Pediatric & Adolescent Gynecology

Additional Info

• Audio File:uab/ua050.mp3
• Featured Speaker:Janeen Lynnae Arbuckle, MD, PhD
• CME Series:Clinical Skill
• Post Test URL:https://cmecourses.som.uab.edu/mod/quiz/view.php?id=4626
• Guest Bio:Janeen Lynnae Arbuckle, MD, PhD, is the Assistant Professor, Department of Obstetrics and Gynecology with UAB Medicine. 
  
  Learn more about Janeen Lynnae Arbuckle, MD, PhD 
  
  Release Date: March 30, 2018
  Reissue Date: March 12, 2021
  Expiration Date: March 12, 2024
  
  Disclosure Information:
  
  Planners:
  Ronan O’Beirne, EdD, MBA
  Director, UAB Continuing Medical Education
  
  Katelyn Hiden
  Physician Marketing Manager, UAB Health System
  
  The planners have no commercial affiliations to disclose.
  
  Faculty:
  Janeen Arbuckle, MD, PhD
  Assistant Professor, Obstetrics & Gynecology, Pediatric and Adolescent Gynecology
  
  Dr. Arbuckle has no financial relationships related to the content of this activity to disclose.
  
  There is no commercial support for this activity.
• Transcription:UAB MedCast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.
  
  Melanie Cole (Host): The American College of Obstetricians and Gynecologists recommends that young women aged 13-15 undergo a dedicated reproductive health visit. The purpose of this visit is for education, prevention and anticipatory guidance and should be tailored to the individual patient. Here to tell us about the clinical aspects of pediatric and adolescent gynecology is Dr. Janeen Arbuckle. She is an assistant professor in the department of obstetrics and gynecology at UAB Medicine. Welcome to the show Dr. Arbuckle. Explain a little bit about pediatric and adolescent gynecology and what types of services do you offer?
  
  Dr. Janeen Lynnae Arbuckle, MD, PhD (Guest): Yes, thanks so much for having me Melanie. Pediatric and adolescent gynecologists are specialized OB/GYNs who focus in the care of children and adolescents. We are able to see patients between newborn up to age 21 and really for any reproductive need or any concerns about their normal development or the development of their genital tract and or breasts.
  
  Melanie: So, when is an exam indicated in a young child or adolescent and what do you do at that first exam to make a young woman comfortable with the difficulties of that first exam?
  
  Dr. Arbuckle: Absolutely. So, it depends on what the patient is presenting for. So, if a patient comes in with a specific problem that warrant an exam, say for instance if they have any concerns about abnormal discharge or the normalcy of their anatomy then an exam is indicated. We don’t do routine pelvic exams in adolescents until they do turn age 21. So, the majority of our patients will not require a pelvic exam unless they are having problems. Definitely navigating that first pelvic exam can be difficult. It is often helpful to have a parent available or find some way to distract the child or adolescent. So, often times in our children’s clinic space we have TVs on, children will use their phone and they just sort of kind of distracted from the fact that a genital exam is going on. In addition, we try to normalize that we all have genitals and we all have body parts – specific body parts that have to be evaluated by doctors to make sure that they are healthy and so we try to make it a comfortable space, allow them to kind of free play and be distracted in doing things that are entertaining for them so that it is not so intrusive to their kind of perception and physical space. Those girls who need a more detailed exam, definitely we see in our adult office and we have an environment that again is really friendly and staff that has specialized training in discussing the components of a pelvic exam with those girls that need a more detailed exam.
  
  Melanie: You mentioned discharge or anatomical concerns. What are some common concerns of adolescents and their parents in terms of visiting their OB/GYN and some common pediatric gynecological disorders?
  
