Who Needs Gynecology Care?

by Dr. Ann L. Engelland

(February 9, 2005) Rachel, 14, has been having periods for a year and a half, but they have become increasingly irregular. It’s wreaking havoc with her travel soccer schedule.

Susan, 17, has a serious boyfriend away at college and would like to discuss birth control pills before he comes back to Mamaroneck for spring break.

Paulina, 15, has had unprotected sex and read something in Teen Vogue magazine at the orthodontist’s office that scared her. She wants to be tested for sexually transmitted illnesses.

Annie, 15, has had severe menstrual cramps for the past year. She is now missing school 2 or 3 days out of a month. She is afraid something is wrong.

All of these teens need help. Where to turn? Whom to ask?

When it comes to gynecological care, adolescent girls and their parents are full of questions: When should girls have their first gynecologic checkups? With whom? When do they need a Pap test? Whom can they approach for confidential care?

First of all, let’s dispel the notion that a girl only needs “gyn care” once she becomes sexually active. Care of the female body, including examination of the external genitalia, should be part of routine pediatric care from birth on. As girls enter puberty their bodies change and concerns can be addressed at each visit. As girls grow up, their “genital” care becomes “pubertal” care and eventually “gynecologic” care, encompassing physical as well as social and emotional concerns, sometimes years before they are actually having intercourse.

All girls should have the opportunity to discuss their periods and their sexuality.

Beyond the routine, any teen engaging in intercourse (or other risk-prone sexual behavior) should be seen by a physician.

If mothers initiate the visit, there should be an open discussion with their daughters about the choice of doctor. Parents need to find a doctor the teen can relate to, and one who is comfortable covering adolescent psychosocial and sexual issues. Girls often balk at seeing or talking to their Mom's gynecologist

Many pediatricians and family practitiioners are capable of doing routine gynecology care. It is often a matter of personal interest and experience, so a parent might start with a child’s doctor and ask if an appointment is appropriate. Some adolescent medicine doctors refer to themselves as “psychogynecologists” because routine sexuality and gynecologic care are part of their basic training.

Text Box: If a girl refers herself to a clinician for gyn care, she may or may not want Mom and Dad to be involved.  New York State law gives minors the right to confidential care related to issues of sexuality, contraception and sexually transmitted illnesses.  However, it may be logistically impossible for a teen to get to a private office or to handle the cumbersome billing, and often  a breach of confidence ensues if the bill is mailed home.    For those teens who require strict confidence and/or have limited insurance or funds, all I can say is, “Thank you, Planned Parenthood!” I have found the quality of care to be consistently good and caring. Counseling is available and teens are assured of confidentiality. Paulina, who had unprotected sex and is worried about sexually transmitted infections could be tested at the nearest Planned Parenthood Clinic in New Rochelle across from New Roc City. She would also be counseled about “the morning after pill” or emergency contraception.

So what is involved in a first time gynecology checkup?

As with all clinical encounters, an interview and discussion should precede the exam. This is an opportunity for the teen to express worries, questions, and concerns. This is the time for the clinician to ask the questions that will determine the nature of the ensuing examination. The discussion should also touch on subjects that are psychological and emotional rather than strictly gynecological. Some important questions might be: “What is your boyfriend like?” “Have you ever had non-heterosexual sex?” “Is sex pleasurable for you?” “Have you had any unwanted sex experiences?” and “Do you have any questions?”

Next, the patient provides a urine specimen, undresses and is examined. There are essentially three parts to the exam:

  • 1.Examination of the external genitalia: doctors look for normal anatomy, rash, infection, and signs of abuse. Many girls have dermatologic complications of shaving and this is a good time for some guidance on this new fad.

  • 2. Examination with a speculum is next: In position on a special examination table, the patient is draped in a way that protects her modesty and privacy, and a plastic or metal speculum is inserted into the vagina. With an attached light, the vagina, and cervix are examined. This is when a swab for a Pap test and for sexually transmitted illnesses is taken.

  • 3. Then there is the “bimanual exam,” when a gloved and lubricated finger is inserted into the vagina, and with the other hand on the abdomen, the clinician is able to evaluate the size and shape of the ovaries and the uterus.

The whole thing takes under five minutes and, if done well and with preparation, is neither painful nor disturbing for most young women. I always recommend that girls schedule their first exam as a routine one, done in a place they know and trust, so that they don’t have their first experience with strangers in a glaring, cold emergency department somewhere at a time when they may be in pain or frightened.

My next column will focus on the Pap test and talk about the newest guidelines and reasons to do Pap tests in teens.


Dr. Engelland has a practice in Mamaroneck devoted to Adolescent Primary Care. She can be reached at 698-5544.

Have a teen health question? Use the form below to send it to Dr. Engelland. Please note: Dr Engelland cannot respond privately to individual queries online. Comments are welcome and anonymous questions may be answered in future columns. Serious medical problems should be referred to your own physician.

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