Puberty and Adolescence

How Old Is Old Enough?

A case history: A concerned mother brought in her fifteen-year-old daughter for a GYN visit. It seemed she was having an unusually painful period. Normally this would require the usual thorough history from both the patient and her mother, and then the young patient would be examined. The initial thorough physical exam includes listening to the heart and lungs, doing a breast exam, and among other things, doing a pelvic exam and pap smear. We learned in medical school that there is no substitute for the thorough physical exam.

But I decided not to be very thorough.

She was only fifteen. The single most important item in her history was that she had never been sexually active. I was sure to get this history in private, away from her mother who had given me permission for this privacy. After all, this was a good mother, interested only in her daughter's well-being.

Being a virgin eliminated 99% of the things I would seriously worry about. The other things I could pick up easily with a simple ultrasound at the hospital--a wand waved over her abdomen to give a complete picture of her uterus, tubes, and ovaries. I wanted to make sure that there were no sneaky ovarian cysts or swelling of the tubes. Once that was done, I could conclude that she had no disease but was just exquisitely sensitive to her periods. Treatment consisted of prescribing anti-inflammatories, and if necessary, birth control pills which have the nice side effect of taming bad monthly cramps.

So I broke the rule I learned in medical school on purpose. I got what I needed from the history and from ultrasound. The important thing is that a young girl didn't require any technical probing that she might not understand. I took advantage of the fact that it just wasn't necessary. No one can be sure that such a legitimate exam wouldn't traumatize a pediatric patient in such a way as to create hang-ups later on in adulthood and marriage.

Of course, had she been sexually active, and some adolescents are at a surprisingly young age, then Pandora's box would have opened to all kinds of possibilities. Pap smears become necessary, sexually transmitted diseases need to be ruled out, or pregnancy can occur. Luckily, this young lady avoided all of that and walked out of my office more comfortable with a doctor's way of thinking.

The only unproven risk would have been endometriosis. But endometriosis, mentrual-like tissue in the abdomen, is a surgical diagnosis anyway; no physical exam can claim endometriosis as a certainty. As it turned out, the young patient improved. Had she not, birth control pills to lessen the pain would have made an exam wise. If endometriosis were to take us down that diagnostic road toward laparoscopy, then the exam could not be avoided. So she would have needed the exam had she not gotten better, but this was one time where it went her way. Which is right where she went--on her way.

To enjoy her adolescence without all kinds of awkward things happening to her.

Should Irregular Period in Adolescents be a Concern?

In adolescence there are still many parts of a young woman's body that are still maturing. Growth as well as development are continuing, and this is especially true in the reproductive tract. The breasts, uterus, and ovaries are coming "into synch," so to speak, with their important function--to make possible pregnancy. One of the most frequent questions that patients who are mothers of adolescents ask me is about irregular menstrual cycles. But before I address that, first know that a young woman can be as old as eighteen before menstrual periods even begin. True, this is the unusual case, but it can be that long before the cycles start up.

Many adolescents who are having periods aren't really having "real" periods. To be an official period, a bleeding episode must be, first of all, periodic. That is, there really should be a menstrual "cycle." If it's not in a rhythmic, cyclic manner, then it's not a true shedding of the lining of the womb after an unsuccessful preparation for pregnancy. And this can only happen if a woman ovulates (releases an egg). For a year and a half after bleeding begins in an adolescent, only about half of them are actually ovulating. The rest are experiencing irregular sloughing off of mixed types of tissue improperly nourished by sporadic hormones. This can happen in a cycle of sorts, but a calendar will prove it's not rhythmic enough to assume ovulation is happening.

