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I saw a young woman yesterday for her first GYN exam. The first exam is an important one, not so much because you are likely to find something serious, but because you can establish the essential doctor patient rapport in this sensitive area that will help her with future exams.
She was 17 years old and came in with her Mom. In general, when a mother and her daughter come in together, it is worthwhile to start by talking to them together to get a brief history. When you move on to the exam, that’s a good time to tell the daughter that your nurse will be assisting you with the exam and then ask the daughter whether she also would like her Mom to be with her during the exam, or have the Mom wait in the waiting area during the exam. Either way is OK. Some women feel reassured by having their mother with them, while others prefer the mothers not be present during the exam itself.
Once the Mom is sitting in the waiting room, then you can ask more personal questions of the daughter, questions that she might be uncomfortable answering with her mother listening. For example, “Are you sexually active?” In the case of the young woman I saw the other day, she responded by asking me, “What do you mean by sexually active?” That’s a pretty good response, since my question was somewhat ambiguous, but designed to elicit a discussion more than an yes or no answer. During our discussion, it evolved that she had not had penile penetrative sexual relations, but was otherwise fairly experienced sexually with multiple male partners, sequentially over the last two years. She was seriously involved with her current boyfriend and wanted to initiate coitarche, but first wanted to go on birth control pills.
Her mother did not know about her sexual activities or plans, and did not know she wanted to start the birth control pill. I asked her whether she felt comfortable discussing this issue with her mother and she said, “No.”
I then asked her more detailed information about her menstrual cycles and determined that her periods were somewhat irregular, heavy, and produced fairly intense menstrual cramps that when present, interfered with her normal activities. I explained to her that everything she told me related to birth control, sexual activity and STDs was strictly between her and me and that I would not share that information with her mother. But I also told her that as far as treatment with medications such as birth control pills, it is usually better to have everyone on board with the use of these medications. Otherwise, she’ll need to be hiding the pills and when they are inevitably found, it creates a fight that could have been unnecessary.
I proposed that I tell her mother that I recommended birth control pills for her to treat her heavy, irregular periods and suppress her cramps., a very legitimate use of OCPs for someone with her history. That way, her mother would understand that she had a need for this particular medication, without going into all of the various indications for this. I explained that my experience with Moms was that they were not usually stupid, often suspected that the daughters were sexually active on some level, and like their daughters, felt a little uncomfortable discussing these issues. Frequently, the Moms are relieved to hear that I recommend OCPs for whatever reason because the Mom perceives a need in their daughter for such protection. My patient agreed to this strategy.
I proceeded with the exam, with the emphasis on confirming that everything looked normal. I did not perform a Pap smear because she had not been sexually active for 3 years. In the olden days, we performed Pap smears on everyone, but the false positive rate is so high among women during the first three years of sexual activity, and true positive rate so tiny that routine Pap smears in this group is not indicated. I did, however, test her for Chlamydia and gonorrhea since her other, non-penetrative sexual activities did make her vulnerable to these illnesses.
After completing the exam, I met with the daughter and her mother and explained that her exam was completely normal in all respects. I did find, though, that the daughter was having a significant problem with irregular periods, heavy flows, and painful cramps that at times interfered with her normal activities. I recommended birth control pills to give very regular, lighter flows, with virtually no cramps. I explained that these heavy, unpleasant periods are common among teenagers and with increasing age, they often resolve, but that in the meantime, the birth control pills can be quite helpful in regulating the flows. It is true that the birth control pills also provide reliable contraception, but that I had many patients who had no need for the contraceptive benefits of birth control pills who nonetheless took them to control very unpleasant periods..
The mother agreed and we started her daughter on the pill. As they were leaving, the mother pulled me aside and privately told me she was very happy we were starting the daughter on the pill since she was concerned about her daughter’s possible sexual activity and thought being on the pill would help protect her against any unwise decision she might make.
