The EngagED Midwife
The EngagED Midwife
Speculums Are Scary, Guidelines Aren’t: Teen Gyn Without The Drama
A packed hallway at the ACNM Annual Meeting turned into the perfect backdrop for a clear, compassionate deep dive on adolescent gynecology. We talk candidly about what really helps teens feel safe in care: transparent consent, real confidentiality, and avoiding unnecessary pelvic exams. From there, we walk through the high-yield topics every clinician faces with young patients—irregular cycles after menarche, painful periods that derail school days, and the difference between normal discharge and vaginitis that needs treatment.
We spotlight the red flags that can’t be missed, especially ovarian torsion posing as vague lower abdominal pain, and why transabdominal ultrasound often beats transvaginal imaging for adolescents. You’ll hear how we build a thorough menstrual history that captures timing, flow, and impact on daily life; how we normalize the maturing hypothalamic-pituitary-ovarian axis; and where first-line therapies like NSAIDs, combined pills, progestin-only methods, and levonorgestrel IUDs fit. We also lay out a patient-led approach to contraception counseling—centered on goals like bleeding control, privacy, and ease of use—while weaving in emergency contraception, STI screening strategies, and the crucial role of the HPV vaccine in preventing cervical and other cancers.
Throughout, we keep the focus on trauma-informed practice. That means offering safe words like stop and out during exams, letting teens handle instruments to reduce fear, and moving complex conversations to when patients are fully dressed. We include considerations for transgender and gender-diverse adolescents, from menstrual suppression to reputable clinical resources. By combining practical tools with a respectful tone, this episode gives you a roadmap to adolescent gyn that improves comfort, detects danger early, and builds trust that lasts into adulthood.
If this conversation helps you care for teens with more confidence, subscribe, share with a colleague, and leave a quick review to help others find the show.
Welcome to the Engaged Midwife Podcast. This is Missy. And this is Kara. Another episode recording here at the 2025 ACM Annual Meeting in Palm Springs, California.
SPEAKER_00:Here we are. Yay! This has been a fun meeting. It has been fun and we've been super productive. And um, it's just been a really nice time to hang out with you, to see so many different friends and colleagues, and um to meet so many incredible students and new grads.
SPEAKER_01:Oh my gosh, the amount of people that we have met since we have been here and people who've come up to us and are like, I listen to you on my commute, I listen to you when I don't understand something. I I used your product to help pass forward, like all of that.
SPEAKER_00:It's been really fun.
SPEAKER_01:Really fun. We can't say thank you enough.
SPEAKER_00:I think I've been telling so many people for the last two years when I talk to them. I'm like, are you gonna be at the angle meeting? I expect a hug. And I'm so thankful that so many of them have followed through on that.
SPEAKER_01:So many hugs and high fives and tears, and I mean good tears, right? So many good tears. But um, today's topic is going is coming from a student, um, actually a group of students that we had at the beach at our relaxed um event in May. And um they were like, we really don't understand this topic, or we like need more information about it.
SPEAKER_00:It's something that they didn't get enough of. And similarly, we needed some time to prep for it because, as well, I don't feel like I had a lot of preparation for this. So we're gonna talk about adolescent gynecology today. And I think the main takeaway for me is that I want midwives to understand what part is in our scope of practice, but also when should we seek consultation, collaboration with our OBGYN um colleagues?
SPEAKER_01:I will tell you, I felt so much actually better and well-versed on this when I was seeing patients in clinic because I was forced to like look at guidelines, understand screening, understand what the topics were that are important to my like 15, 16, 17-year-old patients. Um, but now that I've been in like a practice where I'm strictly doing pretty much IP postpartum newborn for the last four years, it's really not in my brain anymore.
SPEAKER_00:I think the easy part or what seems to come more natural is when things are totally straightforward, it's health promotion and we're talking about contraception and we're talking about STI prevention and vaginitis. But we're gonna talk today about several gynecologic conditions that need a little bit more management. And if that management differs from how we treat our typical adult patients. And then also, again, what are those things that need referral?
SPEAKER_01:Yeah, so I want to put out a definition really quick about what adolescent gynecology really is. And it's a really specialized area of health care that focuses specifically on reproductive and gynecologic needs of people from puberty through young adulthood. So the actual definition is 10 to 21. And when I say 10, I'm like, oh my gosh, but I do know girls who are starting their periods really young.
SPEAKER_00:Yeah, I traditionally have never taken care of patients in my practice, which I predominantly practiced with OBGYNs. We did not see anybody less than like 12 to 13, but certainly we do know girls are having their periods at age 10 or so. And certainly they can start the pubertal process much earlier than they actually have their first minarch.
SPEAKER_01:I think one of the things I learned from a really smart pediatrician a million years ago is that kids are just not little adults, and that really holds true for gynecology as well. And so we are thinking about like, how do we make young people feel comfortable in our office, want to come to our office, feel safe, right? Yeah, listened to, and that they're in an ear in a place that's like non-judgmental.
