Questions to Ask During Your 1st GYN (Gynecology) Visit
Your First Gyn Visit...What to Expect and What to Ask
Spring is a time when many high school seniors are seeing their gyn for the first time before going off to college. In addition, this is the time when high school juniors are completing all of their standardized testing and may finally have time to go to the doctor. They may want to see a gyn for the first time before senior year comes around and they become even more busy with college applications and visits.
These 2 time frames are the most common times that we see teens come in for their first gyn visit. Here’s a primer on what goes on in that visit. Show this to your daughter before she comes in so she will be less worried (fear of the unknown is worse than the actual event!) and so that she will know what questions to ask!
WHEN SHOULD GIRLS FIRST SEE A GYNECOLOGIST?
If there are no gynecologic issues, teenagers should establish a relationship with a gynecologist by junior or senior year of high school. This visit should occur earlier in those girls who have menstrual issues such as periods that are too frequent, infrequent or painful, or those girls who are thinking of becoming sexually active or who have any other gynecologic concerns.
WHAT IS DONE AT THE FIRST GYNECOLOGIC VISIT?
What is done at the first gynecologic visit depends on the reason for the visit and whether the girl is or isn't sexually active. In a routine visit with no complaints or problems under the age of 21, no pelvic exam is performed if a girl is not yet sexually active. We would discuss Gardasil (the HPV vaccination), which is recommended for all boys and girls between the ages of 9 and 26, and we would recommend administering the series if she has not already done so with her pediatrician.
We would discuss safe sex and condom use along with STD protection and prevention and all contraceptive methods. We would also address any concerns or issues about menstrual cycles, breast self examination and any concerns or questions about female anatomy. Young girls often have many questions that they are not comfortable addressing with their mother or their peers, and this is an optimal opportunity to have those questions addressed and answered and concerns alleviated.
If they are sexually active we will do a pelvic examination and culture the cervix for gonorrhea and chlamydia, offer blood testing for STDs such as HIV, hepatitis B and C and syphillis. We would discuss condom use and all contraceptive methods. If over the age of 21 we would initiate pap smear screening.
PAINFUL PERIODS, also known as dysmenorrhea
This is a very common conditions in teens and women in general. Most of the time there is no pathologic reason for dysmenorrhea. It is caused by normal ovulation and cycling where prostaglandins are produced, and some women produce more prostaglandins than others.
Using anti- prostaglandin agents such as NSAIDS (non steroidal anti inflammatory drugs) such as motrin, advil, alleve, anaprox, or another type of drug called ponsel with food so as not to irritate the stomach lining, with the cramping during menses works well. Another excellent alternative is preventing the production of these prostaglandins by using oral contraceptive pills.
INFREQUENT PERIODS- also known as oligomenorrhea
This is also common in young girls. For the first 2-3 years after the onset of the first period (menarche) it is common to have infrequent periods every few months. It can take 2-3 years for the hypothalamic-pituitary axis to mature and develop and give you regular periods.
If the irregularity persists, hormonal blood tests can be drawn to further evaluate the situation and rule out any hypothalamic, pituitary, or thyroid issues, along with polycystic ovarian condition. Most of these situations can be easily treated and managed, and if no cause is found, oral contraceptive pills can be initiated.
TOO FREQUENT PERIODS- menses that occur too frequently (more frequently than every 21 days)
This can be distressing and can also lead to anemia (low blood count) which can cause a tired and weak feeling. Looking for a structural reason (polyps and fibroids which are more common in older women), ovarian cysts, or a functional/hormonal reason, or an infectious reason will be looked into at the visit.
It is important to identify the small subgroup of young women who have unusually heavy periods due to hereditary bleeding disorders such as von Willebrands disease. Blood tests in the office are used to make the diagnosis. A complete blood count is also used to determine if anemia is present, and if it is, iron supplementation can be prescribed. Medications such as oral contraceptives can be used to control excessive bleeding in many cases.