  Dr. Arbuckle: That’s a great question. So, if you kind of divide the population into two halves. The younger patients who will complain of a vaginal discharge or a genital complaint is most specifically and most commonly a nonspecific vulvitis. So, the child will complain of an itch or a burn and just not have – they will have a generalized discomfort in their vulvar area. That’s most commonly due to just overgrowth of normal bacteria that lives in the area, either bowel flora or even respiratory flora and the most important thing to inform the patient and their parent of is that is something that can actually be treated with minimal intervention. The most common thing for young girls is again, the nonspecific vulvitis that we actually recommend just treating with improved hygiene measures and a couple of other things that can make the area more comfortable. It’s rare for there to be anything more than that just nonspecific overgrowth. In older girls, the girls who are post puberty, they will often complain of a vaginal discharge that is actually perfectly normal and what we call physiologic. So, normalizing that there should always be some degree of a vaginal discharge and highlighting those components of an abnormal discharge from just an education standpoint is all that is often necessary.
  
  Melanie: So, if it is noninfectious vulvovaginitis, they don’t like the smell or the look of it and even maybe a mother is concerned; what would you tell other pediatricians and or physicians about explaining to the girls the normalcy of some of this?
  
  Dr. Arbuckle: Yeah, so, unfortunately, in American culture there is a perception that female genitals should all be on the inside and that there should never be anything on the outside. So, one of the common things that we will get referrals for or even questions from parents or children, specifically the post pubertal girls is do my genital look normal and they need to be reduced. So, a common concern is that for instance that the labia minor are too large. So, number one we start with education and I talk about what the genitals look like in a prepubertal child and then most commonly the labia minora are flush with the outside. They aren’t really an external organ and then when we go through puberty the natural progression is for all of those tissues to grow and have a little bit of an external appearance. The labia minora can be anywhere between the size of 4 centimeters to 7 centimeters and still be completely normal. And so, try to normalize that through education and then honestly, I use as a resource there is a plaster mound which is going to sound crazy of various vulvas and it is called the Great Wall of Vaginas and it makes a lot of our adolescents kind of teeter and they think it’s funny or they are grossly embarrassed but it is actually a way to show girls what normal anatomy looks like. So, they have this idea of this perfect vulva that is honestly kind of infantile which is actually not what a post pubertal vulva should look like. So, educate about the normal pubertal progression and then I also refer them to that site so they can see some of other normal variants of what the external genitalia for a female will look like.
  
  Melanie: Dr. Arbuckle, unfortunately children are vulnerable to the same sexually transmitted infections that adults carry. So, if a child comes to you and presents with irritation or some infection, is there some standard of care that you would run to see if it was a sexually transmitted infection or if abuse has taken place?
  
  Dr. Arbuckle: That’s a great question. So, we do at UAB, have a specialized clinic for the evaluation for concerns for sexual abuse. If there is a concern by the family, for sexual abuse, it is most appropriate to go through that clinic. It’s called the Chips clinic and it is run through Children’s. Most people will get referred there through DHR. If girls come in and they have no concern for a sexually transmitted infection, that is certainly something we are still aware as a possibility. Things that would heighten the concern for sexually transmitted infection is if there is a discharge that is purulent, meaning more thick, yellow thick secretions or green, those are things that make us much more concerned for there being an infection that is sexually transmitted rather than just an overgrowth of other bacteria. The screening for that can happen in two ways. The actual secretions can be tested or we can test in urine. Obviously, that is nothing that anybody every wants to go through, but if there is a purulent discharge and there is a sexually transmitted infection it is important that those get treated and then that a case be opened with DHR so that that child can be protected.
  
  Melanie: And along those lines, the HPV vaccine being given to young girls as young as 9 now, and up through the age of 26. Do you as a pediatric and adolescent gynecologist involve in that? Is that just the pediatrician? And how do you discuss that with young girls and what it means?
  
  Dr. Arbuckle: Absolutely. HPV vaccination is one of the things that I’m actually most passionate about. As a consultant, it is often hard to administer the HPV vaccine, so for instance we will often see one patient just once and we may see them once a year and the HPV vaccination depending on the patient’s age does require two or more visits. And sometimes it is not convenient for our- specifically our consulting patients to come to our office for those vaccinations. I do make it a routine part of my practice to educate families about the HPV vaccine and we do offer it in our clinic. If it is convenient for them to start the vaccination series with us, we will and then they are educated on how to complete that vaccination series with their pediatrician.
  
