"Women are not inherently passive or peaceful. We're not inherently anything but human."
~ Robin Morgan
Do Teens and College kids need a Gynecologist?
Seeing the right gynecologist for the first time should be as easy as meeting with a guidance counselor to discuss your "short list" & "reach schools". We another trusted adult they can call from anywhere, to ask for help and get confidential advice. (I encourage my high school and college-aged patients to call or email me to discuss concerns before they become bigger problems.)
We will not do a pelvic exam until age 21.
There is rarely a need to examine a young women who comes in for a consult. The American College of Obstetrics & Gynecology recommends no pap smear until age 21.
If you are having pelvic pain, an abdominal exam combined with an ultrasound often gives us the information we need without any discomfort.
The first visit is a chance to meet and break the ice, before you need me, to get information, counseling and to establish a rapport, to find a comfortable bridge from your pediatrician when you are ready. For several years, we often see you in conjunction with your pediatrician.
We will usually go over issues relevant to your current needs and touch on several topics on my "College Prep Check List". I put this together over the past several years, and the list is always growing, from several yearly conferences I attend on adolescent gynecology and new recommendations from the literature.
I like to be sure to hit all these points before you head for college.
Confidentiality
You are my patient, not your mom, dad, friends etc… nys law protects your rights to confidential reproductive healthcare. Knowing our conversation is privileged allows us to develop a trusting relationship so that you’ll call me when you need me, from wherever you are. I am a mother as well as physician, and encourage you to be open with your mom, your best advocate, but that is your decision.
The fewer partners your boyfriend has been with, the lower your own risk of infections. The math is simple, emotions complicate things. If you are considering being sexually active with your boyfriend in the future, you should be comfortable that he is a good fit for you. (See: “chooserespect.org”)
How To Pick A Partner
Based on data, although the results make good sense. (Felicia Guest, MPH; July 2007.)
Column 1: Column 2: Column 3:
Good Fit You could do better Don't even consider him
•Appealing •Older •Violent
•Listens to you •Dated alot •Needle drug user
•Respects you • Limits you •Wants you to use drugs
•Never scares you •Violent in any way: emotionally,
•Goals that fit yours sexually or physically.
But, what if he isn’t in the "good fit” category, and you are in love anyway? Love isn’t supposed to hurt. It should fit in with the rest of your life, and should bring out the best in both of you.
Abstinence
The best way to avoid STIs, teen pregnancy and dating violence is to avoid sex until you are prepared for all possibilities. Many abstain from sex for various reasons — even after they've been sexually active. A couple may even choose to be abstinent after having had sex with each other. The reasons people choose to be abstinent may change throughout life. Most women do choose to be abstinent at certain times in their lives. Some abstain for long periods.
- prevent pregnancy
- prevent STIs
- wait to find the right partner
- wait until they are in a committed relationship
- wait until they are ready for consequences of sexual relationship with long-term boyfriend
- have fun with romantic partners without the pressure and responsibility that sex brings
- focus on school, career, or extracurricular activities
- support personal, moral, or religious beliefs
- get over a breakup or loss of partner
- save physical intimacy for future husband
Abstinence has special advantages for teens
Sexual relationships present risks. Abstinence is the only guaranteed way to postpone taking those risks until you are better able to handle them. Women who abstain until their 20s — and who have fewer lifetime sexual partners, have specific health advantages over women who do not. They are less vulnerable to STIs, unwanted pregnancy, dating violence, and regret that can decrease self-esteem, to name a few. Because they are less likely to get an STI, they are less likely to develop cervical cancer and infertility.
Your Own Criteria
Consider in your what is your personal criteria for being sexually active with your boyfriend. What do you feel is important for you to feel ready for this next step in your relationship? Sexual activity ought to be a thoughtful, planned activity – not something that ‘just happens’.
Regret
After having sex is generally seen when a young woman is not in a committed, mutually monogamous relationship and the relationship ends soon after sexual intercourse. This regret can hurt in many ways you only begin to understand later in life.
