← This Is So Awkward
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- [00:00]
Kara
This episode is brought to you by Progressive Insurance. You chose to hit play on this podcast today. Smart Choice. Make another smart choice with Auto Quote Explorer to compare rates from multiple car insurance companies all at once. Try it@progressive.com Progressive Casualty Insurance Company and affiliates. Not available in all states or situations. Prices vary based on how you buy.
- [00:27]
Dr. Joseph Sanfilippo
We want you to know about the silent epidemic of chlamydia, where you can get a sexually transmitted infection and never know it. Painful periods? No, because your older sister and your mom had painful periods, it doesn't mean you have to have painful periods. And so there's so many things we can do for that team.
- [00:45]
Kara
Okay.
- [00:45]
Dr. Joseph Sanfilippo
To make this entry into her gynecologic world arena a pleasant one.
- [00:57]
Kara
Hi, Vanessa.
- [00:58]
Vanessa
Hey, Cara.
- [01:00]
Kara
As you would say, buckle up. This is an incredible conversation about a topic that very few people have even heard of, which is pediatric and adolescent gynecology. Gynecology is usually something that we think of for adult women, but there is a field in pediatrics and adolescent medicine. And we have two of the greats with us.
- [01:26]
Vanessa
And you've heard us when we talk to other adolescent medicine specialists, Hina Talib and Sarah Levine, about what unicorns adolescent medicine specialists are. Right? There's just over 700 of them in the country. Well, the folks we're going to speak to today are even more special unicorns, like rainbow unicorns, because there's just over 200 of them in the US and Canada. And the field is absolutely fascinating. They are professors and founders of national organizations. Dr. Tyson is a clinical professor and division chief of pediatric and adolescent gynecology at Stanford University School of Medicine. And you'll understand a little bit about what we're going to talk about because she specializes in patient centered care that is focused on complex contraception, hormone management, bleeding disorders, and minimally invasive surgery for endometriosis and reproductive anomalies. If you think that sounds fascinating, just wait until we get into conversation. And Dr. Joe, who we feel we can call him Dr. Joe because his daughter introduced us and you'll hear more about that. Dr. Joseph Sanfilipo is a tenured professor of obstetrics, gynecology and reproductive sciences at University of Pittsburgh School of Medicine. But there's so much more to his story.
- [02:54]
Kara
I mean, he's the recipient of several unbelievably prestigious awards. Both Dr. Tyson and Dr. Sanfilippo have published multiple books, multiple book chapters, multiple research articles, multiple article reviews. These are such incredible figures. Vanessa, I have to tell you, in the middle of this recording, I Had a total aha moment because, you know, here we are, we're talking to Dr. Joe and we're having this great conversation, and we've been introduced to him by his daughter. And suddenly I realized we were talking to the author of the gynecology textbook, Sam Filippo. It is what everyone went to. It is the book. And I, I freaked. I internally freaked out. I don't think I said anything out loud till we ended the recording. And then I, like, immediately called you and said that was the guy. So, everyone, you've got two unbelievable thinkers in a field that if you've never heard of this, you're going to want to consume everything you can about what they do. We know you will. Enjoy.
- [04:14]
Vanessa
Hi, Dr. Joe. Hi, Dr. Tyson. Welcome to the podcast.
- [04:19]
Dr. Joseph Sanfilippo
Thanks for the opportunity.
- [04:21]
Vanessa
Shout out, Dr. Joe, to your wonderful daughter, Dr. Angela Casey, founder of Bright Girl and dermatologist, who sent us your bio and said, huh, I wonder if you might be interested in having my dad on the podcast. And then sent us the most impressive bio of a medical professional, only second only to Dr. Tyson's bio, which we got later in the month. So you all may be wondering what's happening here. We've got two people on the podcast and you saw that the episode involves pediatric gynecology. What the hell is pediatric gynecology? Isn't gynecology for adults? Aren't I waiting until my kid is a certain age for it to be okay to take them to the gynecologist? And this conversation is really about understanding a. What a unique field it is. So a little bit of education, but also integrating how these conversations in our homes and with medical providers are so critical for long term health of young people and not segmenting our understanding of our growing, changing bodies and also the care we get for the kids that we are responsible for. So with that intro, that very dramatic intro, Dr. Joe, will you please explain what the heck is pediatric gynecology?
