With answers to primary care providers’ most pressing questions, gynecologist Sloane Berger-Chen, MD, delivers this information-packed talk on reproductive system care for pre-adult patients. Learn reasons that young teens benefit from a first gynecology visit years before guidelines call for a first Pap test, and hear expert guidance on investigating and managing such common problems as heavy menstrual bleeding, polycystic ovarian syndrome (PCOS) and vaginitis – all of which require a different approach in pediatrics than they would in adult care. Berger-Chen also explains why specialists favor monophasic hormonal pills and presents a chart that clinicians can use to counsel patients seeking an IUD that meets their goals and preferences.
But I tried to go through all the questions, um, and the survey, um, information. That I received so that I could give just some highlights to some of these major questions. A lot um is about bleeding and bleeding management and hormonal management, as well as there was quite a bit about PCOS. So, um, if I don't hit every single thing on the slide, there's a pretty extensive slide deck um that you can have access to after just for some tips and tricks. Um. So this was sort of the survey, um, and so I tried to hit most of this, um, and I'll just move ahead. So, um, for heavy, 00. Lost it. For heavy menstrual bleeding, I think the first thing is to, um, I just would tip, set the expectation with the family. I think when, and most of you are probably seeing like the immature hypothalamic pituitary axis patients, yours are 1011, 12 year olds who are having bleeding, prolonged or heavy. And I have a lot of anxiety about it. So I'd like to just set the expectation of what we expect as far as bleeding because many times I find that the family expects a pill to start in, in a day or two total bleeding cessation. And so I'd like to set the expectation that complete cessation of bleeding isn't necessarily the expectation, but the cessation of any hemorrhage or bleeding that's heavy enough to cause anemia. But with hormonal imbalance, especially in the younger patients, uh, bleeding that is sort of prolonged or light can be part of the treatment. Process. And so that tends, in my experience, to alleviate a lot of the anxiety associated with those expectations that they come to the doctor, they've been bleeding for 3 weeks, and now you've given them a prescription and within 3 days they expect the total bleeding to stop. So I try to give them parameters of what bleeding. can be acceptable or not acceptable. So talking a little bit about what pads they're using, keeping a pad count, using something like a pictorial blood assessment chart, which is easily Googleable to sort of tally how much they're using, and then to have just some concrete um information that they can hold on to, to just keep track of indeed the bleeding is slowing down. But then what do you offer them? So, we are making a new protocol for both the emergency rooms in San Francisco and Oakland in combination with adolescent medicine and hematology, as well as the ED physicians to start to avoid this start combination hormonal start and taper. It causes a lot of problems and it might be easier to Avoid it. And so we are trying to promote the elimination of a CHC start for these prolonged bleeders and instead to initiate a tranexemic acid, um, which is 1300 mg. It's two pills three times a day for 5 days with concurrent initiation of norithedrone acetate, 5 mg TID. The benefits of this is you have two systems that are working to slow the bleeding in a very rapid way. The risks of high dose CHCs are not present. They can safely be used together. And norithindone acetate doesn't require a taper. So they'll start the TID dosing and then they can just go down to the 5 mg a day dosing. In order to follow up from there and then either transition to a daily combined or continue on the norithedrine acetate. Um, there have been significant clotting events occurring with the higher dose CHC tapers. It can be difficult for patients to tolerate with nausea and vomiting. The instructions sometimes get, uh, are unclear or confusing. So the use of initiation with the tranexamic acid has been really effective. It's a very safe medication. Um, if a patient can't take the larger pills, they can crush, and this is an off-label use, 1 tablet and 1 teaspoon of water and mix it with whatever chocolate syrup, pudding, whatever applesauce, um, to get those medications down. It's a bit of a humbug that they have to take it 3 times a day, but it's only for 5 days total. And with the concurrent use of norithindrone acetate, the bleeding control is excellent. Um, And equal to CHC taper with much less risk associated with it. I know you're gonna have millions of questions about this, so I'm just giving you some information that we're trying to promote sort of this newer, safer, easier to use um regimen for cessation of this irregular bleeding. So when we send somebody to the hospital or what do we consider typically abnormal. So I try to um educate patients regarding 7 to 1. So bleeding longer than 7 days is considered unusual and extended. Soaking through a pad or a tampon, um, there's a typo, um, 1 in an hour for more than 2 hours or passing any blood clots larger than 1 inch, so a quarter or a great size. So that extended heavy menstrual bleeding. If that's a regular bleed for them, it is concerning for a bleeding disorder. If this is prolonged greater than 7 days, then it can be um indicative of either bleeding disorder or immature hypothalamic pituitary ovarian axis bleeding, which is definitely the most common thing that most people will see in a pediatric pros um Practice. If they're otherwise hypertensive or otherwise symptomatic, we'd recommend an ED visit. Um, if they're having sudden