Melanie Cole, MS (Host): There's no handbook for your
child's health, but we do have a podcast featuring world-class clinical and
research physicians covering everything from your child's allergies to zinc
levels. This is Kids Health Cast by Weill Cornell Medicine. I'm Melanie Cole.
And joining me today is Dr. Julia Cron. She's the Site Chief of Obstetrics and
Gynecology at Lower Manhattan Hospital, New York Presbyterian Hospital and Vice
Chair and Assistant Professor in the Department of Obstetrics and Gynecology at
Weill Cornell Medical College. She's here to tell us about adolescent
reproductive health today.

Melanie Cole, MS: Dr. Cron, it's such a pleasure to have
you with us. Such an unusual time and an exciting time for our teens when they
visit the gynecologist for the first time. Do you feel that our kids are more
worldly and informed about sexual health, safe practices today than we were,
say, when I was a kid?

Dr Julia Cron: Hi, Melanie. Thanks for having me. I'm so
happy to be here to talk about one of my favorite topics, adolescent
reproductive health. So to answer your question, "Do teens know more today
than they did when we were young?" I think there is certainly more
information out there. There is no question that social media has prompted an
information overload. The internet alone, not even considering social media,
there is complete information overload for these teens and their parents and
guardians. So, I think the answer is yes. The question is how accurate is that
information? And that's where we come into play because it is our job as
physicians and physicians that care for teens to really be promoting accurate
information and dispelling some of the myths that are out there.

I also think that there is a general increased comfort level in
talking about some of these "sensitive topics." And I think that that
is certainly a good thing and that's why we need to collaborate and join with
parents and guardians, so that we can give them also in accurate information so
that they can have these conversations with their teens.

Melanie Cole, MS: Those are great points and so
important for parents to note, that it can be confusing information. And now
it's even varying by state to state, so it can be even more confusing. So, you,
our gynecologists, are really the person we need to go to when we want that
quality information. So, let's start with our daughters. When do we take them
to the gynecologist for the first time? I remember the first time with little
Cece, and I think I cried. It was kind of exciting.

Dr Julia Cron: So, I just want to back track and comment
on your comment about the variation among states. I think that shouldn't be
underestimated of the importance of providing accurate evidence-based
information to all of our teens, no matter where they live. I think that your
zip code should not dictate what information you are getting. So again, thanks
for mentioning that. And we will continue to work to provide accurate
evidence-based information to teens throughout our country.

Okay. So to answer your question of when should a teen have her
first visit, the American College of Obstetrics and Gynecology recommends a
first visit between 13 and 15. And I like to say that this visit is not just
about sex. So, reproductive healthcare and gynecology is not just about sex. It
is about preventative care. It is about caring for the entire patient and all
of their issues, and that it is really, really important that a patient has a
trusted professional that they can bring questions to and talk about these
"sensitive topics" that they may not be able to talk with their
parent or guardian.

So, a lot of moms will say to me, "Oh, well my daughter's
not sexually active. Therefore, she doesn't need to go to the
gynecologist." And I would say we really want our teens to get into the
gynecologist before they're sexually active, when they're going through all of
the changes of puberty and all of these things are happening to their body and
they have questions and they aren't necessarily getting the right answers. So
to your original point of all that information that's out there in the world,
much of it, which is inaccurate, it's really good to get your teen into the
gynecologist so that they can get accurate information before they become
sexually active, so that they can make informed decisions as they enter
adolescence and become young adults.

Melanie Cole, MS: I think that's so important. I wish
there was a gynecologist for boys because they need to learn this stuff too. So
hopefully, they're getting that from their pediatricians. But for women, we
have you. And I've relied on my gynecologist for 50 years, so I know how
important this is. Now, tell us about the tests and exams during that first
exam. I mean, you're not doing Pap smears on them yet, right? You're just
teaching them lessons. What are you doing?

Dr Julia Cron: So, I think the very first thing is that
the majority of young people do not need pelvic exams. And so, I think a lot of
women my age, your age probably equate a GYN visit with a pelvic exam. And
again, I want to emphasize that for the majority of patients who come for their
first visits, a pelvic exam is not indicated. So, I like to dispel that because
often, when I see patients for the first time, they're sitting on the exam room
table really stressed out, they're kind of completely tuned out because all
they're thinking about is this pelvic exam that is coming. So, first things
first, I like to say that most people do not need a pelvic exam.

You asked about the Pap smear. So, the other thing I think that
is a little bit of a myth is that a pelvic exam equals a Pap smear. A Pap smear
is a very specific test that is a screening test for cervical cancer. You need
a pelvic exam to do a Pap smear. But every time there is a pelvic exam, that
does not imply that a pap smear was obtained. So, the guidelines now recommend
Pap smear starting at the age of 21. So again, back to my point, most people
that have no abnormal signs or symptoms do not need a pelvic exam before the
age of 21.

