>> Psychologist, G. Stanley Hall said puberty for a girl is like floating down a broadening river into an open sea.

Stay with us as we talk with pediatric and adolescent obstetrician gynecologist Doctor Wendy Jackson about how to keep that journey on track.

Next, on Kentucky Health.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.

>> Adolescents.

That transitional period between childhood and young adulthood is characterized by physical maturation and a myriad of psychosocial issues, all the consequence of intense hormonal changes.

For those parents who made it through those years unscathed, congratulations!

If you now have preadolescents, just wait for the fun to begin.

Finally, if you have adolescents with you now, then know that this too shall pass.

Puberty can be a challenging time for boys.

However, it is girls and young women who seem to bear the greater negative and positive burdens of this time.

One reason is the unique body changes that young women undergo, and the social emphasis placed upon those changes.

Studies have shown that between 53 and 78% of young women between the ages of 13 and 17 are at some point unhappy with their bodies.

While body image can be a problem, perhaps more important is the oftentimes lack of understanding by both the adolescent and the parent or guardian of the causes of these changes, what they mean and what is and is not normal.

This failure of understanding can lead to misunderstandings, lack of recognition of problems when they present, and a delay in addressing problems that may be of significance now or cause bigger problems later in life.

I'm the father of boys and as such I have no clue and will not proffer an opinion on the raising of girls and young women.

Fortunately, since this show is about adolescent gynecology, today's guest specializes in pediatric and adolescent gynecology, and it is she to whom we will rely upon for an expert's opinion.

Doctor Wendy Jackson is a graduate of the University of Kentucky College of Medicine.

She completed her obstetrics and gynecology residency at the University of Kentucky, and then did additional training in pediatric and adolescent gynecology at the University of Louisville.

Doctor Jackson is a full professor in the Department of Obstetrics and Gynecology at University of Kentucky College of Medicine, where she has an active, active practice in pediatric and adolescent gynecology with the University of Kentucky Health Care.

In addition to her clinical and teaching duties, she is also the associate Dean for admissions at the University of Kentucky College of Medicine.

Doctor Jackson, Wendy, thank you for being with us today.

>> Thank you for having me.

>> No, it's a pleasure.

How did you wind up doing obstetrics and gynecology?

>> Honestly, I'm first gen, and I really didn't know that.

Journey on how to bridge high school to college.

But I was with a substitute teacher one day who asked what I was doing my sophomore year in high school, when I graduated in two years, and I went home to ask my mom and she said I should be an ob gyn.

>> Really?

>> And I didn't know what that was.

So she explained it to me.

And now I'll tell you that.

That makes me chuckle.

It was a pivotal moment to think that I could just wake up one day and say, I'm going to be an ob gyn.

Understanding the journey through the world of medical school admissions and how competitive it can be, but with lots of support and lots of career exploration, I later found that that truly was my passion.

I'm a product of teen pregnancy and so I love that I have come full circle and that's the cohort that I care for now.

>> Wow, wow.

So what do you tell kids?

Say, I want to do what you do.

So what is it?

A couple of years of college.

What what what's the what's the starting point?

>> What's my spiel?

What do I tell them?

>> Yeah.

>> You know, well, I tell them at first they need to have strong academics because we understand that the academic metrics are going to be one component of the evaluation process.

And then I just explain to them broadly that they're going to need a four year degree.

There's something called a medical college admissions test called an MCAT that they're going to have to perform well on.

So start preparing early, obtain that baseline scientific knowledge, and be able to apply that on an exam.

You're going to need some exposure to the profession.

So some shadowing and you'll need a lot of service.

Because medicine is a career that is embodied in service to others for your entire career, so that early exploration helps them solidify whether or not medicine is truly what they have a passion for.

And then I think the rest is on them the interview, performance, so on and so forth.

>> But it's a fun journey.

I can tell you this.

I always thought it was, you know, recently we were talking to a pediatrician here on the show, and the question was, when do they start seeing patients?

When do you, as the pediatric gynecologist and should I say obstetrician gynecologist or gynecologist?