SPEAKER_00:That's the most important. I think really safe, non-judgmental, and confidential when it can be.
SPEAKER_01:I also remember, and and I didn't grow up with my mom at home. A lot of people who know me know this. Um, so I didn't have to go to the gynecologist. The thing I did was drug myself someplace to get birth control when I was like 17. Um, again, that's a whole podcast episode in itself. But lots of, I think, women, Gen X women, me and you, yes, were like dragged to our mom by our moms or by somebody in our family to gynecology.
SPEAKER_00:I think I've been meant, I've mentioned this before. At like 18, my mom was like, girls, it's time to get a pap smear. It was at the time the guideline, but nothing's changed. And I think one of the most important things is that we don't always have to do a thorough exam. And it certainly does not need to be a pelvic exam for a lot of these different things that we're gonna talk about. Yes, speculums are scary. They are scary. And, you know, we're gonna talk about when you should reserve certain testing for people that have been sexually active versus those that haven't. But the main thing, again, is really helping people to feel safe, to let them know that they are in control of their bodies and what they can and can't, you know, what they can consent to, and really letting them lead, take the lead in what we perform as part of our physical exam.
SPEAKER_01:Also, if we want to have a conversation about consent and you don't follow the feminist midwife, you can go look at her social media and she does a lovely job of outlining consent.
SPEAKER_00:I think that's so important in this context. It absolutely is. And this is also going to be important for people to recognize that confidentiality is really important and is oftentimes led by different states on what is confidential in care. But it is important for us to understand that we should try to protect an individual's confidentiality, especially when it relates to sexual and reproductive health. And you want to, you know, know what your state laws are, know what you can do in practice. And then we will also talk about this a bit more um later, but sometimes insurance and explanation of benefits and that sort of thing will inadvertently expose someone and breaks confidentiality if they're using their parents' insurance.
SPEAKER_01:Yeah, unfortunate. Yeah, it is. So topics that we think are important when we talk about adolescent gynecology are things like puberty, pubertal development. Yes, right. So understanding tanner stages, where girls are in their development, early or precocious puberty or delayed puberty. Correct. Yeah. Um, menstrual concerns, right? So evaluating and treating menstrual disorders. A lot of girls don't know that when they first start their periods that they may be irregular, et cetera. So that's another thing.
SPEAKER_00:Yeah, if they have painful periods, um abnormal uterine bleeding, or just don't get their period. Yeah, that amenorrhea part that we're gonna talk about.
SPEAKER_01:Yeah. Um, I think contraception, again, is really important. Yes. There are lots of girls who are not having sex, but there are girls who are having sex. So do you need effective and reliable birth control?
SPEAKER_00:And maybe, just maybe, using contraception before sexual debut is a great way to prevent pregnancy. It's my favorite two words put together sexual debut. Sexual debut. This sounds so pretty.
SPEAKER_01:And for most of us, it wasn't probably pretty, but it sounds pretty. Yeah. Um, sexual health too is important. And one of the biggest things that I see, especially with sexual health and vaginal health, is girls who don't like discharge. So understanding your body, understanding normal things, understanding abnormals. So that goes into that vulvo vaginal concerns um bucket.
SPEAKER_00:Also protecting health promotion, we're really big on immunizations, vaccines, taking care of ourselves, and making sure that people understand the HPV vaccine is really an important part of sexual health as well.
SPEAKER_01:But then we're also looking at in adolescents, um, like PCOS. Do girls, do people who are coming to see us look like they have PCOS? Is there a family history of PCOS? Do they meet the Rotterdam damn criteria? And um things like endometriosis too, because endometriosis is a product of retrograde menstruation. And as soon as somebody starts to menstruate, they can get endometriosis.
SPEAKER_00:Yeah, and occasionally, occasionally, you might find someone that has a reproductive tract anomaly, like a mulean anomaly. And while it's not common, um, it is certainly something that we have had, you know, you may need to evaluate a patient for, especially if they come in with delayed puberty, they come in with delayed menses, that sort of thing.
SPEAKER_01:Yeah. So I think that there are a few um pillars of what midwives should be thinking about, you know, in terms of caring for young people. Yes. So, and the first one is is that most of the time this is your primary reproductive health provider. Right. Right. We're the ones that they come to for um concerns about puberty, sexual health, menstruation. They're not talking to their pediatricians about those things. They're they're coming to us. And a lot of pediatricians don't have time in the context of well child visits.
SPEAKER_00:Well, and you know, we have boys, but I also have a daughter, and I can absolutely tell you her pediatrician's office did not want to discuss any of this. And it is a flaw in um the pediatrics office that um we used. I love our pediatrics office, but they weren't willing to discuss any of this. But thankfully they did refer us on when we had some questions about PCOS or we had questions about some menstrual issues. And so I'm glad to know that they did that. You're right. A lot of family providers, a lot of pediatric providers may not feel comfortable with this.