Be Clear
It's best to talk about your feelings with your boyfriend before things get sexual. For many people it's hard to be clear about what they want once they are kissing and sexually aroused. It is helpful to think — ahead of time — about how you can say "no" to sex at that point. What behavior will be clear? What words will be best? You can practice saying the words out loud.
Date/Acquaintance Rape
Date rape is not the same thing as stranger rape. (It is actually MUCH more common!) Date rape is committed by an acquaintance, fellow student, friend of a friend; usually not at the end of a true “date”, but following a party where everyone is drinking too much.
“College students are most vulnerable to rape during the first few weeks of the freshman and sophomore years.
In fact, the first few days of the freshman year are the riskiest, limiting the value of any rape prevention programs that begin after that.” – National Institute of Justice, 2008
In recent surveys, 1 in 8 female h.s. students,1 in 4female college students admit to being forced into unwanted sexual intercourse by someone they knew. How do you protect yourself without living in fear of your male classmates?
Strategies: Stay clear of situations where you are not in control?: “ABC”
- Alcohol: is the #1 date rape drug. Approximately 50-70% of all sexual assaults involve alcohol. Alcohol can lower inhibitions, impair judgment and reaction time, diminish recognition of vulnerability, reduce one’s ability to obtain or give consent, and decrease the capacity to resist unwanted sexual activities (Abbey, 2002; Carr & VanDeusen, 2004). Alcohol-fueled sexual aggression is anti-social behavior that harms thousands of students per year.
A sexually motivated guy is likely to seek out a vulnerable young woman: one who is drinking heavily, with impaired judgment.
Before you go out, review with your friends: if you are planning to drink alcohol: consider limiting to 2 drinks in one evening.
4 drinks in one evening is considered “binge drinking” for women and associated with much higher risks for bad outcome. (We have designated drivers, should we consider taking turns designating a non-drinking party-goer to keep friends safe?)
Even when you don’t drink, spending time with guys who have had too much to drink is risky.
They don’t have to fit the profile of a sociopath to be too drunk to correctly interpret that your “no” genuinely means “no” -not, as some misinterpret: a “coy yes”. (Study shows that 1/12 college men surveyed meet the definition of acquaintance rapists, yet of these men, 84% don’t see it.)
- Buddy up: another discussion to have with your friends before you go out: do not go to a party or bar without your close friends and don’t leave without those friends. ‘never leave a soldier behind’ - no matter how strongly she may ask. Remember Natalee Holloway (American girl raped and killed in Aruba) before you watch a friend leave with someone who is not her boyfriend.
- Choose your evening carefully: avoid frat parties, elite athlete parties (football or basketball players tend to expect groupies), nightclubs in early am – consider the agenda – does it meet your goals? Avoid being isolated at a party or bar: keep friends in your sight; do not go into an empty room. If you lose your friends at a party, use cell phone to reconnect, or get another to meet you for the walk home.
[Shifting the Paradigm: Primary Prevention of Sexual Violence was developed by the American College Health Association, supported by the CDC, Aug 2008]
What to do if you or one of your friends experiences acquaintance rape?
Call for help: call a good friend or parent, if close by, campus police, or your dorm’s ra to drive you and possibly a friend to the emergency room. You can call me, and I'll help you figure out the next step.
Don’t shower or change your clothes, to preserve the “evidence.” At the ER you will be met by a team of people who are experienced in dealing with such traumas. Police will talk with you and will stand outside the exam room while you are cared for and specimens are collected; in the event there will be charges.
A social worker or specialized nurse: (S.A.N.E. program) may be there to help you through the exam and recommend follow-up. You will likely be treated with plan B for pregnancy prevention, as well as prophylactic antibiotics to prevent cervical infections. You may have some blood and urine tests. Call me, 24/7, if you’d like to discuss your care or to talk about anything.