And the current recommendations say Pap smears, every three
years for women until the age of 30. So for most young women, they need
periodic pelvic exams, but not an annual pelvic exam. So again, back to my
point of a pelvic exam does not equal a pap smear. So, a pelvic exam has
several components. First, we are just looking at the external genitalia
because remember sometimes we get information from visualization of the
external genitalia. Then, we do the speculum exam, which allows us to see
inside the vagina. It allows us to see the cervix, which is the opening to the
uterus. At that time, we sometimes obtain cultures and screening tests for
several sexually transmitted infections like gonorrhea and chlamydia. And
that's usually just a swab that is done. And then, the last part of the exam is
doing what we call a bimanual exam, where we feel the uterus and ovaries to see
if there's any problems. And again, we are often doing that in patients that
have specific concerns or complaints like abnormal bleeding, abnormal
discharge, pelvic pain. Those are the patients that a pelvic exam is warranted.

So, one thing I do want to emphasize though is although we
don't do the pelvic exam every time, I think it's really important to normalize
the pelvic exam, right? We do not want to, I use the term exceptionalize. We have
to teach people that the female genitalia is part of their body and, to me, it
is similar to listening to the heart and looking in the ears, right? So, it's
my job to normalize this and make people feel comfortable with it in a very
patient-centered way.

The other question I often get, "Is a breast exam
required?" And I would say for the majority of teens, a breast exam is not
warranted, unless they have, again, specific concerns or complaints. I do teach
what I call breast self-awareness, because I think it's important for teens to
kind of know their whole body and get used to what is normal and what a normal
breast feels like. It is exceedingly, exceedingly rare to have a teen that has
any significant pathology of their breasts.

Melanie Cole, MS: I think that was the part where I got
emotional, was when my daughter was learning those things. And it's good when a
gynecologist really listens and says, "Are you comfortable with talking
about this?" or "Are you comfortable with this pelvic exam
today?" And so, she got my daughter so comfortable that now she's just
like, "Yeah, whatever you got to do, it's fine." You know, we women,
we have to learn that. But one of the questions that I know that a lot of moms
like me had, "Can we go into that appointment with our daughters? Should
we not be?" How involved-- I mean, we've learned about with the
pediatrician, kind of when we're shooed out of the room at this point, at some
point in the child's teen years. What about the gynecologist?

Dr Julia Cron: So, I learned many, many years ago, that
if you don't engage the parent or guardian, it's really hard to get to the
teen. So, I do like to engage the parent or guardian. The way that I do most of
my visits is that when I go into the room, the patient is usually there with
her parent or guardian. I usually put it out there and say, "The first
thing we're going to do, the three of us are going to talk. And then, I am
going to ask you, parent or guardian, to leave the room so that I can talk to
your daughter in private." The reason why I do that is because it's really
important for your daughter to have a safe space where she can ask the
questions that she may not be able to ask her friends or her family members.

And as a parent, you really want your daughter to have that
safe space. And when it's framed that way, I think almost no parent says no to
that. And then, the question of the exam, if the patient needs an exam, I leave
it up to her of whether she wants her parent or guardian in the room. And then
if we need to, we regroup and the three of us talk again. But before I do that,
when I'm talking to the patient alone, I say, "You know, here are the
guidelines. What we talk about is between us. There are exceptions to those
guidelines. If there is any concerns about the patient's safety, then by law I
need to talk to a parent. But otherwise, what we talk about is between the two
of us." And then, we will decide how we are going to reengage the parent
or guardian, but again, emphasizing that it's really, really important for
patients to have a safe space so that they can talk to a trusted adult
physician healthcare provider that can give them accurate information. When I
do have that conversation with the patients, I often say that it is best to
engage their parent if they can. However, there are circumstances where teens
can't engage their parents in all of their decision-making. I have two teens
myself and my pediatrician many years ago told me, "You actually don't
want to know everything about your teen." And I think that's an important
point. There comes a point where you don't need to or want to know everything,
but you want your teen to have somebody that they can talk to and get accurate
information.

Melanie Cole, MS: Well, and communication is just
absolutely so important. And one of the things that we hear about today is the
HPV vaccine. You mentioned Pap smears. We're talking about human papilloma
virus and then there's cervical cancer. And all of these things are swirling
around in the media. I'd like you to speak briefly about the HPV vaccine. And
as a gynecologist, do you see, in your opinion, that parents have questions or
the teen themselves, that they think that it's making sex okay and safe and
giving the go-ahead? I think that's a myth.

Dr Julia Cron: Emphatically, that is a myth. So, giving
your daughter or son, it is actually approved for boys, the HPV vaccine is not
going to make them more likely to be sexually active. Additionally, and we
could talk about this in more detail, but contraception also does not make
teens more likely to be sexually active. The HPV vaccine, so HPV stands for
human papilloma virus, it is a virus that is spread through contact. And from a
gynecologic standpoint, it does two things. It causes genital warts and
pre-cancer and cancer of the cervix. So Gardasil, which is the brand name for
the HPV vaccine, there is very good evidence that it protects young people from
HPV and decreases the incidence of pre-cancer and cancer of the cervix. It has
been approved for patients age nine and actually now is approved for older
women up to the age of 45, but it's approved starting at age nine. Many people
choose to give it around age 12 or 13. Importantly, if it's given before the
age of 15, it's a two-dose regimen. If it's over 15, then it's a three-dose
regimen. Many times I hear the comment of, "My daughter's not sexually
active. I don't think she needs it," again, there's really good evidence
that if you give it before exposure to HPV, it is much more effective. So, we
actually want to give it to young people before they become sexually active.