onset with severe heavy menstrual bleeding, we'd recommend a referral to the emergency room. Um, of course, if they have a positive pregnancy test, that's also, um, with bleeding and pain, recommended evaluation urgently. Um, and any family history or other symptoms indicative of a bleeding disorder, disorder, and then menarche, which can often be associated with significant heavy bleeding. So that's sort of joint bleeding, heavy bruising or bleeding, chronic epistaxis complications, surgical complications of bleeding in the past, um, and, um, any sort of dental associated heavy bleeding, as well as a family history. Let's see. As far as outpatient management, I kinda jumped the gun and gave the um tranexemic acid. This is a little bit more detail of how to use it. Both medications are administered orally, have very low risk profiles, um, and no transition from the TID dosing of the norithedrone to the daily dosing is required. You can go directly to the 5 mg dosing, and it's a really easy regimen. The instructions are easy to follow. Um, 3 times a day dosing, drop to 5 mg of norithindrone after 5 days, and it's a very effective, um, regimen. Before I move past this, I've just put some risks associated with it and the combined. Conjugated equine estrogen, which is what we were all taught for urgent bleeding in the ED setting, does have some risk associated. But the main point is, is there's no benefit to using that or a CHC um taper over the norithendrone and traneximic acid. And so, high-dose CHCs do pose risks, thromboembolic risks. We have seen a couple of vaginal venous thrombosis, which are devastating complications. Um, With both high-dose equine estrogens as well as the CHC taper. So norithinone acetate is not associated with these risks in the same way. There's a slightly increased risk, but certainly not to the same degree. Um, and it's an excellent effective, um, progestin. Um, there is some conversion to estrogen activity, so about 5 mg of norithindrone acetate is roughly equivalent to about 4 mcg of ethanyl estradiol. So even at a TID dosing, you're very low in your thrombogenic, um, hormone. Um, before we move on, there was a lot of ovovaginitis questions. Would this be a good time to just take any questions about this, or do you wanna just review it kind of towards The end Doctor Burgerton, we'll just, um, reserve the questions towards the end. OK. Um, so there were a lot of questions on, um, vulvovaginitis, and I think for me, I always break it down to prepubertal or postpubertal. So I kinda made this table, um, I think it hinges on estrogenization of the vulva and what you're gonna see. So in the prepubertal patient, essentially this is just skin, it's low estrogen, it's thin, it's opaque, um, it's susceptible to different sort of types of bacteria and infection than um um postpubertal estrogenized vulva and vagina. So pH is different, um, the nature of the tissue is different, and the anatomy has changed a little bit as well. But I think the key is the microbiome really diff is different between a prepubertal vulva and vagina and a postpubertal one. And that's sort of what makes the person susceptible to one thing type of infection versus another. For prepubertal, um, and I'll go through. And so this is the same vulva actually 6 years apart. Um, and you can kind of see the thin, opaque, um, small labia minora compared to like the well-estrogenized thicker and roidal tissue. Um, and that's just indicative of how the structure actually changes with the onset of reproductive hormone, um, and changes sort of the susceptibility to infection. So in the adolescence, or postmenarchal, um, presentation symptoms are generally sort of abnormal vaginal discharge, odor, itching, irritation, or burning. A complete um history, exposure, sexual exposure is important to sort of differentiating what tests, but most commonly, you're gonna see things like bacterial vaginosis, vulvovaginal candidiasis, and in sexually active teens, more commonly things like trichomoniasis and STIs like gonorrhea and chlamydia. Um, You can do microscopy in the office. You can send an E swab. Um, of course, there's NAT testing that you can do via urine, both for the trichomoniasis and the gonorrhea and chlamydia. In resistant infections, you can also send cultures. Um, sometimes on an exam, you can see sort of the, um, The pink discoloration and fissuring that it can occur with candidiasis, and it can be just sort of a quick diagnosis for that. Bacterial vaginosis has kind of gone back and forth. Is it an STI? Is it not an STI? It's definitely sort of much more common in sexually active people and so it's sort of umbrella under the STI group of infections, whereas candidiasis isn't necessarily considered an STI related infection. Management for bacterial vaginosis, pretty easy. Just the Flagyl, um, which is taken for 7 days. Um, candidiasis, Diflucan, I always give them a refill and give them recommendations. So if they take the 150 mg of Diflucan uh initially and they're not better within 2 to 3 days, I'll have them repeat up to 3 doses. If they have a lot of external itching, irritation, fissuring, and I also will give them some topical, um, like triamcinolone nystatin. And topical just for relief of their symptoms. For trichomoniasis, it's fragile as well. Um, and then I always just educate them if their symptoms are not better within a week or so of completing treatment that they should come back for further evaluation. Um, there are candida, um, that are resistant to some of the, um, azoles, um, and then that culture would be indicated, which, um, you can do with an E swab at that time. Um, as far as supportive, also just evaluating for things that are irritating like their pads, frequency of pad changes, are they changing underwear and bathing suits or leotards for long