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Dr Rosanna Gray-Swain: I'm Dr. Rosanna Gray-Swain, an obstetrician gynecologist, and I'm a mom doc.

Melanie Cole (Host): Hey, welcome to Mom Docs, the podcast from St. Louis Children's Hospital. I'm Melanie Cole. And you know, women, from teens to seniors, should have an annual visit with their obstetrician gynecologist. But just as our healthcare needs change as we age, those annual appointments change too. We're here today to talk about what to expect during that annual visit with your obstetrician gynecologist during each stage of life.

Dr. Gray-Swain, it's a pleasure to have you join us today. I'd like to start with the early ages. When does that first obstetrician gynecologist visit happen? When should we take our daughters for that first visit to the gynecologist?

Dr Rosanna Gray-Swain: That's a great question. And the simple answer is when they first need to go or by age 21. So it surprises a lot of people to realize that we sometimes actually see pediatric patients or even young children in a GYN office for a variety of complaints. They don't need to come as young kids for routine screening, but little girls get lots of little problems or concerns going on in their genital area. And we do have providers who specialize in this, pediatric gynecologists. But many general OB-GYNs are comfortable seeing girls on the younger end of the spectrum, in those adolescent years. If your daughter is a lass or prepubertal, you probably want to seek out a specialist who specializes in pediatric care for gynecologic concerns. But if they're prepubertal or older, most GYNs will see them for any problems. And a problem can be as simple as her periods are keeping her from going to school. So in those instances, we see very young girls. But again, that's not for a routine wellness visit, like they'll be having with their pediatrician. That's on an as-needed basis.

For a routine visit, we like to see girls when we either think or suspect that they're going to be sexually debuting or becoming interested in being intimate, so we can make sure they're armed and prepared to protect themselves. And then from a screening standpoint for a cervical cancer, which is what a lot of people equate going to the GYN, that really should start at age 21 with a few exceptions of young women who are on immunosuppressants or who have HIV.

Melanie Cole (Host): Well, thank you for that. So then, what do you check at those first few visits? You mentioned pap smear, and now we're talking about HPV and we can talk a little bit about the vaccine, Gardasil, you know. So tell us a little bit about what that first couple of visits entail. Are we teaching our teens? Are we teaching our young ladies about their bodies and self-exams? What do those entail?

Dr Rosanna Gray-Swain: So if we're just seeing someone for their routine first visit, they're not particularly coming in with any problems. And let's say they are age 21. As you mentioned, we're going to assess them and do a pap smear. That's the first screening exam for cervical cancer. And currently, that does involve an exam, a physical exam with a speculum. And so as you pointed out, that's a great time to do some body teaching with young women. Some women are very comfortable and familiar with their anatomy and other women really aren't at all. So we'll sort of assess that. And then, often I'll use a handheld mirror with a soft tipped Q-tip to sort of point out different areas and make sure they're familiar with what's what down there. In addition to the pap smear, HPV assessment in terms of risk is a great thing to go over.

Gardasil, just like you pointed out is a wonderful vaccine that is for preventing genital cancers. It's very effective at preventing cervical cancer. It's very effective at also preventing genital warts as well. And that is something that hopefully by the time young women are coming to us, they've already had with their pediatrician. It's FDA approved for young girls and is now part of the standard vaccine series that is discussed and given during those adolescent years with a pediatrician. But of course, some people fall through the gaps or they were hesitant or they had parental hesitancy around it and we can close those gaps and make sure that everyone in our office is up to date with the HPV vaccine. It's now actually approved all the way up into the mid-40s. So sometimes we're catching up that vaccine status with our older moms or women, not all moms, of course, as well.

But at that first sort of screening visit, in addition to cervical cancer screening and HPV vaccination status, we're going to do intimate partner screening for violence or verbal abuse. We're going to be assessing whether or not they are at risk for pregnancy and need contraceptive needs. We're going to assess whether or not they're at risk for any sexually transmitted infections and provide counseling on how to prevent both unwanted pregnancies as well as sexually transmitted infections. We may actually do screening for the infections, if they're at risk for that. We'll do HIV risk assessment as part of that STI screening. We're going to also, in addition to the HPV vaccine status, just check it and make sure they're up to date with their other vaccinations and encourage them to close any vaccine gaps. Most GYN offices are not going to have vaccines available to administer other than the HPV vaccine, hepatitis B and the Tdap or the whooping cough vaccine. But we are happy to check and encourage gap closure for any of the other vaccines as well. We generally will also go over breast exams and evaluation with young women, mostly providing reassurance. Breasts come in all different shapes and sizes. And a lot of young women are unsure if the way they appear is typical. So we will do an exam and almost always provide reassurance or identify any areas of concern with them as well. We also currently do more evaluation for weight management in our young women and try to promote healthy eating and lifestyle as well.

