Intro: Welcome to UAB MedCast, a continuing education podcast for medical professionals, providing knowledge that is moving medicine forward. Here's Melanie Cole.

Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole, and joining me today to highlight pediatric gynecology and what to expect at a first visit is Dr. Janeen Arbuckle. She's an Associate Professor in the Department of Obstetrics and Gynecology at UAB Medicine.

Dr. Arbuckle, thank you for joining us today. I'd like you to explain a little bit as we get into this topic about the field of Pediatric and Adolescent Gynecology, what types of services do you offer? Tell us a little bit about this field.

Dr. Janeen Arbuckle: Thanks so much for having me, Melanie. So, Pediatric and Adolescent Gynecology really spans the gap of the care that a patient might need between a general pediatrician and focuses more on the gynecologic needs of that child. As pediatric and adolescent gynecologists, we see children from birth, all the way up through puberty, and into early adulthood.

Melanie Cole, MS: So then, tell us a little bit about when an exam is indicated in a young child or adolescent. When is the first visit indicated. And what are some special situations where a parent might want to bring their child in?

Dr. Janeen Arbuckle: I would say the vast majority of referrals we get are typically in adolescence. And the American College of OB-GYNs recommends that adolescents have a reproductive health care between the ages of 13 and 15. That can occur with their pediatrician, that can occur with an Adolescent Medicine specialist, or it can occur with a gynecologist.

The important thing about that first reproductive health visit is a focus on the menstrual cycle. It's not only when the last menstrual cycle was, but the pattern of those cycles. So for us, a large portion of our practice is focused on menstrual abnormalities, whether the periods are coming too frequently, they're too heavy, they're not coming often enough. And we help parents and the adolescent recognize when bleeding is normal and when it's abnormal, and what steps we can take to improve the quality of life for that adolescent.

Melanie Cole, MS: What are some of the most common disorders that you see in adolescents and young adults when you talk about breakthrough bleeding and various feelings that they have, whether it's endometriosis or pelvic pain or whatever it is, what are some of the most common reasons that they do come?

Dr. Janeen Arbuckle: Yeah. So, it's super frequent to have pelvic pain, as you mentioned. So, the most common diagnosis for pelvic pain is referred to as dysmenorrhea. And there's lots of reasons for an adolescent to have pain related to their menstrual cycle. That can be the normal physiologic changes related to ovulation, to menses. There's certainly pain that goes along with that. Endometriosis is also on the differential diagnosis, and we talk with families and adolescents about the preferred medical treatments and interventions that can address that pain.

Melanie Cole, MS: When we think of exams and tests, especially at that first visit, as an adult, we know we're going to get a pap smear every couple of years based on our HPV status. We're going to get our mammograms, whatever we're going to get. But when we're talking about adolescence, tell us a little bit about what exams may be done and you can add into that speaking a little bit about HPV.

Dr. Janeen Arbuckle: Those are both really great topics to consider. I know the word gynecologist to an adolescent is never a welcome word, and there's a lot of fear around that first. And as you mentioned, even for adults, it's hard, right? And there's a perception that we're going to do something invasive and/or painful. The reality is the vast majority of adolescents who present, particularly for their first reproductive health visit, do not require an exam. And there are certain exceptions for that, and we can certainly discuss those. But again, the vast majority do not require an exam, and it's mostly focused on their history, their symptoms. Occasionally, we need to do blood work, but that's not any different than the blood work you would have elsewhere.

With regards to dating a pelvic exam, those adolescents who need a pelvic exam often have a pelvic specific complaint, such as abnormal discharge, itching, or burning in the vaginal area, things that we really need to look at to be able to say if there's something wrong or not. That's different than I have pain with my periods, right? Pain with your periods is not something that necessarily means that we have to do a pelvic exam.

As we mentioned in adults, we do screen for cervical cancer, and we're very fortunate in the United States that that's primarily an adult disease, and we don't start screening for cervical cancer through pap smears until the age of 21. There's various organizations who have different ages, but that's the one that's most commonly accepted, is age 21. .

The vast majority of cervical cancer is driven by HPV exposure. And in the adolescent population, the most important thing for parents to do is focus on HPV vaccination. HPV vaccines are cancer prevention. They are just as safe as the flu shot, and they are most effective when administered in early adolescence, even as young as age 9 or 10. I'm a mother myself. I have a 10-year-old and we've initiated the vaccination series. The benefit is that if you initiate before the age of 15, you only need two doses of the vaccine rather than three.

