Gynecology for teens

Written by Dr. Szabolcs Máté

One of the most dreadful things for many teens and young women is the consultation with a gynecologist or the gynecology examination. Since a lot of them don’t know why it is important to consult with a gynecologist and what happens during the examination we would like to answer the questions most of the young women formulate only in themselves or discuss with their girlfriend or mother and raise some subjects that should be known by every young person.

Why is it important to discuss these questions -apart from their mother- with their physician too? Because a lot of changes has occurred in the last few years since the mothers had grown out of puberty. The physicians’ attitude has changed, the diagnostic and therapeutic possibilities have developed and even medicine has expanded continuously with extreme speed.

Enormous social changes have occurred in the last years. People speak more openly about sexuality and young people start their sexual activity earlier. At the same time it is very sad that the knowledge of an average man, especially of the young people’s haven’t changed – neither about health and diseases, nor about the side of sexuality concealing pleasure and danger. The lack of information is certainly not the young people’s mistake but above all they are its sufferers. This general lack of information is due to several things. Our educational system didn’t keep abreast of social changes, and of those new materials of knowledge that medicine has acquired in the last 1-2 decades. There hasn’t been any extended campaign on governmental level for years; the much vilified profit oriented pharmaceutical companies were the only one for a long time who dealt with the spreading of information obviously according to their own interest. The only source of the acquisition of new materials of knowledge  was the media for a long time, where the purpose usually is to have great effect in short form or show preference in taking fashionable but often less important subjects apart… to say nothing about those countless half or false information. The internet has been offering opportunity in the last years to forward great quantities of information to the people. Naturally you can get information easily on the internet if you know what you are looking for and therefore you only have to cope with the flood of information. We would like to render help to this: if you would like to know more about the subjects raised by me you may do it easily with full knowledge of the keywords.

When and why do you have to consult a gynecologist first?

Mainly the medical treatment of diseases is emphasized in the recent European medicine and not the maintaining of human health and therefore the majority of people only consult a physician when they feel ill (specialists only have time for this). In contradistinction to this I would like to suggest to everyone that you consult a gynecologist before you start your sexual activity and get information about the most suitable contraceptive method, the sexually transmitted diseases (STD), and their prevention and get information about the screenings recommended to every woman to detect the diseases in time.

Naturally if you have any complaints you should consult a gynecologist, too.

What are the most common gynecological complaints in teens?

• irregular menstrual cycles
• painful menstruation or abundant bleeding during menstruation
• lower abdominal pain
• vaginal discharge
• vaginal discharge
• in case of vaginal or vulvar itching, burning sensation, oily and bumpy skin, in cases where dermatologist specialists recommend consulting a gynecologist
• period is missed
• first period haven’t developed by the age of 16 years
• recurrent cystitis (common name is “chill”)

What happens during a gynecological exam?

To start with this is not as terrible as it sounds!

The gynecologist consultation starts with a conversation what the physicians call as “recording of the medical history” (anamnesis). Its purpose is to reveal why the patient consult the physician and to get acquainted with her symptoms if any and her previous symptoms, her diseases, the diseases in her family, her menstruation cycle (the first day of her last menses, the length of the menstruation cycle, the length of the bleeding, its strength, the occurred symptoms during the menses). The conversation has several benefits: the information obtained during the recording of a detailed medical history contributes to an exact diagnosis of the disease, it may call the gynecologist’s attention to those dangers (diseases) that haven’t caused any symptoms yet but has an increased risk of occurring later and last but not least it is important for both the physician and his/her patient to find a personal tone and release tension. (A remark: The physician usually addresses the patient in a respectful manner. The pediatrician and the gynecologist for a teen are naturally on familiar terms with the patients but most of the physicians address the young women and girls in her teens. Naturally this is not a rule; there are physicians who prefer being on familiar terms with young patient and the patient may propose it too. The basis of a good physician-patient relationship is communication and it is not only the way a physician addresses the patient but a change may help sometimes.)

The consultation (recording of the medical history) is (or may be) followed by the examination.

The general gynecological examination performed on adult women may be modified in many ways in puberty or in case of virgin girls. Typically only the essential examinations will be performed. The complaints will determine the required examinations.

The examination is always performed in a gynecological exam chair; several chair types exist but they differ mainly in the form of the stirrups. The legs must be placed in the stirrups in a lying or half lying position, so the vulva and the vagina may be examined conveniently both for the physician and the patient.

In case of vulvar complaints or vaginal discharge in virgin girls only observation and incidentally sampling is performed, with a cotton swab from the vaginal opening. The gynecologist opens up the soft folds of the vulva manually to reveal the vaginal opening. This examination may be unpleasant since an intimate part of your body is examined but it is completely painless.

