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What is Pediatric and Adolescent Gynecology?

      When people ask me what I do, I gauge their time and interest. Are they asking out of general politeness, or do we have time for me to share more of what I do? I may answer that I am a physician, which can lead to their telling me a story about their latest encounter with the medical profession, or they may be curious and ask for clarification. If they express interest, I may respond that I am a gynecologist. I am sometimes parsimonious with even this information; I have learned that if I am speaking to a man, the conversation may quickly turn to another topic. This is by no means invariably true, and a man may choose to pursue the discussion, just as the subject may change when I am speaking with a woman. But when I am speaking with a woman, the topic of gynecology is often more of interest to them personally. The conversation may proceed to a discussion of my own practice of pediatric and adolescent gynecology (PAG). (I note to you JPAG readers, that as I am speaking to the choir, I will continue to use the acronym PAG in this editorial, as it facilitates your reading, but in conversations to lay persons, I typically use the more cumbersome phrase “pediatric and adolescent gynecology”).
      If the conversation has proceeded to the point that I have disclosed that I practice pediatric and adolescent gynecology, the statement is typically met with curiosity. Most people respond with some variation of the sentiment that that they didn't know that pediatric and adolescent gynecology was a “thing”. What is pediatric and adolescent gynecology? Some of you may have heard me say that my adolescent gynecology practice includes “preventive obstetrics”—which will almost always get at least a chuckle when the meaning becomes clear. It is true that my gynecology practice includes a major focus on preventing unintended pregnancies in adolescents. Providing contraception for adolescents has been a big part of my clinical practice and academic career. But my PAG practice is much broader than contraception alone. It includes a really wide range of problems that are referred to me because they have stymied other clinicians. In a conversation about what is PAG, if there is sufficient time and my questioner seems genuinely interested, I will explain that I care for girls and teens with problems ranging from abnormal menstrual bleeding to ovarian masses, vulvar concerns, hormonal therapies, preventive health like HPV vaccination, in addition to contraception.
      As I prepared the line-up of accepted articles for the current issue of this journal from the list of accepted manuscripts of original research and case reports (the “traffic book”, as I have learned that it is called by my colleagues in publishing), I was struck by how virtually every article had some relevance to my own clinical practice. Not only that, but my passion to teach PAG was also well served by the submissions from my valued colleagues and teachers in academic PAG.
      JPAG Associate Editor Hina Talib and her colleagues on the Resident Education Committee of the North American Society for Pediatric and Adolescent Gynecology (NASPAG) have come out with “Resident Education Curriculum in Pediatric and Adolescent Gynecology: The Short Curriculum 2.0”,
      • Talib H.J.
      • Karjane N.
      • Teelin K.
      • et al.
      Residents education curriculum in pediatric and adolescent gynecology: the short curriculum 2.0.
      updating the version originally published in JPAG by Fleming et al.
      • Fleming N.
      • Amies Oelschlager A.M.
      • Browner-Elhanan K.J.
      • et al.
      Resident education curriculum in pediatric and adolescent gynecology: the short curriculum.
      The development of a short curriculum has been very helpful for learners from a variety of disciplines, including ob/gyn, pediatrics, and family medicine; I welcome this update. Continuing the PAG education theme, Paritosh Kaul and colleagues describe “Medical Students' Acquisition of Adolescent Interview Skills After Coached Role Play”.
      • Kaul P.
      • Fisher J.H.
      • Hanson J.L.
      Medical students' acquisition of adolescent interview skills after coached role play.
      A number of other original research articles in this issue are relevant to my clinical practice and scholarly foci, including a piece on electronic vs paper menstrual cycle tracking,
      • Jacobson A.E.
      • Vesely S.K.
      • Haamid F.
      • Christian-Rancy M.
      • O'Brien S.H.
      Mobile application vs paper pictorial blood assessment chart to track menses in young women: a randomized cross-over design.
      the topic of herd immunity related to HPV vaccination,
      • Smith C.
      • Ding L.
      • Gorbach P.M.
      • Franco E.L.
      • Kahn J.A.
      Who's not protected in the herd? Factors associated with vaccine-type HPV in unvaccinated women.
      the challenges of parent-teen communication about contraception and sexual decision-making,
      • Ramchandani K.
      • Morrison P.
      • Gold M.A.
      • Akers A.Y.
      Messages about abstinence, delaying sexual debut and sexual decision-making in conversations between mothers and young adolescents.
      • Shakibnia E.B.
      • Timmons S.E.
      • Gold M.A.
      • Garbers S.
      “It's pretty Hard to tell your mom and dad that you're on a method”: exploring how an app could promote adolescents' communication with partners and parent(s) to increase self-efficacy in long-acting reversible contraception use.
      and several case reports of vulvar lesions that I will need to keep on my differential.
      • Jorgensen E.M.
      • Chen P.P.
      • Rutter S.
      • Cron J.A.
