Helping teens make the transition from pediatrics to gynecology
For many adolescents, the first visit to a gynecologist can be intimidating. The prospect of meeting a new doctor who will ask prying, deeply personal questions about sex and menstruation is scary. And, in all likelihood, a parent, older sibling, or friend has warned them about the notorious pelvic exam.
The exact timing of when adolescent patients should start seeing a gynecologist varies based on when a patient starts puberty. Primary care physicians and pediatricians can help teens transition by referring patients to an adolescent-friendly practice and clearing up some of the misconceptions that surround the first gynecology visit. Gynecologists, on the other side of the referral, can help patients transition by guaranteeing confidentiality and creating a safe space for young patients.
Medscape Medical News talked to three experts in adolescent health about when teens should start having their gynecological needs addressed and how their physicians can help them undergo that transition.
“Most people get very limited information about their reproductive health,” said Anne-Marie Amies Oelschlager, MD, a pediatric and adolescent gynecologist at Seattle Children’s, Seattle, Washington, and a member of the American College of Obstetricians and Gynecologists (ACOG) clinical consensus committee on gynecology.
Official guidelines from ACOG call for the initial reproductive health visit to take place between the ages of 13 and 15 years. The exact age may vary, however, depending on the specific needs of the patient.
For example, some patients begin menstruating early, at age 9 or 10, said Mary Romano, MD, MPH, a pediatrician and adolescent medicine specialist at Vanderbilt Children’s Hospital, Nashville, Tennessee. Pediatricians who are uncomfortable educating young patients about menstruation should refer the patient to a gynecologist or a pediatric gynecologist for whom such discussions are routine.
If a patient does not have a menstrual cycle by age 14 or 15, that also should be addressed by a family physician or gynecologist, Romano added.
“The importance here is addressing the reproductive health of the teen starting really at the age of 10 or 12, or once puberty starts,” said Patricia Huguelet, MD, a pediatric and adolescent gynecologist at Children’s Hospital Colorado, Aurora, Colorado. In those early visits, the physician can provide “anticipatory guidance,” counseling the teen on what is normal in terms of menstruation, sex, and relationships, and addressing what is not, she said.
Ideally, patients who were designated female at birth but now identify as male or nonbinary will meet with a gynecologist early on in the gender affirmation process and a gynecologist will continue to consult as part of the patient’s interdisciplinary care team, Romano, who counsels LGBTQ+ youth as part of her practice, added. A gynecologist may support these patients in myriad ways, including helping those who are considering or using puberty blockers and providing reproductive and health education to patients in a way that is sensitive to the patient’s gender identity.
Some pediatricians and family practice physicians may be talking with their patients about topics like menstrual cycles and contraception. But those who are uncomfortable asking adolescent patients about their reproductive and sexual health should refer them to a gynecologist or specialist in adolescent medicine, Romano advised.
“The biggest benefit I’ve noticed is often [patients] come from a pediatrician or medicine provider and they often appreciate the opportunity to talk to a doctor they haven’t met before about the more personal questions they may have,” Amies Oelschlager told Medscape Medical News.
Referring adolescents to a specialist who has either trained in adolescent medicine or has experience treating that age group has benefits, Romano said. Clinicians with that experience understand adolescents are not “mini-adults” but have unique developmental and medical issues. How to counsel and educate them carries unique challenges, she said.
For example, heavy menstrual bleeding is a leading reason a patient — either an adult or an adolescent — presents to a gynecologist, Huguelet said. But the pathology differ vastly for those two age groups. For patients in their 30s and 40s, polyps and fibroids are common problems associated with heavy bleeding. Those conditions are rare in adolescents, whereas bleeding disorders are common, she said.
Most patients will continue to see their pediatrician and primary care provider for other issues. And in some areas, gynecologists can reinforce advice from pediatricians, like encouraging patients to get the HPV vaccine, Amies Oelschlager said.
Primary care physicians can also dispel common misconceptions teens — and their parents — have about gynecology. Some parents may believe that certain methods of birth control cause cancer or infertility, have concerns about the HPV vaccine, or think hormonal therapies are harmful, Amies Oelschlager said. But the biggest misconception involves the infamous pelvic exam.
“Lots of patients assume that every time they go to the gynecologist they are going to have a pelvic exam,” she said. “When I say, ‘We don’t have to do that,’ they are so relieved.”
Guidelines have changed since the parents of today’s teens were going to the gynecologist for the first time. Many patients now do not need an initial pap smear until age 25, following a recent guideline change by the American Cancer Society. (ACOG is considering adopting the same stance but still recommends screening start at 21.) “Most patients do not need an exam, even when it comes to sexual health and screening [for sexually transmitted infections], that can be done without an exam,” Huguelet said.
Confidentiality and Comfort
On the other side of the referral, gynecologists should follow several best practices to treat adolescent patients. Arguably the most important part of the initial gynecologic visit is to give patients the option of one-on-one time with the physician with no parent in the room. During that time, the physician should make it clear that what they discuss is confidential and will not be shared with their parent or guardian, Huguelet said. Patients should also have the option of having a friend or another nonparent individual in the room with them during this one-on-one time with the physician, particularly if the patient does not feel comfortable discussing sensitive subjects completely on their own.
Adolescents receive better care, disclose more, and perceive they are getting better care when is the process is confidential, Romano said. Confidentiality does have limits, however, which physicians should also make sure their patients understand, according to the ACOG guidelines for the initial reproductive visit. These limitations can vary by state depending on issues related to mandatory reporting, insurance billing, and legal requirements of patient notifications of specific services such as abortion.
The use of electronic medical records has raised additional challenges when it comes to communicating privately with adolescent patients, Amies Oelschlager said. In her practice, she tries to ensure the adolescent is the one with the login information for their records. If not, her office will have the patient’s cell number to text or call securely.
“We feel strongly adolescents should be able to access reproductive health care, mental health care, and care for substance abuse disorders without parental notification,” Amies Oelschlager said.
Telehealth visits can also be helpful for adolescents coming to gynecology for the first time. And taking the time to establish a rapport with patients at the start of the visit is key, Huguelet said. By directing questions to the adolescent patient rather than their parent, Huguelet said, she demonstrates that she is there to treat the teen’s needs first and foremost.
ACOG has guidelines on other steps gynecology practices, including those that see both adults and teens, can take to make their offices and visits adolescent-friendly. These steps include asking patients about their preferred names and pronouns at the start of the visit or as part of the initial intake form, training office staff to be comfortable with issues related to adolescent sexuality and gender and sexual diversity among patients, providing a place for teens to wait separate from obstetrics patients, and having age-appropriate literature on hand for adolescents to learn about reproductive health.
After that first reproductive health visit, gynecologists and primary care providers also should partner to ensure the whole health of their patients is being addressed, Huguelet said.
“Collaboration is always going to better serve patients in any area,” said Romano, “and certainly this area is no different.”
Amies Oelschlager, Romano, and Huguelet have disclosed no relevant financial relationships.
Jillian Mock is a freelance science journalist based in New York City. She writes about healthcare, climate change, and the environment. Her work has appeared in many publications, including the New York Times, Audubon Magazine, and Scientific American.
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