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Deborah Howell (Host): , many young women and girls are not comfortable talking about certain health concerns with their parents, pediatric and adolescent gynecology. Dr. Crystal Tomlin discusses the unique gynecologic needs of this age group.

This is Flourish, a podcast brought to you by PRISMA Health. I'm Deborah Howell. Welcome Dr. Tomlin.

Kristl Tomlin, MD (Guest): Thanks so much for having me.

Host: What a pleasure. All right, let's start at the beginning. What is pediatric and adolescent gynecology? And how does it differ from regular gynecology?

Dr. Tomlin: That's a great question. And it's definitely the most common question I get at parties. When everyone goes a pediatric gynecologist, I've never heard of such a thing. So, a pediatric gynecologist, is someone who has specialty training in pediatric and adolescent gynecologic care. Typically what that means is it's someone who completed a post medical school residency in obstetrics and gynecology, but then went on to do another, anywhere between one to two years of additional training, focusing specifically on pediatric and adolescent gynecology.

And it means that with that extra training, we have a better understanding of being able to take care of some pretty unique things that affect children and adolescents that might not affect adults all the way from birth through adolescence.

Host: And how does it differ from regular gynecology?

Dr. Tomlin: So I think that a lot of the healthcare needs of children and adolescents are different than in adult gynecology. So, for instance, a lot of it has to do with age group. In my neonates or my new infants, I get consults for things like concerns for ambiguous genitalia, or abnormal appearances to external genitalia. Sometimes things like neonatal ovarian cysts. As children get older, I commonly will see complaints with things like, again, abnormal genitalia. Vaginal discharge. I see lots of straddle injuries for young toddlers who have falls and accidents. As children go through adolescence, we play a really important role in helping monitor concerns about puberty, either puberty that comes on too late. Puberty that comes on early, lots of menstrual concerns, early menses, late menses, irregular menses, heavy menses, painful menses. Lots of things like that. And then uniquely, also, we do a lot of management with girls and young women who might have special needs or developmental delays or physical special needs that make menstrual management, possibly challenging for them and their caregivers. And then another very unique subset of patients that I take care of are for instance, cancer survivors or children who have recently gotten an oncologic diagnosis or children with bleeding disorders who then have big problems as it relates to their periods, and possibly future fertility. And then surgically, we diagnose a lot of children who have disorders of development, for instance, perhaps unusual anatomy and anatomic structures in their uterus or in their vagina. So these are pretty unique gynecologic needs. And I think not generally what people think of when they think of heading to their GYN as an adult. So, we're just a little bit better poised to deal with these more unique gynecologic needs.

Host: Sure. No wonder you needed those extra couple of years. That is a wide variety of things you're dealing with. So what are the most common conditions you treat in this age group?

Dr. Tomlin: So a lot of the things that I just mentioned. One of the things I really do pride our department in is about 20% of our patients are young women with special needs of one variety and other, be it physical, be it developmental. And so I work really closely with community pediatricians, developmental pediatricians, to work with these families in a multi-disciplinary team setting.

So that probably makes up a good 20% of my practice. Outside of that, the most common things I tend to see are concerns about menstruation or periods, generally irregular, absent, painful, heavy, that's really, really common. And then obviously I do a lot of contraceptive and sexuality education and do a lot of work with adolescents around that. So those tend to be common things that I see in my office.

Host: Sure cause most kids just don't want to talk about that stuff with their parents.

Dr. Tomlin: Yeah. And a lot of times I also find that it's nice to have an outside source, to talk to about these things that are so uniquely girl and that are changing as you get older. So you might've had a great relationship with your pediatrician, your whole life, but as you hit puberty and adolescence, sometimes those conversations can be a little bit harder to have with someone who's maybe known you the whole time.

So sometimes having a fresh set of eyes and a fresh voice means that you're more likely to open up and engage and it helps me take the best care of you.

Host: Right. And what are some of the topics you discuss with these young women who don't want to speak with their parents about such things?

