes

00:00:00 Introduction to Pediatric Gynecology

00:07:20 Abnormal Uterine Bleeding in Adolescents

00:19:36 Contraception Choices for Young Patients

00:29:40 Managing Difficult Patient-Parent Conversations

00:38:04 Pelvic Pain and Endometriosis

00:46:58 Adnexal Pathology and Ovarian Issues

00:50:51 Congenital Anomalies and Vaginal Bleeding

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Chapters

• 0:00 Introduction to Pediatric Gynecology
• 7:20 Abnormal Uterine Bleeding in Adolescents
• 19:36 Contraception Choices for Young Patients
• 29:40 Managing Difficult Patient-Parent Conversations
• 38:04 Pelvic Pain and Endometriosis
• 46:58 Adnexal Pathology and Ovarian Issues
• 50:51 Congenital Anomalies and Vaginal Bleeding

Transcript

Announcer: 0:01

Welcome to Thinking About OB-GYN. Today's episode features Howard Harrell and Janine Arbuckle discussing pediatric and adolescent gynecology.

Janeen: 0:15

Howard.

Howard: 0:15

Janine.

Janeen: 0:16

What are we going to talk about today?

Howard: 0:18

Well, you're going to teach us something about pediatric and adolescent gynecology.

Janeen: 0:24

I will do my best.

Howard: 0:25

All right, well, for the listeners, let me introduce my friend, janine Arbuckle. She's a faculty member at the University of Alabama in Birmingham and she did a pediatric and adolescent gynecology fellowship there I think at UAB right. So we're going to learn some stuff from her today and I thought we could talk about a few things that you'd like to teach general OBGYNs about pediatric and adolescent gynecology, or stuff we do wrong, or whatever.

Janeen: 0:50

Got it, so you're going to sit back and ask some questions.

Howard: 0:55

Well, you'll be able to talk enough for both of us, so I'm not worried about that.

Janeen: 0:58

I'm not sure that anyone talks as much as you.

Howard: 1:02

Okay, so this will be therapeutic for me to see how much I can keep my mouth shut for an hour. Is that what you're saying?

Janeen: 1:10

Or longer, however much time you need.

Howard: 1:12

You might need two hours. That's fine, All right, Well for our listeners. So we have lots of residents too who listen and people who might be interested in pediatric adolescent gynecology, and I suspect a lot of non-obese don't even really know that this is a fellowship. But tell us a little bit about a pediatric adolescent gynecology subspecialty. What's the difference in your patient population and in the normal gynecologic patient population? What kind of issues do you see a lot of? How does it compare?

Janeen: 1:39

Yeah, sure, so I should qualify this in that I do still do general obstetrics and gynecology, so there's a lot of overlap between kind of a general OBGYN population and my PAC population In general. However, when you think about the PAC population, we see a lot of peripubertal concerns Is it happening too soon, is it happening too late? And obviously there's a lot of menstrual irregularity in this population. We've all been familiar with the acronym palm colon and typically our knee-jerk response when we see somebody with abnormal uterine bleeding in the adult population is to start work out for a structural etiology. Right, we live in the South, we're assuming it's going to be fibroids. We're going along with kind of the structural palm component of the acronym. In the reality, structural etiologies for abnormal bleeding in the adolescents are super uncommon and so we think more about that Cohen element. So more of the endocrinopathies, immaturity to HPO access, so imaging isn't super helpful in this population. Health exams are rarely indicated and a lot of what we do is talk and talk and talk and take lots and lots of history.

Howard: 2:43

For the listeners, we're not really going to spend two hours, even though she does like to talk and talk and talk.

Janeen: 2:51

I do love to talk and counsel and so a lot of counseling happens in the PAG environment. So we're all familiar with the gynecology element being an OBGYN and there's a lot of that for adolescents. Adolescents often have a lot of pelvic pain and they will present with primary dysmenorrhea and we will initiate patients on initial therapies even at that first visit.

Janeen: 3:12

We'll also see pre-pubertal children. That's not a large portion of my particular practice, but pre-pubertal children often present with vulvovaginitis and then obviously, where those pubertal concerns of somebody showing some signs of early puberty, and then obviously for those puberal concerns of somebody showing some signs of early puberty.

Howard: 3:26

Yeah, okay. Well, what are some of the misconceptions that general OBGYNs or others might have about PAG? Pag's a cool thing, right, yeah, and is it true? I heard this. Is it true that you all call each other pagans? Pagans?

Janeen: 3:41

We call each other lots of things and I'm sure that there are pagans among us. I think that most people I think people are scared of adolescence for multiple reasons, just because it's such a time of fluctuation and it's sometimes a hard age group to relate to and even more hard to relate to children right. So we can be very concerned about oh my goodness, should I do an exam? I didn't look, what's it supposed to look like? So I think a lot of general OBGYNs kind of enter it with a lot of fear, particularly for the pediatrics, and then not knowing what's best for what's safe in adolescence. So one of the most common hesitancies we see with adult OBGYN providers is that they're fearful to start girls on hormonal therapies for their menstrual cycle. And though we certainly don't want to do hormonal therapies in individuals who have not yet had menarche, once a patient has completed menarche it is really safe to use any hormonal therapy for the management of menses.

Howard: 4:36

Yeah, I think people don't understand a lot of times if you're interfering with the growth of long bones, if that sort of thing. I think that that's maybe the concern there, but it's not an issue.

Janeen: 4:45

That's correct. That's correct. So essentially, once menarche is hit, it's safe to use any hormonal therapy, inclusive of those that have estrogen, provided there is no other contraindication to estrogen. Those contraindications to estrogen in the adolescent population are the same as the adult population, unless that adolescent has multiple comorbid conditions that we don't typically see in adults, such as some of the complex heart defects.

Howard: 5:07

I think we also hear sometimes that maybe a stigma about overtreating with birth control pills or something in the first six months or so after, because I guess we're treating something that doesn't need to be treated or it's going to get better if you just give time.

Janeen: 5:21

You're right. So time is a great therapy and some people elect for that. I think most people in our care are not knowing what's normal and what to expect, and to me, observation is always acceptable, with a couple of restraints, right. So I always review normal menstrual cycles and they're pretty much just like adults, with the exception that we'll let adolescents go 45 days between menstrual cycles. However, if a patient's in our care, if they're coming to a pediatric analyst or gynecologist they've already probably discussed this with their pediatrician it's probably met the level of concern to be treated. Those are girls who have profound dysmenorrhea preventing them from going to school. Those are girls who saturate a pad or tampon in two hours. Those are the girls that are anemic and really need an intervention to protect them and are really seeing quality of life measures being influenced by their menstrual cycle.