- [05:56]
Dr. Joseph Sanfilippo
Well, thank you, Vanessa. And whenever I get the opportunity to talk about pediatric adolescent gynecology, I. I honestly get very excited and say that from my heart. Why? I mean, I am now well over 40 years into, you know, obstetrics and gynecology, and when I was a resident, and I don't want to say I'm embarrassed, but it was a few years ago, like in this, in the, in the late 70s. Okay, not the early late 70s. And at that time I said to myself, you know, we've seen these adolescents, we're seeing them and they come in with pelvic infection or they may come in with painful periods and it's never been catered to. I mean, you know, and this is 70s, 80s, etc. So in 1986, we had a international congress on Pediatric Adolescent gynecology. Okay. And now understand in the late 80s there was maybe one textbook and, you know, nobody knew anything. Well, a group of us literally sat around the table and we said, we have to focus on pediatric and adolescent gynecology from birth. And now we even say before birth, okay, antenatal on through, you know, 21, 22 years of age. Okay? And this is a very important group because they're going to be introduced to the gynecologist. And if that's a bad introduction, I always say it's the closed leg syndrome where, you know, any pelvic examination is traumatic. So we needed to fix that and we did. So we started what we call North American Society for Pediatric and Adolescent Gynecology, naspac. Now that's important for your audience, okay? And the reason for that is if they want to find a pediatric adolescent gynecology, they can go to www.naspag naspag.org and you can find who's local. Now let's get back to your question. So we sat around the table and said, look, we need to start a society that could educate providers, physicians. We didn't have PAs and nurse practitioners back in the late 80s, but we would focus on especially physicians. So we came up with a society that also had a journal and I was essentially the editor in chief of that journal. So we had a means of communication and each year we'd have an annual meeting so that people interested could come and learn how to do an exam on a pediatric patient. And it's not in stirrups. And again, Nicole will elaborate on that in a minute. What about that adolescent? What about, does she need a pelvic exam? Initially, that answer is no. Okay. And then what about things other than painful periods like ovarian torsion? Okay. And can we save that ovary? You know, heretofore, if an adolescent had a torrest ovary, out came the ovary, okay? And we don't do that now. We are very conservative. There's good data to support that. And not to mention some girls over the years are born without a vagina. Okay. And we have the ability to create what we call a neo vagina. And so this whole aspect of pediatric adolescent gynecology, for your audience, to me, the take home message is, when do I get my daughter into this system, into see the gynecologist the obstetrician gynecologist. Who should that be and how do I make that as pleasant an experience for my daughter as possible?
- [09:37]
Kara
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- [11:41]
Kara
I want to jump in and ask the framing question of how we go from problem solving to preventive care. So here's what I mean by that. So lots and lots of kids, not all, but lots, have pediatricians or family practice doctors who take care of them from the time that they are little itty bitty babies. And they generally do the care for those patients all the way through the end of their high school education. Sometimes through college. And there's this intersection of time when kids may need to see a gynecologist for any number of reasons. And they're still seeing those what we call primary care providers, even though I would argue that gynecology also has a very strong hold in primary care. There's this. It's interesting, it's both a specialty and very primary. But I'd love Nicole to bring you into the conversation here to understand when do kids see a pediatric and adolescent gynecologist for problems like when they're really young versus when do they transition to that care as they get older for relationship building and preventive care? And can you kind of walk us through the landscape?
- [13:08]
Dr. Nicole Tyson
Yeah, I mean, that's a fabulous question. And I think some of it depends on where you live and work. You know, we are far and few between us wonderful pediatric and adolescent gynecologists, there's probably about 200 of us in the United States and Canada. So in my dream fantasy, and someday we will be everywhere. And that's what Joe and I have been kind of revolving our career around. So when I started, there was one fellowship, and now there are 20 fellowships to train us. So it kind of, in terms of the landscape, it really depends on where you are. So one of the lovely things about being a pediatric and adolescent gynecologist is we fill a space where no one is. So pediatricians aren't as comfortable and excited about taking care of teens. Now there's some who are, like, fabulous, and they're kind of in their community and have built that. And gynecologists certainly aren't as comfortable taking care of young people and teens, although there are some who need to build that to sort of serve for their community. And so we are these little unicorns that fill that space. So we're very much loved across pediatrics and gynecology because we are knowledge experts. We have skill. We read Joe's journal. We go to these conferences. This is our world. And so we do see children who do get referred to us from all over the place for problems, you know, ranging from not having a vagina to their uterus, not being connected to torsion, things to period things to puberty, things to, I mean, a million different spaces where things kind of don't work. But we also see kids for some of this primary care. So maybe they're not comfortable talking to their doctor. Maybe they want a confidential visit and they can come find us and have that. Or maybe moms have had traumatic experiences and recognize that and bring their kids to, to us. When you look at kind of the big American college of OB GYN, so all OB GYNs, they recommend seeing a gynecologist for your first visit between 13 and 15. And so that, that may just be like a normative, hey, we don't need an exam. We don't want to traumatize you. We want to make this not scary. But I don't think there's any wrong or right H2Cs, you know, I think minimizing future trauma, advocating for yourself at a doctor, practicing being a patient, I don't think it's ever too early to do that.