As these girls grow older, the right things begin falling into place hormonally, and the right sequences of stimulation of the lining of the uterus occur--until the uterus expects pregnancy, of course. When that doesn't happen, there's your "official" period. The metaphor of a period that ends a sentence is quite accurate. The menstrual period is a true end of the body's expectation of pregnancy. But as soon as the body gives up on the idea of getting pregnant, preparations are already underway to prepare for the next opportunity. The low circulating hormones are interpreted in the brain as a need to make more. The pituitary gland in the brain releases hormones which stimulate the ovaries to make estrogen and stimulate egg production. The circulating estrogen causes an increase in thickness of the uterine lining by causing it to grow and heap up upon itself. The stimulation of the egg production ends in one egg winning the race to be released, it's remaining follicle now converting to the production of progesterone, the hormone that has the real bonding effect that keeps the uterine lining from falling apart. This effect on the lining causes it to mature from the heap of thickened tissue it is to an organized mature layer that can receive the implantation of a fertilized egg. When this doesn't happen, which of course should be the case in adolescents, the progesterone stops. Now there's no bonding hormone to hold this lining together and the result is shedding--the period. The end. And of course the beginning of the next cyclic attempt at reproduction.

So if the breasts are not as large as they're going to be, and the height isn't as tall as it will eventually be, and if a lot of other things are still not finished developing, it's easy to see that such a complex cycle can easily be out of synch for a while. And that can be pretty much normal.

There are concerns, however, if a girl begins menstruating and then stops altogether, indicating possible pregnancy, ovarian disease, or serious endocrine (glandular--adrenal, thyroid) conditions. And if irregular cycles cause anemia or are excessively heavy or long-lasting, blood clotting disorders and leukemia should be ruled out. GYN tumors can present as irregular bleeding, but these are extremely rare and usually present with daily bleeding, not irregular cycles.

Certain medications, including several antidepressants, can muck up the works as well, so a careful history can often answer questions posed by a concerned mother. Strenuous exercise affects the hormones as well, which doesn't pose a problem unless a woman is trying to get pregnant. Certainly adolescence is a time when there are possibly the highest levels of physical activity in a person's life, so this must be taken into account before assuming there's an actual diagnosis.

Are irregular bleeding episodes worth treating? Treatment is only necessary if there is a real harm, such as anemia and fatigue, after ruling out all of the above. If there is no anemia, adolescents can be assured they will probably grow out of this, although the proper phrase is that they will grow into it. If the uncertainty of irregular bleeding is affecting sports and daily peace of mind, birth control pills can be used to mask the irregular cycles until she grows "into" her cycles in the background while the pills regulate her artificially.

It is important, though, to emphasize to young women that one of the best kept secrets in the world is that birth control pills do a lot more than control births. So using them for the medical benefits is not a license for sexual activity, as sex is an adult act. (They should not engage in adult acts until they're ready to accept adult repercussions from adult acts.)

We gynecologists should have a lot of patience in assigning a diagnosis to the irregular cycles of a girl becoming a woman. There will be a lot of mistakes the body makes while setting the rhythm. The level of suspicion of irregular cycles is much lower in adolescents than in mature women, and thankfully most adolescents are subjected to only one medical test called time.

Helping Our Daughters

A letter for our daughters about to become young women

Dear daughter,

How you've grown. It seems like only yesterday that we saw you on the ultrasound machine, a patch of what looked like weather radar glowing on a screen in the doctor's office. And it seems like only yesterday that we held you, held you entirely, in our arms. And now you're about to become a young lady, and this gives us the feeling of how fast this life is really going by.

There are changes happening to you that are confusing. It will almost seem like it's unfair that you've been selected to have these changes just because you're a girl. But it's not unfair. True, you've been selected, but it's an honor that you've been selected for, because all of the people in all of the world would never be here without you. Because of what you're about to change into, babies can be born. Without babies, there wouldn't be any more people on Earth in a few years. There is no gift more important than giving our world a baby. Your body is changing so that you can do this. We know you're not ready to make babies right now, nor should you, but you'll be able to for a very long time, and that time has to begin sometime.

