Lisa M. Lowery, MD, Adolescent Medicine
Helen DeVos Children's Hospital

You know that girls today reach puberty earlier and earlier. Which means that gynecologic issues are no longer limited to physicians like me who focus on adolescents. Not only that, but adolescent specialists like myself and my partners are still relatively rare in many geographic areas, meaning that most pediatricians and family practitioners are caring for kids from birth through early adulthood. Since about half of all high schoolers are sexually active, that means a lot of reproductive issues you may need to deal with. 

One is the pelvic exam, which may or may not include a Pap smear.  The first step is usually just a routine external exam assessing for Sexual Maturity Rating.  The American Academy of Pediatrics recently published a review article on the importance of the gynecologic exam for our young ladies, and why primary care physicians are the ideal health professionals to perform a girl's first external and/or internal exam. 

I completely agree with the authors of the article. There most definitely is a role for the pediatrician/family practitioner in a young girl's reproductive health. She has likely been seeing you for years; she trusts you. Who better to prepare her for her first gynecological exam? 

Yet even though we've all been trained in gynecological and pelvic exams, when is the last time you did one? If it's been a while, download the AAP article from the link above. It is filled with valuable information about how and when and why to provide the exam.

As a specialist in adolescent medicine, I see more than my share of teenaged girls who require gynecologic care. No matter where they are in their maturation, I always go slowly and explain everything along the way. If I need to do an internal exam, I show them the speculum, let them handle it, explain exactly how it will be used. I let them lie on the table with their feet in the stirrups while fully clothed, so they feel comfortable and in control of the situation before undressing. 

As for the Pap smear. . . the most recent guidelines from the American College of Obstetricians and Gynecologists recommend a Pap and/or HPV testing at age 21 unless the young lady is immune suppressed or is HIV-positive, in which case the tests should begin with sexual activity. 

So even in my own practice, I'm seeing fewer indications for doing Pap smears. However, we still need to maintain our skills in this area. Another thing I see is more and more of my colleagues shying away from reproductive health altogether, sending their patients to adolescent specialists like myself or to adult gynecologists. That's fine up to a point; just keep in mind your patient won't have the same level of trust with those doctors initially that she already has with you. 

My point is that I hope pediatricians don't lose the skills required to provide gynecological examinations. So read the article by Braverman et al. You'll get a great review in the indications for a pelvic exam as well as some excellent advice on preparing the patient for the exam and conducting the exam in a stress-free, fear-free manner. Remember, that teenager on your examining table will be undergoing these exams regularly for the next 60 or 70 years; don't you want her first experiences to be pleasant ones?

Lisa M. Lowery, MD, is an adolescent medicine specialist at Helen DeVos Children's Hospital in Grand Rapids, Michigan. She is board certified in pediatrics and internal medicine.

Timothy Conroy, MD, General Pediatrics
Helen DeVos Children's Hospital 

I don't know if you saw the story in the Wall Street Journal last month. The headline really caught my eye: "Can't Part with the Pediatrician." Basically, it was about how more kids are staying with their pediatricians through college. As one 23-year-old told the reporter, "I have no plans to leave my pediatrician. It makes me feel safe and not scared about going to the doctor." 

It got me thinking. How old is too old? Some of that decision may be made for us in terms of the health insurance plans we contract with, which may not allow kids older than 18 or, in some instances, 21, to remain on a pediatric panel. And, really, we're trained to deal with kid problems-ear infections, sore throats, developmental issues. Not so much adult issues, like high blood pressure, pregnancy, and high cholesterol although, unfortunately, we're beginning to see more of that in our practices, too. 

One solution to the too-big-for-pediatrics but too-young-for-internists is the growing specialty of adolescent medicine and the increasing number of physicians who are board certified in internal medicine and pediatrics, the so-called med/peds. Interestingly, this combined training has existed for 40 years, yet one of the first analyses of such practices was just published last year. It found that 43% of visits to med-peds were from children 18 or younger, and that these physicians were more likely see children 18 or younger than family physicians (P=0.002), but fewer adults 65 and older (P=0.013). These double-boarded primary care physicians still saw more adults under age 65 than internists, however. 

Meanwhile, a survey mailed to 1,772 physicians who had completed med-peds training found that while all provided care to all ages of patients, most provided more care to adults than children. Both generalists (1,700) and specialists (472) said they felt that their training had better prepared for treating adults than children, which is a bit worrisome, don't you think?

My own kids' pediatric practice sends a letter to patients just before they turn 18 letting them know that their doctors will no longer be able to treat them. Our clinic, a teaching clinic for pediatric and med-peds residents, can keep patients to age 21.  We bring up the possibility of transition to an adult practice between 18 and 21 if our patients have not already asked about other options. Other practices I know maintain patients through college. One of the adolescent medicine physicians in our clinic is still treating some patients in their early 30s!

Of course, kids with special needs are a special situation. Many of us wind up treating our special needs' patients far into young adulthood because we are so comfortable with them and they and their families are so comfortable with us. Simply put, it is often the right thing to do.

What is your practice's policy on patients who "age out?"