SPEAKER_01:Yeah. Also, I really feel like, and every midwife feels like it's our job to provide, you know, holistic care that's patient-centered and focuses on education and support. Yeah. So one of the things we can do with these patients is emphasize counseling and education, right? What are good health promotion behaviors? What are good preventative care things? What can they be looking forward to? Vaccines, condoms, all the good stuff. And then just building trust.
SPEAKER_00:Yes.
SPEAKER_01:Will they trust you to come back if there's a problem? Or will they trust you to come back and ask for something that they need or want, right?
SPEAKER_00:Also, will they trust you enough to disclose if they're in unsafe conditions, if there's any issues of abuse or neglect? Will they talk with you if they're having body image issues? And there's there's so many things beyond just their vagina and their uterus and their breasts that have an impact on their sexual and reproductive health. And we really hope that they feel trustworthy with us and can disclose those things.
SPEAKER_01:Yeah, that allows us to intervene early for things that it could be long-term health concerns. Yeah. Right. Understanding what red flags there are, right? And then initiating management, right? Any of the things. Do they need medication for hormone, you know, control? Like, do they need contraceptive for, you know, period control? Do they, you know, I talk to so many young girls who like want to be on a pill just for menstrual regularity. Yeah. And not because they're having sex. Yeah, absolutely. And also, I also very clearly remember, and you and I have talked about this a thousand times in the podcast. Um, birth control being held over our heads if we didn't have a pap smear. You can't have your birth control if you don't have a pap. Yeah. If your pap's not up to date, you don't get your birth control.
SPEAKER_00:Literally, they have nothing to do with each other. Correct. Correct. Yes. Wild. Yeah. So we want to make sure that we're good stewards of our resources, that we're doing the exams that are necessary, but that we aren't doing things that will prevent people from coming to see us. If I don't have to get naked and get in a lithotomy position, I'm way more likely to make an appointment. Correct. So we want to make sure that we're good stewards and that we're doing things that are evidence-based.
SPEAKER_01:And we're like 50-year-old women. If we don't want to get naked and be in lithotomy, a 16-year-old certainly does not want to be naked and in lithotomy.
SPEAKER_00:No, it makes me sweat just thinking about it. So yeah, you know, as midwives, when we form those really incredible relationships with young people and we give them the empowerment and autonomy to make decisions for their body and to be in control, that's forming a really long-term relationship that they may have with you for a very, very long time. And you can be that continuity of care across their lifespan.
SPEAKER_01:Yeah. So I think again, we've talked about these tenets, promoting, promoting education, addressing puberty and menstrual concerns. What's normal? Yeah. Preventing gynecologic issues, managing them if they have them.
SPEAKER_00:Really fostering healthy relationships and providing education about consent. Yep. So important.
SPEAKER_01:Just being a supportive emotional space and helping with psychological well-being. I also want to add something in that we haven't talked about. And that has to do with transgender care. Yes. I know that a lot of midwives don't feel comfortable in that space yet.
SPEAKER_00:Well, there are a lot of us that didn't get training when we went through our education programs. And it was added to the core competencies for basic midwifery education, basic members-free practice back in 2020. And so while some programs were doing a good job of this before that time, all of us then needed to start doing a good job of this in early 2020, 2021. And so seek out education on that. Seek out really good resources. I would send you to the Finway organization, Finway Health or UCSF. There's great WPath has great resources, but having an understanding of gender and sexuality is really important as we take care of people.
SPEAKER_01:Because maybe you're seeing people who want to suppress their menstrual cycle. They need a long-term thing that would help at least suppress their menstrual cycle until they're at a place in their life where they could make a different decision. Absolutely. And gender-affirming care is hard to find right now.
SPEAKER_00:Yeah, I mean, it's a difficult environment. We've talked about this in so many different ways, and statutes and regulations and all kinds of things are changing. But really providing good education, helping people with health-promoting behaviors, and really understanding what we can do to be of good service to our patients is really important. True.
SPEAKER_01:So we're going to actually highlight some things from a fantastic review article called Pediatric and Adolescent Gynecology, a current overview. This uh was published recently, right? Um 2023. Um, we'll try to put a link in our um notes for it, but it really does um highlight why people come and see like problems that we can manage in an outpatient gynecologic setting.
SPEAKER_00:Yeah. So when we talk about adolescent gynecology, there are specialists that work in children's hospitals. There are specialists within OBGYN departments at major institutions where OBGYN physicians focus on pediatric and adolescent gyne. We're gonna mostly focus on adolescent because that tends to be what midwives are gonna be focused on. But there are some reasons that someone might see um uh a pediatric adolescent gyne before they go through puberty. And those conditions could be things like findings or problems with their outer genitals, like vulvo vaginitis or labial adhesions, maybe lichen sclerosis or unclear puritis. They've got a lot of itching and we can't really figure out what's going on with it. Their family med or their pediatrics provider doesn't really know. And so those young girls that are pre-pubertal may seek out help, but that's not usually what we're talking about with midwifery care, because again, our our scope of practice tends to be from puberty and beyond.