periods of time, just to help prevent recurrence. Um, you know, just a gen review of sort of how they're cleansing, if they are deep into the like highly scented body washes and soaking baths and bath bombs, they can be pretty irritating which can predispose to um infection as well. Um, for teens who are on birth control, they can over time develop sort of an atrophic picture where they have sort of a thinning hypoestrogenic vulva, um, which can be sort of a chronic symptom of itching and irritation. So just inquiring about that, sort of your older teens who've been on like a birth control pill for 34 years. Um, sometimes that can present, um, as like this chronic vulvar itching and irritation. Um, the Depo-Provera too, really hypoestrogenic, and they can really develop those symptoms within a year or so of using the Depo-Provera. Um, lichen sclerosis is also um very commonly diagnosed, um, in these chronic irritated vulva itching that don't seem to be responding to medications. Um, so I would say that if the first round of medications doesn't seem to be, um, uh, uh, successful and they are having persistent symptoms, that would be another, um, appropriate referral probably to gynecology for further evaluation. As far as prepubertal, um, by far and away, hygiene is the number one cause that, in my experience for vulvovaginal symptoms. Um, so topical irritants, um, you know, uh, poor hygiene, um, and urine trapping is actually really quite common. So especially in the, you know, just learning to toilet type patient who is sort of dangling on the toilet, watching their iPad, not really paying attention, chronic constipation. And they have this sort of chronic vaginal voiding, um, where the urine sort of goes back and pools into the vagina and cause pretty Um, significant irritation of the vulva and enteroitis, really beefy red and irritated. The second kind of most common thing that I'll see is sort of the, the nose to vulva infections, often like a strep infection which can look so red and irritated and be really painful for the children. And so, um, after an exam and if I can get some cultures done, just mostly of the external and sometimes I can gently kind of get an E swab in to the enteroitis depending kind of how irritated the patient is at the time, um, I will treat whatever grows. Um, if not, we have a lot of discussion about hygiene. Um, if concern for sort of purulent or prolonged prolific discharge, foreign bodies is always on the list. Um, Pinworms of itching, and we can, we talk sometimes about the Scotch tape test or just impaired treatment with mebendazole. And um of course, lichen sclerosis also presents pretty commonly in the prepubertal patient. Um, so first line for vulva vaginitis for me is just a pretty long, um, History of their sort of genital hygiene, bath, soaps, all of that. And then potential avoiding of irritants, um, encourage of like no underwear at night or loose-fitting clothing at night. Um, constipation is always a, a pretty big contributor to some of this. And talking about that, sometimes it's baths depending, so that's where um they can sit in the bath with like lukewarm water and have the drain open and just let the bath water run consistently instead of Sort of soaking in the bath. Um, barrier creams, uh, really helpful. Um, so Aquaphor, Vaseline, coconut oil, um, diaper creams can all be really helpful in sort of putting a barrier between whatever is irritating them and um can allow for pretty rapid healing. Um, generally, I would say 6 out of 10. This is what we discuss. I give them the tips. They try it for a couple of weeks, they come back and they're better. Um, If the culture's positive, I will call them and usually initiate something like amoxicillin. Um, if they're not better and the kind of acute redness has resolved, but they're still sort of itching or having pain, then we start, then I generally start thinking about things like lichen sclerosis, which is um much more common and I think easily missed. Um, and so I'll give them a trial of steroid and have them back. And if they And then go from there. So targeted therapy education is generally how I will manage the prepubertal patients for their vulvovaginal complaints. There's a lot on PCOS. Um, PCOS diagnosis in an adolescent is different than PCOS, um, diagnosis in an adult. Um, so because menstrual irregularity is so common in the younger patients, um, they need to have been postmenarchal by at least 2 years. You'll see 1 to 2 years, but I give them a hard stop at 2, just most, mostly because irregular periods for the 1st 2, even 3 years are not uncommon. Um, by year 3, most people have normalized, so 95% of people will have regular cycles by year 3. So in year 2 to 3, if they really haven't normalized at all, that's sort of the time when I start considering other diagnoses and evaluation. And the other thing, it's so common to have elevated DHES in the early pubertal stages. Um, it's difficult to call high testosterone levels when they can be fluctuating. So I don't like to call it until they're at least 2 years postmenarchal and it's just, it's not just me. Those are the, the recommended guidelines as well. The other thing, pelvic ultrasound is not required for a diagnosis for adolescence. And the reason being, all really polycystic ovaries are, are those preanteral follicles that are just trapped under the ovarian cortex because they haven't had the signal to release. And so really, that's all we're seeing is just normal follicles and not released. And in a young patient, they have so many follicles anyways. It can often be an overcall on the ultrasound that they have polycystic appearing ovaries on the ultrasound when they really just have young ovaries that are full of follicles, which is expected. So an ultrasound, we don't use that as part of the