Dr. Tomlin: I really make sure that when young girls come into our office, that we're really engaging in a full assessment of who they are. This is such a really exciting and important and interesting time in a young woman's life. And that's one of the reasons I love this job. It's just a real privilege to be able to watch these girls grow. But that means that you have to have a good understanding, not just of the medical reason that brought them in, but who they live with at home and how they feel about school? Are they being bullied? What is the social dynamic like? Who are their support structures, who are adults or other people in their life that they can trust?

And then one of the things that I think is hugely important, is a real good understanding and nonjudgmental assessment of their views towards sexuality, gender identity, sexual attraction, and definitely an assessment of sexual practices. So, I think that's something that we're really comfortable talking about in the office and adept at talking about in the office that a lot of other physicians might not have comfort or familiarity with.

Host: Sure. What about concerns regarding anatomy or puberty and, again, special needs?

Dr. Tomlin: These are all things that we talk about. There's increasing data and a lot of conversation that's being had in various circles about where children, both boys and girls and then not just children, but then adolescents and teenagers get their information about bodies, sexuality, safe sex. And increasingly, it's been shown that a lot of exposure comes from things like pornography, with some pretty startling statistics that a majority, greater than 70% of adolescents report that their sole source of sexual education is actually pornography, which is pretty remarkable if you think about it.

And so that's always something that I'm conscious of. You know, sexual education and access to sexual education can be really varied depending on your school, your state, your county, your family's personal beliefs, not everyone is coming to this from an open slate. So I do get a lot of girls who come in wondering if they're normal, because they don't feel that their external appearance maybe matches something that they have been seeing.

I do get a lot of girls who have questions about kind of normal expressions of sexuality and what's normal and what's safe. And so we have really frank and open discussions about all of those things in my office.

Host: What a jewel you are, and just a great source for young women to go to. Are there signs or symptoms parents should be aware of related to gynecologic issues in young children?

Dr. Tomlin: Yeah, I'm going to tackle that question, I think by age group. So in my little little kids, the things that I think are reasonable to seek medical attention for, are if you have a young girl who has a discharge that's stinky or itchy or profuse or multi-colored, that's definitely something that needs to be assessed.

And clearly, if you have a young prepubertal girl who has any concerns for bleeding, then that needs to be assessed. And then as we move into adolescence and kind of, pre-puberty, the big things that I want families to be aware of is that periods start definitely at different ages for different girls, but generally in the United States periods start around 12.

But that range of normal, you know, on either side can be a little bit varied. And usually we expect periods to start a couple, about two ish, years after breasts begin to develop. And so if I was going to say anything, that's something that I really want families to know about because I sometimes have girls who are 16, 17, 18, and haven't started their periods. And I think families maybe didn't realize that was something that should be assessed. So no sign of a period by 16, definitely, I want you to come in. Any concerns about a period or pubertal development before nine, I definitely want you to come in. So those are big things that I'd love to get out there.

Host: What about women in sports, young women?

Dr. Tomlin: It's a big conversation piece, right? One of the things that I'll say is it's been really lovely to get to watch the different exposure that my patients have to sports and the role that it plays. I think that there are some really great benefits and it's really nice to see healthy active young ladies who who are engaged in things like sports, but there can be some downfalls that come with them. Definitely, there have been reports recently in media about concerns for body image, and whether or not there's some sort of systemic component to how a girl feels she should look if she participates in some sort of sport. And in sports, I also include dance, including ballet. I include gymnastics. I include figure skating. I include all of those in my definition of sport. So, I think that's something. Body image is a big thing that I see sometimes. Perceptions of what is normal and what's normal in terms of external genitalia and appearance there, is something I see a lot of in my athletes. I do have quite a number of athletes who I've taken care of who have underlying eating disorders, and so obviously, that's something that needs to be approached from a multidisciplinary perspective.

