Episode 34: All of your period questions answered! With Obgyn, Dr Sara Twogood

On this weeks episode of Ask Dr Jessica, we welcome Dr Sara Twogood to discuss menstruation.  We review the most common questions I hear about periods. We talk about how to treat menstrual cramps, menstrual irregularity and what can be expected throughout puberty.  Dr Twogood also explains the various options to manage periods---pads, tampons, menstrual cups and even period underwear.  If you are a parent of a preteen/teenage female, this episode will be a great primer for general menstruation questions.

Dr Twogood is a board-certified obstetrician-gynecologist at Cedars Sinai hospital in Los Angeles and is available by appointment at (310) 423-1224.  To find out more about Dr Twogood, check out her blog!  https://ladypartsblog.com
She can also be found on Instagram where she provides female health education: fem.ed

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children.  Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner. 

Do you have a future topic you'd like Dr Jessica Hochman to discuss?  Email your suggestion to: askdrjessicamd@gmail.com. 

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The information presented in Ask Dr Jessica is for general educational purposes only.  She does not diagnose medical conditions or formulate treatment plans for specific individuals.  If you have a concern about your child's health, be sure to call your child's health care provider.

Dr Jessica Hochman is a board certified pediatrician, mom to three children, and she is very passionate about the health and well being of children. Most of her educational videos are targeted towards general pediatric topics and presented in an easy to understand manner.

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Do you have a future topic you'd like Dr Jessica Hochman to discuss? Email Dr Jessica Hochman askdrjessicamd@gmail.com.

The information presented in Ask Dr Jessica is for general educational purposes only. She does not diagnose medical conditions or formulate treatment plans for specific individuals. If you have a concern about your child's health, be sure to call your child's health care provider.

