My 17 year old is going to the gynecologist for menstrual problems (severe pain and heavy bleeding)and I am concerned what to expect and what to allow. We already discussed the possibility that the pill will be offered as a cure all (already been offered by the family doctor, along with the wart vaccine - she said no to both) and agree that the pill is not a cure. What type of gynecological exam is appropriate for a 17 year old virgin, and what sort of tests and treatments would be appropriate?

Dear Mom

I forwarded this question to our physician advisor, Anthony Dardano, MD Here is his response

Menstrual abnormalities are common in this age group and are often a result of irregular ovulation patterns. Estrogen is secreted and builds a lining of the uterus monthly which thickens to become receptive to a fertilized egg and aid in implantation. At ovulation progesterone is secreted by the ovary. Should fertilization occur progesterone continues to be secreted in high amounts and implantation is secured. If fertilization does not occur the progesterone level drops causing the prepared lining to slough off and menses begins. At the end of the flow a new cycle begins. Frequently in the teenage years and again in the peri menopausal years, ovulation does not occur with this clock like regularity and irregular bleeding is the result. The cramping is actually miniature labor contractions where the uterine musculature is expelling the excess blood and or clots.

Having said that how would I address this. A gynecological exam is necessary to properly assess the problem. I certainly would use what is called the "virginal speculum" which is much more narrow and non traumatic. The pelvic exam is looking to rule out other common causes such as a fibroid growth or ovarian cyst. Of course if the exam is for any reason unsatisfactory, an abdominal (not vaginal in this age group) sonogram will give the same information. Blood work should be done to assess anemia, undetected diabetes, and thyroid dysfunction which are real but less common causes in this age group. Polycystic ovary syndrome with the elevated male hormone levels and confirmatory ultrasound exam needs to be ruled out as well. Endometriosis is also a common cause but that work up is down the road a bit and only if the conservative approach is unsuccessful.

I agree the pill is not the place to start. Aside from the obvious moral objections, there are numerous medical side effects which pose a serious risk. I would add that there might be a limited place for the short term use to control hemorrhage in the non sexually active teenager but not right off the bat. I would start with a NSAID such as Aleve three times a day at the onset of menses. This has been shown to control flow and is quite effective on the cramps. Next step is to put progesterone back in the cycle where it belongs. Taking a natural preparation such as prometrium from day 16 through day 25 of the cycle works very well to produce a natural slough in the proper time sequence. Not only is this safe, it is morally neutral as well and therefore acceptable for any age group sexually active or inactive.

Lysteda is a non hormonal medication taken 5 days a month which acts on the clotting mechanism but again this is not a first line therapy. D&C or endometrial biopsy likewise are therapies only to be used when all else fails and the symptoms are intolerable and I only mention them for completeness. Finally laparoscopic assessment of the pelvis is the best way to rule out endometriosis but again, only as a last resort in this age group.

I hope I didn't get too technical with my explanation and if after your exam you have unanswered questions I would be happy to try and clarifying them for you.

May God bless you for your good intentions.

Anthony N Dardano, MD, FACS, FACOG

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