When the patient has previous sexual experience a vaginal examination should be performed since the origin of the complaints is usually the vagina even if there are no symptoms there. The vaginal examination is performed by a metal or plastic tool (speculum) that is available in different sizes. The size must always be chosen according to the size of the vagina to provide an optimal approach for the physician without any pain. The physician observes the cervical os during the vaginal examination; it is painless for most of the women. When the vagina is more sensitive than usual (e.g. in case of inflammation, spastic pelvic floor muscles, especially tight vagina) the examination may be painful unfortunately. It may be easier if the patient relaxes all her muscles. In case of cervical cancer screening (to be mentioned later) the physician collects a sample from the surface of the cervical os by a cotton swab, then he applies certain solutions (acetic acid, iodine solution) on it, and finally he inspects it with a special microscope (colposcope). The colposcope may be traditional, like a microscope or digital, looking like a video camera. A sample may be collected from the vaginal discharge and the cervical os to perform special tests (detection of fungi, bacteria and viruses). A minimal pain may occur during the sampling of the cervical os, including the cancer screening.

A “bimanual” examination is performed following the vaginal approach when the gynecologist introduces one or in case of a loose vagina (multipara women) two fingers into the vagina while express some pressure on the lower abdomen with his other hand. His purpose is to palpate the uterus and the ovaries, and incidentally the pathologic changes in the pelvis (cysts, fallopian tube dilation). Though this part of the examination is usually unpleasant or even painful sometimes, the palpation provides information that cannot be accessed by a medical imaging examination (ultrasonography is the most common in gynecology) like pain, that often reveals the problem itself.

To cut a long story short vaginal examinations – both the vaginal approach with speculum and the “bimanual” examination – are performed on women after they first sexual intercourse. When pelvic examination has to be performed on a virgin woman the physician has two opportunities: the examination may be performed the same way but with his index finger introduced into the rectum instead of the vagina, the other opportunity is that in case of virgin, but mature aged women the hymen is appropriately loose to let the examination be performed carefully with one finger introduced into the vagina. The rectal examination may sound alarming but it is only unpleasant and uncomfortable, but not painful.

Ultrasonography is performed on virgin girls and women in most of the cases instead of the bimanual examination, though the image is not as sharp as in the case of transvaginal ultrasonography but it still provides sufficient information for the physician. The abdominal ultrasonography is performed with full bladder when the patient can hardly retain her urine. In such a case the ultrasound beams passing through the bladder full of urine provide an enhanced vision of pelvic organs (uterus, ovaries), on the other hand when the bladder is not appropriately full, intestines may get between the ultrasound beam and the organs to be examined, they reflect the beams and the vision is blurred.

What is the aim of cancer screening?

Cancer screening means screening of cervical cancer to detect precancerous epithelial changes preceding cervical cancer since cervical cancer may be prevented with appropriate treatment. There are several stages of the severity of precancerous conditions; depending on the stage it may get healed by itself or may develop into cancer if untreated.

When does the cervical cancer screening have to be performed?

According to the recommendation of the Hungarian Professional College of Gynecologists the first cervical cancer screening should be performed one year after the beginning of sexual activity and thenceforward it should be repeated once a year. The recommended frequency of the screenings may be different in every country depending mainly on the type of the screening.

How is cervical cancer screening performed?

Cervical cancer screening in Hungary is performed with the simultaneous use of two methods. The most important is cytology: surficial cells are carefully removed with a cotton swab from the surface of the cervical os, and then it is put on a slide and the cytologist examines the especially stained sample with a microscope. This examination may be supplemented with colonoscopy, the microscopic examination of the cervical os surface. Not the cells, but the epithelial structures and vessels are examined in this case, since they may indicate pathologic cell changes.

If the result of my cancer screening is negative, surely everything is all right then?

As only a few thing in life the result of the cervical cancer screening is not 100 percent sure either! (The physicians don’t really want to talk about it though.) Since the result of the combined method is pretty accurate and the development of cervical cancer is slow, it usually takes years for the cancer to develop and when you have a screening done in every year you may feel pretty secure. If you are keen on even more safety HPV screening is recommended.

What happens if my result is positive?

In case of positive result anti-inflammatory treatment, in case of detected HPV-infection immune-boost therapy is suggested that may help spontaneous recovery, then screening is repeated in 6-12 weeks. If the result is positive again and it is mores serious than a certain degree, surgery is recommended.

What is the role of HPV in the development of cervical cancer?