      Vulvar lesions in an 8-year-old girl: cutaneous manifestations of multisystem langerhans cell histiocytosis.
      • Lawson A.
      • Mir A.
      • Wilson E.E.
      Vulvar nodules: a rare presentation of mastocytosis.
      In addition, my interest is piqued and my scientific curiosity aroused as I think about the additional questions that are just beginning to be answered relating to adolescent menstruation, anovulation and dysmenorrhea.
      • Seidman L.C.
      • Brennan K.M.
      • Rapkin A.J.
      • Payne L.A.
      Rates of anovulation in adolescents and young adults with moderate to severe primary dysmenorrhea and those without primary dysmenorrhea.
      Continuing the theme of clinical relevance, this issue of JPAG includes reports on conditions I see in my practice—whether commonly (adnexal torsion
      • Schwartz B.I.
      • Huppert J.S.
      • Chen C.
      • Huang B.
      • Reed J.L.
      Creation of a composite score to predict adnexal torsion in children and adolescents.
      ) or relatively rarely (vaginal lacerations
      • Vijayan V.
      • Woods G.L.
      • Donnell D.R.
      • Romero J.R.
      Pelvic abscess secondary to mycoplasma hominis after vaginal laceration.
      or vulvar manifestations of inflammatory bowel disease
      • Debiec K.E.
      • Lee S.D.
      • Wahbeh G.T.
      • Amies Oelschlager A.M.
      Outcomes of therapy for vulvar manifestation of inflammatory bowel disease in adolescents.
      ). Finally, I am intrigued by rare conditions or “zebras”: very unusual conditions that many of us may never see, but which deserve a case report to remind us of possibilities for our patients' symptoms or findings that just don't quite seem to fit a common diagnosis.
      • Reed S.
      • Curran K.A.
      • Middleman A.B.
      Delay in an eating disorder diagnosis: the reason was a “Shox”.
      • AlSubaihin A.
      • VanderMeulen J.
      • Harris K.
      • Duck J.
      • McCready E.
      Müllerian agenesis in cat eye syndrome and 22q11 chromosome abnormalities: a case report and literature review.
      Some of the reports in this JPAG issue were outside of my regular clinical practice--but of intellectual interest, and still informative to what I do as a clinician, such as the large case series reporting the ano-genital findings in exams for sexual abuse.
      • Smith T.D.
      • Raman S.R.
      • Madigan S.
      • Waldman J.
      • Shouldice M.
      Anogenital findings in 3569 pediatric examinations for sexual abuse/assault.
      Not all JPAG readers' practices will include all of these aspects of PAG. Your practice likely differs: one of the strengths of NASPAG and PAG is that it is a discipline that includes individuals who come from the disciplines of both OB/Gyn and Pediatrics. That mix of pediatrics and gynecology provides rich interaction within the society, but as the specialty of PAG grows, we are becoming a brighter rainbow of specialties/specialists. When we see patients with challenging problems, we come together with individuals from a variety of medical backgrounds, working together to address the medical challenges our patients bring to us. The individuals that I work with include those listed on the accompanying table (Table 1); your own table may look somewhat or very different from mine. As you work with individuals in other specialty areas of medicine, let them know about NASPAG; share with them a particularly compelling recent publication from JPAG; invite them to attend a NASPAG annual clinical and research meeting.
      Table 1Conditions in Common Between Other Specialties and PAG
      SpecialtyConditions in Common with PAG
      General PediatricsVulovaginitis, labial adhesions, contraception, sexuality, obesity
      Pediatric EndocrinologyTransgender individuals, PCOS, puberty issues, amenorrhea
      Pediatric SurgeryOvarian masses, acute pelvic/abdominal pain, congenital colorectal anomalies
      Pediatric UrologyGenitourinary anomalies and symptoms
      Pediatric DermatologyLichen sclerosus, vulvovaginitides
      Pediatric Infectious DiseasesHSV, HPV, genital schistosomiasis, PID
      Sexual Abuse ExpertsGenital injuries
      Reproductive EndocrinologyGenital anomalies and subsequent fertility, ovarian insufficiency and hormone replacement, endometriosis
      Psychology/PsychiatryDepression, mood disorders, PMS/PMDD
      Allied Health (NPs, RNs, PTs)Patient Education, family involvement, myofascial pain
      Public HealthWomen's health, contraception, vaccinations, violence prevention, reproductive justice and choice
      My PAG practice is never intellectually boring. Every day I am challenged by something I am not as familiar with as I would like to be. In response, I search the medical literature and read JPAG and other specialty and subspecialty journals to learn of the latest scholarly studies that inform my practice; I talk with, consult, and learn from colleagues in other disciplines. It is my belief that the more that we cross disciplines, the more we “stretch” our own knowledge in order to apply it to the challenging medical concerns and problems that our patients bring us.