Melanie Cole, MS: That's so important. Great points that
you made. So now, I'd like you to speak about birth control because that is a
question on the minds of both parents and our teenagers. And certainly, as they
get into later high school years and head off to college, these are things that
are so important and indeed top of mind for some of our girls. So, speak about
birth control briefly for us, and just tell us how you speak and how you
counsel our teenage girls and their caregivers.

Dr Julia Cron: First, I want to just make a comment of
the use of birth control for non-contraceptive reasons. And I always say to my
patients, I kind of wish that we didn't call it all birth control. I think
there are instances where I wish the medication that we used was called like
the period regulator or the hormone modifier because a lot of birth control we
use for non contraceptive reasons. We use it to manage heavy periods. We use it
to manage irregular periods. We use it to manage pelvic pain, painful periods.
So, there are many, many young people that are using birth control for
non-contraceptive reasons, and I would love to normalize that. If a young
person is missing school every single month because of problems with her
period, and we have a really good way to manage that. I think we should, and we
shouldn't not use it just because it's called birth control. And back to your
point of putting young people on birth control for that reason, to modify and
improve their periods, is that going to make them more likely to be sexually
active? The answer is no. So, that's where education comes into play.

Melanie Cole, MS: And acne.

Dr Julia Cron: Great point. Yep. So, there is really
good evidence that control pills improve acne. There's actually birth control
pills that have been FDA approved for acne.

Melanie Cole, MS: I agree with you, it shouldn't be
necessarily called birth control. And with my daughter, you know, and pelvic
pain, girls have all these other issues that various forms of the pill can help
or various hormone modalities. So, I agree with you there, and I think it's so
important to maybe let's look at the nomenclature, change it up one day.

Dr Julia Cron: Yeah, that would be my dream. So then,
moving on to young people that need contraception. So, the first question, the
first things that we talk about is the decision to become sexually active and
the importance of consent and the importance of healthy relationships is really
important. So, that's the first part of the conversation. And then, there's the
conversation about protection from pregnancy and protection from sexually
transmitted infections. So really at this point, the only way to protect
against sexually transmitted infections is condom use. So, we talk about that.

And then in terms of pregnancy prevention options, young people
today are actually pretty lucky. There are a lot more options today than there
were, say, 20 years ago. And I have a lot of options to offer my teens. And I
usually start out with kind of the, you know, "least invasive" to the
"most invasive." And there's a whole spectrum of options. So, the
traditional pill, the same medication is now able to be delivered via a patch,
the birth control patch. And there's also a ring that can go inside the vagina,
and that lasts for three weeks at a time. So for young people that can't
remember to take a pill every day, there are other options. Some people choose
the birth control shot, which is a three-month shot. Interestingly now, there is
a one-month shot available that patients can self-administer. This became more
popular during the COVID pandemic when patients couldn't come into the office.
So, I'm thrilled that there's so many options for young people out there today.
So, I would encourage everybody to talk to their gynecologist about what option
is best for them.

Melanie Cole, MS: We are just giving such great
information here today. Dr. Cron, I'd like you to wrap it up with a summary,
what you would like parents and their children, their teen girls to know about
their first adolescent preventive gynecology visit and reproductive healthcare,
learning about our bodies, knowing what's going on, and anything else you'd
like to mention for the listeners?

Dr Julia Cron: I do want to make one comment about the
gender-diverse teens. Throughout this podcast, we talked about girls and young
women. But another population that I care for that kind of fits into the
adolescent gynecology realm is the transgender patients who need certain things
like menstrual suppression for their gender dysphoria. And that is a Unique
population that fits into this reproductive gynecologic care. So, I just want
to put that out there.

And in summary, what I'd like to say is that parents and
guardians should think about bringing their young patients to the gynecologist
early in their reproductive years, around puberty, so that they can have
conversations with a trusted adult who can provide evidence-based information
that can help their teens as they go through the incredible transition of
puberty into young adulthood. There's lots of things to think about, and I
would encourage you to have your gynecologist be part of that team that helps
care for your person.

Melanie Cole, MS: I agree, part of that team. And it's
so important. I mean, I am still with my gynecologist literally 40 years after
I met her. And now, she sees my daughter, and so it really does carry on.
You're such an important part of our lives. Thank you for joining us today.

And Weill Cornell Medicine continues to see our patients in
person as well as through video visits, And you can be confident of the safety
of your appointments at Weill Cornell Medicine.

That concludes today's episode of Kids HealthCast. We'd like to
invite our audience to download, subscribe, rate, and review Kids Health Cast
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to weillcornell.org and search podcasts. And don't forget to check out Back to
Health. We have so many great podcasts there. I'm Melanie Cole. Thanks so much
for joining us today.

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