SPEAKER_01:Correct. And then we're also, again, like I was mentioning before, seeing patients who are having menstrual problems. Yes, right? Yeah. Um, menstrual disorders, a primary or secondary amenorrhea, looking for contraception, understanding um sexual relationships and how to navigate those.
SPEAKER_00:Yeah. So now let's talk about some of those different issues and if there is any type of difference in care when we're taking care of adolescents. So, you know, we're really focusing on that premature onset of puberty. We're talking about delayed puberty, we're talking about pain in the lower abdomen, those sorts of things. So, one of the first things that is important to understand is ovarian torsion. An ovarian torsion is a surgical emergency and it occurs in almost 3% of all pediatric or adolescent patients. That's kind of a high number.
SPEAKER_01:Yeah, I kind of think about this in relationship to testicular torsion, yeah. Which also happens in boys with a, you know, at a surprising rate.
SPEAKER_00:And we've done a recent episode on ovarian masses, and we talked about how follicular or functional cysts can be so common. But sometimes, occasionally, they do grow to a pretty good size, and that just increases the likelihood of ovarian torsion.
SPEAKER_01:Yeah. So on the differential list for girls who present with lower abdominal pain, yeah, torsion should be on there.
SPEAKER_00:It should. And it really is typically um a kind of a vague presentation in that it's severe abdominal pain. Um, and they may not have the words to say pelvis, or they may not be able to really describe where it is. I'm thinking appendicitis, I'm thinking ovarian torsion, I'm thinking um, you know, a ruptured ovarian cyst. There's so many different things that could be on that differential list, but it is an acute emergency, surgical emergency. Um, and again, it's almost always acute abdominal pain that is presenting symptoms.
SPEAKER_01:Other things that cause abdominal pain, like dysmonarrhea. Yes. Um, and like so dysmonorrhea, painful periods, right? Abnormal uterine bleeding, right? Yep. Um, those are other things that I think we can address. It's also interesting. This is the whole thing that we were just talking about exams, right? Imaging versus pelvic exams.
SPEAKER_00:Oh, yeah, yes. Yeah. Um, so you know, a pelvic exam is rarely helpful in patients that are have not been sexually active. Yes. And oftentimes can be traumatic. And even when we talk about imaging, imaging can be really, really helpful, but it rarely should be a pelvic transvaginal ultrasound if you have someone that is not sexually active. We can do abdominal imaging.
SPEAKER_01:Yeah. For things like you were just talking about ovarian torsion, ovarian cysts, right? Absolutely. Um, now, but when we talk about painful periods, right? And there are things where a bimanual exam may be helpful. Could be. Do you have an enlarged uterus? Is it boggy? How does it feel? Is it nodular? Right. Right. So there are, I think, cases where you have to really weigh whether or not a bimanual, and I'm not saying a speculum, but a bimanual exam may be helpful.
SPEAKER_00:Sure. Yeah. So really quickly, just to follow up on the ovarian torsion thing, that's going to be managed by our uh surgical colleagues, right? Correct. But it is important to know that you would want to follow up um ultrasound three months after that detorion. So fixing the torsed ovary, most of the time the ovary can be saved. Even if there is some necrosis, they really recommend saving the ovary because the follicular development and so forth often returns, which is really great. Um, but we should have imaging um about three months after the procedure, make sure there's no other concerns. Yeah. Okay. So then with that dysmenorrhea and abnormal uterine bleeding that you were talking about, I think a history, taking a history is so important. A really, really good menstrual history.
SPEAKER_01:Yeah. And I there are way too many apps out there for people to not be keeping track.
SPEAKER_00:Right.
SPEAKER_01:And even if you don't have a phone, you can still keep track of what your menstrual history looks like. And I think if if we don't know, and the picture is vague, that that's something that's reasonable to have somebody do for a few months.
SPEAKER_00:Yeah. I I not even just the timing, because timing is so important. So much of abnormal uterine bleeding in adolescent girls or adolescent people is really an ovulation. They're not, you know, their their hypothalamus, pituitary ovarian access isn't working perfectly yet. It just hasn't quite figured itself out. And so there's some irregularity. And so, you know, helping people to understand the normalcy of this, that sort of thing, but also just all the symptoms that go along with it. How many products are they using when they do bleed? I think that's such an, you know, like some people will tell you they're hemorrhaging and they wear one tampon a day. Correct. Other people will be like, my bleeding's okay. And they're going through a super tampon and a maxi pad every two hours. Asterisk.
SPEAKER_01:If you still do not love the menstrual cycle, please go back and listen to our menstrual cycle podcast episode because Was it episode two? It was very early in season one. Yeah. Um, because here's the thing when with puberty, you have to understand that all of that starts in the hypothalamus. And GNRH is the thing that starts to stimulate the pituitary gland to make FSH, right? Which then starts to tell the ovaries, wake up, time to do your work. Right. Right. So what we're saying is that like that the hypothalamus in puberty is like the big like exclamation point. It is the thing that is responsible for that, for that GNRH, you know, um stimulation to the pituitary gland. Correct. Yeah. So it again, some of these things could just be uh hormonal. Like you were just saying, the hypothalamus hasn't figured itself out yet, right?