There is a significant variation in normal in young women with regards to breast size. There are many factors that can impact breast size such as weight, heredity and medications. Many young girls who have recently gone through puberty are self conscious about breast size, and this is one of the questions they may pose to the gynecologist at their visit.
Girls with extremely large breasts may develop problems with posture and back pain, as well as grooving at the shoulders where their bra straps overly burden the area. They can also develop skin rashes and irritation as well as yeast infections under the breasts where moisture is trapped and chafing can occur. They may have difficulty comfortably wearing certain clothing and swimwear.
Many of these girls come in to see if they are candidates for breast reduction. In very young girls we try to wait until full breast maturity occurs prior to considering surgical reduction. We also try to encourage weight loss in those girls who have large breasts in conjunction with obesity, prior to the consideration of reduction. In those girls who have breast maturity and are close to their ideal weight and have significant problems with large or pendulous breasts, referral to a qualified plastic surgeon is warranted.
Teens often are self conscious when they perceive their breasts to be too small. Girls go through puberty at different times, and many girls are concerned that they go through puberty later and have delayed breast growth, which can be very normal, requiring only reassurance from a doctor.
Other girls have already gone through puberty and have totally mature albeit smaller breasts. Many come in asking about breast augmentation. In these patients, risks, benefits and alternatives are reviewed and referral to a qualified plastic surgeon is warranted.
In all women, one breast is smaller than the other. Just like the ring you wear on your right ring finger is unlikely to fit on the left ring finger because it is either a bit smaller or larger, the same is true of breasts. Most size disparity in breasts is subtle, but present.
However, in some women, there can be a normal but marked breast size discrepancy, with a difference of a cup size or two. Most of these discrepancies are handled by reassurance that this is normal, but if the discrepancy is very marked, that small subgroup of patients are also referred to a plastic surgeon.
PUBIC HAIR- SHAVING, WAXING AND LASERING
Young girls often have concerns about the safety and particulars of shaving, waxing and layering pubic hair. Social norms have been favoring less pubic hair in younger women, leading to many questions about how, where, why, and how much.
Many girls who shave can get ingrown hairs that are painful and unsightly, and less of this is seen with waxing, and even less with layering. Many young girls feel that they have this conversation with their mothers because hair removal techniques, patterns and modalities may be generational.
Waxing should be done at a reputable place that has confirmation of cleanliness and strict rules (i.e. no double dipping) and reputable laser establishments, preferably associated with gynecologists or dermatologists should be strongly considered.
LABIA- ARE MINE NORMAL, DO I NEED SURGERY?
A very frequently asked question by the adolescent and the teen a\"Are my labia normal?"
There is a strong desire in modern culture for very “pre-pubescent” appearing genitalia, which is very strongly influenced by social media and society in general. There is a wide variety of “normal” labia minora and majora sizes and many girls with larger labia are very self conscious, and feel very abnormal. The request for labial reduction surgery is a common one, and it is very rare that someone truly has abnormally large labia that should undergo reduction.
Reassurance of normality is often the only thing that is required in most of these patients, but evaluation and assessment is important, and this concern should not be dismissed. The American College of Obstetrics & Gynecology does not support cosmetic labial reduction procedures, as they can be frought with sexual, emotional, and physical complications. Scar tissue can form after this type of surgery that can cause painful sex in the future, so unless there is an extreme anatomic reason to do so, labial reduction is not encouraged.
WHAT ARE THE TYPICAL SEXUAL CONCERNS IN YOUNG GIRLS AT THE TIME OF THEIR FIRST VISIT TO THE GYNECOLOGIST?
IS IT NORMAL THAT SEX HURTS?
With so much in the media and social media talking about how amazing sex should be and with women's magazines touting articles about “How to have the best sex”, many young girls feel very “abnormal” when they begin having sex and it is painful. Sometimes reassurance is all that is needed, whereas other times there can be lack of foreplay and lubrication. Sometimes water soluble lubricants are encouraged, and evaluation to rule out infection is also warranted.