Every month you'll see some blood from your vagina. Actually, it comes from higher up, from the womb, which is mostly inside your belly. Your womb has an opening that peaks out of your belly deep up in your vagina. You can't see your womb so high up inside you, but the blood will come from it, drip down your vagina to the outside of you where you can see it. Every month this will be a signal that you're having something called a menstrual cycle. The blood part is called a "period," because like a dot at the end of a sentence, it's the end of the menstrual cycle. It's called a cycle because it's something that will keep happening over and over, like something going round and round. And that thing that's happening over and over is this:

Because you're a girl, you will make tiny little eggs, usually one at a time. They'll be made in your ovaries, which are little clumps of a gland that's inside your belly along with your womb. And that egg will be let go from the ovary and move down a little tube. Every month it will do this. Until one day you will make an egg that is supposed to grow into a baby. This special egg will then fall down the tube into your womb and stick there so that the baby can grow from it and stay there--cozy, warm, and tucked away for safe-keeping till he or she is strong enough to be born and stay alive on the outside. Just like the blood that comes from your womb and leaves your body through your vagina every month, a baby is born by leaving the womb, using the vagina as a "birth canal."

(Now if your parents have this newspaper clipping on the refrigerator, then I figure they're ready to tell you how an egg becomes special enough to become a baby. So ask them.)

Anyway, since you're not going to be making a baby for a long time, every egg is just sort of practice until that time. In your womb it's all soft inside, like a fluffy bed waiting for that special egg I talked about. But just as it gets kind of nasty not to change your own bed sheets at home every now and then, the same is true for the womb. Each time you have a practice egg, your womb, in a way, tosses out the old bed sheets to remake its bed, so that it'll be fresh for the next egg. And the next, and the next. And it won't get tired of doing this. And one day, when you're all grown and ready for children, there'll be a fresh bed for a baby to lie in and to grow in. But for now, just like your bed sheets you've been using for a while, they need to be changed.

So this fluffy stuff gets thrown out each month. Of course, by the time you see it, it will look kind of like bloody stuff. Remember, we're people, made out of flesh and blood. Your Mom will show you how to keep yourself tidy when this happens. And there will be times when you think the whole thing's icky. But keep in mind that when you finally do make a baby, it won't be by magic. God made us a certain way, and the way He made us means that our bodies will follow certain rules. The real magic is not how you will make a baby when the time comes. The real magic is that you are designed in such a way that if your body just follows the rules, it can in fact make one. All you have to be is a girl, a young lady, a woman. And you're on your way.

Problem Solving Mistakes People Make (Suicide)

This is an essay on suicide. It is included here because of its high incidence in adolescence.

In life, choices need to be made. Most of us with our higher brain activity intact make these choices from moment to moment throughout every day. One of the hallmarks of maturity is when one realizes that there are repercussions to the choices we all make.

This milestone is referred to as the age of reason.

There is no "undo" button in our lives. So it is true in medicine, where both patients and physicians alike are presented dilemmas from which choices need be made. Particularly troubling are permanent solutions, for they create forks in life's paths. Permanent solutions are appropriate for permanent problems, but it is a weakness and a fallacy to seek permanent solutions to temporary problems.

Sterilization, for instance, is not an appropriate choice to make while experiencing a painful labor or while trying to get through life with a couple of toddlers having hissyfits at your feet. These are temporary problems. Labor and delivery will pass, and the toddlers will be dressing, feeding, and cleaning themselves in a few years. At that point one can enjoy a family and finally consider in a reasonable atmosphere whether additional children would enrich life's experience for all.

In my opinion, a man striking a woman (which should be a felony) is a permanent solution to a temporary problem. One can never take that "hit" back. After all, dealing with anger is what the higher brain activity is for. Unfortunately, some make permanent decisions with the lower brain activity in sorting out their problems.

Murder, too, is a permanent solution to a temporary problem. Unless an assailant is lunging at you with mortal intent necessitating self-defense, we are not qualified to make capital judgements on anyone. That's what governments are for, and even that is controversial. The hippocampus is that area in the brain that reacts with snap precision in life and death situations. But evolution has kindly wrapped many brain convolutions around it to suppress the self-indulgent impulses that deep down inside make us want to strike out at any irritation without discretion. I lift a cup to toast those convolutions, for they are what make it possible to have government, civilization, and, well, just get along. And they are what make it possible to solve temporary problems with temporary solutions and permanent problems with reason and the weighing of consequences.