HPV (Human Papillomavirus) infection causes cervical cancer. Well, certainly this is not that simple and we could be lost in details but it makes no difference. HPV-infection is essential in the development of cervical cancer according to our recent knowledge. HPV is a sexually transmitted virus that has several types. There are low-risk and high-risk types of HPV according to their role in the development of cervical cancer. None of the types is bound to cause symptoms and especially cervical cancer; therefore you don’t have to be frightened if a high-risk type virus infection is detected. Low risk types rarely cause cancer, and certain types never does but they often cause very unpleasant genital warts that are hard to manage. HPV-infection is often asymptomatic and what is more important, they don’t cause any problems since the immune system can neutralize the infection in time. (Precancerous epithelial changes and early stages of cervical cancer are asymptomatic, too; that is why cervical cancer screening is so important even if you don’t have any symptoms). The detection of HPV has become available in the last years. The purpose of the screening is to detect asymptomatic HPV-infection and make every effort helping the immune system to defeat it (unfortunately antiviral medicine or therapeutic vaccine doesn’t exist against it), and by increasing the frequency of cancer screening to be able to screen in time when pathologic epidermal changes (precancerous condition) have developed as a consequence of an HPV-infection.

Can HPV-infection be prevented?

Vaccines have been developed in the last years against certain types. The vaccine provides a very effective protection against types HPV 16 and HPV 18 that most commonly cause cancer and against types HPV 6 and HPV 11 that most commonly cause genital warts, but it is effective only if given before someone gets infected.

Vaccine is recommended mainly before starting sexual activity but it may be also effective in the cases of those women who were demonstrated not to be infected with these specific types.

Since HPV vaccine provides protection only against certain types the most important preventive measure is to avoid encountering the virus. Unfortunately this is not an easy job! Though condom use provides some safety it doesn’t provide a full protection since HPV may be present and infect on other parts than those covered by a condom (penis, vagina), like the vulva, or the scrotum. Therefore it can be declared that there is no such thing as safe sex in case of HPV. For these reasons it is important to avoid casual partners.

Women who had surgical intervention because of the positive cancer screening when answering the question how many sexual partners they had during their life typically marked 3-5 partners in a survey under way right now. Is five partners too many? One infected partner is enough to get infected with a lethal disease (e.g. AIDS), even so 5 partners don’t seem too many for young people. But let’s count a bit! If your 5 partners had had 5 partners too before he met you it means that you contact indirectly with the bacterial and viral flora of 25 other people! When we give blood, we usually give the blood from 2-3 people who were screened previously but still we are afraid of it. Why aren’t we afraid to have an intimate relationship with 25 people?!

What are the possibilities?

Decrease the number of your casual partners and avoid partners who are well known of changing partners regularly and the most important and easiest way of prevention: use condom to have effective protection against most of the pathogens. Finally if you want to be extremely careful go with your partner to a consultation where they can screen and incidentally treat the pathogens professionally.

Does HPV vaccine protect against cervical cancer?

It offers effective protections against the types of HPV (HPV 16, HPV 18) most commonly associated with cervical cancer, and therefore it prevents those cancerous changes caused by these types. The protection of the vaccine was demonstrated in case of less common types, too – but it is much less effective. At the same time it is good to know that there are HPV types causing cervical cancer which currently cannot be prevented with vaccination, and therefore traditional cervical cancer screening is essential even for vaccinated women.

Does HPV cause other tumors beside cervical cancer?

Unfortunately yes! Much less commonly, but HPV infection may be associated with vaginal, vulvar and oral cancers and the more common rectal cancer; though it is not essential in the development of the cancer but HPV may often be detected in the tumor.

How can I get HPV vaccine?

Currently there are two types of vaccine available. It is prescribed and given by the gynecologist usually. 3 doses are required for the full protection, the second 2 months after the first shot, and the third 6 months after the first one. Side effects are rare.

What is menstruation, menses?

Menstruation shortly is a vaginal bleeding caused by the cyclic shedding of the endometrium. Naturally it is much more complicated. The cyclic hormone producing of the hypophysis and the ovaries evolved during puberty causes the cyclic change of the endometrium: in the first 14 days of the cycle the endometrium is thickening (proliferative phase) in response to estrogen hormone then in response to progesterone hormone following the ovulation the uterus is preparing for implantation (secretory phase), and finally if fertilization is not occurred the endometrium is shed with bleeding (menstruation). The menstruation cycle and its problems indicate the normal or pathologic hormonal changes in the background.

Nowadays girls’ first menstruation (menarche) occurs at the age of 12.6 years as the average in Hungary. Initially irregular menstruation cycle is typical but it gets more and more regular in time. One and a half year after the first menstruation only the menstruation cycles not shorter than 22-23 days and neither longer than 34-35 days are considered normal.