SPEAKER_00:Well, it's communicating with the pituitary, and then the pituitary is trying to send a message to the ovary, and the ovary's talking to the endometrium. I mean, all these things are going on.
SPEAKER_01:I liken this too at first when the hypothalamus starts to do this, it's like occasionally firing off, like ping. And then like two more months later, it'll be like ping. And it'll be like every once in a while, you get like a little pinball situation where it's like, I'm gonna do this. And then you start to get in a rhythm after a certain amount of time where it's regularly doing what it's supposed to do to go to the pituitary plant.
SPEAKER_00:And sometimes you're one of those girls that literally from the very first month you were every 28 days. Yeah. I mean, there's good parts of that. Yeah. And there's some not so great parts of that.
SPEAKER_01:But you could look at one 15-year-old who is bleeding every 28 days, yeah, and another 14-year-old who has only had three periods in a year. Yeah. And that can still be normal depending on when menarchy was.
SPEAKER_00:Yeah. So getting that great history, getting a really, really thorough menstrual history, it's helpful to have, you know, a parent there that can talk about what was mom like, what are sisters like. I once had a set of twins come in and one was delayed Minces and the other had been, you know, totally fine. We found a Mularian anomaly. Um, and when you have twins, that's fascinating, right? Because we we do have a comparison, you have a control subject.
SPEAKER_01:Yeah. I also like when you're thinking about these kinds of things, I also think is mom saying that every month she's coming home from school, one like the first day of her period or the second day of her period, and or is she like unable to do activities of daily living on the first few days of her period? Right. I think how girls act, right? Some girls just have a period and like go about life, right? I was never somebody who had really terrible menstrual cramps.
SPEAKER_00:Oh god.
SPEAKER_01:I never had that. Uh but I also didn't start my period. You ready? 16.
SPEAKER_00:Oh, wow. Yeah. So, and then I was someone that literally the first year of my period missed a couple of days of school each month. Yeah. Yeah. And I remember vividly, you know, like I remember, you know, when they do those puberty classes and they're like, it's not gonna be so bad when you start out. And I'm like, I swear to God, I was hemorrhaging, having horrible cramps and passing clots from the time I started menstruating. Terrible. Yeah, it really is. But I think one of the most important things is that you want to be thoughtful about what you include in your exam. You want to take a really, really good history, and you want to understand that most of the time, first line treatment might be oral contraceptives.
SPEAKER_01:Yeah, and I think we're past the place. We're Gen X moms, right? Right. We have kids who are teens. Yes. And I think if I had daughters, I would have been like, hey, I don't care if you're not sexually active. If you want to be on birth control, I'd rather you be on birth control. It will help with your periods. And if you ever decide to be sexually active, then you know you have it.
SPEAKER_00:Yeah. I mean, I feel no shame in that. I have a daughter, and I don't think she would be upset with me disclosing this. That we did start on contraception for PCOS at age 13. Yeah.
SPEAKER_01:I think the clutching of the pearls that happened with our boomer parents, yeah, is so different with us Gen X moms. I don't want to be a grandma right now.
SPEAKER_00:No.
SPEAKER_01:And I am not just saying that I think girls need to go and start on contraception. You can talk to any one of my three boys and they will tell you a couple of things. They will say, con my mom says condoms every time. Great. But condoms sometimes fail, right? And right now, boys don't have any other options except for that, right? Or conversations with their partners, right? Right. Brooks will also tell you, because I have drilled this into his head, no pills ever. Don't ever take a pill from somebody. So, like, so true, we're having conversations and hard conversations, but I do think there's this generation of us, Gen X parents, who are now just really clear with our kids. Like, you're probably gonna go to a party and drink. You're probably gonna have sex at some point. Pondoms every time, never take pills. Don't leave your drink alone. Don't leave your drink alone. That's boys and girls. Don't leave your drink alone.
SPEAKER_00:The other thing that I will say about that is that also I don't want my daughter or anyone's daughter or anyone's child to miss school because of their period. I there's options available, and we're so lucky to live in a time where it's not just even just pills. We have love and digesteral IUDs. Where implants. Yeah, we have other progestin devices, you know, like the implant, the um depoiraa, we can really decrease people's menstrual dysfunction and their pain just by using some different types of therapies.
SPEAKER_01:Yeah. So I think other uterine pathology that I think is less common that we see in young girls are things like fibroids.
SPEAKER_00:Yeah, really uncommon for adolescents, but can happen, but you basically manage it the way you would with adults. Yeah, same way.
SPEAKER_01:Um, and that can, you know, a lot of people with fibroids have no symptoms, but a lot of people with fibroids also present with abnormal uterine bleeding.