The most distressing permanent solution to a temporary problem is suicide. The psychology of this final solution is well beyond the scope of this article, but suicide can basically be thought of as one's desire to make a painful situation stop. Unrequited love, financial doom, dehumanizing one's self in the misthinking that everyone would be better off without you, or just the thought of enjoying "showing" someone what one would do to make them sorry are all temporary phenomena. The unrequited love problem's best solution is adopting the many-fish-in-the-sea school of thought. Financial problems are only frets from day to day in a society that offers food, support, and medical care regardless of intent to pay it back. Would everyone really be better off without you? No matter what, life is a gift. To experience at all is better than oblivion. You don't show anyone anything with suicide--people are shocked, heart-broken, or dismayed, but they continue on with their lives without you. And they continue on unapologetically. Vengeful retaliation by seeking remorse from others is a ridiculous miscalculation of time, because you aren't there in the future--permanently--to collect on a present fantasy.

Permanent solutions to temporary problems are a bad idea, but suicide is the worst of all because as we jockey for position along the forked paths of life, the paths end abruptly at that particular fork. There's just one less web interwoven with the rest of the webs. Suicide is hippocampal thinking at its worst, and it's a deluded hippocampus at that. Suicide remains one of the most dangerous risks to our adolescent population. If one can make it through those years, it will become apparent how temporary certain problems really were.

With age comes perspective. We become wiser as we live through the life experiences of interactions with other people and the world in general. As our needs change and our sense of what's important does too, we realize that we were never qualified to make permanent decisions during adolescence no more than we were qualified to think our lives were ruined when the favorite blanket was lost during childhood. In fact, we're never qualified to make the particular decision of suicide, because the wisdom of the future is aborted along with the misconceptions of the present.

Many of our adolescents, along with all of the other pressures in their lives, are taking Geometry. In this mathematical discipline they are exposed to what are called postulates. For instance, a postulate may claim, "If a line is perpendicular to one of two parallel lines, it must also be perpendicular to the other parallel line." Postulates go theories one better--they are just accepted as a presupposition, condition, or premise of a train of reasoning. No proof necessary. If we exist as human beings and regard this world and how we fit in, our reasoning must start somewhere. The Hebrews did it with the ten commandments. The United States does it with the Constitution. Marriage, ideally, does it with vows. These are all postulates, accepted as the basis of how we are. They are the building block of life for us, as solid a basis as the atom is for the periodic table of the elements.

As human beings we are seeking, and that's why life is important. Life experience is the continuing fulfillment of that seeking, and life experience is its own reward. But we can seek nothing without life, and in snuffing it out the seeking stops. Salman Rushdie said that being alive makes up for what life does to you. There is a beauty in the verb to be, and as an obstetrician I see this beauty with every baby I deliver. So in regards to that most precious of gifts I will now state what I consider the postulate on suicide:

Given: A permanent solution to a temporary problem is no solution.

One would sooner successfully divide by zero.

STDs--The Gift from the Goddess of Love

We used to call them "venereal" diseases. The origin of this word comes from the goddess of love, Venus. Interestingly, so does the word, venerate. Today, gynecologists call them sexually transmitted diseases, or STDs. A patient of mine came to my office recently requesting to get "checked out." She had apparently had a foolish, regrettable, unprotected sexual encounter with someone she didn't really know well and asked me to check her out for everything imaginable that may be sexually acquired. Unfortunately, I don't have a tricorder like on Star Trek, so I set out to evaluate her according to 1998 standards so as to give her peace of mind.

This type of work up is time-consuming and expensive. But now that unprotected sex may involve death-defying risks, it's worth it.