  As far as the conversation about the vaccine, I try to highlight that it is a vaccine that has been proven to protect against cancer and that’s a rare opportunity. It talk about the prevalence of HPV and that the vast majority of adults through consensual sexual contact will come in contact with HPV. We talk about the sequelae of HPV, head and neck cancers, genital cancers and that those cancers that are indiscriminate so regardless of your own behavior, you may be exposed to those viruses through sexual contact. And then we talk about the vaccine, that it is very well tolerated. Unfortunately, there is a lot of misinformation in the culture, especially with social media regarding the safety of HPV vaccine and then those patients and specifically those parents who are concerned about the safety of HPV vaccination, I refer them to the CDCs website as well as the Institute of Medicine’s most recent study where they looked at the safety of all vaccines and actually showed that HPV vaccine is no more dangerous than the chickenpox vaccine and while parents wouldn’t hesitate at all to immunize their children against chickenpox, they likewise should not hesitate to vaccinate against HPV.
  
  Melanie: The landscape has changed for both pediatricians and for pediatric and adolescent gynecologists in the impact of social media and the sexual and social wellness of adolescents. Is this something that you think pediatricians and physicians should possibly delve into because it really has changed how we speak to our young children and what they are learning in the outside world.
  
  Dr. Arbuckle: Yeah, I completely agree with you. So, we try to talk about oftentimes when I walk into a patient’s room, daughter has her phone, mom has her phone and they are both navigating their own social networks and their own resources which may or may not be accurate and so we try to talk about specifically relationships and how to have safe and healthy relationships. Unfortunately, I think a lot of girls kind of underestimate the internet world and how widespread it is and how depersonalized it is and so try to help them build self-esteem as well as take steps to keep themselves safe on the internet. I think there is a lot of photo sharing apps, live chatting that can actually put girls at a place – in a vulnerable place where they could be potentially victimized and so I try to educate them about safe spaces to be – to share their bodies. For instance, it is inappropriate to be sharing physical pictures of any private parts via text or over the internet and really just try to help them realize that their bodies are precious and that though it may be convenient and easy to share images of it, that those images are really inappropriate to be shared in that medium.
  
  Melanie: So, in summary, Dr. Arbukle, tell other physicians what you would like them to know about pediatric and adolescent gynecology and when to refer to a specialist.
  
  Dr. Arbuckle: Yeah. So, pediatric and adolescent gynecologists offer that care again from newborn to age 21 and there are some general OB/GYNs who are comfortable seeing across that spectrum and there are some pediatricians who are comfortable seeing across that spectrum. In addition, adolescent medicine providers also have a lot of overlap in the patients that we see. Often our referrals will come from physicians who are not comfortable seeing that age group and so if there is a physician who thinks heh, I think this patient might be better suited by an IUD and I am not comfortable placing it in adolescent, that’s a great referral. Or if there is recurrent problems. Recurrent ovarian cysts, disorders like polycystic ovarian syndrome, Mullerian anomalies, abnormal uterine bleeding, or amenorrhea. Those are probably our most common consultations and then we are always available for even just curbside so if somebody is managing somebody and they have gotten to the point where they are not really comfortable, just a phone call to say heh, what would be your next step and if that next step doesn’t work, always being available as a backup and to go a little bit further in the exploration of the patient’s pathology.
  
  Melanie: Tell us about your team. Why is UAB so great to work with?
  
  Dr. Arbuckle: Yeah, so I am fortunate to have two partners. Kim Hoover is the director of the pediatric and adolescent gynecology subdivision and we have just hired a new partner Dr. Erin Cook and you really truly could not find a more dedicated and passionate set of coworkers to work with. Each of them has their own niche and their own favorite patient populations. They are great communicators with both patients and their mother’s and then we have a dedicated team of nursing staff and CMAs who are really passionate about advocating for these young women and providing them safe and comfortable care.
  
  Melanie: Thank you so much for being with us today. And a community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That’s 1-800-822-6478. You are listening to UAB MedCast. For more information on resources available at UAB Medicine, you can go to www.uabmedicine.org/physician. That’s www.uabmedicine.org/physician. This is Melanie Cole. Thanks so much for listening.
• Hosts:Melanie Cole, MS