- [15:21]
Kara
Can we dive into that age for a second? Because it feels to me like the recommendations really vary. They vary depending upon who you ask. They vary depending upon what the relationship is with that pediatrician or family practice doctor who, as you said, there are some who are extraordinarily comfortable with doing these exams and having these conversations. There are some, I would argue there are probably many who are not. You are, by the way, heroes to pediatricians. Like, let me just underline and bold that sentence and that sentiment, because you are the. All 200 of you are a small army of people who are willing, able, and capable of going places, having conversations that are very scary, overwhelming. The knowledge base is not really well understood among a lot of primary care people. So, like all that, I'm sitting here wondering, you know, when A child is 13, 14, 15, and is getting regular primary care and has a really good relationship with their physician, who's really doing the examining and asking all the questions, and the child is not sexually active in any way, like, they're all these, you know, if, if we want to build a little sort of a yardstick on one end is this kid who doesn't quote, unquote, need the services. And I'm curious about the recommendation. We can get to the ones who do need the services in a minute. But for the ones who don't, I'm curious about the recommendations. And how should a listener who has a kid in this age range think about getting their child the best care? Do they, do they need this care if nothing's going on? And they already have a lot of those pieces in place.
- [17:08]
Dr. Joseph Sanfilippo
First of all, it's a golden opportunity at that 13, 14 year old. And I also like to rephrase, and I like to use the term first gynecologic encounter because I want to remove that exam because that immediately, mentally, could be traumatic for your daughter. Oh, you're going to get that Speculum and it's going to hurt. And no, it's very rare that a pelvic exam is done on the initial visit unless, you know, very extenuating. Number two, just like I'm going to draw the analogy to a woman who wants to get pregnant, it's a good idea for her to have a preconception counseling discussion with her OB gyn. We're going to talk about timing of intercourse. We're going to talk a little bit about ovulation, cervical mucus. We're going to talk about being on prenatal vitamins and the importance of folic acid. All of this ahead of time. So that's what we're bringing to your audience and to that teenager. Okay. That preventive. Okay, she's not sexually active. That's fantastic. Excellent. We want you to know about the silent epidemic of chlamydia, where you can get a sexually transmitted infection and never know it. And then you want to get pregnant and you can't because your tubes are all messed up. We want to talk a little bit about painful periods. No, because your older sister and your mom had painful periods, it doesn't mean you have to have painful periods. I mean, I heard that beaucoup times over the years. And so there's so many things we can do for that teen. Okay. To make this entry into her gynecologic world arena a pleasant one. So that's my answer. Nicole has got a total different perspective, I'm sure.
- [18:57]
Vanessa
Do you have a different perspective, Nicole? Cause if not, I have a follow up question.
- [19:01]
Dr. Nicole Tyson
No, go ahead. No, I'm curious to hear your question.
- [19:04]
Vanessa
So that's sort of the vitamin version of going to see, you know, an adolescent gynecologist, which is amazing. In an ideal world, we would all do that. Then we get to sort of the, the medicine version. Right? The, the. Not the preventative version. And I want to just rewind the conversation a little bit because some of our listeners may not be aware you both made reference to someone who doesn't have a vagina. And unless our listeners listened to our episode about MRKH with a young woman who has MRKH and shared her story of discovering what was going on. Let's use that as a sort of case study for having a conversation, A, about what is mrkh and B, what does it look like when someone comes to you all because there's a problem or a worry or concern. So, Nicole, why don't you start. Start us on that journey?