Transcript

Unknown: 0:00

Hello everybody thank you so much for tuning in to another episode of Ask Dr. Jessica I'm your host Dr. Jessica Hochman as today's guest I welcome Dr. Sarah to good Dr. To good is a mom herself and a really passionate OB GYN. Today I asked her the most common questions I hear about menstruation. We get into it all puberty, menstrual cramps, heavy periods, and she even explains menstrual cups. Yes, menstrual cups. If you are a parent with a preteen or teenage girl, I think you'll find this information really helpful. Also, if you are enjoying this podcast, I would be so grateful if you would subscribe and share with a friend. So first before we get into it. Can you explain what is an OB GYN exactly like what is the OB part? What is the GYN part? What what do you do? Yeah, so an OB GYN is a female health specialist. We focused primarily on reproductive health for females of all ages. We'll talk in a second about kind of when someone should see an OB GYN for the first time. OB GYN stands the OB part stands for obstetrician and then GYN or GYN or sometimes people call it Guinee stands for gynaecologist. So. obstetrics is the practice of helping pregnant people so we deliver prenatal care deal with prenatal issues, do ultrasounds for pregnant people, answer their questions, deliver babies, you know do C sections and postpartum care. And then gynaecologist is that part of my practice is basically everything else that does not include pregnancy. So things like periods, you know, encompassing painful periods and irregular or missing periods. We do pap smears, STI sexually transmitted infections, contraception, vulvar, vaginal health ovarian cysts, pelvic pain, fertility, your breast health and we menopause and menopausal hormonal therapy. So it's, you know, it's basically any female reproductive health issue that you can think of it's that's probably in our wheelhouse. So lots of now. So a question I get a lot from parents, they will ask when should my daughter see an OB J. OB GYN? So what what is the official recommendation? Actually, there are no formal recommendations for the first time. So oftentimes, people use getting their first pap smear as a reason to visit an OB GYN. And that should be done at age 21. A lot of primary care doctors internal medicine and some maybe even paediatricians, if you're seeing patients, you know, that all that are continuing in your practice, they might do pap smears themselves, but I use that as sort of a nice time to establish care with an OBGYN, just kind of moving forward in their life. But we see patients younger than 21 all the time. And the main reasons why people come to us are for periods, either painful periods, or irregular periods, just issues that they're having to talk about sexually transmitted infections, we talked about kind of preparing for having sex, talking about consent and contraception, you know, birth control, but not meaning birth control pills, just any sort of contraception that they would choose to use. I have a lot of patients that come to me and their senior year of high school as I think their parents just want them to establish care with an OB GYN as sort of an introduction to your you're gonna not live in my house anymore, you're going to college or you're transitioning into adulthood. And this is part of being a female is you you seek care from an OBGYN to kind of introduce them into that level of health care. I view OBS as a very integral part of female health care. A lot of people I meet do not actually have a primary care doctor, I think you would probably agree but they view their OB GYN as as their primary care doctor. Yeah, and I think that that's a little bit of an older way to view this. It's, I definitely do not consider myself a primary care doctor. If someone has an ear infection. I don't have an otoscope in my office to you know, to evaluate that and treat that or for people who have high blood pressure or diabetes. You know, I don't treat those I don't I don't see patients exclusively for those issues. So sure. I like to really encourage people to have a primary care doctor and OBGYN that they see. Absolutely me. Okay, so talking about the subject of menstruation. It's such a dreaded event that, unfortunately, is a normal part of being a female. But I wanted just to talk about some of the basic questions I get, because I think hearing what is normal, what isn't normal will be really helpful so that families aren't clear on, you know, what they can do to make things better at home when to see new OBGYN. So first, when at what point do you expect a female to start menstruating? Is there a certain time where if it hasn't started yet, they should see you? Yeah, I, you know, a lot of that depends on puberty development. And so if typically, one of the first things that happens during puberty is the breast buds start to develop, and that can be around eight to nine years old, typically, right? And puberty has this wide range of normal. And so in that rage, that's from different families and ethnicities and races. And so there's not this specific criteria that everyone has to have breastfed development by nine years old. So there is a wide range of normal here. And of course, I always recommend if if you think that your kid is outside that normal range, talk to your paediatrician because they can tell you yes or no, this would be expected or not. But the first period typically starts two years after breast buds develop. So most of the time, parents can tell that breast buds are forming just because they're looking at their kids bodies, right. And it's something that is a little bit more obvious. So that's kind of a nice timeline