Howard: 6:07

Well, we can talk more about some of that stuff in a few minutes, but before we get going too much, can you describe maybe for some of the med students or residents that listen like what is the? What type of fellowship training? How do you become a pagan or, I'm sorry, a PAG specialist? And then, and what is your training? What unique skills and knowledge makes that fellowship worthwhile?

Janeen: 6:28

Yeah, so I will say that the pediatric and adolescent gynecology is a newer discipline. It's not one of the ABOG recognized subspecialties, so it doesn't have all the formulaic things that, for instance, a, an MFM fellowship would have. So there's some variability in what you're going to get exposed to across the country. The fundamentals of pediatric and adolescent gynecology, the sub-sociality training, are going to get you exposure to pediatric urology, pediatric surgery, adolescent medicine and definitely pediatric endocrinology. These are the people that have typically been handling these before the advent of pediatric and adolescent gynecology, right? The reality is that a lot of urologists don't want to deal with adolescents going through puberty, right? A lot of pediatric surgeries don't want to manage adnexal masses, and there's actually good data that girls with adnexal masses are more likely to have ovarian conserving surgeries if they have a pediatric and adolescent gynecology care for them, and so that's why this subdiscipline arose.

Howard: 7:24

Okay, Well, you already mentioned abnormal uterine bleeding. That's certainly in my mind that's going to be one of the more common things that at least a general gynecologist might see from an adolescent population, if not in the subspecialist office, but a very common issue. So what's different about it? What are some of the common etiologies in the adolescent group? You mentioned that the structural problems are less of an issue, which again in adults, gynecologists go straight to those things, but how does the diagnostic workup and the approach differ for the adolescent population?

Janeen: 7:54

So again, the very first thing is going to be taking that really good history and making sure that they really are having amniodarum bleeding, and again that's bleeding that uses more than lasts longer than seven days, is using more than six pads a day, and so we really focus on the normal functioning of the HPO axis and that's by far derangements in that functioning is by far the most common reason for an adolescent to present for that normal uterine bleeding. So, as we previously discussed observation sometimes we'll just iron this out it's also really important to realize that this is when menarche and menses will often be the first time a patient's hematologic system is really first challenged. These girls may have never had surgery, they've never had a requirement to activate their clotting cascade, and so this will also be a time when we actually do have to work up a patient for hematologic abnormality.

Howard: 8:41

And that's a difference too. In an adult population you might not think to just based upon abnormal bleeding alone you might not do a workup for a bleeding disorder. But in a pediatric population it really should be part of that workup, right.

Janeen: 8:54

That's correct.

Howard: 8:55

So how do you do that, like practically speaking?

Janeen: 8:58

As a referral center, we will often do more extensive testing because, again, these patients have already been screened. Obviously, the very first thing you're going to screen for anybody with abnormal bleeding is their just baseline count. So a full CBC with a ferritin, looking for that iron deficiency, looking for anemia In those women who are having bleeding to the point of anemia. It is super important to look at their COAG. It's important to screen for von Willebrand's factor deficiencies and it's also important to look at platelet aggregation. Those are the three things that you want to look at. Those are some specialty tests. Not all centers are going to have those tests, so it's going to be important to know what's locally available. For instance, at my institution you can't do a platelet aggregation study in the afternoon, so understanding some of the limitations in your own hospital system or own laboratory system is going to be super valuable as you try to navigate that for your patients.

Howard: 9:47

And for Von Miller brands. Do you start with like a platelet function assay or do you go to genetic testing?

Janeen: 9:53

I don't. I do the activity assay. So we have the, we have a power plan that allows me to do all the parameters of the. Von Miller brands testing. So you do that as a screen and then you proceed.

Howard: 10:04

Yeah, correct, all right. Well, and we also briefly mentioned well, we mentioned birth control pills and people's hesitancy for that but what would be the first line of medical treatment? So I guess in the vignette I'm imagining you've got a 14-year-old. She's had her period, you've done some watchful waiting. They've not gotten a lot better. She's just having very heavy bleeding. It is causing us to the point where it's causing anemia. So what are the indications for hormonal therapy and are there specific formulations you prefer or what treatment options do you go to?

Janeen: 10:34

Yeah, this is my favorite question, because I always have parents like well, what is the best therapy? And the best therapy is truly very individualized, and so I try to really empower the patient, as well as their parent, to recognize that there is a wealth of options, and I really view this as your menstrual cycle management journey. And what works right now at 14 may not work at 17, may work again when you're 22, and you may change your mind completely and do something different at 25. And so it's going to be very personalized. The reality is that most people in the United States are most comfortable with the birth control pill. They like that it's rapidly reversible. They like that it's been around for 70 years, right, and so it's something that they themselves have more likely used themselves and it's just a little bit more familiar.

Janeen: 11:14

The reality is a lot of girls have a different goal of care, right, the way I counsel patients about birth control pills is that I would expect a regular, predictable, lighter and less painful menstrual cycle. Some girls are like but do I have to have a menstrual cycle? And the reality is you don't, right. The only reason to have a menstrual cycle is if you want to make a baby and some of our therapies work by suppressing the menstrual cycle, and that is actually the goal of the adolescent is like I don't want to think about a period until I'm ready to make a baby and start my family, and so that gets you into the. That could be a combined birth control pill that you use continuously, or it could be a long acting, reversible form of contraception.

Howard: 11:49

And maybe she doesn't meet the strict heavy, abnormal uterine bleeding numbers that you gave pad counts, things like that. But maybe she's an athlete and periods are at inconvenient times or they're just for her. They're problematic and that's all that really matters, right 100%.

Janeen: 12:03

So a lot of this is a quality of life measure and it deserves to be addressed right. That's not to minimize it in any way. This is not like oh it's your period, just get over it. It definitely impacts girls' quality of life and if that means that she's going to be able to enjoy school and not have to be picked up midday because her ibuprofen's worn off, then it's totally worth it to start something hormonal.

Howard: 12:24

Yeah, and two follow-up questions. So when I see these patients who are 14, 15, something in that age group I'm obviously thinking about you might have told mom that you have bad periods because you want birth control Mom's here with you, I'm thinking you might be considering sexual activity or already be sexually active and then I feel the burden to really get into failure rates and more encouraged long-term reversal contraceptives, particularly for that patient population, rather than just give them a pill to appease mom. How do you do that practically? Mom's there, mom's here for bleeding. How do you screen for sexual activity in a way that leads to that conversation?