>> I'm a trained general OBGYN, so I still practice obstetrics.

I staff our teen pregnancy clinic here.

So the fact that you're not saying just peds and adolescent gynecology, you've added obstetrics.

I'm fine with that because I still practice obstetrics, but I see them from birth on depending on the situation, right?

>> Really?

>> Yeah.

>> So I'm a parent and I have a daughter.

Are they being seen by you as children or through the pediatrician or how does that work?

>> I think I get them both ways.

So peds will take care of some conditions.

If it's something they feel is beyond the scope of their practice, they will then refer to me sometimes folks self-refer and I'll get them in my clinic through that route.

>> It seems that the adolescence is an interesting time by the image and other things, and there are a lot of physical changes, psychosocial things going on.

What is it like in the exam room?

Do you have the parents there?

Is it just the child patient or is it a combination or how do you blend this whole thing?

>> Yes, I think I think it boils down if we're talking about the adolescent, it boils down to patient preference.

The visit normally starts off with a guardian or a parent that's in the space with the adolescent.

And I'll begin the history taking to see what the primary agenda is, what the chief concern is, what brought them in.

Once that shared, we navigate through history taking right.

We can develop, we can perform a physical exam, develop an assessment and plan, make sure all questions have been answered and that the agenda has been met.

And then I like to create space at the end of the visit for the adolescent to be seen alone, without the guardian in the room.

And, and I make sure that everything has been addressed that the Guardian wished to have addressed on that day.

And then I normally send them either to the lobby or out to schedule the follow up, and I let them know we're going to go through a series of questions with their teen.

Everything is confidential.

Unless it's something that's life threatening.

I would then come back out to get them, and we cover content like Home life.

And do they have an adult that they can lean into and ask questions to?

I get into education.

I get into nutrition, physical activity, mental health, substance use, sexual activity.

All of that content is covered in a span of a few minutes.

And we can kind of unroof a lot of information with an adult out of the room.

>> How do you find the discussion is different with that adult out versus in.

>> Plus minus?

You know, I have a questionnaire, I have them fill out.

But you can imagine that if a parent is sitting beside you, you might not always be honest on that questionnaire.

So I've had times where there is one response on the paper and as I'm navigating through the answer is modified with the adult out of the room.

I think that's the beauty of having that confidential time with the adolescent patient, right?

They may need STI testing.

>> What is.

>> That sexually transmitted infection testing that would not have otherwise been disclosed.

If we didn't have space for that, they may have put they've never been sexually active when really they are.

And they need that screening.

So they might be suicidal and no one knows that.

But that would come out in a private session session where we're covering that content.

>> Tell me a little bit about menarche.

What is it?

When does it start, and is there a standard time for it all to start?

>> Yeah.

So when I think about the onset of menarche or the onset of a period, I think the average age is around 12, a little over that in my mind.

I have a timeline in, in in the literature, it would suggest that if the age of puberty onset is before age eight, that's premature.

Okay.

Right.

So that's when we get into precocity that requires a separate workup.

I normally will provide some education because I'll begin seeing patients when they have their first period.

And I like to set the standard for what normal parameters are.

And that's important because it can help guide when the visits occur for for the patient in the future.

What's the norm?

What would be abnormal?

When should we come see you?

When when should we consider hormonal management of menses?

But menarche is the onset of menses that typically occurs 2 to 3 years after the onset of breast budding, which is that first sign of puberty?

>> You mentioned about precocious puberty.

What does that really mean other than just starting?

Or is that all that it means?

Is that the starting periods early and do things around menarche?

Are there some things, any abnormalities that can occur that may portend problems down the road?

>> Yeah, I believe so.

So oh my gosh.

You know precocious puberty is its entire lecture on its own.

But I think the time frame we should think about is less.

The onset of puberty under age eight would be too early.

Right.

And that can manifest with full blown puberty that's occurring in a similar timeline.

The age is off.

Or it could be partial.

You could have breast budding, but not any further progression progression.

So that's why I said it's kind of its own separate lecture.

And then the follow up question that you wanted me to answer, what.