SHOULD I START A BIRTH CONTROL PILL?
The birth control pill is very commonly prescribed for adolescents and teens for non contraceptive benefits of relief of dysmenorrhea (painful periods), reduction of heavy periods (menorrhagia), correction of oligomenorrhea (infrequent periods), or irregular periods. It is also given by dermatologists and gynecologists for treatment of acne, and they are also used to treat polycystic ovarian condition, in addition to being an excellent and safe form of contraception.
Many of their friends are on the pill, with good outcomes, as well as those who are not happy because of side effects. Exploring the reasons behind wanting to start a pill, along with a very thorough explanation of what to expect on the pill is critical in successful pill use in any patient, but particularly in the adolescent and teen age groups.
HOW EFFECTIVE ARE THEY?
Many young sexually active girls are very concerned about getting pregnant while on the pill. Counseling patients that with perfect use and compliance with the pill they can have over 99 percent efficacy is reassuring. Reinforcement of the need for concomitant condom use for STD prevention with the pill is of paramount importance.
WHAT IF I TAKE OTHER MEDICATIONS OR ANTIBIOTICS?
It is unlikely that pregnancy will occur or efficacy affected by common antibiotics or over the counter medications. There are some categories of medications such as anti- seizure medications that can lower the efficacy of the birth control pill.
It is very important that you discuss all of your medical issues and medications that you take on a regular basis with your gynecologist so that we can counsel you appropriately on the appropriateness of the pill for your particular situation.
WILL I GAIN WEIGHT?
One of the most common reasons for young girls to not start the pill, or to discontinue the pill is concern about weight gain. The teenage years are a very vulnerable time for weight gain, and this side effect is most feared and most unacceptable. There is no question that it is not uncommon even with low dose contraceptive pills, to gain a few pounds initially. It is not common to gain large amounts of weight with the pill.
Unfortunately, many girls come to the gynecologist for the first time in the summer prior to leaving for college. They begin the pill and go right off to college, and they come back a year later 10-15 pounds heavier and blame that weight gain on the pill.
The problem lies in the differentiation of the “Freshman 15” from pill related weight gain. Most of the time it is the lack of exercise and more sedentary lifestyle of the college freshman, along with pizza and beer in the evening hours, as opposed to just the pill. The pill, however, is an anabolic steroid and can make you more hungry but the reinforcement of good food choices can ameliorate pill related weight gain.
In summary, some girls will gain a few pounds, some will lose a few, most will remain quite weight neutral, but some girls will gain more than the average. Staying in close communication with your gynecologist regarding how you are doing with the pill can help to guide pill related weight concerns. I always tell my patients to please call and talk before taking it upon yourself to just stop the pill all together.
WILL MY BREASTS GET BIGGER?
If you gain weight, the first place for it to go is your breasts in most cases. When patients come in complaining that their breasts have grown due to the pill, in some patients this can be seen, but most often if you check their weight and they are up 5 pounds, much of this “breast growth” can be managed by weight loss.
WHAT SIDE EFFECTS CAN I EXPECT?
It is very common to have breakthrough bleeding for the first 3 cycles of the birth control pill, until your body gets used to it. Irregular bleeding, persistent staining and unscheduled bleeding are all really common in the first three months and patients should be encouraged not to stop the pill or change pills for the first 3 months.
Skipping periods all together is very common, and with low dose pills we see this a lot. The period we give you on the pill is an artificial one, and it is not “necessary” to have a period. There are pills that we can give you where you only have a period once every three months or not at all. This is not unhealthy, and if you havent missed any pills there is no need to worry about pregnancy.
Other side effects can include breast growth and tenderness, weight gain and nausea (take it at night if it makes you nauseated, and if this persists, ask your doctor for the lowest dose of estrogen in the pill or consider taking the pill in a vaginal ring form (nuvaring).
In patients who are headache sufferers the pill can make your headaches better or worse. Some patients who never experienced headaches before can develop headaches. Some girls on the pill can develop Melasma which is a facial skin discoloration condition that is related to the estrogen in the pill (it can also be seen in pregnancy when estrogen levels are increased).