And I've had quite a few in the last year or two who have developed eating disorders, and that can have gynecologic implications because, there's a condition which was previously called female athlete triad, but is now called REDS, which stands for relative energy deficiency syndrome, which is when a girl has a mismatch between her nutritional intake and her output, either that's because she's intentionally or unintentionally not taking enough intake or her expenditure of energy is just so much that her body can't keep up. And sometimes one of those early signs is changes in the menstrual pattern. And that can have lifelong implications for things like bone and cardiovascular health.

So that's something that I do see with my athletes on occasion, and something that I work closely with other members of the PRISMA team, including nutrition, sports medicine, orthopedic surgery, psychiatry, and psychology, and then the child's primary pediatrician. So that is something that I see.

Host: Always great to have the team approach. Now, at what age should GYN visits start and what can be expected at a first GYN visit?

Dr. Tomlin: The American College of OB GYN recommends that sometime in early adolescence, sometime between like 12 to 15 is a nice time for a young girl to meet a gynecologist. And that obviously precludes any sort of problems that may have brought you to me or one of my colleagues earlier than that.

But at that visit, when I'm meeting young ladies, we talk about a lot of the things that we were mentioning. I love to learn a little bit about them, who they are, what their interests are, who they're safe with, but I also like to help them understand a little bit more about themselves, how they identify, who they might be attracted to, if they've engaged in any sort of sexual activity or behaviors.

And if they did that, how can we talk about that to make sure that what they're doing is safe or appropriate? Safety is a really big component of that. I try to create a safe and open space for all of my patients. I do a lot of transgender care, even in the adolescent population. And we really pride ourselves on being a place where adolescents can come and talk to us openly about all sorts of things related to sexuality and gender.

I do get a lot of parents and patients who are worried that at that first exam, they're going to have a what at most adults consider a routine gynecologic exam, including things like a speculum and a pelvic exam. And that is not typically a part of it. Sometimes if girls have concerns, we might do a breast exam together.

Or I might look at external genitalia. And just reassure them that what I see looks normal. Sometimes we don't even do that. But a routine pelvic exam is not a component of those early visits unless it's clinically indicated for another reason.

Host: I think that's really smart. You can build some trust and go from there. And what is your best advice to help females develop healthy habits at a young age?

Dr. Tomlin: Obviously everybody comes from different backgrounds and different environments, but one of the things that I really encourage girls to do is, be active, be healthy, try and find something that gets you moving every single day. I'm not saying you have to join the track team.

You can walk your dog or play hacky sack, or do Zumba in your room to a YouTube video. I don't care, but do something that gets you healthy and moving every day, because that's a really great start. Know that there are adults in your life who care very much about you and always want the best for you. And it may not always feel like that, but find them.

And if you don't know of anyone, come see me. Cause I promise, I promise there are adults in your life that care about you and want to help. And then the other thing to remember is that you are beautiful you. And even though it might not always feel like it, even though sometimes you might feel like you're different or maybe unusual or things aren't matching up with your friends or the people around you. You are still beautiful you and there is always a place for you. And we will always make sure that no matter who you are, what you look like, how you feel, who you love, you are respected and valued, because girls can change the world.

Host: Wow. I'm getting a little verklempt. Yes, indeed. Everyone created as they should be. Want to thank you so much for all this great information today, doctor. Do you have anything you want to add to that?

Dr. Tomlin: You know, pediatric gynecology is this really unique, place. So, I just think that it's nice to know that it exists. We have pediatric gynecology here at PRISMA, and we're very privileged to have pediatric gynecologists here in the Midlands and in the upstate. And so, that's a nice resource that really isn't accessible to everyone.

And I think particularly if you have concerns or if you have a daughter who's or someone in your life who's anxious, and the thoughts of going to an adult OB GYN, who might not be used to just that specialized kind of communication that you sometimes need with an adolescent, that there's a place for you. We really strive to make sure your girls feel comfortable, safe, warm, accepted and safe.

Host: Be not afraid. Dr. Kristl Tomlin is a Board Certified OB GYN with PRISMA Health. For more information and other podcasts like this one head on over to prismahealth.org/flourish. This has been Flourish, a podcast brought to you by PRISMA Health. I'm Deborah Howell. Have yourself a terrific day.