>> Does it portend any particular problems down the road.

>> Yeah.

So I think there are some clues for us with menarche.

Right?

I think it's important for the public to know that periods can be irregular in the first year, as the signal from the central nervous system, the brain to the reproductive tract, is really trying to connect and be consistent.

So we might see some menstrual irregularity.

However, beyond that, we should be pretty cyclic or pretty ovulatory.

Having our cycle length of every 21 to 35 days in our adolescent population, clues that there could be something that's going on that would negatively impact us downstream might be extremely painful periods.

We call that dysmenorrhea.

So most people would say, yeah, we have menstrual cramps and we take Motrin, or I use my heat pack, or I have a rice pack that I heat up and apply to my abdomen.

That's fine.

Sounds like straightforward menstrual cramps.

But if I'm talking about dysmenorrhea, beyond the standard menstrual cramping, nausea, vomiting, missing school, clearly incapacitated, right?

That's something that would manifest with the onset of periods.

And we would need to consider treating that might be a downstream diagnosis of endometriosis.

Right.

So that's why it's really important.

That can impact fertility and quality of life.

Obviously delayed puberty.

You said the onset of menses.

But if menses doesn't happen right, there could be a whole host of medical conditions that are occurring.

>> Gotcha.

>> So if we're off that timeline, those are some of the things that stand out to me.

>> Once a young woman starts having her periods, is that when she can, from that point, become pregnant, right.

>> We're releasing an egg.

That's important.

>> Really.

So from that point on there, she can become pregnant, right?

>> But she has reproductive capability.

>> At that point.

So to that degree, with the whole village involved, or maybe just the patient, is there a discussion about sexual activity which would include, as you mentioned, some STIs, sexually transmitted infections and all things that contraception and or things to help control some of the problems that may be around having one's period.

>> It's almost like you're sitting in the exam room with me.

These are all conversations that we have, and ideally we would have those discussions before someone has their sexual debut.

Right.

Preventive care.

And that's a huge part of adolescent gyn to make sure that one we are educating on bodily changes.

Number two, you understand this reproductive capability.

Number three, if you make the executive decision to become sexually active, that we can be proactive in providing access to not only contraception but hormonal contraception, but contraception and barrier form that prevents us from getting infections, things like condoms.

Right.

We call that dual methods of contraception, something more reliable than a condom that would prevent a pregnancy, but also paired with a condom to prevent infection.

These are all conversations that are so important behind the door.

>> Since you're still behind the door.

To add to your woes, we know that infections like herpes, and particularly human papillomavirus are very prevalent problem.

They're also particularly human papillomavirus associated with certain cancers.

Correct.

So once we get that individual who can make the executive decision, I like that term.

Do you talk about vaccines that may prevent that?

And also do you mention that this thing also may be occurring if you become sexually active?

>> That's my job to mention.

>> It, right.

>> It's so important.

Normally by the time I've seen them and they're menocal.

Yeah.

They will have already had discussions with their pediatrician.

So most are familiar that this HPV vaccine exists because the age of vaccination is nine through 26.

And there are some newer guidelines that suggest up to age 45 in certain demographics.

That's shared decision making.

The average age and best age to vaccinate would be ages between ages 11 and 12, and I have a discussion with them if they've not been vaccinated.

Understanding based on their age, how many injections they would need because that varies.

If they're less than 15, they need to give the first one and then 6 to 12 months later, get the second.

If you're 15 or older, it's a series of three, so you get the first injection two months later, the second four months after that, the third one and complete the series.

If they initiated the vaccine with, say, their pediatrician, but never followed up, you can pick up where you left off.

And so I highlight that.

I also, if there are fears about a vaccine, right.

If I see someone who's not been vaccinated and the parents in the room.

Right, we're not interested in that.

>> Yes.

>> I feel comfortable saying, can you share with me why?

I'm just curious, you know, and that opens the door for further conversation, at least to get the wheels turning again.

But maybe this is something valuable I like to also share.

And I'm not trying to coerce anyone, but I'm a mom of sons and I'm vaccinated them, right?

