An introduction to Adolescent gynecology

Adolescent girls are a relatively healthy subgroup of the US population.  However this is offset by the fact that their behavior puts them at substantial risk for poor health. Normal adolescent behavior is characterized by exploration, experimentation, and differentiation (See Psychosocial development in adolescents below) . Dysfunctional adolescent behavior takes these normal behavioral patterns and devolves to be oppositional, overly risky and dangerous. In this setting, risks include alcohol and substance abuse, sexually transmitted infections, including HIV, unplanned pregnancy, eating disorders, depression, suicide, violence, and injury. 

< Insert here a graphic of hideous stats regarding the above risks. >

These health problems have become so common as to be considered commonplace. Therefore it is important that caregivers and parents be willing and able to distinguish the normative from the problematic, and these from the truly pathological. Adolescents themselves are in no position to reliably make these distinctions. Parents, concerned adults, and health care providers need to be the ones to ensure adolescents know the importance of health care, and that they have access to it. 

Adolescents underuse existing healthcare services. Barriers to care include finances and confidentiality. It is natural that adolescent girls are reluctant to discuss behaviors that may have put their health at risk, or which may get them in trouble at home. For this reason, they are best approached in a non-punitive and supportive way. For underage patients confidentiality issues should be discussed beforehand with the parent. Parents should be counseled that when adolescents develop a confidential relationship with a physician their health care interests are better served. They should be reassured that the American College of Obstetricians and Gynecologists, ACOG, "recommends that providers should encourage and, where appropriate, facilitate communication between a minor and her parent." "The involvement of a concerned adult can contribute to the health and success of an adolescent.". (Guidelines for adolescent health care.pdf, ACOG )

Psychosocial development in adolescents

In adolescence children are forming their own separate identities. This psychological process based on their level of brain development is called differentiation. Before this process is complete, adolescents may not be completely capable of using hypothetical and deductive reasoning to make decisions, especially during pressure or stress. They may have trouble seeing how general rules apply to them. In other words, they do not have a fully developed sense of self versus others, and may still have a degree of egocentrism. As they mature they will have a continually improving ability to handle abstract ideas and to understand future consequences of present actions. It is essential to keep these processes in mind when interacting with adolescents.

A word on brain development in adolescents

In the preteen years there is an extensive proliferation of neurons and synapses. However in the next 5 to 10 years there is an extensive pruning of synaptic connections. Neural circuits that are retained as a function of the so-called "use it or lose it" pattern that depends on the skills which adolescents are allowed to develop during their experiences. (Guidelines for adolescent health care.pdf, ACOG ) This is why it is critical to provide preteens and teens numerous extensive opportunities to develop their minds and bodies through thoughtful conversation, academics, athletics and extracurricular activities such as playing music and travel. 

Adolescent health care

According to the ACOG, adolescent girls should first visit an obstetrician gynecologist between the ages of 13 and 15 years with subsequent annual visits. Of course if there are problems or concerns, these visits can happen earlier. At these visits, the modern-day sources of illness and problems among adolescents are addressed. It is interesting to note that these illnesses and problems have their roots in the behavior of adolescents. Such behavioral problems include lack of exercise, unhealthy eating, depression, unsafe driving, sexual activity, and substance-abuse including tobacco, alcohol and drugs. OB/GYNs can collaborate with a girls other caregivers such as a family doctor and nurse practitioner or pediatrician to best deal with these problems.

The actual visit

Normally the beginning of the visit takes place in the office sitting at the caregiver's desk for a discussion. There, issues of confidentiality can be addressed, as well as the establishment of open lines of communication between patient and parent. A history will be taken. This includes the patient's medical and surgical history. Ideally the patient is allowed some private time with the caregiver. At that point she is also asked questions about how she's feeling, how she is getting along with others and how she's doing in school. She may be asked if she is sexually active or if she has experienced any relationship abuse. Thereafter some sort of examination is usually indicated. The patient is free to choose whether she wants to have her exam with or without her parent present. The first visit with the OB/GYN generally does not involve internal exam with a speculum. This is something that parents can convey to the patient before the visit ever takes place. On the other hand, if there are problems such a abnormal bleeding or discharge, a speculum exam may be indicated. The first actual Pap smear, i.e. cervix cells sent to the lab,  is not indicated until age 21. 

Once the patient is again dressed, another discussion may take place about the findings and the plan. Any indicated tests such as bloodwork or imaging can be discussed and ordered. Discussion is then twofold, on risk reduction and health promotion. 