SPEAKER_00:Heavy, heavy bleeding typically.
SPEAKER_01:Yeah.
SPEAKER_00:Yeah.
SPEAKER_01:I think another important topic that I don't want to exclude is teen pregnancy. Adolescent pregnancy, it happens.
SPEAKER_00:And it has increased risk with it.
SPEAKER_01:Yeah. And those um, you know, adolescent pregnancy has risk in terms of outcomes, things like preeclampsia, PROM, so premature pre-labor rupture of membranes, anemia, STIs, depression.
SPEAKER_00:Um and neonatal outcomes are impacted when we have adolescent pregnancies as well. So we have increased low birth weight, we have prematurity, increased stillbirth, and even neonatal demise and low abgar scores. Yeah.
SPEAKER_01:I think this is that that part has been such a nice review. I want to talk for a second about vaginitis. And it's mostly because I think this is a conversation that you and I have a lot. And we've had a whole like podcast episodes on STIs and STEs, as well as the care of your vagina and how we feel about vaginas. Again, listen to the podcast episode on the care and keeping of your vagina. Yes. Um, but one of the things I've noticed with us, particularly girls from 15 to 21, is they don't love discharge.
SPEAKER_00:No, I mean, I don't think anyone does, but it can be quite distressing to teenagers and um helping them to understand what is normal physiologic discharge is really important.
SPEAKER_01:Also to stress that you shouldn't really be using a tampon or anything inside of your vagina if you're not menstruating. Right. We're not wanting to dry out those tissues. Or if you take out a dry tampon, tampons are made from wood fiber. Yeah. It can cause micro tears in the vagina that then make people susceptible to STIs and STDs.
SPEAKER_00:Yeah, absolutely.
SPEAKER_01:So I also will say what one of the most profound things that has happened since I've been a midwife, especially in the last like 10 years as my boys have gotten older, is I have a lot of friends who have girls that are my age and they don't really want to talk to their daughters about their vaginas, but they'll be like, call Missy. Yeah. Or text missy.
SPEAKER_00:Yeah.
SPEAKER_01:Like she'll tell you. Or I'll get a call from a mom, like, what do you think about this? And I'm like, I think this is fantastic. And I'm happy to be a resource for people that I know. But also like, find that person that you trust that you can take your daughter to. And absolutely, maybe that's a midwife.
SPEAKER_00:Yeah, I feel like I get um, I've I've shared this before, but I get a text message like once a year from one friend. She's like sitting around with a bunch of girlfriends and they're talking about their daughters or talking about themselves. And she's like, remind me of like that care and keeping of your. Vagina speech that you give. Um, because it's just helpful to remind people of what's normal and what they can do. Yeah.
SPEAKER_01:And and normalizing to our girls, right? Yeah, absolutely. Um, Brooks will also tell you two things. He'll say, My mom always says to carry a hairband on my wrist because a girl always will need a hairband, and then I can be a hero. Okay. The other thing is that ever if a girl has blood through her clothes, you take off your shirt or your sweatshirt or whatever and you wrap it around their waist and you don't speak of it. Because then he knows. He's like, I'm sure it's embarrassing to bleed through your clothes. I was like, Yeah, it is embarrassing to bleed through your clothes. Yeah. It's also embarrassing for other girls to make fun of you or for boys to make fun of you. And we're not, we don't want girls to feel ashamed. This is normal physiologic function.
SPEAKER_00:It can be so traumatizing. I will share one thing that I loved with my adolescent daughter is the period underwear. And she could, you know, like in those years where it's not so predictable, if she was wearing period underwear, she didn't have to worry about having as many accidents. And I think that can be life-changing for people.
SPEAKER_01:Period underwear are also great for girls who don't like pads because they're bulky and they don't feel good, or they're not comfortable with a tampon. Yeah. I've lots of women, like grown women who still don't like to use tampons.
SPEAKER_00:Yeah. And I'm knowing younger and younger people that are getting totally comfortable with menstrual cups, which is awesome. Yeah, amazing. Yeah, absolutely.
SPEAKER_01:So um, when we talk about the vaginitis with girls, I have we have talked about this topic before, but I have had patients who've presented with like a um atypical vaginitis. Um, you know, we've tested them for, we've done wet preps for typical yeast BV trick. And then, you know, you try things, you've tried um diflucin, you've tried things in the vagina, you've tried boric acid, which is another one of my favorite roads. Yeah. But um a gen probe is also a great tool for somebody who is having an infection that you can't really put your finger on because it will test for a lot of the atypicals. One of my adolescent patients just had a really severe overgrowth of GBS.
SPEAKER_00:I was gonna say GBS. I've also heard of mycoplasma or urea plasma. Uh and you won't see those on a wet prep. Yeah.
SPEAKER_01:So doing and you don't have to do a speculum exam necessarily to do a gen probe. You can just insert a Q tip or have the patient insert a Q tip.