So for me, I know the literature that exists, I know the safety profile, and I know how protective it can be against one cervical cancer to genital warts, three or pharyngeal cancers, and for some potentially and vaginal cancers.

If we can do anything to minimize the risk of someone developing a cancer through a vaccination when they're naive to the virus, we should be thinking about that.

We should be promoting it.

>> What are some other conditions that tend to bring someone into your office who might not have been there before?

>> Okay, I mentioned to you dysmenorrhea.

That's probably one of the number one things, painful periods that are debilitating.

>> Do you do about it?

I mean, you mentioned putting I'm trying to imagine someone putting the rice pad down there on top of their butt.

I'm surprised you didn't mention good old Midol from when I was a kid.

I mean, obviously, but anyway.

>> Definitely get there with over-the-counter medications.

But yes, Midol viable option.

My number one is scheduled ibuprofen.

>> Really?

>> NSAIDs.

That plus heat is the first line treatment for painful periods when it's extending beyond that, when you can't get a handle on it, compromising day to day life.

We need to have a discussion about hormonal management, okay?

And take into account one's past medical history, one's family history, and then choose the best option, right?

Because if we're if we're talking about hormonal management and someone has a strong family history for breast cancer, right, then that's a different discussion.

But the first line I think the the most individuals will choose a combined oral contraceptive pill, and I have them follow up in three months to see if it's helping improve their symptoms and quality of life.

Oftentimes it does.

If not, that next step would be instead of taking it cyclically every month and still having a period, we consider continuous oral contraceptive pill use where we suppress a period.

Obviously, alternative therapies would be something like an intrauterine device that could help along the way.

>> What are some of the theories as far as why women may have these painful periods?

It's just luck of the draw is just is there something physiologic that's going on?

>> Well, there's something physiological.

Right.

But prostaglandin release is what's making the uterus contract and cause that discomfort.

We can use an anti-prostaglandin to treat that.

It makes sense.

But I shared a little bit earlier that someone may have a condition like endometriosis.

Right.

And they're not as responsive to that initial medical management.

And that might take us down the road to diagnostic laparoscopy or putting the camera inside the abdomen, looking in the pelvis and trying to see if there are lesions significant for endometriosis.

>> What is it?

What is endometriosis?

>> That's where you have the glandular cells that are typically inside the uterus that are located then outside the uterus, resulting in a patient to present with extremely painful periods, chronic pelvic pain, pain with intercourse, pain with defecation or bowel movements.

Those are oftentimes the clinical signs and symptoms that we see.

>> Okay.

So dysmenorrhea is a big one.

That's a big one.

What else tends to bring folks.

>> In contraception really birth control.

>> Talking about that.

>> Yeah they come for cramps.

But we have a need for contraception okay.

So that's a big one.

Ovarian cysts or something that's common that we see really heavy menstrual bleeding that has resulted in a need for transfusion or visits to the emergency department.

They need an evaluation for underlying thyroid disease or an underlying bleeding disorder that needs to be managed.

So those are some of the big ones that I see.

>> You mean.

So excessive bleeding can be caused from thyroid problems?

>> Absolutely.

Undiagnosed thyroid disease.

>> That's interesting.

Put you on the spot.

So what other kind of conditions might you see in your office that may suggest a systemic problem?

>> Well, Crohn's disease comes to mind.

>> Interesting, right.

>> And so maybe I'm leaning into that because I'm sitting in front of you and I know you're and I know you're training, but that's something that comes to mind because you can have vulvar manifestations.

Right.

Or someone may come to me with oral lesions and vulvar manifestations.

And so I will lean into a multidisciplinary approach and utilize our pediatric gastroenterologists that we have in our facility.

>> What about skin diseases?

Do you tend to see some of that also around the vulvar area and vaginal areas of your patients?

>> I do.

Lichen sclerosis is a big one, and that's typically in a prepubertal population.

So the main thing is that we would recognize it.

One number two treat before there's loss of architecture of the vulva.

So I get a lot of referrals for that.

And my pre-pubertal population, a lot of vulvar concerns I think because they're trying to master hygiene and toileting, and there's been so many creams applied to them, and they really just are trying to figure out how to wipe, you know?

