Young Women and Gynecology

Most adult women are aware that they should see their health care provider once a year for a gynecologic exam. But what about girls and young women? Do they even need to visit a gynecologist? When should they start?

Michael Lund, MD, Assistant Professor of Obstetrics and Gynecology at the Medical College of Wisconsin, says it all depends on the young woman in question. A family physician or pediatrician can usually provide general gynecologic health care for young women, he says. "There isn't any reason for those under the age of 18 to see a gynecologist, unless they are sexually active or are having reproductive health concerns." For teenagers, that might include painful periods, heavy periods, ovarian cysts, vaginal discharge, lack of periods (amenorrhea), or contraception issues.

Routine Pap smears to test for cervical cancer don't usually begin until age 21, or 3 years after a woman has first been sexually active. "Of course," emphasizes Dr. Lund, "if a young woman would like to talk to the doctor about any of her concerns before becoming sexually active, that is certainly encouraged. Many mothers of teenagers will bring them to the gynecologist's office just to talk about these things."

The First Visit
Dr. Lund says that often, the first visit is just a time for patient and practitioner to meet. The health care provider will first take a history, which typically include the following questions:

• Age at first menstrual period?
• Current menstrual history (How often are your periods? How long do they last? How heavy is the bleeding? Do you have pain?)
• Sexual history (Have you had intercourse or any other sexual activity? Do you use condoms? Have you ever been tested for STDs?)
• Any history of abuse or violence?
• Any concerns or questions?

"We ask additional questions based on her concerns," says Dr. Lund. "For example, for someone who has never had a period at age 16 or 17, we would ask if/when breast development started, if/when pubic hair development started, and if/when the growth spurt started."

"We obviously concentrate on prevention of pregnancy and sexually transmitted infections in all healthy patients," says Dr. Lund, "but the majority of adolescent patients who see us are requesting contraception or sexually transmitted disease testing, or are having particular health concerns."

"We make sure the first visit isn't threatening," says Dr. Lund. "We provide education and take a history. Often, we won't even do an exam until there's a good reason to do one." The physician will also make sure there aren't any major symptoms that need further evaluation. For example, painful periods in young women are generally caused by an excess of prostaglandins - the chemicals that mediate pain.

"Ibuprofen, naproxen and other drugs in that class block these chemicals so they are the most effective way to treat painful menstrual cramps," says Dr. Lund. "If that doesn't work, we might prescribe hormonal methods such as birth control pills because these also help to lessen cramps. If that doesn't work, we might look for other causes of the pain, such as endometriosis or infections." Another problem young women might experience is heavy periods. Heavy periods are often caused by anovulation in the early teenage years."

"Anovulation means that ovulation doesn't occur regularly at first," Dr. Lund says. "And ovulation is one of the keys to having regular, normal periods. The average young woman doesn't ovulate consistently for the first 12-18 months after the first period; they generally become more regular with time. We can temporarily regulate the periods better by using hormonal methods such as birth control pills, which are safe in this age group. We also make sure there isn't another problem going on; some women might have a bleeding disorder such as von Willebrand's disease, which will make their periods very heavy."

Sexually Transmitted Diseases
Unfortunately, sexually transmitted diseases (STDs) are an issue in adolescent gynecological health. "The best advice regarding STDs," Dr. Lund says, "is that abstinence is the only sure way to avoid them. Really." Having said that, Dr. Lund notes that condoms help lessen the risk of acquiring most STDs, including HIV, the virus that causes AIDS. But it's important to remember that some STDs are difficult to prevent, and Dr. Lund recommends that any woman who has been sexually active should be receiving annual STD screening.

As far as statistics, Dr. Lund reports, "HPV (Human Papillomavirus) and chlamydia are the two most commonly acquired STDs during the teenage years. HPV causes genital warts, which are treated with a topical medication, by freezing, or by injections if necessary. Then he gives a staggering estimate: "HPV affects up to 60% of the sexually active population at some point."

According to the National Institutes of Health, chlamydia is the most common of all bacterial sexually transmitted infections. It is easily treated with antibiotics, but may go unnoticed, as many people have few or no symptoms. Again, Dr. Lund offers an unfortunate statistic: "Chlamydia affects somewhere between 2% and 10% of females age 15 to 19," he notes, but since this statistic is a percentage of all females in that age group, including those who are not yet sexually active, the incidence of infection among sexually active young women is actually much higher.

Birth Control
"Any time we talk about STD protection we should be talking about pregnancy protection as well," states Dr. Lund. "Again, nothing is failsafe except abstinence, but there are some very effective methods available." Information about contraceptive options, including risks and failure rates, are listed on the website of the US Food and Drug Administration, including:

• Male and female condoms
• Oral contraceptives
• Diaphragm
• Cervical cap
• Injected contraceptives
• Implanted contraceptives

It's important that all contraceptive options, along with their rates of effectiveness and possible side effects, are discussed with the health care provider.

In addition, girls or young women seeing a gynecologist for the first time might have questions such as:

• Why haven't I had a period yet?
• Are my menstrual cycles normal?
• What happens during a pelvic exam?
• What's the purpose of a Pap smear?
• How do I avoid pregnancy?
• How do I get/avoid sexually transmitted infections?

Dr. Lund says a visit to a gynecologist or other health care provider is essential for any young woman who has questions or issues that need to be addressed. "There are often things we can do to make life better with regard to very heavy periods or very painful periods," he notes. "If young women are missing school or work or things they enjoy because their period is that bad, we can generally make their lives easier." He also emphasizes that any girl or woman who is sexually active, regardless of her age, needs to have regular reproductive health care.

P.J. Early
HealthLink Contributing Writer

This article includes information from the National Institute of Allergy and Infectious Diseases/National Institutes of Health.

For more information on this topic, see the HealthLink article Sexually Transmitted Diseases: 15 Million Every Year.