WHAT SIDE EFFECTS DO I HAVE TO LOOK OUT FOR?
There is a small but real chance of blood clots in the lungs, legs and brain with the pill. The risk is highest in those patients who have hereditary blood clotting disorders and patients who are smokers over the age of 35 (neither of these patients should be started on the pill at all), but even patients with no risk factors at all can rarely be faced with this complication, and the implications can be significant especially if they are unrecognized. If there is redness, pain and swelling in the leg, shortness of breath, or signs of stroke, immediate emergency medical attention should be sought out.
WHO SHOULDN'T USE THE PILL?
Patients with active liver disease, pregnancy, undiagnosed genital bleeding, smokers over 35 years old, patients with cardiovascular disease, lupus, blood clotting disorders and stroke should not use the pill.
WHAT IF I MISS A PILL?
If you miss a pill you should double up and take 2 pills the next day. Try not to do this more than once in a month, otherwise you can get break through bleeding and there is a higher chance that you can get pregnant.
HOW DO I PREVENT MYSELF FROM FORGETTING TO TAKE IT?
Set the alarm on your phone to ring every evening at the same time so as not to forget to take the pill. Some patients rubber band their pill pack to their toothbrush. It is unlikely you will forget to brush your teeth at night, so you wont forget your pill if it is close by.
If you keep forgetting despite these prompts, the pill may not be for you and you should consider the nuvaring (just like the pill but it is a vaginal ring that you put in the vagina once a month and you only have to change it once a month- you can swim and bathe with it and can have sex with it).
Alternatively, if you keep forgetting, than an IUD or Nexplanon (progesterone implant in the arm) may be better for you.
WHAT IF I DONT GET PERIODS ON THE PILL?
It is completely normal with current low dose pills to not get periods at all. It is not unhealthy and the period that we give you on the pill is an artificial one. If you haven’t missed any pills there is no need to take a pregnancy test. If it really bothers you that you are not getting a period and you want one, just speak to your gynecologist and they can go up a little bit on the estrogen dosage in your pill and you will likely resume getting periods.
Bottom line is there is no health or reproductive downside to not getting a period.
I HAVE HEARD A LOT ABOUT IUDS (Intra-Uterine Devices)
ARE THEY SAFE?
IUDs are very safe, and are being prescribed more often in current times. They are approved and encouraged for use in teens and adolescents by The American College of Obstetrics & Gynecology.
WHAT ARE THE RISKS WITH AN IUD?
Risks are uncommon with the IUD, but there is always a small chance of developing an infection from insertion of the IUD, rarely you can get pregnant with the IUD in situ and if this happens it is more commonly an ectopic pregnancy in the fallopian tube which can be a surgical emergency.
Perforation of the uterus with the IUD escaping into the abdomen requiring surgery is an unusual but not unheard of complication. Pain with insertion of the IUD is not uncommon, but is usually brief and well tolerated. The IUD can fall out or be expelled.
WILL I GAIN WEIGHT?
There are 2 categories of IUDs. A non-hormonal copper IUD and a progesterone releasing IUD. The copper IUD is not associated with weight gain. With the progesterone releasing IUD only a small amount of progesterone is actually absorbed in your blood stream, and there is no estrogen, so it is very unlikely, but not impossible to gain weight from this type of IUD.
DOES IT HURT TO PUT ONE IN?
IUD insertion in teens and adolescents, especially since most of this population has never had a baby, can cause discomfort. This discomfort can be ameliorated by taking motrin or Alleve an hour before insertion. The entire process of insertion takes less than 5 minutes and is usually well tolerated. For the progesterone releasing IUD there is a smaller version called Sklya which is good for 3 years, and it is less uncomfortable to insert.
WILL MY PARTNER FEEL IT?