Unpleasant complaints accompanying menstruation

Menstruation is often accompanied with unpleasant symptoms: lower abdominal pain, headache, breast tenderness, irritability, depression. These symptoms can range from mild and easily tolerated to intolerable symptoms both for you and your neighborhood. A lot of people think that it is greatly influenced by what you saw from others and suffering is an obligatory attribute of menstruation. How you bear it, holding it back, trying hard to maintain your regular life, or making your complaints obvious to your neighborhood is also a behavior that you have learnt from your mother, sister and girlfriends and depends on the expectations of your neighborhood and yourself. Complaints typically start a couple of days before menses and subside with the beginning of menstruation, then cease quickly. Though not all the unpleasant accompanying symptoms of menstruation may be cured, most of the complaints can be treated. First organic diseases in the background of the symptoms (primarily pain) should be ruled out by a couple of routine examinations. As long as the complaints are not associated with organic diseases abnormal hormonal and biochemical processes (functional/idiopathic type) are most commonly in the background. When organic disease is not confirmed (this is typical in young women) herbal medicines, painkillers, anti-inflammatory drugs, antispasmodics and contraceptives are recommended. The majority of the symptoms may be significantly reduced with the proper choice and application of medication.

Irregular menstruation

When menstruation cycles are still irregular one and a half year after the first menstruation or the previously regular cycles become irregular again, hormonal disorder is assumable in the background. The hormonal system is a complex network; its details are still under investigations. Since its complexity this system is liable to damage: several exogenous factors have indirect effect on the regulation of the menstruation cycle, (e.g.: emaciation, overweight, psychic stress, increased physical stress). Though a lot of women think that irregular menstruation is not a problem and at least you suffer less from the unpleasant symptoms, they are wrong.  The defect of the hormonal regulation may indicate an irregular ovulation or that you have no ovulation at all and the corpus luteum that produces progesterone hormone is not developing. Since the natural balance between the two main female sex hormones, the estrogen and the progesterone is not formed in such cases several unpleasant symptoms may occur: a more abundant and prolonged bleeding than the usual, breast tenderness, vaginal discharge, lower abdominal pain, development of ovarian cysts, and last but not least, in case of irregular menstruation cycles the unwanted pregnancy is usually recognized later. The treatment of the problem is much to be desired! If there is an exogenous factor mentioned above that may be changed e.g. weight gain in case of emaciation, losing weight in case of overweight, decrease of the physical and mental stress, it may get the irregular cycles on normal track effectively and without any side effects. If there are no exogenous factors in the background, or their change was unsuccessful, a quicker solution is desired. The treatment consists of medication acting on the endocrine system, drugs with hormone activity and contraceptives.

Menstruation with abundant bleeding

In the background of increased amount of bleeding in teenagers there is usually not an organic disease but an irregular, unbalanced hormonal function is found, and their treatment is similar to the treatment of irregular menstruation. The appropriate diet and iron supplement are important to prevent and treat anemia and iron deficiency caused by the blood loss.

Absent menstruation

The most natural cause of missing a period in a fertile age woman is pregnancy; therefore if the menstruation is late in a sexually active woman always think of this obvious opportunity which is not really desired in teenagers! Nowadays with the very sensitive and accurate urine pregnancy tests available in pharmacies and chemist’s anybody can make sure simply whether she is pregnant or not. In case of a positive result the chance of mistake is very low but there really are some cases of false positive tests. In case of a negative test there are three possibilities:

• not pregnant
• pregnant, but the test was performed too early so the pregnancy couldn’t been detected (Pay attention! The majority of pregnancy tests can detect pregnancy within days after the missed menstruation only!),
• a very rare case of a false negative test is when the test is faulty.

When the control line is not visible either or you have a well-grounded suspicion of the pregnancy, but the test was negative, you should repeat the test the next day with morning urine.

Since there isn’t any 100 percent method, the protection, the use of contraceptives will not exclude the possibility of pregnancy! If you are unsuccessful or your unwanted pregnancy is confirmed, consult a gynecologist!

If pregnancy may be excluded, since you have no partners, or the test was negative, there may be hormonal problems in the background. In puberty a 6 months period of absent menstruation is considered pathologic, while later a 3 months period should be examined and treated.

Frequent bleeding

A shorter than usual menstruation cycle (only menstruations earlier than 22-23 days are considered pathologic) or a midcycle bleeding (not related to the length of the cycle) may be in the background of frequent bleeding. Midcycle bleeding may come from the uterus, the surface of the cervical os or sometimes from the vaginal wall. It may be harmless (like the midcycle bleeding occurring around the 14^th day of the cycle) but it may indicate a more severe problem that should be treated, so you should consult a physician with this complaint.