diagnosis for PCOS in young people. They have a big table sort of adult versus adolescent, but menstrual irregularity, hyperandrogenism must be present. So they're having persistent acne, hirsutism, um, acanthosism and hyperandrogenism specifically, but I certainly note that on their exam, um, for insulin resistance. Again, we discussed ovarian morphology and ultrasound is not diagnostic. Um, And then the differential, so physiologic pubertal um changes is high. Hypothyroidism, so TSH is always part of the evaluation. For irregular periods, hyperprolactinemia or prolactinoma is on the list. Um, Uh, adult-onset congenital adrenal hyperplasia. So your 17 OHP is gonna help rule that out. Um, and exogenous-induced androgen excess. They have a boyfriend who's using hormones or they read something on the internet that they're supposed to use these supplements to like make gains in the gym or whatever. That's actually not uncommon. Um, that they're taking something purchased in the TikTok shop or wherever that's supposed to kinda help them do whatever. So I always try to ask about supplements as well. Cushing, relatively rare, but certainly in the larger individuals with Uh, ankyanthosis or buffalo hump or, you know, uh, that's always something to think about. And those people generally make sure that endocrine sees and does the evaluation and the dexamethasone suppression test. Androgen-secreting tumors are relatively rare in younger patients, but sudden onset, hirsutism, voice changes, clitoromegaly, those types of things certainly um alert for that as well as very high levels of total testosterone. Um As far as management, so PCOS number one, we have very long discussions about lifestyle modification, which I think given our current epidemic of obesity is probably the majority of everybody's annual visit. But lifestyle, we talk about it, um, and I usually see them back every few months to continue to reinforce those messages. Um, Combine oral contraceptives or hormonal contraceptives in general for menstrual irregularity, increasing sex hormone binding globulin and lowering their circulating testosterone levels are really helpful. If they have elevated insulin or significant insulin resistance, we also talk about initiation of metformin. And then sometimes I'll also add spironolactone. Um, There's been some stuff about spironolactone augmenting sort of or harming bone health. Nothing concrete yet, but it's just something that I keep in the back of my mind about spironolactone, but especially for the kids whose acne is just out of control and the pills are not helping enough, adding spironolactone can really be very helpful. Um, so here's sort of a overall, um, chart that will be at your disposal, um, just how we make the criteria a little bit different. But there was a few questions about adult versus adolescent, so I just kind of made up this little table to, to review. Um, as far as testing, these are the testings that's recommended, um, and that I will do when I test them. So, um, I try to get them on cycle or after I withdrawal bleed to just do a reset if I can. If I do random testing, um, the, I usually have them do it fasting before 9 a.m. since prolactin can be abnormal, um, throughout the day just because it's um it can fluctuate especially with stressors. Um, so usually, um, depending on sort of their habitus and their risks and their symptoms, we'll either at the onset do the hormonal panel plus things like fasting glucose, insulin, and perhaps the hemoglobin A1C. Um, I don't do the 75 g oral glucose tolerance test except in patients who have, um, a borderline elevated hemoglobin A1C, but it's a really difficult test for especially teens and families to do. Um, so often I'll just initiate metformin and have them see endocrine. Um, and then I will also do a fasting lipid panel for baseline, um, and repeat that every 1 to 2 years depending. All right. Um, some questions on IUDs. I'll just let you know my practice. I offer all patients a milligram of Ativan to take 30 minutes to an hour prior to their procedure, 6 to 800 mg of ibuprofen, and do a cervical block for all patients, um, which involves 10 cc's of 1% lidocaine, um, that's, um, administered at the time. Um. All teens are eligible for all IUDs. Um, there is no restriction based on their nullliparity or age. And so generally we just counsel based on their goals. So is it primarily contraceptive or is it menstrual management primarily? Do they wanna go hormonal-free, which seems to be trending right now. Um, and the only caution with the copper IUD is it doesn't connote the um protection for potential PID that the hormonal ones do. The hormonal ones initiate after about two weeks of placement, um, a progestin plug at the cervix which decreases their likelihood of PID, um, after the first Generally about 2 weeks, 2 to 3 weeks. Um, whereas the copper IUD doesn't induce any hormonal changes. So, um, They do have sort of a higher risk of infection if they get infected with their sexual practices. And the only other thing with copper is they may experience prolonged or heavier bleeding and cramping, especially within the 1st 6 months of placement. So making sure they're very clear on that and understand what that is and giving them strict precautions about it. Um, is an important part of counseling. Here is um all the uh diagram of uh or chart of all the IUDs currently available and the years that they are effective. Um, so the ParaGard is good for up to 12 years. Um, Lileta and Mirena are good for contraception up to 8 years. If we're doing it for Bleeding control, generally, the dose starts to decrease between years 3 and 5, and sometimes bleeding control isn't as good, and so we will replace it sooner. That's for my Von Willebrand's patients, the gender patients who opted for an IUD who really