Melanie Cole (Host): Wow. It is such a great thing to have a gynecologist that you trust that you can rely on and that you can tell everything. And I feel lucky because my daughter is now seeing the same woman who I've been seeing for 35 years and who delivered her. And so really, a family thing. And it's so important, Dr. Gray-Swain, to have a doctor that we trust. So as we get into our older years, 22 to 40, we're past those teen puberty, all that areas. Now, we're thinking about reproductive years, contraception, family planning, stress management, having kids. I mean, there's a lot that starts to go into that time. Tell us a little bit about the importance of those exams. Also, trusting your doctor so that you can tell her or him anything that you have concerns about.

Dr Rosanna Gray-Swain: Absolutely. You mentioned the family affair. So we take care of lots of generations of ladies in the office. And just like you pointed out with you and your daughter, I see many moms and daughters. Often, one of the very first things in those scenarios, you know, I'll have a mom in one room and the daughter in the next room, the first thing I like to make sure I have the daughter understand is that everything that we talk about is confidential. Even though she may have come with her mom and she can share any and everything she wants to with her mom, trust starts with understanding that we are in a closed door and this is between us. So understanding that these conversations are private. Of course, there's a medical record and we do document our visits in there. Patients now have really good access to that so they can see exactly what we put in the record. But starting that conversation some boundaries, if there's any confusion like moms and daughters coming to the same office on the same day, or if they're like, "Oh, I saw my friend in the waiting room reestablishing." Yes, that's great. I'm glad you are bringing friends to us. We appreciate that, but they will not be privy to anything we're talking about.

And then beyond that, establishing trust often takes time. And so the first visit hopefully will feel comfortable and familiar in the sense that you feel like you can speak openly. And over time, that comfort level will just grow. I like to get to know my patients beyond just their medical stuff. So I'm always curious about patient's lives, what they like to do, what they're interested in. That also gives me an opportunity to better understand what happens when they're not in my office and where are opportunities to promote better lifestyle choices or health or to connect with the patients to build that trust.

It is an unusual and intimate exam we do. So I always start by the conversational part of our visit before ever jumping into an exam with a patient, asking questions about the patient and asking, What are your goals? What are your concerns today?" I want to make sure that patients feel heard and that they have a chance to ask their questions as well.

Melanie Cole (Host): So just briefly, can you touch on those years? Starting menopause after age 55, after we start getting into our mammograms, pap smears become just a little bit less frequent. Tell us a little bit about those years and what you feel, Dr. Gray-Swain, are the most important things that we, as women, keep our minds on when we're thinking about taking our best care of ourselves, because we cannot take care of the loved ones until we take care of ourselves. You know, they say put your own mask on before you put the mask of your loved one's on, so you are one of our first lines of defense in that way. So tell us the most important aspects of ages 45 and up.

Dr Rosanna Gray-Swain: I think the first thing is making sure that you're making that appointment. I can't help you if you don't come in to see me. So making sure that you prioritize that wellness visit once a year, so that we can make sure we're hitting all of the high points for wellness and identifying things that maybe we need to come back and dedicate a whole 'nother visit to. And you mentioned talking specifically about our latter reproductive years and post reproductive years. Women spend a lot more of their life post-reproductively now than ever before. The life expectancy for women is extending and likely will continue to extend. So we spend a lot of time after our childbearing years or after our menopausal transition.

And menopause is something that I like to clarify, because menopause is actually a moment in time. Menopause is once you've gone 12 months with no bleeding and that is an important mark in the reproductive journey. But really, that transition is much longer than that. And I think a lot of women and even society as a whole don't understand that it's not a light switch. So that transition from reproductive capability to no longer being able to reproduce happens over many years. The premenopausal or the premenopausal years often start about seven years before that moment of menopause before your period starts for around seven years before that your body is already going through changes that you may be experiencing. And this is a shock to a lot of women and they often think something's very wrong, when in fact it is very normal physiology. So as you enter your mid-40s, for some people, it's a little sooner or a little later, being sure that you are paying attention to what's happening with your body and not just brushing off changes or just assuming that this is normal, but bringing up these changes to your gynecologist, so she or he can really help you understand if this is just the normal transition, which is fraught for many symptoms for many women and none for others or are these things that you're experiencing potentially a symptom of something gone awry.

Melanie Cole (Host): So many things to think about. If you were to summarize, because this is such a huge topic, Dr. Gray-Swain. It really is. And you and I could do many, many podcasts on each of these stages and the things that are important, but if you were to summarize your best advice to women, on being our own best health advocate and helping our daughters start that process of trusting their gynecologist, finding someone that they love as much as I love mine. What would you tell us?

Dr Rosanna Gray-Swain: Come in and see us. Bring your questions. Be open to discussing things that may feel uncomfortable in other settings and recognizing that this is a unique space with a unique person who is there only because they want to help you achieve your reproductive destiny and be your best version through all of these transitions from pre-pubertal to pubertal to the reproductive years, to the sexually active years, to the post-reproductive years and into the years where sexual intimacy looks different than you ever might have imagined it looking.

Melanie Cole (Host): Wow. What an informative podcast. Such great information. Doctor, thank you so much for joining us in sharing your passion and your incredible expertise with us today on Mom Docs. And for more advice and articles, check out the Mom Docs website at childrensmd.org. That concludes another episode of Mom docs with St. Louis Children's Hospital. I'm Melanie Cole.