It’s worth telling your daughter: you have a vagina. Health requires breaking taboos
Magdalena Warchala-Kopeć: Gynaecological prophylaxis in girls is still a taboo subject. Parents do not talk to their daughters about “this stuff”, they often don’t even know that something disturbing is happening because the daughter is ashamed to tell them.
Prof. Agnieszka Drosdzol-Cop. PhD, MD: Parents should talk openly about sexuality with the child from the very beginning, whether it is a boy or a girl. First of all, about the structure of the genital organs, which should be named according to the nomenclature. Even to a six-year-old child, you should say directly: “You have a penis”, “you have a vagina”. Parents should work on children’s trust, be open to their questions. Children should not feel that there are taboos that they cannot discuss with their parents. Of course, the scope of the conversations should be adjusted to the child’s level of development. I have a ten-year-old son and I answer all his questions. I can see when his curiosity is satisfied and no further continuation of the topic is needed for the moment. On the other hand, I know children at his age who are more interested in the subject. That is why it is important that the child receives the amount of knowledge they need from the parents and they do not have to supplement it by browsing the Internet.
When should you take your daughter to a gynaecologist for the first time? Many parents only think about this when their daughter shows some disturbing symptoms.
Back in the days of my adolescence, my first visit felt shameful. It was believed that if a girl visited a gynaecologist, she was probably pregnant. Nowadays, doctors are of the opinion that the first visit should take place when the girl has her first period. The purpose of the visit should not be to do examinations, but to educate. This is an opportunity to talk to your doctor about what your menstrual cycle is and how your days should be counted. Even adult women often have a problem with this. During the first visit, the doctor will explain how to take care of hygiene during menstruation, and the young patient will have the opportunity to get used to the office.
So there is no need for a preventive examination?
If nothing disturbing is happening, there is no need for a vaginal examination. However, you can ask for an ultrasound scan at your first visit. This examination is performed through the abdominal wall with a tightly full bladder. It is worth doing it, for example, in the case of, say, a 14-year-old girl who does not menstruate yet. Thanks to the examination, we will find out at what stage of gynaecological development the child is, whether she can expect her first menstruation within six months, or whether the ovaries do not secrete oestrogens yet or secrete them in small quantities, and there is still a lot of time until the first menstruation.
How can you prepare a girl for the first visit to the gynaecologist?
A mum can take her daughter to her own doctor, tell her that this is a specialist she trusts. However, if the parent herself does not know how the visit will go because, for example, as a child she did not see a gynaecologist, it is better not to go into details. I’ve had many young patients who, after the visit, confess to me that they were terribly afraid after what they had heard from their mother earlier. It is enough for a parent to tell their daughter before the visit that the doctor (in the case of a young patient it seems more comfortable to me when it is a female doctor) will not hurt her or do anything that she herself will not allow. In the case of patients who have not yet had intercourse, and for whom it is necessary to undergo a full gynaecological examination with specula insertion, this examination is performed under general anaesthesia in a hospital so as not to expose the child to trauma. Sometimes the hymen is ring-shaped and flexible enough to use a virgin speculum. I sometimes use ENT specula that are generally used for the nose. It is important for the girl to trust the doctor.
When is a visit to the gynaecologist indisputably necessary? What symptoms should worry the child and the parent?
Again, I would like to emphasise how important it is to break the taboo. Parents should encourage their children to view their genitals. It’s easier for boys, but girls should also do it. If a girl notices any change, a rash, discoloration or whitening on the labia, she should report it to the parent. In the case of a small child, the parent should pay attention to whether there is any discharge on the underwear, whether the child is scratching, has no problems urinating. An older child should alert the parent to this. The parent should make sure that the child’s entire body is inspected by a paediatrician during periodic check-ups, which take place every two years. In older girls, the cycle should be carefully monitored for regular and heavy periods. Each girl should keep a calendar. These days, applications that help with this are fashionable. It is enough to mark the days of bleeding and the application will count everything else.
What do irregular or too heavy periods refer to?
Not every paediatrician or even gynaecologist knows that regulating the menstrual cycle, starting with the first menstruation, can take up to six years. This is an individual issue. In a teenager, the cycle is normal if the periods are between 21 and 45 days. In a woman of reproductive age, this is already an abnormality. Bleeding should last for 2 to 7 days. If it is longer, or if a girl uses more than 8 tampons or pads a day, the blood loss is too heavy.
What about pain?
Older gynaecologists maintain that if you’re on your period, it must hurt. This is not entirely true. The menstrual cycle may be associated with some pain, but if it is so severe that the girl is unable to go to school during menstruation, experiences nausea, vomiting, or even faints and these symptoms occur in every cycle, then you should look for the causes of the pain. In the past, gynaecologists used to say that everything would pass after having a baby. This is a myth. Typically, in the case of such ailments, you should start with checking whether the girl responds to painkillers. However, this does not mean an over-the-counter pill taken when it hurts, but about appropriate drugs selected by a doctor, taken according to a prescribed schedule. Then, it is checked for three months to see if the symptoms are reduced by hormonal contraception. If both do not work, the adolescent should have a diagnostic laparoscopy to see if there are endometriosis implants in the peritoneum, uterus, or bladder. It has been known for over a dozen years that endometriosis, a disease that was previously considered only a disease of women of reproductive age, also occurs in teenagers. Up to 17 percent of girls in their teens can suffer from it. The youngest patient in whom I diagnosed endometriosis was 12 years old, and her pain started already six months before her first menstruation.