have a goal of amenorrhea. Kleena can lighten menstrual cycles, but it's mostly used for a contraceptive benefit that is extended, and the Skyla doesn't really provide any bleeding management. It's such a low dose. OK. Let's see what's our timing. Um, so as far as troubleshooting patients who are on combined hormonal contraceptives, so one of the things that I noticed quite Frequently, patients are often underdosed. So are given 10 or 20 mcg pills, which aren't recommended at this time. So 30 to 35 mcg pills um are suppressive for granulosis cell development and ovarian cysts, um, and also provide better bone support. So for all adolescent patients, I will offer them a 30 mcg pill. Generally, we'll also offer them a pill with a second-generation progestin. They're the least thrombogenic, um, and very well tolerated. Um, Levoniestrol can be more commonly associated with, um, Unscheduled or irregular bleeding. Um, and in higher doses like in an IUD about 10% will have, um, Get some acne associated with it. So if acne is something that's really bothering a patient, I definitely won't offer them a pill with Levonigestrel. Um, something with norithindrone is probably my first choice for them. And there are, the third generations are probably a little bit better for acne per se. Um, so for atypical uterine bleeding, generally 30 to 35 mcg pill with the second generation progestin, same for ovarian cysts, same for menstrual pain. Um, they're more likely to stabilize the endometrium, so unscheduled bleeding is less likely, um, more so with lemonadestrel than norithindrone, um, and always a monophasic. There's just not a reason to use a triphasic pill. Um, I don't know why multiphasic formulations. are even used. And I think people try to mimic a normal menstrual cycle, but troubleshooting on a multiphasic formulation is a nightmare. So if I see somebody with that on a multiphasic, the first thing I'm gonna do is just switch them to a monophasic pill. Um, extended cycle, a lot of times people have breakthrough or irregular bleeding, unscheduled bleeding on the extended cycles. I generally have them get through 12, or 3 packs just normally with regular menstrual bleed after the 3 weeks. And then once they've sort of adequately thinned their endometrium, And um suppress sort of that granulosa cell activity in the ovaries, then I'll have them start to extend their cycle. If they've been on extended cycling for quite some time, they can take a shorter break with just a 5-day break every 12 weeks or so, and that's generally enough to um Stop their unscheduled bleeding. So avoidance of ultra low dose pills, significant complications of breakthrough bleeding. These are really best suited for your 40 year old woman, your, um, that's sort of the ideal candidate for a 10 mcg pill. Um. I think I've kinda gone through all of that. Um, also consider transdermal patch and ring. Transdermal patch is higher estro Like a higher estrogen dose than the ring or the pills and has a progressively increasing um dose, but for the younger, especially HPO bleeders, um, the patch works really great. It's a weekly change, easy for parents to help. It's consistent dosing, they don't forget. Unscheduled bleeding is really uncommon. And so especially for the younger kids, a short course of the patch works really nicely. Um, vaginal ring, kind of the leading questions if they don't use, um, Tampons, they're unlikely to use a vaginal ring. So it just, that's kind of one of my like weeding weeder questions is are you using tampons or a menstrual cup? Um, would you feel comfortable placing a ring? But that's really nice too. It's left in place for 3 weeks. They take it out for a We. You can also use continuously. Um, so if they're going to camp or going away and they wanna leave it in for 4 weeks, you can use that as well. It avoids first-pass metabolism of the liver. So if people are nauseated, it's also a really nice option. Um, and it's really nice consistent dosing that you cannot forget. So it really helps with some of the unscheduled bleeding and um Issues that people have when they're taking the pills. Um, I mentioned the bone health already. So, monophasic, 30 mcg, second-generation progestin um for continuous or extended, give them a little time before you start the extended regimen. Um, And this is a first-line therapy for atypical uterine bleeding that's been evaluated, ovarian cysts, dysmenorrhea, and it's the safest combo for bone health. Um, OK. I kind of address the atypical bleeding associated with the CHCs, but for general atypical bleeding, um, usually assessment will include things like CBC, a ferritin level, always a pregnancy test, TSH, and prolactin with based on history, we'll do a bleeding workup depending if their atypical uterine bleeding is in, um, Are they skipping periods or they're having heavy, heavy, heavy periods? So that's gonna be based on your menstrual um history at the beginning. Um, and also on your evaluation, are they showing signs of hyperandrogenism? Is this somebody you're gonna think about for PCOS? Um, so to initiate the workup, um, then follow up the workup and review results to make recommendations. Um, if treatment remains refractory and they continue to have atypical bleeding, that might be a good time to refer to gynecology, um, or refer from the beginning if it's easier to do a workup then. Um, and if they're having complications or intolerance with interventions, then you can, um, refer to gynecology at that time. Um, I think we've gone through this a little bit, the unscheduled bleeding on hormonal therapy. Um, so the five-day break is a really good trick. Um, You can also try a course, short course of NSAIDs which can help with the kind of vascular irritability and bleeding that can be associated with um unscheduled bleeding on hormonal