to keep in mind that breast buds develop. And about two years later, you would expect your kid to get their first period. If all other physical development is happening normally, then we should see the first period by 16 years old. And if the period hasn't started by 16, that would be considered outside the normal range. And we would start doing an evaluation. And that could either start with the paediatrician or that's something that people refer to us to. Now let's get into when they do get their period. Some of the most common questions I get are how to deal with menstrual cramps, what is your advice? So there are a lot of things that you can do at home that sort of count as supportive care. You Some people swear by heating packs, you write or like a nice heating pad or taking a nice warm bath or a hot shower. But heat is really wonderful at helping with cramps. And so I like to get one of those plug in heating pads, you know, not just a hot washcloth because that loses the heat really quickly. But a nice heating pad that provides a little bit of longevity to put on either the front or the back. Depending on where the menstrual cramps are the worst. Exercise can really help even though a lot of people don't feel like exercising when they're having their period. But exercise can really help make people feel better. Medication wise, Ibuprofen is preferred over other things like Tylenol, acetaminophen, because it actually stops some of the the messengers that are causing the cramps to come called prostaglandins. Ibuprofen actually stops those from forming. So it's, it's both preventing more cramps and treating the cramps because of its pain medication too. So I like that a lot to a lot of people use Mitel. And Mitel is used a lot for PMS symptoms, and it helps with bloating, and that feeling of just kind of fullness right before a period starts. Oftentimes Mitel has Tylenol in it as the as the pain medication component. And so that's not as good for period cramps. And so if you look for the Mitel make sure that it has ibuprofen in it as the pain medication component. Yeah, that's a really good tip. Sometimes I don't know what you think about this, but I'll tell parents, I'll tell the patients to try to take the ibuprofen right when the cramps are starting because it's easier to get ahead of it if you take it earlier, because a lot of people I feel like they want to see if they can soldier through it and handle the pain. And I always think it's better to start on the early side. I 100% agree with you. And we also use the prescription dose ibuprofen if you start that right at the beginning of your menstrual cycle that you know that those that our that you're like, Oh, I'm about to get my period. You start it then and you take it every six to eight hours for the first 72 hours of your period. It can actually decrease the amount of bleeding that you have to So for people who are trying to minimise you know it's not it's Not as good as some other medications. But for people who just want a little bit of help, they want help with cramps and pain. And oftentimes, those are related to heavy bleeding that can decrease some of the bleeding too. And so that's my other kind of first line recommendation, if they just want something simple that they can, you know, they can do just with their period. That's a great tip. A lot of parents will ask if they're, they're concerned that their children have too heavy periods, they'll say, you know, they're leaking. And they're concerned that, that it's more than what's normal. How can someone determine what is too much? You know, in other words, when should they see an OBGYN For having too heavy periods? When they're when I'm having a patient describe it to me? I usually say how many Pat? Like, what do you use for your period product? You know, do you use pads, tampons, menstrual cup period? Underwear? What are you using? And then if they say, I use pads, I say what size pads? The regular the super the overnight? Okay, how often you changing them? Are you changing them every three hours? Okay? Yeah, you change them every time you go to the bathroom? How much blood is on there, then? If it's not soaked? What percentage is? So do you know? Is it 50%? Is it totally saturated? And then especially for teens that are just starting to use and experiment with different period products. Sometimes they're just not using them, right? That's one of the big things with menstrual cups is they're really wonderful if you're using them correctly, but they're actually hard to learn how to use correctly. And so there's a lot of leaking and spilling the first few months that you're using them. So sometimes it's hard to know that they're leaking and spilling, because they're because they're have a heavy period and their flow is too much. Or is it because they're just not using it correctly. And they need a little bit of education on how to best use their period product. Um, I just I like to get, you know, very as much information like that as I can to get a really good description of what it is to them, because heavy to one person is not heavy to another. Right? Absolutely. Okay, and so I'm so glad you brought up menstrual cups, because this is something that has been in vogue and more popular in recent years. Can you describe what they are? Exactly? And how, how can a teenager find the best fit for them? Menstrual cups are a reusable period product. And it is kind of the shape of a cup. It's kind of like this shape. And the top part right here goes up around the cervix. And then it all the blood collects here. So it's it's a, you know, it's they call it a cup, it's more like a dome or something like upside