Pediatric Gynecology: What Parents Should Know

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things reproductive health. I'm your host, Dr. Erica Newlin. This podcast is intended to help you better understand your health, leaving you feeling empowered to live your best. On each episode, you'll hear from our experts on topics such as pregnancy, fertility, menopause, and everything in between.

On this episode, I'm joined by Dr. Erin Isaacson, who will be helping us better understand pediatric gynecology, an area of care that often raises questions for parents. We'll cover what it is, when to seek care, and how to support your child's health. Thank you so much for joining me on the podcast, Dr. Isaacson.

Erin Isaacson, MD:

Thank you for having me.

Erica Newlin, MD:

Before we start, can you tell our listeners a little about your role in the Cleveland Clinic and about your background?

Erin Isaacson, MD:

Yeah, so a little bit about me. I'm from a small town outside of Green Bay, Wisconsin, Go Packers. And I did my medical school training at the Medical College of Wisconsin. I then spent four years down in Austin, Texas for some warmer weather for my OB/GYN residency before coming back up to the Midwest for a two-year pediatric and adolescent gynecology fellowship at the University of Michigan. I joined Cleveland Clinic just this fall as the first fellowship trained pediatric and adolescent gynecologist in the Cleveland Akron metro area. But actually, Cleveland Clinic has been really fortunate in the past to have physicians like Gita Gidwani and Marjan Attaran who helped really develop pediatric and adolescent gynecology into a recognized specialty, and I'm just really fortunate to get to build on the foundation they started decades ago.

Erica Newlin, MD:

Perfect. And we're so happy to have you here. Welcome. First, let's begin with what is pediatric gynecology and what does it cover?

Erin Isaacson, MD:

Yeah, so pediatric and adolescent gynecology, which I'll refer to as PAG for most of this talk is truly gynecology care for patients starting at age zero through the late teens, early 20s. PAG physicians manage common gynecology issues like menstrual and vulvar concerns, but we're also trained to care for complex patients like patients with conditions with differences in sex development, anal/rectal malformations, and mullerian anomalies, and so many more different conditions where we have to collaborate with other pediatric specialties like endocrinology, hematology, pediatric surgery. It's really important to have physicians that are really specifically trained to care for this population because the vulvar, vaginal and menstrual issues that kids and adolescents face, they may look similar to adults, but they often need, need to be managed or worked up differently.

Erica Newlin, MD:

Great. Can you go into a little more detail about how pediatric or adolescent gynecology might differ from an adult gynecology?

Erin Isaacson, MD:

Yeah, I think one really important example is thinking about a common gynecology concern like abnormal uterine bleeding. Both adolescents and adults often deal with this, but in adults, it's more likely to be due to an underlying anatomy issue. Whereas in teens, it's more likely to be due to immature hormonal cycling or an underlying bleeding disorder. So the underlying etiology is significantly different depending on the age of the patient. And so it really is important to understand what age a patient you're dealing with in order to make sure we're optimizing the workup and treatment plan.

Erica Newlin, MD:

I get asked by a lot of parents, "Should my daughter come to see you? When should my daughter come to see a gynecologist?" Can you go into a little more detail about when someone might want to have that introductory visit and whether it should be with a pediatric adolescent specialist versus a general gynecologist?

Erin Isaacson, MD:

Yeah. I think that there's no right or wrong age to see us in pediatric gynecology. We're here for whatever age we're needed for different concerns. Like in adults, there's no need for a routine exam at any age specifically, but parents are always welcome to bring in their kids or their teens if they have questions related to puberty, related to questions with their menses or any problems they might be having or for anything else gynecology related. There's no perfect age, but there's no wrong age either.

Erica Newlin, MD:

Sometimes in the general gynecology world, I see teenagers and it's mainly an, I'm not scary visit and I walk them through, "This is what the exam will be like in the future, but I don't have to do anything today."

Erin Isaacson, MD:

I love those visits. I love those visits when they're just coming in for a couple questions or wondering whether their period is abnormal or not and it's not. And we do counseling. We talk about any other questions they have, but then they understand gynecologists aren't scary and they're set up with someone where if they have any questions in the future, they've already built a relationship with.

Erica Newlin, MD:

For sure. And I find it a nice visit too to kind of introduce that discussion of sexual health and consent and relationships and can be a really nice resource.

Erin Isaacson, MD:

Yeah, absolutely.

Erica Newlin, MD:

What are the most common conditions you see in a pediatric patient?