management. has also been shown. I hardly ever need either of those. The five-day break really works great. Um, sometimes, um, I'll do 5-day break with the tranexamilic acid during that time too if they've had heavier unscheduled bleeding. And then just really getting a history if they're taking it on time, um, and considering alternatives like the patch or the ring unless they're interested in something like the Nexamilon or the IUD. Um, and then you can refer to gynecology for that. Um, Good. So should we start thinking about doing questions? Should I keep going? It's 1:05 right now. Um How many more slides do you have, doctor? Um, a lot. I mean, this is just first UN visit recommended between 13 to 15. I think I have like 35 slides, but we don't have to go through all of them. Um. We have about 10 questions in the chat or, or in the Q&A, excuse me. So maybe we should start um wrapping it up. Um, I wanted to do just a couple of things as far as somebody had asked about STI screening. When I have a patient come in, every single person leaves a urine to not arouse suspicions or during their private visit if they are wanting STI screening or a a pregnancy test. We already have the urine, they don't have to go out. Their parents aren't aware of it, and we just say that's our routine practice. So that's how we sort of handle STI screening in our, in my practice. Um, there's a lot on dysmenorrhea, but there's some slides on that. And there was one thing I just wanted to point out. So labial adhesions, no more estrogen. Estrogen, no. So conservative management with traction and emollients is the first line recommendation unless a patient is symptomatic. With regular pain or urinary retention or UTIs. Other than that, just topical emollient and teaching the parents about good hygiene and traction is all we recommend. It's because if you're gonna do estrogen cream, it will never be a permanent fix, especially if you're trying to treat like an 18 month old. They will have recurrent labial adhesions until they start having their own endogenous estrogen, and it just doesn't make sense to continue to treat them with estrogen. And I know we were all taught that, but there's some pretty good evidence now that just the conservative management with education and some traction, um, with emollient barrier protection and avoidance of irritants works just great. OK, let's go to questions. OK. Yes, there's about 11 questions. Um, I can read them to you, Dr. Burger Chen. Is there somewhere that I can see them or no? Um, you can definitely go in the Q&A if you want to read them on your own, but there's a couple questions in the chat or in the Q&A regarding, um, brands of OCPs that you would recommend. Is there a particular brand that you prefer? For teenagers? Um, it, uh, a brand, not necessarily, but I usually just, um, Loestrin is a great family. It has the norithenrone and they have both a 30 and a 35 mcg with 1.5 mg. So I usually use a 30. microgram ethenyl estradiol with a 1.5 mg norithindrone and then I modify based on what the symptoms they're having. So if they're, um, and that's a whole another discussion, but that's what I generally will start with. Um, my other ones I use depending sort of PMDD type symptoms or even some PCOSers, I'll use the Yasmine or drospirinone. Um, and then if they want a progestin-only or would benefit from progestin-only, my first choice at this point would be um slind, which is risperone only, which is 4 mg and it's really excellent, super well-tolerated. The only humbug with that one is it's not covered by all insurance necessarily cause it's brand only, but it works great. And then there's also the old pill that's available over the counter which is also a progestin only. Great. Um, uh, in relation to that, what COCP is recommended for PCOS? Uh, Yaz has anti-androgen effects, but it's 20 mcg 20 mcg. Yasmine is 30. Um, it actually hasn't borne out to be any more significant than any other type. I mean, we can choose it, but low estrogen is just fine. They're all gonna increase the sex hormone binding globulin, which will pull the testosterone out of the system. And if they really need extra testosterone, you can add some like 25 of spironolactone or even up to 50 of spironolactone, which is much more than the drispirone is in the Yasmine. OK. Or try the splint, which is the 4 mg of risperidone. All righty. You mentioned the preferred progesterone for acne. What about estrogen dose? Does it matter if it is 25 mcg versus 30? Do you ever use 25 mcg pills, or should we always use 30 or more for bone health? Current data supports 30, especially for bone health. So for all my young patients, I start with a 30. If they're having nausea and other issues, I will switch it around. Nausea is really dependent on estrogen dose, it seems like. Um, for acne, it's more the Combination. It's not necessarily the estrogen dose that's helpful. Um, so I choose a 30 for them and I can, you can always add in spironolactone and that combination works really great for a lot of patients. OK. What's the best progesterone for hirsutism? Um, I, I don't know if there's a progestin per se for hirsutism. Levoniestrel is very testosterone acting. So, I mean, in, in terms of hirsutism, I would choose spironolactone to treat, which is a testosterone blocker. Um, you can also use Vanica, like, it's effluorinehane or something, which is a topical cream, especially for the face, um, but it needs to be used daily forever. Um, and I also like to counsel for hirsutism that if any, for example, if they have heavy hair growth on the upper lip, Any treatment is not going to take that away. What has changed is changed. So what it does is slow the return. So let's say somebody's shaving every day. With treatment, there'll be um longer time period between the frequency of debilitation