down dome, but most menstrual cups are, they're pretty uniform size. I would just pick the one that you want. I mean, there's you know, brands have different have different sizes. If you're a teen or a preteen pick the smallest one if there's some options. And just experiment. What I would do with them overnight. Yeah, yeah, you can put them on an overnight. You can keep them in generally, it's up to 12 hours that you keep it in, and then you pull it out, the blood gets everywhere. So you take it out, pick in the shower, or over a toilet usually dump out the blood and then go rinse it off. Wow. And are they? I don't know if there's an answer to this. But are they able to absorb more than a regular tampon? In other words, if someone who has a someone has heavy periods, is this a good option for them to think about first, the difference is that tampons absorb the blood. And then you kind of like block it and absorb it, versus the menstrual cup collects it. Okay, the menstrual cup is usually a like silicone material, kind of a flexible silicone material. And so the blood just kind of comes down and it gets collected there. And so then when you take it out, you have to dump it into the toilet or dump it into the garbage. Okay, and what about the No, I think it's really important to talk about this because you know, if anything that can help, I feel like the girl getting their period is a very, it's a universal situation. But it can be embarrassing to talk about, but anything that we can do to make it better and easier is a good thing. Right? Absolutely. And talking about like, yeah, you know, sometimes period blood gets on my underwear, you know, talking to your friends about that and just saying what are you using? Oh, which tampon are you using and why do you like it? Which menstrual cup are you using which pad I mean this this shared information, these little tips here and there I think can be really helpful and talking about it out loud to friends just You know, it's not a it's not a secret that people are having their periods but for some reason we keep it a secret, right? Absolutely no, it is talking about definitely normalises it. So, yeah, which is, which is why I'm so glad you're on here. I talk about all day every day. And what about period underwear? So for people listening, I've never heard about this what what is period underwear. Period underwear is underwear that you wear during your period, and it has an absorbent section of it that actually absorbs the blood. Some people use it, you know, in addition to a tampon, or in addition to a menstrual cup, if they're worried about leaking or spilling. So for teens, especially who are wanting to experiment with tampons, or especially menstrual cups, but there's worry that it's not going to work and they're noticing that it's just kind of spilling out. Period underwear is a is a great thing to do in addition to that. It's good. We have options. Yes, yes. plenty of options. Now one of the options that you mentioned tampons, I get a lot of questions about how to introduce a tampon. What's the best way to start? Do you have any advice for families that want to use a tampon? Yeah, so a few things to remember, I usually recommend that they start with the slim tampons. Sometimes they're even called Teen tampons. But just the tiniest diameter, starting with the thinnest possible, the slimmest diameter will make it more comfortable to learn how to insert it starting on their heaviest period day when the flow is actually really heavy, because that helps lubricate the tampon going in. And so it doesn't get kind of stuck on the skin. And then experimenting with different angles and positions to how to get the tampon in the easiest. So most people think that it should just go straight up, right where they're like leaning over their body, and they're trying to put the tampon straight up. But if you look at anatomy, the vagina actually kind of goes back in towards the back. But changing positions like lying flat on your back with your legs up in the air, like the happy baby pose, versus kind of tilting over with your leg up on the toilet, that changes the angle of the vagina slightly. And so that's the reason to experiment with that experiment with the way that you're putting the tampon in, and the position that your body is in when you're putting the tampon in. And you know, the first few times, you're probably going to mess up the first few times you probably won't put it in all the way and then you'll feel it inside the vagina. And that's a sign that it's not in the right place that you need to put it in a little bit deeper next time. I always tell parents or I tell you know, usually it's the mother and and the teenage girl that you can't, you can't put it in too far. You know, a lot of people are afraid to put it into fire, but you really can't hurt yourself. Right? Correct. Now that the cervix is there, the vagina is not an open tunnel. Right? It's the vagina is here. And then the cervix is here. And this is the uterus. You cannot put a tampon inside the cervix into the uterus. It's it's impossible. So if you put the tampon in really far, the furthest it's gonna get is to this little bit behind the cervix, and then it will stop. Right? It's like a pouch that's there. And is there an age that's too soon to start using a tampon? No, I don't think so. You know, I people have have always had problems. You know, I don't know, issues with putting something inside the vagina. I mean, there was a rumour when I was a kid that using a tampon meant that you lost your virginity. And, you know, I don't know if that's still something that people say. But that's so ridiculous, right? And I