Erin Isaacson, MD:

Yeah, I would say for our pediatric or prepubescent population, the most common reason someone might come to visit us are for vulvar vaginal issues like discharge, itching, or even prepubertal bleeding. Most of these are benign issues, but it's really important that they're seen and monitored to not miss something more concerning.

Erica Newlin, MD:

Now that we've kind of discussed what pediatric gynecology involves, and you've alluded to it a little bit in your previous statements, let's talk about the signs and symptoms parents should watch out for. What symptoms should prompt a visit to a pediatric gynecologist?

Erin Isaacson, MD:

So I think it really depends on the condition. There's, in gynecology, the different concerns are so wide. I would say, especially related to menses or menstrual concerns, if your kid is missing school or having difficulty with their activities because of the amount of bleeding they're having or the pain that they're having, it truly deserves further evaluation. Or in young kids, it can be difficult because they have difficulty expressing what they're feeling or expressing what symptoms they're having, especially in a private area. So anytime you notice different behaviors or any concern that your child's trying to express, it's worth a question, it's worth evaluation.

Erica Newlin, MD:

For sure. How do you approach those conversations about puberty and menstruation with younger patients?

Erin Isaacson, MD:

Yeah, I really love the opportunity to teach young patients about their anatomy and give them a baseline understanding of what's actually going on with their bodies during this transition, and especially when they start their menstrual cycle. Adolescents who have more knowledge really feel more confident in their ability to engage and participate in their own healthcare decisions, which is really important when you're talking about possible treatment. They have to be engaged and want to be involved in the decision making because they're the ones who are going to be managing it. Each age is really unique, and so every patient that walks into my clinic, no matter if they're 11 and 12, their maturity levels are really different. So I think you really have to take each patient and also each patient and parent combined visit. You have to treat it in a really unique manner and kind of understand the population that you're facing and what their goals are for the visit and tailor the education that way.

Erica Newlin, MD:

How do you recommend parents approach those conversations about puberty and periods?

Erin Isaacson, MD:

I think it's hard and they can be uncomfortable, but I think the best times and best kind of conversations I've seen between parents and kids is when the conversations are just open. Starting the conversation at all is the biggest step and giving kids an opportunity so they don't feel like it's something to be embarrassed about or shameful about just to talk about it in general. And I think that having kids understand that it's something that they can come to their parents about helps them to bring up concerns when they feel like something's not normal when they're having concerning symptoms rather than just kind of pushing it aside and dealing with it on their own.

Erica Newlin, MD:

For sure. What are some common misconceptions parents have about pediatric gynecology?

Erin Isaacson, MD:

I think one of the most common misconceptions is that when their daughter comes to the visit, that they're going to get an internal pelvic exam. It's so rare that we need to do an exam. And I do love that parents prepare their kids for this, but it ends up that they come to the gynecologist nervous and scared. Again, because kids and adolescents are different from adults, it's so rare that we're going to need to do an exam, especially an internal exam, unless they're getting an IUD for a specific reason. Really, it's usually just external exams or no exam at all that involves any private area. And so I think that's the most common misconception I face. Another misconception that could really be its own topic is the misconception surrounding hormonal management of periods. Parents come in concerned that their kid being on hormonal management is dangerous or it's not appropriate for teens, and that definitely takes a lot of education and discussion during the visit.

Erica Newlin, MD:

Are there any resources that you recommend for more accurate information?

Erin Isaacson, MD:

Yeah. I think that, you know, the internet can be a confusing place. Some great resources is actually through kind of our national association. The North American Society for Pediatric and Adolescent Gynecology, their website is open to the public and they have really amazing patient handouts that cover so many conditions, as well as things just like the HPV vaccine, puberty, what's normal for menses, menstrual hygiene. These are all available to the public, and it's handouts that I always make available for my patients as well during the visit.

Erica Newlin, MD:

Perfect. We've talked about symptoms and concerns. Now, let's move on to treatment and care. What does a typical visit with a pediatric gynecologist look like?

Erin Isaacson, MD:

Yeah, so our visit will start with a discussion about the concerns that patients and parents are coming in with and all the underlying symptoms, as well as a medical and family history as it relates to the complaints that they're having. We'll definitely make sure to review any prior workup and treatments that have been previously tried so that we can make a successful treatment plan that hasn't been tried before, so that we're making sure we're making progress and managing the condition. Like we kind of chatted about previously, it's really unlikely that patients would need an exam, especially a pelvic exam. But if there is a vulvar or vaginal complaint, we may need to do an external exam to see the concern or make sure there's no skin changes or any concerning discharge. After that, we'll discuss other necessary recommended workup for what the complaint is and management options.