- [19:58]
Dr. Nicole Tyson
Yeah, absolutely. And I think we could expand it if it's okay to not just mrk, no vagina, but maybe no open vagina. So we see them in two different ways. So we may see a little girl with no vagina who just hasn't started her period and she's 15 or 16, right? And so we kind of go through the story, which pediatricians do as well, and they'll be like, hey, we got an ultrasound, and lo and behold, there's anatomy missing. Right? She doesn't have a uterus, she doesn't have a cervix, she doesn't have a vagina, which, again, is not an emergency. That's just a conversation and we can discuss. So that. I think that is a really great space where we have a lot of skill because it's a very. It's like a cancer diagnosis, right? That's shocking for moms and kids and families. This has a lot of devastating consequences for people, right? To process. Like, in my body, I don't have this womb, and what does that mean for my future in childbearing and things like that.
- [20:53]
Vanessa
Can you just say how common this is? Because people may not be aware. They might be really surprised to hear you say this in a totally, like, matter of fact, hey, we got this kind of way. Can you just talk about some of the data around how common it is?
- [21:08]
Dr. Nicole Tyson
Well, I think. I think it varies because there's so many variants, but, you know, somewhere between like 1 in 10,001 and 40,000, looking at how it's built. And that's why I say there's also these forms where you can still build part of your anatomy. I kind of joke with my patients all the time. You know, we're just a bunch of tubes rolling around together in our mom's forming, and we need to, like, connect and resorb, connect and resorb. And sometimes we just don't. And so there may be parts of the uterus that forms form or things that are not opening and don't connect. And so girls may be collecting their period, but it has nowhere to go. And so they're in excruciating pain. And sometimes they'll see physicians who do interventions that are not great. Like, we don't want to do surgery multiple times. We don't want to disrupt good, healthy tissue. So finding the right procedure at the right time with the right doctor who can help stop all those periods until you're ready and poised and able to have these great discussions are really, really critical. So I think there's two different spaces where, you know, we are super important in A lot of these spaces at a really critical time. And that's where I see it is, I think, when you're thinking about when should a patient see PAG if they have no problem? So PAGs, pediatric adolescent GYN. I think that you have a valid point, Kara, like you can see your doctor that you have a great relationship to. And there are so few of us, and sometimes it's hard for us to get in those ones that are acute at a critical time. And so that's a little bit tricky navigating that. So there can be people who have what we call like a uterine horn with a remnant. So part of their uterus is hanging out to the side collecting blood and it has nowhere to go. So those are patients who may need surgery and who may need suppression of their period, stopping their period. So that can present a little differently, but those come to us in a problem way.
- [22:54]
Kara
Yet can you walk through a couple of the more common scenarios or diagnoses that are urgent versus ones that are not? Because all of this can feel very urgent to the family. So can you help people distinguish.
- [23:09]
Dr. Joseph Sanfilippo
Well, I wanted to take that and maybe step back just a little bit. Okay. And now we're in the scenario where your daughter, your teenager is in the office. First of all, they have to hear and understand the word confidentiality. And I think your audience has to understand that. What you know, and forgive me, I'm preaching to the choir out there. But what is said is between the teen and the provider, the teen and the pediatric adolescent gynecologist. Okay. And the teen should be comfortable saying, I am worried I have a sexually transmitted infection. I don't want my parents to know I'm sexually active, et cetera. So confidentiality is one thing. The second thing is back on that initial encounter to talk about how do we prevent sti? You know, I'm one more time old fashioned. I always talk about belt and suspenders. You're on a birth control pill, but use a condom because one day you're going to want to have kids. And if you contract a sexually transmitted infection, they may not be possible. So those are the kind of things. Now back to your question. What do we see? Painful periods is a super common thing. And what's the mechanism of action? And back to the science. We know prostaglandin is the key word. What does that mean? It means the uterus produces this substance and it basically has the uterus contract and it's painful. So if that's the problem, how do we prevent synthesis of Prostaglandin, well that's with a non steroidal anti inflammatory agents NSAIDs. Okay. Ibuprofen are taken, but they gotta be taken the way I prescribe it is let's say with regular periods, three days before onset of the period and then into the period, you want to prevent synthesis, you want to prevent levels of that. So that can be the saving grace. Or sometimes we put somebody on birth control pills because they have painful periods, because you eliminate the ovulation piece and they're pain free. So these are the again, more common things. Granted there's the entity of endometriosis and maybe I want to just save that for a minute, but those are the more common things. And Nicole, maybe what's your practice like?