SPEAKER_00:Yeah.
SPEAKER_01:Um, it doesn't have to be a speculum exam.
SPEAKER_00:Yeah, absolutely.
SPEAKER_01:Um, the one thing we didn't talk about in terms of speculum exams, and I think um getting people comfortable with a speculum if they need a speculum exam is let your patient hold it, understand how it works, also as the provider, understand when it's necessary and when it's not.
SPEAKER_00:Absolutely.
SPEAKER_01:Um and just being super patient.
SPEAKER_00:Yeah. You know, the other thing that I like to teach and all to my students, but it's really it applies to anyone. But I think with adolescents, this can be so important as them being like the driver of the bus and um understanding stop and out. If you say stop, I quit moving.
SPEAKER_01:And out. If you say out, I take it out. Yes. This is something I have now carried into my practice in inpatient um obstetric. Yeah. I say to a patient, especially my not epiduralized patients, I say, I'm gonna put my hands in. You have two safe words, your safe words are stop and out. And I explain exactly that. And rarely do people use them, but when they want to, they do. And I like that we've given them permission, we've given them an opportunity to say, I'm done.
SPEAKER_00:Yeah. I I mean, in full transparency, I think you and I are pretty good at this of saying the things that we wish we could go back and do over. But there are too many people that I've done exams on that I was like, just one more moment. I'm almost there, I've almost got it. And I didn't stop, or I didn't take my hand out, or I didn't take the speculum out. And, you know, regret is a horrible thing. Um, I think when you know better, you do better. And I'm so proud of where I am as a provider now and that I can pass these lessons on to students and new grads and so forth.
SPEAKER_01:Yeah, I like the no better, do better thing. Yeah. Um, and I think there are a lot of opportunities for us to give patients an opportunity to consent. Another thing that I have carried over is um, you know, when I go into rooms and ask, I'm gonna do a public exam or a vaginal exam, is is it okay if I touch you? Yeah. It's the very first as soon as I sit down with a glove on, the very first thing I say is, is it okay if I touch? Um, because it's not then jarring to the patient. And if they're not ready, they can say no, not yet.
SPEAKER_00:Yeah. And, you know, also just that idea of I used to come in a room and be like, okay, we're gonna do an exam. And now it's like, you know, talking with them and saying, I'd like to do an exam. Is that okay with you? Right.
SPEAKER_01:Or are there things that you want to know beforehand? Right, right. And also a lot of the rationale is just why? Why do I need to have an exam? Right. So this goes to breast exams as well. We know there's not great evidence around self-breast exam or clinical breast exam. Exactly. Especially for adolescent patients. I I want to tell my adolescent patients, don't take your top off. I'm gonna talk to you about what breast self-awareness is. You should know what your own breasts look like. You should know what your own breasts feel like. That way, if something does change, you're able to notice a change. Um, and I think that's healthy for all women, all people who have the breasts, but also particularly for young people, they don't have to disrobe.
SPEAKER_00:Right. And also, like after if you do an exam, let them get dressed before you talk to them. I can't think straight with my pants off in a room with people that are fully dressed.
SPEAKER_01:I used to have a doctor, Dr. Hackett, he worked in um in Columbus at Professionals for Women's Health. I think he's still practicing. But he would meet all of his new patients fully clothed first. Yes. He would go into the room, he'd take their history, he'd listen to their heart, lungs, and belly, he'd listen to why they're there and what they need. He would then step out and let them get undressed and do his exam. I always thought, I was like, that is so respectful. Yes, of women, yes, and girls and people that are coming to the office to see you. 100%.
SPEAKER_00:I agree.
SPEAKER_01:I know it's not efficient for time. And he used to even say that he's like, I know it's not time efficient, but while she gets undressed, I can pop in and see a return OB patient and then go back. Yep, absolutely. So there is an ACOG committee opinion on um how we counsel adolescents about contraception. It's um committee opinion number 710. It was from August of 2017. It was reaffirmed in 2019. There is not an update since then. Right. And so it gives us a short list and we're gonna go over those. And you can read this committee opinion. I don't think we need to highlight all of it.
SPEAKER_00:I think it's gonna make total sense to all of our midwives.
SPEAKER_01:Yes. So um it's just got some bullet points, and we're gonna go through those. The first thing is no matter what, despite how old somebody is or what their sexual activity looks like, that you should address what their contraceptive needs are, what their expectations are, and what their concerns are.
SPEAKER_00:Absolutely. And we mentioned it previously, but statutes on the rights of minors to consent to healthcare services do vary by state, and you should know what those are in your state.
SPEAKER_01:Yes. Um, another bullet point is that emergency contraception should be included in those discussions. Like, hey, you don't want to be on long-term contraception. If something were to happen, emergency contraception is available.
SPEAKER_00:Well, and I remember even back way, way in the early 2000s, um, that every visit that I had as a student at Planned Parenthood, we gave a prescription because at the time a prescription was necessary. But if you came in for a birth control visit, you went home with a birth control pill prescription, you also went home with an emergency contraception prescription. So just understanding that there are times that methods fail.