Janeen: 13:05

Yeah, that really, in my heart of heart, believes that you're not going to get the right answer unless you get mom out of the room. And so, unfortunately, there's a lot of concern for parental rights right now, particularly that's one of the issues in our state, and I want, by all means, we want, parents to be involved and to have an active role in their patients and their daughter's lives and reproductive lifespan. But the reality is we've all been adolescents. We've all had the things that we weren't comfortable discussing with our parents, and one of those is sexual activity, and it's delicate and it's private and sometimes it's horribly embarrassing. And even if a mom oh, she tells me everything and we're so close, that doesn't necessarily mean that she, that patient herself, was comfortable having that conversation.

Janeen: 13:46

So we try, with some hesitation by our parents and even the patients themselves, to actually interview the patient alone. Right now, let's say, it's 14 and above, but this is going to vary state by state and this will actually probably change in our state in the near future. But whatever your state allows for confidentiality for your patients is to see them alone and really explain that this is just an opportunity to have another advocate for the child. Right, we're going to have a girlfriend conversation. We're going to talk about her life, we're going to talk about what her concerns are and by all means, mom, I'm going to bring you back and add you to the conversation and you're going to actually hear all the counseling and you guys together are going to make an informed decision.

Howard: 14:22

And I think people just have a discomfort. Like you guys together are going to make an informed decision and I think people just have a discomfort, like non-pediatricians have a discomfort with that. Yeah, but I think one of the things is like it's just okay, and moms don't typically think it's weird to ask them to.

Janeen: 14:35

Yeah, I would say it's variable. Some moms are really upset. I do think if they're explained beforehand that that's our expectation, it helps prepare them. So if you're considering increasing the access of care to adolescents in your practice, I would have something on your website or a letter that's sent to parents priori that says hey, we want to meet you, we want to meet your child, this is your child's visit. We encourage them to be interviewed alone, independently, so that your child can start having a patient relationship now. That prepares them for the future.

Howard: 15:03

Okay, now another therapy question. What do you think about tranexamic acid for this population of heavy bleeding?

Janeen: 15:11

Great question. So tranexamic acid is a great option for all heavy menstrual bleeding and it is safe in adolescence. And though we're all hesitant about using it with combined hormonal contraceptives, it's safe to use in combination with combined hormonal contraceptives. The hardest part about tranexacin in adolescence is the pill size and the pill number right. So it's basically a horse pill that you have to take three times a day and that's been our biggest limitation in getting uptake. But 100%, if you can find a patient who is a good pill taker and not afraid of it, it's great for that. Prn use right. So, contrary to needing something for hormonal management, right, a lot of girls are like well, I don't want to be on the pill because that has some sexual activity implications. Sometimes it's easier for the family to adapt to. I can use something that just limits the degree of bleeding and it's going to come with a frequency that it would normally come with.

Howard: 15:59

And it's the same dose in adolescents as adults.

Janeen: 16:01

It is the same. Thank you for clarifying. It is the same dose in adolescence as it is adults.

Howard: 16:06

Okay, so you mentioned already that I love the palm coin thing. I think it's one of the best sort of like thought provoking visualizations we have for differential diagnosis, and when you tell a student or a resident about palm coin I actually will take the coin and put it in my hand. They remember it and it helps them think through the workup and the differential diagnosis and the evaluation follows naturally from it. But you mentioned already, of course, that these structural abnormalities that we think a lot about in a 40-year-old population are not of concern in that 15-year-old population. So when would further investigation meaning, at the basics, just an ultrasound, which itself and you can talk about that if you want. But you know, obviously the goal I think for many of these patients is to avoid vaginal ultrasound.

Janeen: 16:50

Sure.

Howard: 16:50

And then sometimes you get into technical limitations depending upon her size. Sure, but ultrasound or hysteroscopy or other things, when do those come into play?

Janeen: 16:59

Yeah. So again, it's uncommon and certainly not knee-jerk first-line therapy or first-line in your evaluation. To me, the girls that I'm most worried about for imaging are those, first and foremost, from a bleeding standpoint, who failed multiple modalities, girls who continue to bleed on. Depo-provera like this is a therapy that has a 70% amenorrhea rate. How could you still be bleeding, right? So if somebody hasn't responded to the therapy that we've initiated and we've given it a good trial, those are girls that I will usually get an ultrasound. Sometimes we'll see like a decidual cast, for instance with Depo-Primerine. So sometimes it can be very insightful, but I would say it's a minority who require it. It's a minority of those who are in whom it's telling right? There was an article in the Journal of Pediatric and Asset Gynecology that showed that it really didn't influence anyone's care when done as a part of their evaluation again, unless it was in any word calcitrant cases.

Janeen: 17:51

We do a lot of ultrasounds for pelvic pain. That's probably a more common indication, and we see a fair amount of anexal masses in adolescents. The most common ones are dermoid, with which we're familiar from our adult populations, but we also, surprisingly, see a lot of cirrhosis, adenomas and mucous adenomas, and so when a girl has a lot of pain that is not necessarily menstrual related and is more pervasive throughout the cycle, those are girls that will typically get imaging in. As you mentioned, an ultrasound is still our preferred modality and I don't know if we were just super blessed at my institution, but transabdominal is usually still pretty telling that we have the unique. Our ovaries are really unique in the way they appear, right, and so you've got that good chocolate chip cookie and as long as you can see the ovary and say yes or no is there a mass there? That's usually sufficient when you're evaluating for an exopathology.

Howard: 18:40

Okay, well, good, so we touched on contraception for the treatment of pain and bleeding, but let's talk about contraception for contraceptives sake specifically, and so this is really crucial. I often tell the students that one of the number one things we do for patients in this age range who are sexually active is help them not have an unplanned pregnancy, just in terms of the trajectory of their lives and things like that. So contraceptive counseling and management are absolutely crucial. So what are some of the things you think about and the challenges in particular, when you discuss the range of options for them?

Janeen: 19:15

Yeah. So, as we already kind of established, everybody's most comfortable with the pill because it's so tried and true and it does have a lot of non-contraceptive benefits menstrual management, acne, ease of dosing. It's often free with most insurances, so there's a lot of eagerness to use a birth control pill. The reality is that it's one of the least effective, right, and we all have in our offices that beautiful chart that has. These are the orders of magnitude of contraceptive efficacy, with condoms that being up there at the top, pills being at the top, and the most effective being sterilization, right, and so we have those in our office as well. But I truly try to really put that in the context of like an absolute number, right? What does it mean to be not very effective as a form of birth control, right? So perfect, use it. If you are perfect and take this pill every day like you're supposed to and there you have a hundred friends who take it exactly like they're supposed to even then one of them is going to get pregnant each year, right? But the reality is we're human, right? I have pills I have to take every day and sometimes I forget to take them. And if I forget to take my birth control pill and I have a hundred girls who take it, like most of us do, because we're human. Eight girls are going to get pregnant each year. And I pause and let that kind of sit in.