- [25:30]
Dr. Nicole Tyson
No, I mean I, I think that you have a really great point that goes back a little bit too to what Cara was saying is when do you see an OB gyn? And that when you talk to teenagers, they don't talk to their pediatricians the same way they talk to their OB GYNs or to us. The pediatrician is kind of for the parent, right? They interact with the parent and then the kid is there like as a byproduct sort of. But when they come to us and pag, the parents are the byproduct and in front of us is our patient because we're trained as gynecologists. So you know, in my dream world, which doesn't happen as often anymore, I see the child first. So you know, the 12 year old, the 14 year old, the 16 year old, I'll see them by themselves, introduce, let them speak, kind of advocate for themselves, have that awkward, ah, I don't know what I'm doing. But we can grow together and then bring the parent in. And I think that is a huge place for medical literacy for young people. Whereas I don't know about you, Joe, but I was, when I was doing obstetrics, I don't deliver babies anymore. But when I was, it was not unusual for me to see a 30 year old pregnant woman with her mom doing all the talking.
- [26:38]
Dr. Joseph Sanfilippo
Oh yeah.
- [26:39]
Dr. Nicole Tyson
Now new mom to be has no skills at talking to a doctor. We need to like work with our young people to be strong and wise and say this is my body. And I do think that's a cool place to see Pat is we empower and we enable and we teach that medical skill and literacy from a very young age.
- [26:56]
Vanessa
Right. So there's the skill building involved in being self advocate and being in charge of your health Care and building relationships with healthcare providers. I want to name the sort of unnamed situation 1 Joe, you. You raised sort of obliquely, which is like a kid may be sexually active and the parent doesn't know, and some of what may be going on may be the result of a sexually transmitted disease. So that's one thing. There's also the concern that a child is being sexually abused or is being sexually active in a way that is not just concerning because they're not using protection, but is dangerous to them in other ways. Can you speak to the sort of critical and special role you can play in those circumstances?
- [27:43]
Dr. Nicole Tyson
I mean, I think that that's kind of a really special place that we work in a lot is, number one, helping to have those conversations. You don't, you know, dive in with someone you're just meeting and say, all right, are you having sex? What position? Penis? Vagina toy? Male, girl? You know, it's. It's learning how to get that kind of interview skill and warming up. And it may or may not happen fluidly, but then getting to some of the risk behaviors that make you concerned and disclosing honestly what you need to share, you know, if you're a risk for yourself or going to harm others, and then talking about the sexual health. And there, you know, there are people in my world all around who are, you know, victims of self trafficking or, you know, maybe family members. It's a very tricky world we live in. So sometimes it's very dark and very sad. But we've learned these interviews techniques. We've learned what to do with interview information that you get, like depression and suicide. Nobody wants to ask about depression or suicide. It's a great analogy because then what do you do? So we all have social workers and psychologists and resources, and if we don't have them, we still have those skills ourselves. So we can navigate how to keep these girls safe and how to not breach confidentiality, but then, you know, be honest about when we need to. And I think those are tricky scenarios, but we see them a lot with young people.
- [29:06]
Kara
I think it's important to jump in just with two side comments here. One is about how it's not that pediatricians shouldn't do this. It's that they haven't really been trained to integrate this type of conversation, interviewing and care into their practice. But many have, and they have in large part because they see the disservice of not doing it. And because if you're sitting here listening, thinking, well, wait, girls get this and boys don't, where do boys get these conversations? It's the right way to be thinking. And this is why pediatricians and family practice doctors need to evolve to include so many of these skills. I figure I'm just saying what you're thinking, the little thought bubble in your head, but it's really an incredibly important set of clinical skills to have. So that's just one comment I want to throw in there. The other is just a clarifying comment about questions about sex. Insofar as when Vanessa and I speak or when we put up a social media video and we talk about something, like when someone has a conversation about sex, so often the audience will assume that, okay, your role is to have conversation about sex. And therefore, any conversation you, Nicole, or you, Joe, have with my child will automatically have content about sex. And I just wanted to make sure to make crystal clear to the listener that you have a lot of clinical conversations with your patients that don't have to do about sex with sex. That you might be seeing young kids who have diagnoses like an ovarian cyst or an ovarian torsion or endometriosis. And I would love for you to speak about this where it's appropriate to take a sexual history. But the conversation may end after one question, and then the rest is about what their body is doing and not what they are doing with other bodies, because that's just not relevant to the situation. Will you explain that so that you can help people whose kids are maybe not sexually active understand the value of your care and the relationship with someone like you?