Risk reduction should address:

• Abstinence as the best method of preventing STIs and pregnancy
• Condoms and birth control as the next best method
• That all forms of sex confer risks of STIs (sexually transmitted infections) including HIV. 
• That sexual victimization and acquaintance rape are not uncommon, especially if drugs or alcohol are involved
• Abstinence from alcohol
• Abstinence from drugs, including marijuana
• Abstinence from tobacco in all forms
• Not driving or riding drunk
• Acknowledging the health risks of tatooing or piercing
• Using seatbelts
• Not using tanning beds
• Avoiding weapons except for formal, properly supervised sport
• Discussing in advance a plan for parents to pick up an adolescent should she end up in a dangerous or uncomfortable situation, or have consumed an illicit substance and cannot get home safely

Health Promotion Should address: 

• Peer pressure and memes, and how behavior is contagious
• The association of good school performance with short and long term health
• The influence of the Hollywood, advertising and various forms of media on our health and choices
• The health role of sexism in our culture 
• The importance of awareness of mental health issues such as anxiety or depression and the ways they can be dealt with
• The critical importance of early nutrition and the concept of windows of opportunity 
• The importance of regular exercise and healthy exercise habits

Assisting the parents of adolescents

The first few adolescent visits are also teaching experiences for parents about how to guide adolescents into healthy lifestyles. The following is a short list of the topics which parents should cover with their children. 

Health discussion topics for parents of adolescents 

1. The stages of puberty and normal development
2. Differentiation and establishing one's own sense of self
3. Parental authority and the adolescent autonomy
4. Family rules and consequences of breaking them
5. Use of motor vehicles and passenger responsibilities
6. Establishing safety rules such as location check ins
7. Family rules regarding use of technology and the Internet
8. Family rules regarding any weapons in the home
9. Hazards of early sexual activity including discussions about pregnancy and sexually-transmitted infections
10. Hazards of relationship abuse. According to the Commonwealth Fund's Commission on Women's health, 26% of adolescent girls in grades 9-12 report experiencing physical or sexual abuse or sexual assault, including acquaintance rape
11. Hazards of harmful substances such as tobacco in all forms, alcohol, and drugs
12. Nutrition, including the concept that adolescent nutrition provides an irreplaceable foundation for later life, especially regarding bone density in young girls. Include a discussion of the risks of obesity.
13. Exercise in the form of sport as well as formal conditioning

Helpful parental behaviors and strategies

1. Spend ample quality time with teens and preteens in a variety of activities
2. Minimize criticism and maximize praise
3. Praise effort and dedication rather than results
4. Meet all disappointments with resilience
5. Anticipate challenges to authority 
6. Establish clear and reasonable rules and consequences and follow through with them 
7. Minimize relationship conflict in the home and model good communication skills with other members of the family, especially spouses and significant others
8. Respect privacy as appropriate, within reason 
9. Become educated as to health risks for adolescents 
10. Stay technologically competent
11. Be aware of the adolescent's relationships especially their dating relationships. Pay special attention if the adolescent is in an unequal relationship, such as with an older partner. 
12. Model excellent health maintenance behaviors yourself such as regular exercise, good nutrition, avoidance of unhealthful substances, use of seatbelts and use of sunscreen
13. Provide healthful meals and snacks as well as a means for the child to obtain these when she is away
14. Have a sitdown family dinner which is at a time when most everyone can attend. Make it a carefree time with festive qualities. 
15. Help the adolescent obtain materials to stay organized, such as a day runner or other electronic equivalents 
16. Meet with teachers regardless of the student's grades and attend all school activities in which the student participates. Make sure to discuss this with your employer beforehand so you can get time off. 
17. Meet the parents of your childrens' friends
18. Model a vibrant lifestyle. Read and participate in interesting activities yourself. Provide a wide variety of books, newspapers and other reading materials for the children and have some time such a Sunday morning when the family reads together. Establish these traditions when children are young so that they are normative when they are older, busier and more apt to question things.
19. Strongly consider getting rid of your mainstream network television, cable and your gaming consoles. Alternatively, use these deliberately and judiciously, and do not feature them centrally in your home or in children's rooms. Participate in technology but do so mindfully. Watch quality content as a family and discuss what you see.
20. Have a social life based in the home. Invite other family and friends for social dinners, holidays and other special occasions such as birthdays. Make your home the place to be.
21. Find help in meeting these goals if you are struggling.