that's required and less um The hair will, um, there'll be less hair growth over time as far as like it won't continue the process. But what's there is there and so setting that expectation and explaining that, um, is generally helpful. I mean, it seems to be helpful that they are understanding that as a concept. Great. Um, does Mirena always cause amenorrhea? No. Amenorrhea is expected in 50% of people by 12 months and within the second year is 60%. OK. Can we empirically test or or treat for bacterial vaginosis based on symptoms without testing if not available? Uh, I mean, to give somebody Flagyl if you're sure they don't have like gonorrhea or chlamydia or anything, if you wanna do an impaired treatment of the 500 mg of Flagyl, certainly you could try. Um, Often, I just find that young patients are not the best historians and then they aren't better because we treated them for yeast or BV and um that's not indeed what they had, but there's, I don't think any empiric harm to it. OK. Please review why or for whom you would advise use of Depo. I am not a fan of Depo in general. I think I, I would use Depo in somebody who didn't want any other contraceptive and was at, at high risk for a pregnancy. That's, it's a good contraceptive. And I think the dangers of pregnancy are much greater than any medication that we can give. So that's the Primary patient I would use it in who doesn't want pills, doesn't want a patch, can't, you know, doesn't want anything, can't be compliant and is a sexually active person, but who will accept Depo, that's who I would use it in. OK. Um, for high dose CHC and taper, are you referring to the 4321 containing 30 mcg ethanol? OK. That's the high dose taper. Um, what is the best way to postpone periods in a teen if requested for travel or exams, etc. Well, if they show up right before and want to postpone it, that's hard. So planning ahead is helpful. Um, it also depends where they are in their cycle. So if you start them with a cycle, you're more likely to suppress the next one. and generally, they'll have more success if they've been on the method. For a longer period of time. Um, so I don't make any promises that they come, you know, and see me two weeks before they're gonna go on vacation or go to camp. I will offer it to them but also set their expectations that it may not be effective. You could try. Um, putting them on something like norithendrone acetate if they're not sexually active. 5 mg is really effective, about 75% achieve amenorrhea on that. Um, and then for any breakthrough, they could do tranexemic acid, but, um, the hard part of that is they need to know longer than a week or two before they want suppression, um, to really get uh the promised effect. OK. Um, another question, do you discuss why abstinence is the best choice and how would you present facts and truths in the motivational interview? Um, I don't recommend any particular choice or, and I don't often, I see a lot of sort of complex medical management. I don't see a lot of just sort of healthy teens for contraceptive counseling. Um, often they will be seeing adolescent medicine, but, um, I don't counsel, you know, if somebody's seeing me for contraception, I don't always counsel regarding abstinence. I try to, I mean, If they're asking me for contraception, I don't sort of backpedal to abstinence. I mean, it certainly can be part of an annual exam, but I think by the time they get to gynecologist, we sort of have passed go on that. Um, and I, and I very rarely am counseling people just for Like if I see a healthy teen without 4 medical problems, it's a pleasant surprise for me, but I, I don't, I often offer in the general range, all the choices that they have available, barrier, abstinence, all of that is generally what we will counsel on. OK. Um, it is hurtful if teens just want to have OCP active pills without break and for more than 6 months. Is it, I'm sorry, I didn't understand. Is it hurtful if teens just want to have OCP, active pills without a break, and, um, for more than 6 months? I think for more than 6 months. I mean, the only reason the placebo pills were built in was to um eliminate unscheduled. Scheduled bleeding complications. So if a patient can get 6 months out of it and their insurance will get them that many pill packs, it's not harmful to them at all. But unscheduled bleeding for prolonged extended use is just the most common complication. It's not dangerous inherently so. Um there's no real Inherent danger to skipping the placebo pills. It's mostly inconvenience with the unscheduled bleeding. OK. Um, another question, if recurrent bacterial vaginitis and candida vaginitis, would you also go ahead and treat their male partner? That's an interesting question. Um, for bacterial vaginosis, um, not necessarily, but I do talk to them a little bit about their partner and their sexual practices. I mean, we usually try to get, I get some of that during their sexual history too. Um, so if they're participating in frequent oral sex, if they have multiple partners, if their partners circumcised, um, Diet and constipation can also play a pretty big role in their vaginal biome. So I try to kinda talk through why they might be having that. Um, but I don't always treat their partner inherently. I have, um, especially for recurrent candidiasis in an uncircumcised patient. Um, the partner was uncircumcised. Um, So, generally, I try to sort of figure out in general what's the risk factors um before I just jump to treating the partner alone. And I also welcome their partner to the office if they wanna come in and sort of hear about it. Um, but I find that oral sex plays a pretty large role in the recurrent infections. Um, so we talk a little bit about that and oral hygiene and things like that. And so that has been effective, um, for some of the patients