- [31:27]
Dr. Joseph Sanfilippo
I'm looking this. Kara has two questions. Okay. And let me step back to the first one. Okay. And your audience needs to know several things. Now, number one, obviously, we do four years of med school and four years OB GYN residency. A pediatric adolescent gynecologist does two additional years. Okay, so that's six years after med school now, where the medical and surgical aspects of pediatric adolescent gynecology are required. So. So training is different. Number two, as Nicole stated that there's not a lot of pediatric adolescent gynecologists. However, our North American Society of Pediatric Adolescent gynecology is almost 500 providers. Now, they may not all have gone through formal training, but they are qualified in my opinion, because they come to conferences and they know they learn those skills that we were just talking about. So the audience needs to know a regular OB gyn, especially if he or she is a NASPAC member, has those skills. Okay, then to go to your second question, we are trained. Again, we're in the middle of writing another edition of a. Of a textbook. And I'm gonna show this, just. If that's okay with you. And it's basically goes through all of these things. For instance, there's something called heads and other things where the provider, whether it's pediatric adolescent gynecologists, or it's a nurse practitioner pa Goes through, are you safe? Do you feel safe? What about home? All of that kind of stuff. Okay, so just like you said, yes, sex is part of it, but it is even kind of low on the tower pole. All right, but again, if you're going to become sexually active, think about your reproductive organs. Protect them, okay? Condoms, okay? That's your best protection against STIs. I will now turn it over to Nicole.
- [33:30]
Dr. Nicole Tyson
Well, and I was going to say, Carrie, I think one of your comments sort of alludes to the idea that, hey, if we're going to talk to your kids about sex, we're going to expose them to these ideas they wouldn't otherwise have, and maybe they're going to have sex. And what we've actually learned through some great studies about sex education is that's the opposite, right? So we kind of assume everyone tend to have sex because humans have sex. And we probably have sex a lot earlier than our parents want us to have sex. And a lot of high school students are having sex. We've done so many surveys. We're really bad at using Joe's suspenders. We're really bad at using all kinds of birth controls. You know, what happens is you get a pregnancy scare, the boy or the girl, and then, lo and behold, they show up at your office, right? Like you're a pediatrician. So I think having those conversations are actually great because they're sometimes hard to have with the parent or trusted adult. So that doctor who you're seeing for a torsion could be that trusted adult for your kid. And it may not be even right now. They're like, roll your eyes. Oh, my God, Dr. Tyson. Like, I, you know, a month later, they come in your office like, oh, my God, you know, I met this guy, and all of a sudden the door is open for that conversation. And you've just really prevented something horrible, right? Like an ectopic pregnancy, chlamydia infection. I had a little girl who, you know, got gonorrhea and found out through the pediatrician. And again, these. All these conversations were not happening. So I would just say kind of assume that and have open and honest conversations as a parent and as a doctor, right?
- [34:59]
Vanessa
I mean, sometimes there's stuff going on with kids and we can't quite put our finger on what's going on, but the spidey sense is telling us there's something going on. Right. And what I hear you saying is you all are trusted folks to go to, not because you have necessarily a specific issue. And obviously that's part. We're going to get into some of the specific issues that people may, may come to you about. But also you are trained in interview techniques. You are trained in addressing this stage of life in kind of broader, more curious, less judgmental ways. You are trained in navigating the ways in which they need support and resources, but don't always know exactly what support and resources those are. So, I mean, it's the story that I, that I always like to tell, which is like parents of a friend of mine who was a professional in this field had a conversation with her 10 year old about porn and everyone was aghast. Oh my God, this is now several years ago. Oh my God, you're talking to your fifth grader about pornography. So she, she girded her loins and had the conversation, and lo and behold, what happened. Sorry for the terrible pun.
- [36:16]
Dr. Nicole Tyson
Girded your loins. It's been a little while for that.
- [36:18]
Vanessa
I know. She.
- [36:20]
Kara
Vanessa's 150.
- [36:21]
Vanessa
I know. Apologies for the biblically pornographic reference. Her kid came back to her a week later and it turned out he had been exposed to porn and it was only because she'd had the conversation. I think of you all as a similar resource where it's like you're not really sure when your kid is going to need or how they're going to need you, but they're going to need you most likely in one way or another. And I want to just use that point as an entree into some of the ways in which folks might need you.
