Most parents are well-versed in schedules for their kids. They know to schedule an annual physical—or else the school nurse will call, or their child can’t join the soccer team. They know when their kids need to start dental checks, and inevitably, when to see an orthodontist.
But when it comes to teenaged girls, many parents may not realize a first gynecologist visit should be scheduled between ages 13 and 15. “Gynecologic care for girls falls into what I call a gap,” says Alla Vash-Margita, MD, chief of Yale Medicine Pediatric & Adolescent Gynecology (PAG). “And that’s where we come in.”
PAG, a new clinical service within Obstetrics, Gynecology and Reproductive Sciences, focuses on providing care for young women from birth to age 21. In addition to routine preventive care, PAG physicians treat problems ranging from infections to heavy menstrual cycles to disorders of sexual development.
We sat down with Dr. Vash-Margita, one of Connecticut's only gynecologists with this highly specialized training, to learn why young girls may benefit from early gynecologic care and to find out what drew her to this field.
How did you become interested in pediatric and adolescent gynecology?
After working as an Ob/Gyn in private practice, I came to the Hospital of Saint Raphael (now part of Yale New Haven Health) in 2008 and would see girls who came into the emergency department with gynecologic problems. I felt for these girls and developed a passion for taking care of them.
I decided to pursue a fellowship in pediatric and adolescent gynecology at the University of Michigan. It empowered me. I felt eager to work with this age group, which is underserved when it comes to gynecologic issues.
Why is it important to have specialized care for young girls?
A young girl is not a small woman; she has special needs. A pediatrician can provide general care—but it’s often helpful to see a specialist geared toward specific issues, whether it’s persistent discharge or a complex birth defect.
We take time to talk about sensitive issues. Our appointments can be long, because we touch on many different topics, including heavy periods, ovarian cysts, sexual abuse, substance abuse and mental health.
My role is to help my patients make good choices and stay safe. I interview older girls alone, providing confidentiality. But I’m also an ally to parents and caregivers. I work closely with them, offering the best information and guidance they need.
The American Congress of Obstetricians and Gynecologists (ACOG) recommends girls have their first gynecologic visit between ages 13 and 15. Why is that?
Naturally, a girl should see us at any age if she has medical issues or questions. But even if there are no concerns, 13 to 15 is when a girl’s body is changing and she starts exploring her sexuality.
This initial appointment is meant to educate patients and to establish a relationship with them. We discuss menstrual issues, puberty and prevention of pregnancy and STIs (sexually transmitted infections). I have found that, at times, girls are more open with their physician than they are with a parent. In those cases, I encourage girls to try talking to their parents, too.
As a gynecologist, I am comfortable prescribing different methods of birth control, including contraceptive pills, patches, vaginal rings, IUDs (intrauterine device) and subdermal implants. I prefer the term “hormonal regulation,” since these can help menstrual irregularities, in addition to preventing unintended pregnancies.
What should a girl expect at her first appointment?
Girls often think there will be a pelvic exam, which is not true. In the beginning of the visit, I tell my patients that, most likely, they will not need an internal pelvic exam. After that, there is a visible sigh of relief and the conversation goes more smoothly.
In fact, unless a patient has specific complaints or needs, I will not perform a pelvic exam until she needs a cervical cancer screening (PAP smear). According to ACOG guidelines, PAP smears should begin at age 21, regardless of when a girl becomes sexually active.
I will, however, perform a general physical exam. If I do need to perform a pelvic exam, I am very conservative. If it’s an exam to address a specific concern, it is typically an external inspection without any instruments.
What I tell young girls is, “If you don’t like something I do, tell me, and I will stop.” And with a young girl, the mom or caregiver is always present. Teenagers decide whether they want their mom or caregiver in the room, but I always have a chaperone during a pelvic exam.
So, at that first appointment, we meet each other, we talk. Parents are part of the conversation when I get the family history, as young girls typically do not know those details. And at some point during the visit, we speak privately with teens.
What is typical of a young girl’s menstrual cycle?
In the U.S., 12 and a half is the average age when a girl starts her period. At first, menses are typically irregular and may be heavy for the first few years. Usually, in four to five years, 85 percent of girls have regular or normal periods. But for the remaining 15 percent, menses will stay irregular for the rest of their reproductive lives.
Periods that are irregular, heavy and painful can lead to missed days of school and missed sports activities and social events. Heavy vaginal bleeding can lead to anemia. All of this can really impact a girl’s life. And if she doesn’t want to wear a tampon, she maybe won’t swim or do gymnastics or even wear white. That’s where hormonal regulation of menses can be helpful.
What can cause pelvic pain in girls?
Pelvic pain is common in adolescent girls. Usually, it is related to menstrual cramps, though many other conditions can cause it, including endometriosis, a painful disease in which uterine tissue grows outside the uterus.
Constipation or bladder problems can present as pelvic pain, so I also ask patients about bowel habits and urinary symptoms. (The uterus and ovaries are positioned next to the bowel, the bladder, pelvic muscles and joints.) Teenagers often don’t get enough fiber in their diet or drink enough water. If constipation is an issue, we discuss dietary changes and if that doesn’t work, I recommend stool softeners or laxatives. If needed, I will suggest they see a pediatric urologist or pediatric gastroenterologist.
What conditions do you treat in prepubescent girls?
We treat a variety of issues from vaginal itching to unique conditions like Mayer-Rokitansky-Küster-Hauser Syndrome, in which the uterus is underdeveloped or absent at birth. It occurs in about 1 in 5,000 girls. Many challenges come with this diagnosis, which must be managed for life. We have ways to help girls and women cope.
We also talk about how to maintain personal perineal hygiene. If irritation is an issue, I provide tips like wearing only cotton underwear and not wearing underwear to bed. For bathing, I advise using just water, no soap. Or, if she must use soap, I tell her parents or caregiver to make sure it’s hypoallergenic. Applying Vaseline also prevents irritation.
What other topics do you discuss during a visit?
My colleagues and I call ourselves the HPV (human papilloma virus) vaccine police. We are making efforts to ensure our patients receive the vaccine, which is approved for girls and boys ages 11 through 26. Our target age for vaccination is between 11 and 13. If my patients are younger than 15, I tell them, “You only need two injections. But if you wait until you are 16, you will need three.” This often works! We also screen for STIs, including chlamydia and gonorrhea.
Additionally, we discuss general physical health, including BMI (body mass index) and involvement in sports, and emotional and social health. I ask what they do after school and about their interests. As a pediatric gynecologist, I strive to provide comprehensive health care—from the physical to the emotional—to young girls as they grow older.