So it's interesting.

We've got the entire gamut in PD gyne.

>> How do you get into the urinary tract problems that may have or does that kind of cross over more to the urologist.

But I would imagine it's you who are seeing this.

>> They come to me.

Right.

And I think a lot of the initial screening that I'm going to do is ruling out urinary tract infections or again, leaning into those hygiene measures.

And can we educate on how to best care for the vulva in the prepubescent patient?

I do involve our pediatric urology colleagues though along with that care.

But we I mean there can be things that are that come to mind, like vaginal voiding for individuals who might be suffering from constipation.

And that's then leaning.

You can imagine that anatomy is modified and resulting in leaking of urine.

In some of my patient population.

>> I would imagine one thing that would inhibit or scare young women as the speculum examination.

How do you get around that?

>> Well, you just did that speculum exam.

Not everybody needs a speculum exam.

>> Oh, really?

That's right.

>> So, you know, they come in all sizes and we would buy, you know, under no circumstances use an adult speculum on our pediatric patient.

We have pediatric specula, but we can also perform different exam techniques to be able to visualize various aspects of their anatomy.

>> Gotcha.

>> Yeah.

>> So the concept of that big metal thing of years past that's gone, it's you have adjustable sizes and things.

So young women need not be afraid.

>> They need not be afraid.

They should come for gynecologic care.

>> What are the three most important things you think someone should come away from with our discussion?

But when they leave your office, what are the three things you want them to make sure that they know about?

>> First and foremost, that in the gynecologist office, anything is fair game.

You don't need to be embarrassed.

You can disclose anything.

I always tell them that.

Number two, vaccinations prevent other medical conditions, and HPV vaccine is the one that we carry in our office that we're willing to offer.

And number three, your periods do not have to compromise your life.

You can be productive members of society and still menstruate.

And we can manage your cramps.

>> Are we providing enough hygiene products?

And I'm using the whole broad gamut of things that women need.

Are we providing enough for women right now?

Thinking in public spaces such as the schools or whatever?

Are there enough availability?

>> Well, if you ask my patient population, likely not.

They have a max number of hall passes.

They can get to go to the restroom.

So sometimes I have to write on a prescription pad that they need permission to go to the bathroom.

And then I've heard varying stories about what is in those restrooms, right.

Behaviors that are occurring in there, and so on and so forth, that might make a patient not want to go, so much so that they will wear a menstrual panty with a pad in it, or layered pads, and just quickly take the top pad off the second one's in place and get out of the space.

So we've been very tactful in adapting to the current environment.

>> Do we have enough manpower right now to cover the needs of your patient population?

>> Absolutely not.

I think we need more pediatric adolescent gynecologists.

>> So we should anticipate seeing a rise in the number of applications that the University of Kentucky School of Medicine, of people interested in doing what you do.

>> Maybe I try to sway them on their clinical rotations.

>> Any success with that?

>> Some.

I need them to come back to Kentucky, though.

>> Yeah, yeah.

Good old Bluegrass State.

>> Exactly.

>> Doctor Jackson, thank you very much for being.

Absolutely.

It's been very interesting talking to you and thank you for being with us today.

I hope that we have provided a little more insight into when gynecologic examination should begin, what to expect during those examinations, and some of the conditions that patients may face and or need to be addressed.

If you wish to watch this show again, or watch an archived version of past shows, please go to ket.org.

Forward slash.

If you have a question or comment about this or other shows, we can be reached at Chi health at ket.org.

I look forward to seeing you on the next Kentucky Health.

And if you're a young woman or you're a parent of a prepubescent or adolescent child, please make sure that they're getting care.

There is nothing to be ashamed of, and it is something to have good care for everybody.

And I'll put in my own plug.

Please consider the HPV vaccine.

It does work wonders.

Thank you very much.

And thank you, Doctor Jackson.

>> Thank you.

>> Good luck.

>> With that.

>> Kentucky Health is funded in part by a grant from the Foundation for a Healthy Kentucky.