don't know where these where these ideas come from. But I had a, you know, a 10 year old patient who got her period and she wanted to use a tampon because she goes swimming all the time. And I want people to be able to use period products that fit their lifestyle. So I said go for it. You can you can use it. She only she had just gotten her period. And I said, trying experiment around with it. That's great. Remind people that you're experimenting with different period products, especially now that there's more options out on the market. And also knowing that just because it doesn't fit you right now and it's not comfortable for you and right now, doesn't mean that you shouldn't try it a few years later because your body changes the way that you are kind of associating with your body and your comfort level with your body changes. You know, so going back and forth between period products, finding something that that works for you is wonderful, but also being open To experimenting with other products, because you might find something that's even better. Absolutely. It's true. You never know till you try. Yeah. Now in terms of when girls first get their periods, I know it's common for periods to be irregular. Maybe can you describe how long they're typically irregular for when we might start to expect to see, you know, more regular monthly periods? And, and maybe also what, what is the definition of irregular? I know, I'm asking a lot of questions. But yeah, a lot at once. So, you know, it's normal for the first few years. And I don't like to give, you know, an exact timeline. But it's normal for the first few years after someone starts their period for their periods to be irregular. So you know, number of days that you have bleeding, what's normal for that amount of bleeding you're having what's normal for that? How frequently you have your period, what's normal for that. So there's a bunch of normal or not normals in there. So it's hard to say what is a normal period, because there's a wide range of normal, and that range is considered normal, if it's between 21 to 35 days. So someone's having a period every 21 days, that could be normal for them. If someone's having a period every 35 days, that can be totally normal. What's most common is that people have sort of a range of two to three days that they have their period that they will expect their period. So for example, you know, a period happens every 28 to 31 days, that would be normal and expected, it's really uncommon to get it exactly the day that you know, the same exact time every single month. It's not so common for that range to be normal. So if someone said, I got my cycle, 21 days this month, the next month, they it takes them 35 days, that's a two week range. That's not so normal. So even though the number of days fits that 21 to 35 day range that is considered normal, that their periods are fluctuating so much within that range would not be as normal. Does that make sense? Absolutely. No. So I'm just thinking, let's say, you know, I have a 12 year old who's had her period now for a year and she's having those two week fluctuations. You know, what would you advise her? Because I know, as you mentioned, in the first couple of years, it's normal to have fluctuations. And at what point should she expect to for it to normalise? Yeah, so part of that, that normalising process is, is all the hormones sort of communicating with each other. I think just knowing that that is a normal expectation, the first few years of life is important. And also reminding them that that's not the way their periods going to be the rest of their life. A lot of what we do is reassurance right, is that yeah, that sounds normal to me, let's troubleshoot it a little bit. So it makes it more comfortable for you. And it makes it you know, more sustainable for you and your symptoms, but also just reassuring them that this is this is going to get better by itself probably. Now, what if and I agree with you? I mean, of course, by and large, most teenage girls that I see that irregular periods, eventually they do normalise after a couple of years. But let's say they don't normalise it. At what point should we think about other measures? For example, I get asked a lot about starting a birth control pill so that their periods are more regular. Do you do you recommend that? And do you know is that something that you advise? I think it depends on how much the irregular periods or the amount of bleeding they're having whatever their symptoms are, that are worrisome to them. A lot of parents have concerns and some kids but I find that it mostly comes from their parents that they have concerns about them starting hormonal contraception when they're so young. Sure, and it's actually been shown to be safe once the first period starts adding birth control pills, or hormones of some kind doesn't stunt growth, it doesn't change, you know, eventually what their breasts are going to look like or their fertility or what their periods are going to be eventually. Birth control pills don't change those. So birth control pills are absolutely an option. It's not honestly, it's not usually the first option that I go to. Mostly because people don't want to jump straight to that most of the time. Both the kid and their parents want to start with something a little bit different, something kind of to work their way up to that. Like what, um, you know, the ibuprofen regimen that we had talked about earlier, with taking 600 milligrammes of ibuprofen, which is a prescription dose you. And I like to prescribe it just to make sure that they're, you know, getting to swallowing one pill and not having to go against the package