Janeen: 20:23

And then I talk about the more effective forms of birth control. Right, the most effective form of birth control is the next one, right? The total gestural implant, unintended pregnancy of one in 10,000. 10,000 girls have to have one in their arm for one to get pregnant each year. So try to really play it out as like it's hard. If you think one in 10,000, one in 100, those numbers don't really mean anything, unless you think about the absolute number of unintended pregnancies. Again, it doesn't mean that the next one is the right choice for them. It doesn't mean it's the best thing for them, right, because it certainly has its own side effects.

Janeen: 20:56

And then we talk about those and, through shared decision-making, say what's going to match your lifestyle. Maybe you have the most regimented life in the world and you have hypertension. You have hypertension. We're going to give you slend, right. Maybe you already have something that you take medicine for every single day. You're really good about your Vyvanse, right? You're taking that every day, and adding another pill is no big deal, then a pill might work great for you.

Janeen: 21:17

Other thing I really recommend is really close follow-up, and this is where we acknowledge that we're human right and we acknowledge that it's hard to get medicine from the pharmacy every month. It's hard to remember I've shared time at my mom's and my dad's. It's hard to remember to pack my pills, so I'm one of my dads. I might not be on my pill right, and so we acknowledge that there are those realistic challenges and say let's meet back in three to four months and see what's worked for you, right, and let's just be honest with each other. If it's not working, I have an arsenal of other things that we can be using to help both your bleeding and your need for contraception. For some individuals that means just switching to the contraceptive patch or the contraceptive ring. Those are equally efficacious as a birth control pill and, with their different dosing regimens, might be easier to adhere to.

Howard: 22:00

Yeah, and you said that those posters in their offices, you and I have them, but for people who don't, bedsiderorg is one group that makes these wonderful posters of all different sorts and you can get them for your office and they're really nice infographics that show the different levels of birth control. So I know in my office we have one of those in every exam room and so they've made those for years and so folks can check that out every exam room and so they've made those for years and so folks can check that out. Okay, well, and on that, of course they have three tiers of birth control, and the tier one is definitely the next one on in IUDs. The sterilization is on there too, but not something we normally think of for an adolescent population. And then tier two are pills, patching and depo. And then tier three are barrier methods and natural family planning and coitus interruptus and things like that.

Howard: 22:45

But we definitely know that long-actual, controversial contraceptives are more effective for a variety of reasons, both for, probably, the mechanism by which they work and for compliance issues, like you mentioned. I'll often point out to them if I'm making a comparison, say, to the rod, the next one on, I might say well over three years. If you cause it's a per year failure, right, right, over three years, 24% of girls, or 24 of a hundred girls who are given a pill will become pregnant, versus less than one with the rod or something like that. To try to put it in a scale comparison that makes sense to them, but it has a special challenges.

Howard: 23:20

It seems like with TikTok I felt this that there's more animosity towards birth control in general and long-term controversial contraceptives specifically in the last two or three years of my practice. But what are some of the pros and cons of LARC for this population and considerations there?

Janeen: 23:37

Yeah. So you're 100% right that social media seems to be the most effective way to influence the population. We probably are not using it to our best ability as far as providing evidence-based information, because unfortunately, there's a lot of misinformation on those platforms. Everybody has seen a video about somebody who had a terrible experience with an exponent, and everybody's seen it in a video of somebody who had a terrible experience with an IUD, and I would say that those certainly exist, right, there are pros and cons and there are risks related to every modality, which is unfortunate because only the negatives usually get publicized. As far as to me, I think they're very different, right? So the pros for the Nexplana are 100% its efficacy. It does not require a vaginal exam, it does not require a speculum exam. We place these and remove these in the office with no hesitation and very little pain for the patient. Those are great things, right? One in five girls who uses the next one will have no period. That's a great thing, and probably another third will have very minimal bleeding. That's, admittedly, unscheduled, but not bothersome. The big con is the irregular bleeding, and oftentimes we end up using different modalities to chase that or reset it or get them to acclimate and that's probably the most common reason why we see them being removed.

Janeen: 24:52

When you think about an IUD, to me the big pro, multiple pros I'm just going to be honest like I think it's a great long acting form of contraception and then, honestly, for menstrual management, with the great menstrual suppression rates, the big pro to me is its longevity and that it is efficacious as a form of birth control for eight years.

Janeen: 25:13

Admittedly, we don't have menstrual suppression data beyond five years, but anecdotally it seems to even work up longer than the five years, and so it sometimes takes a lot of hoops to go through to get it placed, and those are its limitations, obviously. But if you can get it placed, the majority of patients are going to do well with it, from my experience. So longevity, good menstrual suppression, out of sight, out of mind, the cons are the placement for an adolescent right. So there I have had many girls who have not yet become sexually active really want an IUD, and the idea of having a general exam in general, even without a speculum, is very aversive to them, and so to facilitate that, we'll often offer them an anxiolytic with just ibuprofen in the clinic, or even sedate them at our pediatric hospital and place it under sedation.

Howard: 26:01

And I think we're going to learn a lot more. You're seeing protocols organically turn up around the country about ways of helping to minimize pain with insertions. One thing that's becoming popular is like a lidocaine gel-infused tampon that they wear for as long as possible 30 minutes or so before a procedure, and things like that. So I think we're going to see a lot more that helps with that aspect of IED placement, which is harder in a 15 year old than a 25 year old. Yeah, you mentioned the Nexplanon and it's big yes, it's big side effect is I'm bleeding all the time. Dr Arbuckle, why do you hate me? So she's had the Nexplanon for some six weeks or something like that.

Howard: 26:44

She's back and she's or she's back for your visit and she's like yeah, I'm basically bleeding every day. What's your treatment?

Janeen: 26:50

Yeah.

Janeen: 26:51

So I do ask for both of the long-acting reversible contraceptives, both the Nexplanon and the IUD.

Janeen: 26:56

I try to frame it as there's going to be a timeframe in which you hate me and that's even true for the IUD, and what you hate me, and that's even true for the IUD and the reality is our bodies, you take some time to get alchemated to both the next one on and an IUD.

Janeen: 27:07

So I try to ask them for a six month kind of commitment. It does not like I'm not going to be signing on a dotted line, right? I'm not ever going to refuse to remove a device at six weeks, but I do try to prepare them that we're going to see you're not going to love me when you first have this device, right, there's a good chance that you're going to have your regular bleeding and so and I'll honestly, at six weeks, if it was just your regular low volume bleeding, I'd probably recommend observation the. If, however, that bleeding is persistent and we're getting to the six month mark and they still want to keep the device I will often offer and that combined birth control pill for one to two, one to three months, just to get that endometrium synchronized, and sometimes that acts as like a reset and they'll they'll start having more scheduled bleeding and then get into that amenorrhea that we want to see with the next one. You can also do scheduled NSAIDs and you can also do doxycycline for a week.