with recurrent symptoms. OK. Um, how should we think about, um, forgive my pronunciation, drosperidone versus, uh, noroethedrone. So drospirin is a 4th-generation progestin. It is formulated a little different than norothedrone, which is a 2nd generation. Um, and drospirinone is formulated similar to Aldactone, so a mineral corticoid, um, versus norothedrone, which is sort of based off The testosterone molecule. Um, and they have different sort of activities, but I don't think getting caught up in it too much. It's just, um, risperidone can be really helpful for some, um, people who are androgen dominant. Um, and now they have the risperidone-only pill which is just been so great with very little side effects. Um, and the northindrine is just really a nicely balanced progestin, so it offers really good endometrial stabilization, so it avoids a lot of the um Irregularities and complications of some of the other combined hormonal contraceptives. Right. If a parent is really resistant to hormone therapy for their teen to stop menorrhagia, would it be OK to stop bleeding with uh examic acid alone? That is like my favorite trick. Um, so tranex acid. And then the other thing is, um, there's a very fine line between sort of Taking a birth control pill, which is emotionally difficult for a lot of parents, and then offering them northanurin acetate or Aegistin, which is non-contraceptive hormonal medication. Sometimes pairing those two things out, especially since northanurin acetate is really effective at supporting menstrual control, um, is a really nice way to traverse that concern. There's a lot of sort of emotional overlay about using birth control, especially in younger patients. So traneximic acid, great. And then the northendrone acetate 5 mg is also really great too, especially since it's not a contraceptive. OK. Um, I know you were about to talk about this, but what do you tell parents as the reason for their first dying visit to be at 13, between 13 to 15 years? I usually tell them 21 years since, uh, that is when their first Pap smear will be. Right, 21 years old is the first Pap smear. So, um, there's a big push, especially for pediatric gynecologists, to Get patients in sooner rather than later. One example is the delayed diagnosis for endometriosis, and we didn't really get a chance to talk about dysmenorrhea. The average time for delayed diagnosis of endometriosis is 7 years. So 7 years of missed school, missed activities. Um, and so getting somebody in earlier um to discuss sort of menstrual concerns. Anticipatory guidance, expectations can be really helpful and to demystify what it means to go to the gynecologist. Often it's the only opportunity a lot of kids have to talk about their sexual health, their gender concerns, and there's just so much to do at their annual pediatric visit. It's kind of nice to just have that opportunity to talk and Um, we'll see the patient by themselves first and then we invite the parent in who also often has an agenda and some questions that they like to review. But so many times, I pick up patients who have like just unacceptable levels of pain, heavy bleeding, or having trouble with their menstrual hygiene in general. Um, and so that's kind of the nice thing about getting them early that we sort of pick up some of those things and it's just I can't imagine doing all those things as a pediatrician for every single visit. There's just so many things. Um, so it's nice to take that burden off. Great. Um, lastly, if you can go over briefly the difference between monophasic, biphasic, and triphasic contraceptive pills, in what condition should we consider each of them? Um, I would consider nothing but monophasic. Um, monophasic is just one dose for the 3 weeks. That's it. The other ones vary either the progestin or the estrogen. They were marketed at some point to help better with like sort of mood. If people had progestin sensitive mood, have never been shown to actually be effective for that. There were some that were um for menstrual-related migraines were recommended. So they were sort of marketed. For these things but haven't borne out to actually be helpful. So I don't really know any gynecologist who doesn't just choose a monophasic pill. So that's a single dose of progestin for all 3 weeks, um, and a single dose of um ethenyl estradiol. Great. Um, one more question popped in the chat. Hopefully you have time, Doctor Chen. I know you have to hop on to the clinic, but which is better for acne, um, norethidone or norjustamet? Norgestamib is a 3rd generation which is shown to be better for acne for sure. Um, and it's, if that's the primary reason, so that's sort of your Ortho Tri-Cyclen group of medications. Um, those can be more helpful. They're slightly more thrombogenic than the second generation but not significantly so in otherwise young, healthy, non-smoking patients. Um, so the primary reason for taking a pill is that, um, Totally fine to use it. I think um being super specific is mostly when you're trying to actually treat something versus just somebody who needs a contraceptive or somebody who, um, you know, wants a contraceptive that's good also for acne. And so that's where I think being specific really depends on what you're using the medication for. Awesome. Another question um popped up. Do you have any resources you recommend for patients who can't afford tampons or pads, etc. I wish. Um, I don't have any right now. Um, menstrual poverty is a really big problem. Um, Uh, yeah, I mean, the state was supposed to supply public schools, but I don't know what happened with that, but I don't, I'm sorry. No worries. Well, that completes all the Q&A, um, and we thank everyone who participated in the survey and for attending our session today, and hopefully we can, um, see you guys on the 29th. Thank you.