inserts. But taking the 600 milligrammes of ibuprofen, and taking that every six to eight hours for the first 72 hours of bleeding, that can actually cause some pretty noticeable changes. And then there's also another medication, a non hormonal medication called TSA, which is kind of helps with with over bleeding. And so we use it during surgical procedure, sometimes to help minimise bleeding for that, but it's also been shown to decrease menstrual bleeding. And in some studies, it's pretty preliminary right now. But some of the studies show that it's as effective as hormonal medication. So this is a really great option, you do have to take it three times a day, and this max of five days, but starting that, right when the first period starts, and taking it for five days, each cycle has can decrease the amount of bleeding pretty dramatically, too. And in general, decreasing the amount of bleeding you're having is going to decrease the cramps that you're having too. So like, those are the first two, yeah. Now this is really helpful information. I was just thinking, you know, in terms of birth control pills, one of the biggest problems I find with birth control pills for teenagers is that it's hard to make sure they take them every day. So they get a lot of I hear a lot about breakthrough bleeding. And so I find that to be a tricky part. So, you know, I really, if I do prescribe them, I really want to make sure they know what's involved. Yeah, and what I usually recommend is, there's often rituals that people, you know, go through in families every day. So a lot of parents of teens that have their own phones have every single night that the teen gives the parent their phone, right, and it's something that the parents not going to forget, because they don't want their teeth that's really important to the parent. And so tying the taking the birth control pill into a ritual that you already have in place as a family is helpful. So that's one of the first recommendations that I have is thinks think of something that you do every single day. And taking the phone away at nighttime is usually the thing that parents think of and so they take the phone away, the pills are right in the container where they keep the phone at nighttime. And so the you know, the teen takes the pill at that time. So it's it's just incorporated into something else that they're doing every single day, it can be brushing teeth, or eating dinner, or driving to soccer practice or, you know, any any of those things to think about that that helps with compliance for sure. Is there any last minute advice that you want to offer to anybody listening about the subject of administrating anything that we didn't cover? You know, I think I think I think a few things, you know, number one is talking about it, and not feeling ashamed. And knowing that whatever you are going through with your period, you are not alone, there are other people who have gone through the exact same thing. And just remembering that and feeling like if I talk about this, you know, someone might feel embarrassed about it. But it's overall, it will be helpful. And, you know, talking to parents and friends, or teacher or your paediatrician, I know that they will be supportive. And so asking questions that may seem intimidating or embarrassing, or, like you don't want someone to know that about you. It's just just know that everyone is here to try to help. And in remembering that and just being and trying to be as open as possible, I think that you'll learn a lot more and feel more comfortable with your body and menstruation if you do that. The second part is, there is a lot of information out there, especially on the internet, about periods. And it's not all true. And people who do not have a solid basis of information of the way a female body works. Might make up stuff about a period or about using tampons. And these myths perpetuate. And so if you don't know if something's true or not, ask your doctor ask an OBGYN. You know, ask your parents and as parents, we shouldn't lie if we don't know the answer to something we you know, we should say we don't know. But just not you know also not believing everything that you read on the internet. That's good lesson for all of us. Yes, exactly. Well, I cannot tell you how much I appreciate your time and for all this great information for answering all of the questions that I know so many people want to know about want to ask about, but they might be embarrassed to do so. So thank you for being such a wonderful resource and I really appreciate it. Yeah, now this has been great. I'm I obviously am passionate about it and love talking about it. Where can people find you if they want to see you? Where do you work? Tell them so I work at Cedars Sinai and with the Cedar Sinai Medical Group, and they can find me on the Cedar Sinai website, if they want to call to make an appointment with me in the office. I also have a health education resource called female health education, and an associated blog called female health collective, which is a collaboration of multiple female physicians and we write articles about female female health. And then I also have a blog called Dr. Sarah Tougas. Lady Parts blog that I write about gynaecology OB issues. So that stuff on the internet, you can't actually believe it's okay. All right. Well, thank you so much, and I and we'll talk soon. Yeah, thank you so much for having me. I hope you enjoyed my conversation with Dr. Sarah toogood. If you are enjoying ask Dr. Jessica. I would be so appreciative if you would rate and review this podcast from whatever platform you are listening. Your support is what helps this podcast grow