Howard: 27:57

Yeah, and that's a similar approach that I use. I think that for a lot of OBs or maybe non-OB providers even more so the idea that you're using two concurrent hormonal birth controls seems weird or abnormal to them. It even does to the patients, but it's perfectly fine if they don't have other contraindications to add that combo pill back, correct.

Howard: 28:16

So we talked a little bit about I asked about screening for sexual activity to start the conversation about maybe which failure rates or how we counsel about those things. But clearly, the conversation about confidentiality in regards to sexual issues and things like that, or even abuse or STDs, mental health, things like that, it's a different level of confidentiality expectation, I believe, than just for I have heavy periods, sure, and this is one of the hard things and it is as you said. It's different in your state than my state. It's going to be different in your state next year than it is right now. Yeah.

Howard: 28:54

The rules are all over the place and they're often in conflict. In my state they seem to be in conflict, so, but how do you navigate parental involvement, also maintaining confidentiality, particularly with contraception, because now we're talking about something that may be a secret? Yeah, but we also need to help her get that IED if that's what she wants.

Janeen: 29:15

Right. So in general. So right now, with our current law, the age of consent is 14. And that has been long held as the age at which confidentiality rules should apply. And so and as you mentioned, there are certain times when confidentiality rules are broken, right? So if the patient's going to harm herself is going to harm somebody else, if somebody's harming her, if they disclose abuses or things that we have to share, we're mandatory reporters on. That being said, we do try to really hold patients' privacy close and not share their information, and there are certain language we use to help them navigate even conversations with their mother, right? So it has become my policy, and I say this to my adolescents who need, for instance, even screening for sexual transmitted infections. I've got Allison here. She's doing so good with her pills, we're so proud of her, she's got the periods that we want. But my policy is, once somebody is on birth control, I screen them every year for sexual transplant infections just across the board, and that way, if the mom gets the explanation of benefits for them, she's not like well, why did Dr Arpukul get this screen? And it just makes it just the clinic policy and it doesn't put the patient on the spot as far as why they're getting certain care. So that's one way at least for the screening of sexually transmitted infections. We've handled it Again that private time is super important.

Janeen: 30:32

Talking about interpersonal boundaries with their partners right. Only having sex if you want to have sex, it's okay to say no, oh no. And any sexual favors, right. Being that advocate for your patient is super important. And then I do think, if the adult sense comfortable with it, it's bringing the parent in and summarizing the goals, right. Hey, allison's here. These pills really don't seem to be working. Have you noticed she's been complaining more about her periods? She and I were talking about some other ways that we could improve her bleeding and we think that these other strategies an IUD or an Explanon Depo might be better for her. What are your thoughts and do you think that'd be something that could work for her? So not keeping mom completely out, because the reality is mom has to buy in too and mom needs to be a part of the conversation. But it doesn't have to be necessarily because Allison's not using her pill like she's supposed to.

Howard: 31:22

Okay, and you mentioned your procedures for dealing with parents and creating expectations, which I think is great and something that, in a general clinic like mine, how many of these patients do I see in a week or two even and so we certainly aren't doing a good job, I'm sure, about creating the expectation before the visit that we need to have a private interview and that's the expectation.

Howard: 31:42

I love the part, though, about creating expectation when you prescribe the pill that this is what we do once. We do this because at some point, even if she's not sexually active at 14 or 15, hey, she might be at 16 or 17. And, as you said, the moms don't like to see certain things on the explanation of benefits. So I love that strategy and something I never thought of. But talk a little bit more about dealing with parents during interview, and obviously some of them are difficult. But what are some effective communication strategies that you use for both building rapport and trust and maybe, if you want, dealing with that mother who are guardian of any sort, who's really upset about the conversations?

Janeen: 32:18

Yeah, those are probably the most challenging clinical scenario I find myself in, right, so, as in my adult population, I've learned how to adapt to everything, but the angry mother is the hardest of all the things that we have to deal with. I would say, okay, stillbirth, that's number one, but number two is the angry mother, and so those are really hard. I have grown or I'd like to believe that I've grown into being more accepting of mom wanting to be there from the beginning, and even sometimes the adolescent wants the mom to be there from the beginning, and so sometimes I'm not able to have that private time and I'll, in general, be a little bit silly, right? So I'll do my review systems very matter of fact, very serious, like nausea, vomiting, fevers, chills, chest pain, shortness of breath, and are you dating? And there is like almost all of them have a tell, right, and you'll be like and then mom will be like, oh, she is. And then I'll be like, oh, well, then, mom, you need to step out, and generally they will, right? So we've established that we're going to be having this conversation. I'm like I don't want to embarrass her.

Janeen: 33:20

There might be things she's wanting to ask about her, about her body that she doesn't really understand, that are hard to talk about with you. Would it, would you mind stepping out for a minute? And I get a lot of reception to that. And that parent that was like no, no, no, I'm not leaving If I have already built rapport. They've seen that I am not this. I'm not here to groom their child. I'm not here to influence her child to make poor decisions. I'm here to be their advocate. And then and that's one of those, that's one of the key words that I use when I'm talking to to moms that are mad, and again, like I can see one mom in my mind and it haunts me. It's so sad and it hurts really bad because I am your daughter's advocate and I will acknowledge like you are so important in your daughter's life and you, she will, she, you guys are so close and I'm so glad that you guys have spent the time to nurture this relationship and she has that trust in you.

Janeen: 34:07

The reality is a lot of our patients don't have that parental advocate and really need an adult in their life to listen to them and advocate for them and give them guidance. And I, as a provider for all those patients never know who is who, and that is where our policy comes in, that we really want to have these adolescents have a relationship with the provider, because you don't know who needs extra care. The reality is that your adolescent is also going to become an adult and they're going to be navigating these situations on their own. In another two, three, four years, right when they're at college and they have an ear infection, they're going to be seeing the campus doctor on their own. They might have they might have worsening gynecologic problems and they will be on their own. And I want them to be prepared for the questions that will be asked and be comfortable talking about their bodies. And right now you're still here. You're our buffer, but it's not going to be long that she's not going to have that safety net.

Howard: 34:57

A lot of that conversation makes me think of just the challenges sometimes with Gardasil in this age group, which I think that OBGYNs are relatively protected from. We're usually seeing the person after the age at which Gardasil hopefully has been. The conversation has been had with the pediatrician, but I'm sure you must see patients all the time who did not have Gardasil from the pediatrician but you still have a young lady who's a candidate for it and those may be the refractory patients. Right, they may have already declined it at the pediatrician's office but at least in the early days of Gardasil resistance one of the reasons was this is a sexually transmitted disease you're wanting to vaccinate my child from. So there's a lot of overlap in those conversations where she's going to have sex at some point.