The first thing I did was perform the usual routine exam. I checked for inflamed lymph nodes and pushed on her liver. Lymph nodes can enlarge with any infection from an area of the body that drains their way. The liver can indicate hepatitis, one of the deadliest risks from sexually transmitted disease. It's ironic that most people fear AIDS, because age-old hepatitis can be quite lethal. The pelvic exam is done to see if there's any undue tenderness, indicating possible infection in the tubes from gonorrhea or chlamydia. In the course of the pelvic exam, specific cultures for gonorrhea and chlamydia are taken as well, and a pap smear is done which could show infection with Human Papilloma Virus, or HPV.

HPV, a sexually acquired virus, can lead to cancer of the cervix, especially in smokers. After the physical exam, two cultures, and pap smear, I performed what's called a "wet prep." This is the same test that can see yeast, but it's also used to diagnose sexually acquired trichomonas, an organism that can lead to severe burning and vaginal discharge as well as be passed on to other sexual partners. Finished yet? Not really.

Next comes blood work. Syphilis is making a big comeback. The initial lesion is painless and therefore often missed. A patient leading what she thinks is a normal life may one day develop severe neurological dysfunction as an end stage of this easy-to-cure disease if undiagnosed during its first stages. As mentioned above, the risk of hepatitis lurks as well, and blood tests can tell whether there is an acute infection as well as indicate whether there is something chronic going on. HIV infection, the virus that causes AIDS, is also a blood test. All of these tests need to be repeated some time later, as these diseases may take some time to show up. The pap smear should also be repeated several months later, just in case a pre-cancerous lesion from HPV was too early to be picked up or even missed altogether.

Unless there's an obvious lesion,herpes can't be diagnosed without a positive culture. But herpes cultures are frequently unreliable. Blood work may show the body's reaction to herpes (antibodies), but this STD is a loose end that only time can diagnose or exclude. Besides herpes and syphilis, there are other nasty skin lesions. Molluscum contagiosum is a little organism that can cause raised bumps that need to be scraped off of the labia, thighs, or perianal areas. HPV, besides precancerous lesions of the cervix, can cause venereal warts which can be very difficult to eradicate. More exotic diseases can involve severely ulcerating groin lymph nodes.

Suddenly, condoms seem like a good idea. Always. No condoms--NO SEX!

Occasionally I'll have a patient tell me "he" won't want to have sex if she were to insist on a condom. She underestimates the groveling power of testosterone. The woman calls the shots. She is the gate-keeper on sex. If she were to insist that Tom Jones himself serenade their foreplay, he'd be calling the William Morris Agency before the lights went down.

Sadly, even condoms are no guarantee, but they certainly help the odds with all of these different STDs. Some can be diagnosed quickly; others take longer. The wet prep will give an answer immediately on trichomonas. The blood work takes a couple of days. The cultures can take the better part of a week. So the important question is does a gynecologist start treating a patient immediately while waiting for all of these results to come back? The people in academics might say no; treat only when you have a clear indication based on a culture.

In private practice, however, a place where we see the same patients over and over, there's a more sensitive feeling of responsibility on our part. We're probably more inclined to start antibiotics to guard for syphilis, gonorrhea, or chlamydia right away, knowing we can stop treatment if all turns up negative. Of course, with some treatments it's too late to call off a prescription, because many protocols involve single doses of a pill or a shot. This becomes a case wherein a patient was exposed to antibiotics unnecessarily, and the academicians groan about making the world less safe because of the needless sowing of these antibiotics in the environment that may reap resistant bacteria.

We may reap what we sow, but this pales in comparison with what goes on in third world countries where antibiotics are sold over the counter. Meanwhile, I may have to face a patient with infertility one day who may want to know if those few extra days of treatment might have made the difference. Probably not is the phrase that would be the correct answer, but still there is some dividing line between when her infertility was preventable and when it was not. Also, some tests and cultures are just plain wrong. I don't blame a woman who doesn't want to take even the slightest chance with her health, fertility or otherwise. We private clinicians have had a very honorable battle with the academicians for a long time--it's quite traditional. They espouse what's right, and we freely admit that, but we individualize for what's right for our patients.