We usually do recommend close follow-up visits depending on what management or what treatment plan that we've chosen to make sure that symptoms are improving. That's usually within two to three months, but I always encourage patients after the visit to set up their MyChart so that they can communicate with me and save visits to the hospital or visits to the Clinic if possible if things aren't going well.

Erica Newlin, MD:

For sure. How do you help children feel comfortable during things when you have to do an exam?

Erin Isaacson, MD:

Yeah. I think this is a really important question. I think one, engaging the parents is really important, allowing the kid to sit with their parent next to their parent. Another thing that can be really helpful is actually having the kid, especially younger kids, participate in the exam. I, you know, instead of me touching or, you know, using tools to look at the area that they're concerned about, I ask them, you know, "Point to me where it hurts. Point to me where it itches. Can you pull back the labia for me? " And kids are often way more comfortable and relaxed when they're able to do it themselves. And I find that that helps with exams as well and helps build a trusting relationship.

Erica Newlin, MD:

For sure. I know this is a really broad question, but would you say most conditions that you see, are they treated with medication, lifestyle changes, procedures?

Erin Isaacson, MD:

Yeah. I think it really does depend on the condition. I think that a lot of conditions can be treated with medications, lifestyle changes, or a combination of both. I think it's really important for the patient, the parent and myself or any other PAG physician to work together to determine what the best treatment plan is, both for making sure we're improving symptoms and also for whatever the patient's lifestyle is.

We always have, in our visits, we always talk about a first step and then we always have a backup plan. So we always know what we're going to go to next if the first thing we try isn't working. We always want to make sure that the steps that we're doing are improving the patient's quality of life, and so open to not just medication, not just lifestyle changes. Obviously, there's conditions that require procedures, things like larger ovarian cysts that cause pain have to be removed via surgery or different high middle abnormalities, extra hymenal tissue that can't be treated with lifestyle changes, but we do try to avoid surgery when possible.

Erica Newlin, MD:

How do you, especially in our teen or adolescent populations, how do you involve parents in the care process while respecting the patient's privacy?

Erin Isaacson, MD:

Yeah. I think it's important to acknowledge that parents are just a crucial part of the care process. And it's often their desire to advocate for their kids that gets them to me in the first place. And so I really want to respect and honor that during the visit because most of the time they're coming in because they're concerned about their kid. However, for all of my older preteens and teens, I usually will do a confidential visit during our visit in general to have the parents step out and talk one-on-one with the teen, to see if they have any questions, to see if there's anything that they don't feel comfortable asking in front of their parent. Usually that answer is no, but sometimes you may find that you uncover things that they are not willing to share in front of their parent, they're uncomfortable talking about, but it also just gives them that first avenue of recognizing that they have someone who is confidential, who will listen to them, and who they can ask uncomfortable questions to, even if they don't have any at that moment.

And so I think that that helps really to build a good patient relationship, which is important. You need to have a good relationship with your parent and a good relationship with your patient and to build trust.

Erica Newlin, MD:

Let's move on to prevention and education. We know education is key to preventing issues and helping kids feel confident about their bodies. What can parents do at home to support healthy development?

Erin Isaacson, MD:

Yeah, I think one thing, like we talked about previously, I think encouraging conversation about periods, about vulvovaginal health at home is really important. It helps just open up the conversation so that kids feel comfortable bringing up concerns to their parents. However, there are some other really simple things that parents can do and encourage in the home that can help support vulvar vaginal health. So some things that we see as an issue quite often is younger kids or even teenagers coming in with vulvar itching, light discharge and discomfort. So some of the kind of lifestyle changes we usually recommend are to avoid scented things in the home, avoid scented laundry detergent and strong scented bath lotion. The vulvar skin is incredibly sensitive, especially in younger kids. And so those scents can cause a lot of irritation that lead to redness, itching, and discharge, which is often what they come in and see me for.

As well as when you're teaching your young girls about potty training, really making sure that you're advocating for like good wiping techniques to keep the vulvar skin clean and avoid irritation. A lot of these small lifestyle changes can prevent a lot of issues and a lot of symptoms in, in young patients specifically.

Erica Newlin, MD:

For sure. I, in my general practice, also do a lot of vulvar care and a lot of it is kind of stepping back on all of the scented products. What about bubble baths?