Janeen: 35:46

Right.

Howard: 35:47

And there's education and things to do. I wish sometimes we had a more standardized approach where, say, every young woman at age 13 just had a visit with a gynecologist or maybe with a PAG person and the point of it is not to do anything other than education about the changes happening to her body. If we could normalize that a little bit more, which sounds like what you're trying to do some.

Janeen: 36:10

Yeah. So what I would say about Gardasil is for whatever reason we and I don't know if it's all healthcare or OBGYN, in particular we are just terrible marketers, right? So the reality with regards to Gardasil is that we have not done a good job of marketing it and explaining the rationale for it, and unfortunately, it has that sexual innuendo connotation that this means that your nine-year-old is going to go and have sex if they get it. Number one. That's not true, right? Protecting somebody from a sexual transphobia does not then make them sexually active.

Janeen: 36:41

But the reality is, above and beyond that is that they will eventually be exposed to HPV through some means, and HPV can cause cancer.

Janeen: 36:50

And I really try to put it in the context of not just reproductive cancers but also head and neck cancers. And the reality is, in the United States, the number one HPV related cancer is a head and neck cancer, and it's mostly in men. And it's unfortunate to me that cervical cancer gets the spot on billing right. But when, as soon as you put it into that context, people are like, oh well, we should totally be vaccinating because of the head and neck cancer, and the reality is that HPV is everywhere, right, hpv is spread through open mouth kissing right. Who's going to freak out about their 16-year-old kissing somebody? Right, that's what they're supposed to be doing. It's spread by hands right, it can live under your fingernails, and I have individuals, I have young adults, who've never had penile penetration and have cervical HPV right, it's a real thing and so obviously I don't go that far and that explicit, but it is a very prevalent virus and it is cancer prevention.

Howard: 37:44

And other countries have done a great job with this. We just haven't had the uptake here. But okay, well, I've been avoiding this to spare you. But let's talk about pelvic pain. Pelvic pain in younger patients, boys and girls, I think is a bit more complex. I mean it's complex in adults, but there's so many other factors I feel like in adolescence. So what are some common gynecologic and non-gynecologic causes to consider?

Janeen: 38:12

Sure, so obviously. So I would say premenarchal. In the absence of a structural abnormality, there really shouldn't be any gynecologic pain, right? The vagina isn't necessary, the vagina is inactive, the cervix is inactive, the uterus is inactive, everything is quiescent, and so those structures really should not be causing pain. Certainly, there can be like an acute ovarian torsion, right, but there's usually not a gynecologic pain entity in a pre-pubertal child.

Janeen: 38:39

Most of it is going to occur peripubert or during, after onset of menses, and all the gynecologic things that can affect adults can certainly affect adolescents. So there's primary dysmenorrhea, there's middle schmertz, if you will. Definitely girls can sense when they're ovulating. Girls can often be very symptomatic to cyst rupture, the formation of hemorrhagic cysts. So those are probably I would say those are the most common things that we see. Certainly, endometriosis is on the differential, and I have diagnosed 14-year-olds with endometriosis and I've diagnosed 14-year-olds with advanced endometriosis, and so it's certainly something that we need to consider. I would think. The majority, however, is those more physiologic related. I've got a new organ system that is doing really mean things to my body. I've got programmed cell death happening and it hurts, right, and so we talk about strategies to treat it, and that is a combination of the things we've already checked the hormonal management as well as SEDS.

Janeen: 39:33

Non-gynecologic etiologies certainly contribute as well, and I like to say our pelvic organs are in a bowl of soup and even though it's in that space, there are other organs that are also in that space and it's not necessarily going to be your reproductive organs. So the bowel and the bladder obviously contribute. We see a lot of IBS, ibd, inflammatory bowel disorders, stones causing a lot of chronic pelvic pain, and so if you have a patient, they're like okay, you've got some pelvic pain and I'm exhausting on my gynecologic therapies and you're still symptomatic number one should we scope you for endometriosis? But should we also look for other potential etiologies? Constipation is a huge problem in adolescents. I don't know if it's like I'm embarrassed to go poop in public, but the constipation is a huge issue and so sometimes even just talking about bowel regimens as a gynecologist can be pretty impactful.

Howard: 40:22

And in younger women too, pain presents differently, right? I mean a lot of young patients nausea is more of a pain complaint than is in adult women. Is that true? They may come in with nausea as a symptom of painal cycle tons of nausea.

Janeen: 40:38

So when we were talking earlier about like what's my threshold to treat that if the girl's having tons of nausea, that would be another reason to initiate hormone therapy.

Howard: 40:52

Yeah, I think the adult patient may describe it differently, but nausea seems to be more active. I think I learned that in pediatrics so that we'll get responses from our pediatric friends if that's not true. But in chronic pelvic pain in all populations are frustrating and I think we don't do a good job in all populations of having a multidisciplinary approach. As you said, overall pelvic abdominal pain in women as a whole is most likely to have a GI etiology if you know nothing else about what's going on, with things like constipation or irritable bowel syndrome being more prevalent. And when we emphasize and talk about multidisciplinary approaches, but then a lot of times for the GI stuff, for me GI consultants are sometimes frustrating because they tend to exclude Crohn's disease or exclude inflammatory bowel disease.

Howard: 41:42

But I don't find them that helpful with this IBS or things like that that are particularly just a diagnosis of exclusion, and I get them back and it's like, well, I still think you have IBS, I'm glad you don't have Crohn's disease. But I don't know if that's a universal frustration with our GI consultants. But what's the approach with that multidisciplinary approach, particularly with chronic pelvic pain patients and then beyond that, the person with resistant pain we're starting to get into? We've ruled out structural things. You're starting to get into the endometriosis conversation. Is it just? Primary dysmenorrhea.

Howard: 42:16

Is it something more? What do we do with those patients?

Janeen: 42:19

Yeah. So in response to the GI, at least at our institution, I feel like the pediatric GIs do a really good job of talking about bowel motility and.

Janeen: 42:29

Bristol Stools categories and really getting them into a more regular regimen. So I do feel very well supported by our GI colleagues here. Endometriosis for adolescents is probably one of the most difficult things to treat. The reality is the treatments are the same as adults, right? So you have your gene ag agonist and antagonist and your ad back therapies and you have your same limitations, right? So there's the end point at which you can no longer use it because of their impact on bone health.