      I would like to challenge you to be a PAG evangelist. The next time someone asks what you do, tell them you practice pediatric and adolescent gynecology. Talk about a patient whom you recently helped when previous doctors were unsure of the diagnosis. If they are a clinician, tell them about something you've just read in JPAG that might overlap with their expertise, or pique their intellectual curiosity. If they are not in medicine, talk about how gratifying it is and how privileged we are to be able to care for girls and teens with medical problems that they may be shy about confessing. By addressing their concerns, we are contributing to a healthier and happier world, not only for girls and women today, but for our children tomorrow.

      References

        • Talib H.J.
        • Karjane N.
        • Teelin K.
        • et al.
        Residents education curriculum in pediatric and adolescent gynecology: the short curriculum 2.0.
        J Ped Adol Gynecol. 2018; 31: 71
        • Fleming N.
        • Amies Oelschlager A.M.
        • Browner-Elhanan K.J.
        • et al.
        Resident education curriculum in pediatric and adolescent gynecology: the short curriculum.
        J Pediatr Adolesc Gynecol. 2014; 27: 117
        • Kaul P.
        • Fisher J.H.
        • Hanson J.L.
        Medical students' acquisition of adolescent interview skills after coached role play.
        J Pediatr Adolesc Gynecol. 2018; 31: 102
        • Jacobson A.E.
        • Vesely S.K.
        • Haamid F.
        • Christian-Rancy M.
        • O'Brien S.H.
        Mobile application vs paper pictorial blood assessment chart to track menses in young women: a randomized cross-over design.
        J Pediatr Adolesc Gynecol. 2018; 31: 84
        • Smith C.
        • Ding L.
        • Gorbach P.M.
        • Franco E.L.
        • Kahn J.A.
        Who's not protected in the herd? Factors associated with vaccine-type HPV in unvaccinated women.
        J Pediatr Adolesc Gynecol. 2018; 31: 89
        • Ramchandani K.
        • Morrison P.
        • Gold M.A.
        • Akers A.Y.
        Messages about abstinence, delaying sexual debut and sexual decision-making in conversations between mothers and young adolescents.
        J Pediatr Adolesc Gynecol. 2018; 31: 107
        • Shakibnia E.B.
        • Timmons S.E.
        • Gold M.A.
        • Garbers S.
        “It's pretty Hard to tell your mom and dad that you're on a method”: exploring how an app could promote adolescents' communication with partners and parent(s) to increase self-efficacy in long-acting reversible contraception use.
        J Pediatr Adolesc Gynecol. 2018; 31: 116
        • Jorgensen E.M.
        • Chen P.P.
        • Rutter S.
        • Cron J.A.
        Vulvar lesions in an 8-year-old girl: cutaneous manifestations of multisystem langerhans cell histiocytosis.
        J Pediatr Adolesc Gynecol. 2018; 31: 153
        • Lawson A.
        • Mir A.
        • Wilson E.E.
        Vulvar nodules: a rare presentation of mastocytosis.
        J Pediatr Adolesc Gynecol. 2018; 31: 156
        • Seidman L.C.
        • Brennan K.M.
        • Rapkin A.J.
        • Payne L.A.
        Rates of anovulation in adolescents and young adults with moderate to severe primary dysmenorrhea and those without primary dysmenorrhea.
        J Pediatr Adolesc Gynecol. 2018; 31: 94
        • Schwartz B.I.
        • Huppert J.S.
        • Chen C.
        • Huang B.
        • Reed J.L.
        Creation of a composite score to predict adnexal torsion in children and adolescents.
        J Pediatr Adolesc Gynecol. 2018; 31: 132
        • Vijayan V.
        • Woods G.L.
        • Donnell D.R.
        • Romero J.R.
        Pelvic abscess secondary to mycoplasma hominis after vaginal laceration.
        J Pediatr Adolesc Gynecol. 2018; 31: 146
        • Debiec K.E.
        • Lee S.D.
        • Wahbeh G.T.
        • Amies Oelschlager A.M.
        Outcomes of therapy for vulvar manifestation of inflammatory bowel disease in adolescents.
        J Pediatr Adolesc Gynecol. 2018; 31: 149
        • Reed S.
        • Curran K.A.
        • Middleman A.B.
        Delay in an eating disorder diagnosis: the reason was a “Shox”.
        J Pediatr Adolesc Gynecol. 2018; 31: 138
        • AlSubaihin A.
        • VanderMeulen J.
        • Harris K.
        • Duck J.
        • McCready E.
        Müllerian agenesis in cat eye syndrome and 22q11 chromosome abnormalities: a case report and literature review.
        J Pediatr Adolesc Gynecol. 2018; 31: 158
        • Smith T.D.
        • Raman S.R.
        • Madigan S.
        • Waldman J.
        • Shouldice M.
        Anogenital findings in 3569 pediatric examinations for sexual abuse/assault.
        J Pediatr Adolesc Gynecol. 2018; 31: 79