Erin Isaacson, MD:

We do kind of try to avoid the bubble bath if possible. Again, every patient is so different and it really depends on how sensitive their skin is. I think baths are wonderful and a bath with no soap whatsoever, a warm bath can actually be really gentle and healing for the skin. I think an occasional bubble bath probably would not hurt most patients, but if your kid is extra sensitive and has other underlying skin issues, any sort of bubbles or scents could really flare up or aggravate the vulvar tissue as well.

Erica Newlin, MD:

How should parents approach conversations about body changes and menstruation as young girls are getting older?

Erin Isaacson, MD:

Yeah, I think just encouraging your child to ask questions, keeping that open line of communication. Once they start to go through puberty, start to talk about periods and what they might expect so they're not embarrassed when they're not afraid to bring up concerns. I think another important thing before and during puberty is to talk to your kid about safety and privacy. Who is allowed to do exams? Who is allowed to look at private areas and having those conversations really early on so that they can advocate for themselves in the future.

Erica Newlin, MD:

Are there any specific resources or books you recommend for patients and families?

Erin Isaacson, MD:

Yeah, I think North American Society for Pediatric and Adolescent Gynecology, that's kind of our kind of governing body. The website's open to the public and their patient handouts are really straightforward talking about acne, periods, PCOS, pubertal development, and can really walk patients and parents through what to expect, what's abnormal, and when they should talk to their doctor about issues.

Erica Newlin, MD:

What's your advice for parents who feel nervous about these topics? Maybe they didn't talk about it when they were kids, and it's really tough to bring up some of these topics.

Erin Isaacson, MD:

Yeah, I think just do your best. Talking at all is a huge first step. For parents that want more information and education for their kids, that's why we're here as gynecologists. We can provide that and an educational visit is never wrong and never a bad thing, but I think talking about puberty, periods, sexual health in general just helps build openness and trust with your kid. And so I always encourage you, even if you don't know if you know the right thing to say, saying anything is a great first step.

Erica Newlin, MD:

And like you mentioned, it's always nice to come for these education and just introductory visits. Nothing makes me feel older in my office than having a 14-year-old in my office, but it's so nice to talk with them and be like, "I'm not a scary person, I promise."

Erin Isaacson, MD:

Yeah, I love it. I love it because I think there isn't always a great age to start going to the gynecologist. Obviously, in the adult world, we recommend a visit in a pap smear starting at age 21, but a lot of times these kids are already in college, they might be busy, they've never seen a gynecologist before, they don't understand like why they're going, why it's important. And so if we can see a lot of these teens earlier and start to educate them on menstrual health, safe sexual practices, and also why, you know, the HPV vaccine, why we screen for cervical cancer. I think that it helps build trust for future visits and really establish care in a gynecology setting so they understand why they're recommended to come in for visits in the future.

Erica Newlin, MD:

As we wrap up this episode, let's leave our listeners with a key takeaway. For parents, what is your biggest piece of advice when it comes to pediatric gynecology?

Erin Isaacson, MD:

I think my biggest piece of advice is don't hesitate to get your child's period pain evaluated. Although not all period pain is necessarily due to endometriosis, endometriosis is a chronic pain inflammatory condition associated with menses. Data shows that the delay in diagnosis of endometriosis is at least five to 10 years, which can just be years of chronic debilitating pain and heavy periods. The sooner we can evaluate, intervene, and treat period issues, the sooner kids can just get back to being kids. So don't hesitate to get it evaluated if you have any concerns.

Erica Newlin, MD:

Anything else you'd like to add before we wrap up?

Erin Isaacson, MD:

I think that, you know, I love a question, what's one thing you wish every parent knew? Something that a lot of parents don't know that I think it's just good to understand is that period irregularities like some missed cycles or some slightly shorter or longer periods is extremely common and normal for up to three years after patients actually have their first period. It's normal not to have a perfect 28-day cycle for the first couple years or even ever. However, if periods are lasting longer than a week, quite frequently, that always warrants further discussion and evaluation, and it's never wrong to come in and discuss concerns, even if someone might say it's normal.

Erica Newlin, MD:

Dr. Isaacson, thank you so much for joining me on the podcast today.

Erin Isaacson, MD:

Thank you so much for having me.

Erica Newlin, MD:

For more information on pediatric gynecology, visit clevelandclinic.org/pedsgyn. If you found this episode helpful, subscribe and share it with a friend. Remember, understanding your child's health is the first step to supporting their wellbeing.

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.