Janeen: 42:57

So we use a lot of multimodal approaches, ideally my initial approach, if it's tolerated by the adults and as if I'll often counsel them before we go back for a diagnostic laparoscopy about an IUD insertion. I think IUD is just from a menstrual standpoint. It has caused a lot of that. Local prostaglandin is so good at menstrual suppression, it helps a lot with the pain and I think it simplifies the add back with a Justin. So that's probably my preferred kind of first therapy if they've failed other therapies. Essentially, in general, if I'm going to the OR with an adolescent, they've probably already failed one or more therapies.

Howard: 43:30

Yeah Well, I was going to ask that, like what's your threshold for doing a diagnostic laparoscopy? Another thing social media talks about is medical gaslighting, and I went for X number of years with undiagnosed endometriosis, and there's some truth to that. I mean, there's a lot of data that shows a multi-year failure to diagnose endometriosis and there's some truth to that. I mean, there's a lot of data that shows a multi-year failure to diagnose endometriosis, although sometimes we don't need to diagnose it if we can treat and be successful. So I see both sides of that.

Howard: 43:56

And then I worry, though, that some of our colleagues are being too surgically aggressive in all ages with endometriosis, but let alone in a 15 year old-old. Who what is failure? You were on a suppressive regimen for three months and you still complained of pain. So we're going to scope you, or just we're going to scope you because I don't want you to go undiagnosed with endometriosis and I hear patients tell me, if we don't find it and operate now at 16, you're going to be infertile. That stuff feels like too much to me.

Janeen: 44:29

Yeah, I definitely. I can see both sides as well. I think it's. It goes back to that shared decision-making and being very honest with your patient about what the diagnosis is going to give them versus what it's not going to give them. Right To me, having failed medical therapy is at least six months of hormonal therapy.

Janeen: 44:39

The document has changed as far as ACOG guidance for endometriosis, but it was the first line. Therapies are either a birth control pill or a gene range agonist and they go to a birth control pill continuously. So typically we have tried at least six months of a good menstrual suppression and and if you've, and certainly if you're doing, if you're still cycling doing another six months of just continuous use so that we're completely suppressed. So I would say six to 12 months of pervasive symptoms despite good adherence to a good suppressive therapy. But then again, being very honest, like and I've I acknowledge patient's frustration.

Janeen: 45:11

I would say the delay in diagnosis certainly feels like somewhat of a betrayal, but I guarantee that it's been on everybody's differential. It's just that the therapies are not super, are not going to be any different, even if I make the diagnosis Right, and so I have adolescents as well as young women and like I really want to scope and I'm like help me understand what that gives you right. What will we gain from it? Yes, there'll be some implants that I can treat, and the frustration is there's going to be a lot of implants that I can't safely treat. They're on your bowel, they're on your ureter and what? And if I get in there and I make the diagnosis, how does that change things for you? And, just being very acknowledging that it has its limitations, it's not going to be a cure. If you need to know, for you to know. I think it's reasonable and it does make me, admittedly, a little bit more aggressive. I'm much more likely to give a GRI diagnosis to somebody who has advanced endometriosis than somebody just who has uncontrolled dysmenorrhea.

Howard: 46:04

Right. I think most of us in general practice rarely operate on people under the age of 16. Are there special considerations? Like with laparoscopy, I mean things like insufflation pressures and things like that that you change in those younger patients.

Janeen: 46:18

Yeah, so in general the adolescents in whom we operate are really adult size, right. So that's certainly a consideration in the pediatric population, a lower max pressure. I think they use 12 instead of 15, but for most gynecologic surgery I still use 15. I still use the same insufflation rate, same entry techniques. It's hard to operate on someone's child, I'm not going to lie. It's like merging onto the highway for the first time and once you're in, but it's always a little angst.

Howard: 46:42

But in general, gynecologic surgery is in an adolescent who's menstruating is the same. Okay, so the other reason why you might have a reason to do a surgery sometimes might be adnexal pathology, so let's just spend a couple of minutes on that.

Howard: 46:56

Sure, we get a lot of ER. They went in the ER, they got the pan workup and of course, there's a 2.3 centimeter ovarian cyst in the middle of the month, or there might be a four centimeter hemorrhagic cyst or something like that. So what's your general approach to evaluation and management of these cysts?

Janeen: 47:11

So certainly it's important to a lot of PAG is counseling, and so I do a lot of picture drawing and I'll do a lot of orientation to HPO access and what it means to menstruate right. That is the ultimate result of ovulation. So we talk about ovulation, we talk about normal byproducts of ovulation and I give them the reassurance that, as a reproductive age female, every month they should have one or more cysts. And I normalize that because I was like, oh well, she gets cysts and it's a little bit. It's sad to me that we haven't done a better job of educating women about their own bodies, because every woman's body should make cysts every month, right. So I try to number one, normalize it, I try to walk them off the ledge as far as, like, this is a normal byproduct.

Janeen: 47:52

Hemorrhagic cysts can be a little bit tricky. So, for instance, you mentioned a 2.3 centimeter cyst. I'm not going to follow that up. It's a simple cyst, it's doing its job and if you don't like it and you sense it, we can talk about ovulation suppression. Hemorrhagic cyst's are a little bit trickier because they can be small endometriomas and are not as easy to slam dunk and ignore. So I usually follow those up six to 12 weeks and assess them. It's the larger masses that I get more worried about being neoplasms, but if it's less than three centimeters, we're going to just obse and we're going to talk about if this becomes a recurrent problem for you. Every month you're in the ER because you're hurting.

Howard: 48:23

We need to suppress your ovulation every month you're in the ER because you're hurting. We need to suppress your ovulation and then occasionally, you might have the more emergent ovarian torsion or even isolated fallopian tube torsion. I do feel like I get my fair share. I actually I think I've had well over a dozen of just isolated fallopian tube torsions in sub 14 year olds. So I think we don't need to spend much time on this, but I think that the things that I see done poorly are removal of these ovaries, sometimes by pediatric general surgeon colleagues or people like that. But they look at it and it's black or blue and they think it's dead, so they remove it. Yeah, and so? No, it's going to be. Hopefully that's your answer and you agree with that.

Howard: 49:02

There is controversy, though, around isolated fallopian tube torsions. I've been removing those if the tube looks large and diseased and damaged. There are some case series now of isolated fallopian tubes being left. If the thought, I think, was that it tors due to, maybe, a paratubal cyst and the tube itself might have a chance of resolution, then maybe you remove the paratubal cyst and let the tube play out and see if it works. But I think that's still controversial about what's the right approach. I don't know what your thoughts are.

Janeen: 49:32

Yeah, I would posit that the majority of pediatric and also gynecologists are not removing tubes that have torched. If you think of it as being an acute event and if you get there early enough, then obviously if it's necrotic and adherent and it's clearly dead, I think it's appropriate to remove it because you're just protecting them from ectopic pregnancy in the future. But the majority of torsions that I have seen have been, like you mentioned, associated with the paratubal cyst. The tube itself looks very healthy. It's pink fleshy, not dilated. I would be very hesitant. I've certainly seen some that look somewhat diseased, but I would be very hesitant to remove a tube in an adolescent.