Melanie Cole, MS: Dr. Arbuckle, as you're speaking to other providers and their patients, their parents, and even maybe the kids have questions about that vaccine and about whether or not this is something that the child really needs. Is it harmful when you counsel your patients? For other providers doing the same, what is some of the wording that you use? What is your best advice in that regard?

Dr. Janeen Arbuckle: So, I really want to stress that it is cancer prevention, and the reality is that HPV is everywhere. HPV, though it is sexually transmitted, it lives on surfaces, it's spread through open mouth kissing, it's spread through hand contact. So, it's not necessarily something that requires somebody to be sexually active to be exposed.

In the United States, the fastest growing HPV-related cancer is actually a head and neck cancer. So, we're not just talking about cervical cancer anymore either. So, I try to destigmatize that this is something that's only women who are promiscuous are at risk for, or only adults are at risk for. And the reality is that we're all going to be exposed to HPV. Yes, the vast majority of us will clear the HPV to which we're exposed, but we don't have a way to differentiate who will clear it and who won't.

So to me, the benefits of vaccination far outweigh any risks. Again, the risk related to HPV vaccine are no different than those related to the flu shot. The Institutes of Medicine did a large series reviewing all the literature on all the vaccines. And vaccines can certainly have a vaccine-related reaction, low-grade malaise, low-grade fever, but certainly doesn't have any long-term sequelae that would harm your patient.

Melanie Cole, MS: I think one of the more important aspects and interesting to me of your profession is the private conversations between you and your patients, different than when the caregiver, the guardian, is in the room. You have private conversations. Speak to other providers about the importance of this and what it is when patients are talking to you. What are some of the most common concerns that they would bring up to you when their parents aren't around?

Dr. Janeen Arbuckle: So, we really honor and respect the individual and their autonomy and their right to confidential medical care. And so, we focus at UAB on interviewing all patients age 14 and above initially independently. And that gives them an opportunity to have a rapport with a person that they know is their confidant, that they can trust in, that is in addition to their parent.

And I really try to stress that to parents that I am just another advocate for your patient, and I want them to know that I am their doctor, and they can come to me for anything. Various adolescents have various comfort levels, sharing personal and private information, certainly, concerns about sexual intercourse, interpersonal relationships, those are probably the most confidential topics we talk about.

Unfortunately, a lot of girls have fears about future fertility. So, we talk about things we could do now to maintain being healthy, and give reassurance that fertility for the vast majority of women to be achievable in the future.

Melanie Cole, MS: I think you can play a big role, as does their pediatrician, in helping them to lead that healthy lifestyle that might carry them through and discuss those kinds of behaviors and risky behaviors with them. And I imagine that birth control is something that comes up, and not only to use for sexual intercourse, but also for other situations like acne. So, speak about some of the birth control discussions. What does that look like, before we get ready to wrap up this episode?

Dr. Janeen Arbuckle: Birth control has tons of non-contraceptive benefits, and I would say at least half of my adolescents are on birth control for non-contraceptive benefits. Earlier in this session, we talked about dysmenorrhea, we talked about endometriosis. Another common diagnosis we didn't talk about is PCOS. And in reality, the first line treatment for all of those is a combined hormonal birth control. Combined hormonal birth control is great for acne. And so, those are all things that we use birth control for.

So, my counseling typically, I give the full scope of contraceptive options, and all their kind of strengths and weaknesses. And the language I use is, "Which of these best suits your needs right now?" And the reality is for a lot of women and adolescents is that they're going to have a contraceptive journey. What they choose for now may not know what they choose in five years or ten years, and they have the luxury of making those changes over time.

Melanie Cole, MS: Great information, Dr. Arbuckle. You're such a great educator. And I also love your passion for your field, and I can hear it. And I imagine the teens that come to you are really drawn to you as a physician. And sometimes, your gynecologist can be somebody that you follow through life, that they become your doctor for the lifespan of your reproductive years. I'd like you to offer your best information for other providers about Pediatric Gynecology and UAB Medicine. What you would like the key takeaways to be?

Dr. Janeen Arbuckle: So, I find for me one of the most rewarding parts of my practice is the care of the adolescent and it is something that the vast majority of general OB-GYN practitioners can practice themselves in their own clinics. It's super valuable to create an adolescent-friendly environment, again, to prioritize adolescent confidentiality. But we pose, as gynecologists, a unique opportunity for adolescents to have another advocate in their life, to have somebody that can give them guidance, and help shape their future relationships, and establish important boundaries as they age.

Melanie Cole, MS: Thank you so much, Dr. Arbuckle. What a great guest you are. Thank you for joining us. And for more information, please visit our website at uabmedicine.org/physician. That concludes this episode of UAB Medcast. I'm Melanie Cole.