Do parents come to the gynaecologist with their daughters to prepare them for sex, choose contraception for them? Or is that a complete taboo?
More and more mums and underage daughters come to me to choose the best contraception for them. They say that the girl has a boyfriend and is planning to start intercourse or has already started it. I believe that such a joint visit is a very wise, trust-based approach. For the doctor to prescribe contraception before the age of 18, the parent’s consent must be given. When such a consent is obtained, we choose the best method, paying attention to the girl’s health condition, but also to which method will give her additional positive effects beyond contraception, such as a beneficial effect on acne-prone skin.
And what are the most common ailments girls come to the office with?
I would divide them according to the gynaecological age of the child. Pre-pubescent girls are in a period of hormonal silence in which nothing should be happening within the reproductive organs. Recently, however, I have had a case of a four-year-old in whom the paediatrician had failed to diagnose the symptoms of premature puberty in advance. The girl had fully developed breasts, pubic hair and was bleeding from the genital tract – she was just menstruating. My youngest patient with such symptoms was 2.5 years old. When a girl’s body begins to release oestrogen prematurely, which has its receptors in the epiphyses of long bones, the baby’s growth stops. As a result, the girl will never reach the height that was genetically programmed. In this situation, puberty-blocking treatment must be instituted quickly. However, girls with inflammation or gluing of the labia, which consists in joining the labia minora, come to me more often. This happens because during adolescence, a girl’s body does not release oestrogen. As a result of sticking together, urine may be retained. It sounds scary, but the treatment is simple: the girl is given topical oestrogen cream and the labia come apart by themselves. Later, proper care is important: the area around the vulva should be lubricated and washed with an emollient. In older girls, the most common symptoms are related to the menstrual cycle – irregularity, pain. Girls come with menstruation that occurs every 3 months, or menstruation with so-called adolescent bleeding, which may continue without interruption for up to 3 months. In such a situation, treatment must be implemented because without it, curettage of the uterine cavity may be necessary. In the 16 years that I have been dealing with paediatric gynaecology, I have noticed that the problem of menstrual disorders related to eating disorders is growing. There are girls who, due to their body fat content below the necessary 22 percent, do not even get their first periods. I don’t know whether this issue is related to the environment, peers, media, or social media. The eating disorders that affect my patients are not necessarily the most famous ones, such as anorexia or bulimia. There are plenty of them, e.g., orthorexia, which is excessively healthy eating. I also meet girls who play sports, not necessarily professionally. There are many girls who exercise every day, often locked in their rooms so that their parents do not see them. By means of compulsive exercise, they unload and regain a sense of control. Especially now, during the pandemic, the phenomenon is gaining momentum. If menstruation is stopped due to a decrease in the level of adipose tissue, I make a deal with a teenager that within 3 months she will gain 1-2 kg. When I see that the disorders are so severe that there is a need for the intervention of a psychologist or psychiatrist, such treatment has priority.
You are the co-founder of the first children’s and girls’ gynaecology ward in Poland, which has just been established in the hospital of the Order of Bonifraters in Katowice. Was such a place needed?
The proof that we need a specialised place for elective gynaecological surgeries in girls is the fact that patients from all over Poland come to us: from Nowy Targ, Toruń, Warsaw, Kielce, and Poznań. If a gynaecologist from any city gives the patient a referral to us, the girl and her parents come for consultations, which for now take place in the emergency room, but a paediatric gynaecology clinic is already being established for girls who do not require surgical treatment.
What problems do patients come to you with?
Recently, an eight-year-old girl from Rzeszów, who suddenly started bleeding from the genital tract, came to us with the parents. Examination showed a tumour in the vagina. The doctor referred her to our ward and she was operated on. Fortunately, the tumour turned out to be benign. However, such cases are rare. Most often we have girls with cystic changes on the ovaries, which can twist and which is accompanied by severe pain. We also have girls with suspected endometriosis, patients with defects of the reproductive organ, e.g., obstruction of the hymen, or patients referred for vaginoplasty. Sometimes we take samples from the vulva if a girl is suspected of having lichen sclerosus.
Prof. Agnieszka Drosdzol-Cop, PhD, MD, gynaecologist, obstetrician, specialist in the field of children’s and girls’ gynaecology and sexology
Author: Magdalena Warchala-Kopeć
Illustration: Marta Frej
The text was published in „Wysokie Obcasy” a magazine of „Gazeta Wyborcza” on 19 June 2021