Contraceptive Choices = Condoms Plus:
- No other contraceptive method prevents STIs.
- Latex condoms are very protective against HIV, hepatitis, syphilis, gonorrhea & chlamydia.
- They are somewhat lesseffective against genital warts and herpes: contracted by skin-to-skin contact.
- Careful partner selection should decrease these latter risks, but many people are ‘asymptomatic shedders’: they have no sign of infection but can be contagious with sex.
- Condoms also offer 90% protection against pregnancy.
“Double dutch” technique is highly recommended.
In Holland, (the country with the lowest teen pregnancy and teen STI rate in the developed world), they teach their children from a young age about the need for routine condom use. “you don’t drive a car without a seat belt, you don’t have sex without a condom.”
Why not learn from their success and use 2 methods: condoms plus another method for complete protection against pregnancy and sexually transmitted infections?
Emergency Contraception: Now 2 choices: up to 5 days after unprotected sex:
EC: Plan B is over the counter for women over 17. Send him to the pharmacy, or go together, preferably the same night: take 2 pills (1.5 mg) and forget it. Plan B will prevent 90% pregnancies if used in first 24 hrs, 70% if within 3 days, and 50% if used up to 5 days later.
EC: Ella: new to U.S. market, need prescription, works up to 5 days, still 90% effective.
These are not the abortion pill: will not interrupt a pregnancy;
safe for everyone.
HPV Vaccines
A relatively new approach to prevent cervical disease, even cancer. hpv is a sexually transmitted virus, (80% sexually active people in the u.s. are ultimately exposed to the virus.) 2 vaccines have been developed via technology developed by nci/nih. Both are most effective if given prior to sexual activity. Vaccine is recommended by your pediatrician for ages 11-12, if you haven’t been vaccinated yet, we recommend “catch up” vaccine up to age 26.
Gardasil, was FDA-approved in June, 2006. Cervarix, was FDA-approved October, 2009. Both are given as a 3 shot series, over 6 months, and are covered by most insurance plans. Vaccination against the most virulent HPV types: 16 & 18, decreases the incidence of cervical cancer by at least 70%. Gardasil also vaccinates against low-risk HPV types 6 & 11, which decrease the incidence of genital warts by 90%. Neither vaccine is 100% protective, so you will still need to see your gynecologist every year to prevent cervical cancer.
The NCI/NIH are currently investigating preventative and therapeutic modalities to continue to fight cervical disease.
STDs
Many STDs have no symptoms, and your partner may not know he has been infected. (This is one reason why partner selection and limiting total number of sexual partners is so crucial.)
Always use condoms to minimize risk of infections.
Signs, symptoms of STDs: colored or increased vaginal discharge, vaginal odor, bleeding after intercourse, painful intercourse, painful urination, pelvic pain, blisters or lesions growing on the labia (lips covering vagina) or vulva.
STD Screening: we recommend annual testing for urine gonorrhea and chlamydia in young women without symptoms until age 26 (as the CDC advises.) If you have an STD or feel like you are at increased risk, we recommend including blood tests for HIV, syphilis, hepatitis and herpes. This can be done confidentially at the office.
Pap smear: a gentle sampling/scrape of the superficial cells of the cervix (mouth of the uterus) to detect precancerous changes, caused by HPV. This is accomplished by placing a small speculum in your vagina, and identifying your cervix, at the end of your vaginal canal.
To balance likelihood of finding relevant info (abnormality we would want to treat) with consideration of patient’s comfort with this exam, we start annual Pap smears at age 21, as ACOG now recommends. The exam is essentially painless, but the position is a bit awkward at first. We will talk you through every step.
Great Websites for young women's reproductive health:
- youngwomenshealth.org
- goaskalice.org
- plannedparenthood.com
- chooserespect.org
- loveisrespect.org
- scarleteen.org
- athinline.com
- breakthecycle.org
"To tell a woman everything she may not do is to tell her what she can do" ~ Spanish Proverb