Howard: 50:10

And the challenge, I think is it actually a large hydrosalpinx or is it just edematous?

Janeen: 50:15

because of the torsion, I think that's where it's confusing. Yeah, and I think the counseling in that scenario is really important, right? So you've had this assault to your tube. It's going to be super important that you get care, when you're ready to reproduce it, that people are aware of your history. Maybe this is somebody you would have a lower threshold to get an HSG in as an adult who's trying to conceive, but I would more than likely leave as much as I could.

Howard: 50:38

Yeah, and definitely ovaries. I mean you should err way on the side of leaving virtually every ovary in that age group. So okay, maybe in the last couple of minutes let's talk about just congenital anomalies. So when might a general OB-GYN suspect a congenital anomaly, or what are some of the most common anomalies? You see, how do you image them? Ultrasound versus MRI, those sorts of things.

Janeen: 51:03

Yeah. So the most common anomaly and I'm going to include vaginal anomaly is the imperfect hymen, and this is what we all learned in medical school the blue bowl, she'd all solve as it moves, and the reason why we learned it is because it is the most prevalent Its incidence is one in 1,000. So it's going to be pretty. You're more than likely going to see it at some point in your career.

Janeen: 51:22

A couple of caveats are if you think you have an imperfect hymen, the right treatment is incision, but nothing should be done in the clinical setting, right, it should be done in an operating room. So I think the most likely anomalies that an adult OB-GYN are going to see are going to be a patient who's basically had normal pubertal progression and no onset of menses and there's some obstructive process, right. So it's either at the hymen, they have a vaginal septum or even uterine agenesis. So I think those are the ones that you're most likely going to see. And then I want to see that order of incidence is. Actually I didn't list it correctly so number one is the imperfect hymen, number two is actually uterine agenesis and then third is a transverse septum.

Howard: 52:01

And then imaging. Do you have a preference MRI versus ultrasound?

Janeen: 52:05

Yeah. So I would say your exam is going to be the most important, initially because if you see your blue bulge you've got a pretty good idea. And then I think, early on, ultrasound is important. Ultrasound can say is this a? I see a hematometrioclopos, I see absence of uterus. Right, you don't need an MRI to be able to say there's uterine agenesis. So I would probably start with an ultrasound and make sure that there are upper tract structures. If there's a massive hematometriocopos, I would probably get an MRI. If it's not clear that it's an imperfect hymen, the value of an MRI is that it can help you distinguish the thickness of whatever the obstruction is. So is it that I have a one millimeter imperfect hymen, which hopefully you'd already been able to say, or is it that I have a two centimeter transverse septum? Or is it that I have complete distal vaginal agenesis and that's going to be? That's where your MRI is going to come in and be helpful as far as determining the thickness of the obstruction.

Howard: 52:55

Essentially, All right, we're almost out of time, but I have one more vignette or scenario for you. There's a bunch of things we could have you back on in the future and talk about primary amenorrhea, precocious puberty, a lot of things, and a lot of these malaria abnormalities. Some of them are quite bizarre and you get little things like non-communicating horns and cyclic dysmenorrhea and things like that, and so there's a lot more there to potentially talk about. But the other thing that I think is a common thing general OBGYNs will sometimes see is the young pre-pubertal girl. Let's make her eight and she has vaginal bleeding.

Janeen: 53:30

Again, if you're giving me top five things I don't like, yeah. So the most important thing is to think so. Number one is this acute or is it chronic? And then is are there signs of puberty? Right, there are a lot of non-pubertal causes of vaginal bleeding. Vaginal colonization by number of bacteria can cause vaginal bleeding. But the most important thing is to consider if they have secondary sexual characteristics. The reality is that at eight, the acquisition of some secondary sexual characteristics is appropriate, right? So if we say that it's acceptable to have menarche at age nine, which is the lower end of normal for menarche in the United States, then having some secondary sexual characteristics at eight is acceptable. And so really seeing where they are along their pubertal progression.

Janeen: 54:12

My daughter's no longer eight, but I certainly would not have wanted her to be menstruating at age eight and then we would get into is it truly pubertal bleeding or is it bleeding from another etiology? And pubertal bleeding can be meaning it is the lining of the uterus that's shedding. It can be due to central precocious puberty, meaning the brain just woke up early. It can certainly be precocious puberty that's peripheral, due to just endogenous activity of the ovaries. About that particular scenario of an eight-year-old is even so, one of the goals of delaying puberty is acquisition of a greater adult height, and if you are already at menstruation at eight, even if we suppress you, you're probably not going to get additional height. But we can certainly use things to improve their quality of life, like we talked about.

Howard: 54:57

When do they need exams? So the med student is going to think foreign body abuse, things like that. When do they need exams? And do you do those in the office? Do you do those with sedation?

Janeen: 55:08

Yeah, so if they don't have secondary sexual characteristics. So, first and foremost, most exams are going to be sufficient in the office because and truly, just a frog-laid exam you don't have to do an internal exam to be able to tell if somebody has pubertal progression, right? So we think about the sexual maturation scale. Do they have the acquisition of body hair? Do they have body odor? Do they have breastfeeding and development?

Janeen: 55:30

And the route is, the vagina itself undergoes a sexual maturation and the epithelium of the vaginal tissues in the hymen changes drastically from a prepubertal standpoint to a pubertal standpoint. So if we're thinking about puberty, it should be pretty obvious on exam. And then there's obviously laboratory analysis that's going to support that. If you've done that exam and they're not pubertal and you're concerned for a foreign body, you're not going to miss it. On that exam there will be the smell of death and you will have a very high suspicion for a foreign body and will be prepared to care for it. We can do a vaginal lavage in the office if there's a foreign body and then some girls will require going to operating room for a vaginoscopy and removal of any foreign body.

Howard: 56:11

All right. Well, that's an hour, at least we're not doing two hours. But we could fill a second hour at some point with some of those other topics which are a little bit more complicated to talk about in terms of evaluations and workups. And I'm going to find out which one of us spoke the most in this hour. So we'll there'll be a minute count report and we'll see. I think it's going to be you.

Janeen: 56:34

I think, but I am your guest and you were asking me questions. There's going to be something wrong, Howard, if it's you talking. The most is all I'm going to say.

Howard: 56:45

I'm just saying you're the talky one, so okay. Well, thanks for being on and we'll maybe have you on in a in next season some time to do those other topics, and we'll see everybody in a couple of weeks with another episode.

Announcer: 56:58

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