SPEAKER_01:Yeah. For this particular group of people, long-acting reversible. So LARCs have a higher efficacy, a higher continuation rate, and a higher satisfaction rate compared with any kind of short-acting contraceptive. Um, and they're great choices because they have higher um like user, right? Higher uh rates of oh my gosh, I can't even think of the right word. Um typical use. Yeah, typical use, right, versus perfect use. Yeah. Because there's not a lot of ways your LARC is going to get dislodged.
SPEAKER_00:I'm not saying it can't. I always say the reasons that some of those LARCs um are more effective is the less you have to interact with it, the better more effective it is. Correct. I love that. Yeah. So one of the things that is I feel a bit dated about these recommendations is that this committee opinion does say that we should start with in a conversation about contraception with information about the most effective methods first. And I think some of the newer information really talks about being very patient-centered and that you should understand what their interest is and what's most important to them about contraception and start there. We oftentimes think that talking about the most effective methods is the best way to start, but that can also turn into a little bit of coercion.
SPEAKER_01:Correct.
SPEAKER_00:Okay.
SPEAKER_01:So initial thing, initial visits and follow-up visits should be just um the provider continuously reassessing sexual concerns, any behaviors, relationship changes, prevention strategies, um, and then things like testing and treatment for STIs. So let me be clear. And there are two episodes that you should go back to if you don't know them. One is our episode on contraception where we outline all of the things, the other one is on STIs and STDs. And that um is really pertinent for this group. But the biggest thing is your patients don't need a pap until they're 21. It doesn't matter how many sexual partners that they've had. Yes. Talking about HPV vaccine, because if you go back and listen to our HPV episode, HPV is a vaccine that prevents invasive cervical cancer.
SPEAKER_00:And head and neck cancer, and penile cancer, and rectal cancer.
SPEAKER_01:So are there vaccines that can prevent cancer? Yes. Yes, there are. Yes. Um, so but the STD, STI thing is also an important conversation. Right.
SPEAKER_00:So I think, you know, one of the biggest takeaways about if you are a provider that provides contraceptive counseling and methodology to your adolescent patients is thinking about a follow-up visit. And you do want to assess how they're able to use the, you know, whatever the method is, make sure they're happy with it. You can do that with either an in-person visit, a telephone call, or an electronic communication. You don't have to demand that they come back in for a physical exam. It could be a follow-up by phone or electronics.
SPEAKER_01:So easy. Yeah. And telehealth is so um abundant now.
SPEAKER_00:Yeah, absolutely. I think this has been such a nice little, you know, refresher on so many different topics: confidentiality, consent, evidence-based care, really thinking about being good stewards of our resources. And as midwives is really focusing on all those hallmarks, patient-centered care, trust, good communication.
SPEAKER_01:I want to add a really quick little like antidote about something that I used to do when I was in clinical practice with my young patients. Okay. And my nurses used to leave markers in my room. And I have, you know, your tables have table paper. I was gonna say, I'm I know this is going to an art project. It is going to an art project. So I'd have my patients keep their clothes on and I would draw like hormonal methods, right? Combined is one column, progesterone only is another column, and then non-hormonal methods, and it was all like a flow chart, right? Yeah. And when we talked about like the pros and cons, and I would talk to them about progesterone, is really what causes contraception. And we add estrogen if you want bleeding control. And I would draw all the things. And so many of my patients that were 25 and under took pictures of it with their phones. And they were like, this is a great description of birth control. I think you, as an individual person, need to figure out how you can effectively explain birth control methods to your young patients.
SPEAKER_00:So true. And I have also, I mean, drawn the menstrual cycle. Helped. I have drawn the external genitalia so that people know what their vulva is compared to their vagina. You are such a vulva girl. I do love a discussion about a vulva. The other thing is that I think just good education and being able, if you can explain it to a lay person, and especially you can explain it to a young person, then you have that helps your understanding of the topic as well.
SPEAKER_01:Yeah. So get comfortable. Yeah. Um, we we were joking last night that my boys know all the things about STDs and STIs because I like harp on it. Talk about it a lot. My boys also do not flinch when I say the word vagina. Yeah, they shouldn't. So I think um test out the things that you want to say to people, right? It might feel unnatural at first, but now, like if I'm talking to a 13 or 14 or 15-year-old girl, I have I feel not at all self-conscious about the conversations that I can have with them about their bodies.
SPEAKER_00:Yeah, absolutely. So we hope this was helpful to you. Um we hope it was, I mean, it was certainly helpful to me to have this conversation. Yeah, yeah. And thanks to the students who requested this topic of adolescent guy. I think it's been really good.
SPEAKER_01:Don't be afraid of that young person that's on your schedule. It's a it's an opportunity. It absolutely is. Well, thanks for joining us for the Engaged Midwife podcast. We can't wait to talk to you again. Take care.