When should my daughter have her first gynecology visit?

Have you "been there, done that" with your teen when it comes to check-ups? "Time for your annual physical!" "K!"  "You need to go to the dentist!" "Whatevs!"  How about this one? "Time for your first gynecology visit!"  "No way!"  She may counter, "I'm not old enough!" but there is no arguing this point: all females (adolescents and beyond…) need regular visits with a health professional to talk about their reproductive health.

An adolescent "gynecology visit" may be done with a gynecologist, adolescent medicine physician (like me) or family practice provider. It may or may not involve an actual pelvic examination.

Here are some common reasons why your teenager may need a gynecology visit: 

1. She has had no menstrual period by age 15. A girl's first menstrual period (menarche) can occur anytime from age 9-15. If she has not started her monthly periods by the time that she …

is 13 and has also not started breast development (thelarche)

has had thelarche five or more years before

is older than 15

... then, in medical terms, she has "primary amenorrhea".

2. She hasn't had a menstrual period for three months or longer. The menstrual cycle is counted from the first day of one period to the first day of the next. They usually occur every 21-35 days and last two to seven days. For the first few years after menarche, irregular cycles are common. They may skip a month or two and vary in length. Menstrual cycles tend to become more regular as a girl gets older. Girls who are extremely active in sports and/or have eating disorders may disrupt their normal menstrual periods. Stress is another common cause of abnormal menstrual bleeding. (Teens never have stress, right?) Regardless of how recently menarche occurred, if a girl has gone three or more months since her last period, she should be evaluated.

3. Her menstrual period occurs more than once a month, lasts too long, or is very heavy. Menstrual cycles that are less than 21 days apart (polymenorrhea) are too short. Menstrual periods with abnormally heavy or prolonged bleeding (menorrhagia) — requiring more than one pad or tampon every hour or having clots larger than 1 inch in diameter — are too heavy. Both can be signs of a hormone disorder such as Polycystic Ovary Syndrome (PCOS) or a bleeding problem such as Von Willebrand Disease.

4. She has extreme emotional and/or physical symptoms before her menstrual period. Premenstrual Syndrome (PMS) occurs one to two weeks before the period. There are over 150 known symptoms of PMS including mood swings, breast soreness, bloating, acne, food cravings, increased hunger and thirst, fatigue, and constipation or diarrhea. Premenstrual dysphoric disorder (PMDD), a condition in which a girl has severe depression symptoms, irritability and tension before menstruation, is more serious than PMS.

5. If her menstrual periods are so painful that she is missing school. Painful lower abdominal cramps (dysmenorrhea), which may be accompanied by nausea, diarrhea and lightheadedness, may start one to two days before the period begins and can last two to four days.  Dysmenorrhea usually responds to non-steroidal inflammatory drugs such as ibuprofen. Extremely painful cramps may result from a medical problem such as:

Endometriosis, a condition that occurs when uterine tissue is found outside its normal location, can cause pain before and/or during the menstrual period.

Pelvic inflammatory disease (PID) is a serious infection involving the uterus, fallopian tubes, and ovaries.  Pelvic pain, fever and abnormal vaginal discharge are signs of PID. PID is caused by sexually transmitted infections.

6. If she has had sex. The best-case scenario is that your teen has had a gynecology appointment before ever having had sex (vaginal, oral or anal) or other intimate sexual contact. It's not just about birth control (contraception) — it's also about preventing sexually transmitted infections (STIs). Sexually active girls or women under the age of 25 should be screened for STIs — chlamydia and gonorrhea — at least once a year.

7. For a Pap test (cervical cancer screening). If the six issues do not occur above then her first exam should occur at age 21. The American Cancer Society recommends that beginning at the age of 21, all women should have a Pap test.  A Pap test checks the cervix for abnormal cells that may become cervical cancer. Abnormal Pap tests are usually caused by the STI human papilloma virus (HPV). The HPV vaccine prevents over 70 percent of cervical cancers.

My advice: Talk with your daughter about her menstrual periods and make sure she has a primary care provider who spends some one-on-one time in a confidential setting discussing female health issues. No worries...in most cases, it'll be okay.

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