There are IUD strings that protrude out of the cervix, but these are rarely perceived by a partner during sex. These strings are cut a certain way when the IUD is inserted to minimize any discomfort to a partner. If they cause any discomfort, they can be trimmed appropriately by your doctor.
DO I STILL HAVE TO USE A CONDOM?
You should still use a condom for STD protection, even though you are well protected against pregnancy with use of the IUD. If you and your partner are monogamous for an extended period of time and both of you have tested negative for all STDS, you may then consider with caution, sex without a condom.
WILL I STILL BE ABLE TO GET PREGNANT IN THE FUTURE?
Any of the IUDs should not cause infertility. Removal of the IUD should cause prompt return of fertility. Rarely, if a significant infection occurs with the IUD (uncommon), tubal infection leading to tubal compromise can occur.
HOW LONG ARE IUD's GOOD FOR?
The copper releasing IUD (Paragard) is good for 10 years, the progesterone releasing IUDs are good for 5 years (Mirena) and the teenage smaller progesterone releasing IUD (Sklya) is good for 3 years.
WHAT WILL HAPPEN TO MY PERIODS WITH THE IUD?
The copper releasing IUD can make your periods heavier and crampier. If this happens, you can take motrin around the clock with food for the first few days of the period and this will decrease the bleeding significantly.
The progesterone releasing IUDs are excellent for giving you very light to non existent periods. In the first 3-6 months you can get a lot of unscheduled spotting and break through bleeding, but after that the periods are light or absent. These progesterone releasing IUDs are used specifically to reduce heavy bleeding in women even when contraception is not desired.
WHAT IS THE DEAL WITH CONDOM USE?
Latex condoms are a must, and should be put on before the penis goes near the vagina. Remember that sperm swim and even before ejaculation one drop of that pre-seminal fluid can contain 20 million sperm.
You should buy your own condoms and have them with you, and never have sex without one, even if you are on the pill or have an IUD. Condoms are the best protection against STDs and are also an excellent and safe method of birth control (85% effective so even better if you use them with a birth control pill or an IUD). If you are allergic to latex go out and buy polyurethane condoms. Do not use lamb skin because the pore size can be too large to prevent STDs.
I HAVE SEEN COMMERCIALS ABOUT NEXPLANON. WHAT IS IT?
Nexplanon is a long acting reversible method of birth control which is excellent for young girls. It is highly effective (99%) and it is a thin flexible rod about 1 and 1/2 inches long which is placed in the skin of your inner upper arm by your gynecologist and it is good for 3 years.
This implant slowly releases a tiny continuous amount of progesterone into your blood stream and is very well tolerated. Nexplanon can cause your periods to be shorter, lighter, longer or absent. Patients who should not use this method include those with breast cancer, pregnancy, liver disease, undiagnosed genital bleeding, history of blood clots or concomitant use of certain medications.
WHAT DO I NEED TO KNOW ABOUT THE MORNING AFTER PILL?
All sexually active girls should know about the morning after pill and how to obtain it. Plan B is now over the counter and you can go to the drug store and purchase it without a prescription.
It should be taken within 72 hours of unprotected sex or after a condom breaks. It is very effective (over 90%) and is more effective the sooner you take it, but it is not perfect, and if your period is late you should take a pregnancy test.
Plan B is progesterone only and very safe and is only one dose, so almost everyone, even with medical issues, can take this. It will not get rid of an existing pregnancy, and also should be used as an emergency contraceptive, not regularly for birth control. If it is more than 72 hours after unprotected sex but less than 5 days, call your doctor because they can prescribe Ella.
IS ORAL SEX REALLY SEX AND DO I HAVE TO WORRY ABOUT ANY CONSEQUENCES?
Oral sex is definitely real sex and you can catch all of the same STD's (sexually transmitted diseases) with oral sex as you can with vaginal sex, you just cant get pregnant this way. A dental dam should be worn, as should a non lubricated latex condom on the penis to prevent transmission of STDs.
**Have Questions About Your 1st Gyn Visit or Planning to Schedule Your Daughter's 1st GYN Visit? **
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