- [36:54]
Dr. Nicole Tyson
Right.
- [36:54]
Vanessa
We talked about building medical literacy. We talked about learning how to build independent relationships with healthcare providers. We talked about the ways in which kids are making some interesting decisions or they may be in scary situations. Right. Those are some, some examples. I want to talk about two specific examples and we can build on that. One is a kid is considering becoming sexually active. They are not yet sexually active, and IUDs are all the rage these days. And there's lots of misinformation about who will give you an IUD and can you get an IUD and what needs to happen before getting an iud. Right? So that's one place where I'd Love to sort of get rid of some of the misinformation and clarify and then we'll get into some of the PCOS endometriosis conversation. But if you can start with the IUD convo, that'd be great.
- [37:48]
Dr. Joseph Sanfilippo
How about we divide and conquer? If Nicole is willing to take the iud, I'm happy to take the polycystic ovary approach because that's more my line of reproductive endocrine.
- [37:59]
Dr. Nicole Tyson
Perfect. Okay, I'm happy to take. I love the IUD misinformation. My, my patients are like a mecca of Reddit and a hundred percent social media. And I know what's out there. But I mean, I think what's really come to pass is that it does hurt. I mean, it's uncomfortable to get an iud and it is really not. It doesn't behoove us to say it's just a little pinch. It's going to hurt for a second. It's no big deal. Toughen up, relax. Like we've learned that it's kind of not great language. It's sort of this trauma language. It's minimizing, diminishing women, I think, looking to ways to validate and minimize pain. And some women, I'll be honest, like go through that IUD like a breeze. And some people don't. And it isn't always age related. Right. Like some of my 45 year old patients when I was doing adult gynecology was like, it was like they gained birth and I'll have the same day of 14, I'll be like, what was everyone talking about? It was fine. So it really is an individual experience. I don't think anxiety helps it for anyone. So kind of having a counseling opportunity to talk through it. We do have a lot more pain modalities available both in the office setting and with anesthesia or even sedation. So it's something you'd have to individualize with the person and then the provider who's going to place the iud, when I'm sure Joe can speak to this. Because when I first started out as a doctor, the idea of putting an IUD and I would talk about this at conferences and people would like throw food at me and oh my God, like they were up in arms, I kid you not. So it just was a lot of bad information in the 80s, really not great studies at different IUD. So spending some time, kind of like estrogen, spending some time demystifying these studies and how do we go like going crazy over this one set of facts to Liberalizing it in the way that we have today.
- [39:54]
Vanessa
And Nicole, one of the pieces of information circulating Amongst, you know, 16, 17, 18 year old girls is you cannot get an IUD if you've never had sex before.
- [40:04]
Dr. Nicole Tyson
Garbage talk. Yeah. That's so 70s. No. Anybody? I mean, I put IUDs, you know, I, I take care of kids who have bleeding disorders so they have a horrendous period. So little girls will show up with a bleeding disorder upon their first period and get eight units of blood and pass out in the shower and have horrible periods. And we will put IUDs in these 10 and 11 year olds, most often with anesthesia. And they do miraculously well. It's amazing. So little people who've started their periods can also get IUDs. And so that, that is no longer the case. And that come that myth comes from, oh, you're going to get pid. It's going to crawl up your uterus and out to your tubes and you'll never be able to have babies. The reality is what Joe is saying, don't get chlamydia because chlamydia crawls up your uterus to your tubes and causes scarring, not your friendly iud. So I think just demystifying what that kind of mythical talk is about is really informative.
- [41:02]
Kara
We'll be right back, but first a word from our sponsors.
- [41:07]
Dr. Joseph Sanfilippo
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- [41:13]
Dr. Nicole Tyson
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Kara
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Dr. Joseph Sanfilippo
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Dr. Nicole Tyson
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Dr. Joseph Sanfilippo
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- [41:37]
Kara
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- [41:39]
Vanessa
That's why this matters.
- [41:41]
Kara
TikTok Shop has a huge selection of products with surprising deals. You don't expect affordable fines for everyday life. Download TikTok now. Nicole, another one with IUDs is that a lot of kids who older teens and young 20 somethings who go to get IUDs placed are being seen by generally adult, adult gynecologists who ask the patients, hey, do your own research and come in and tell me what you want. Which I feel like has created its own disastrous situation for all the reasons. And I'm wondering if you might be able to give some guidance on how much the kids should actually know and be researching on their own. And if the onus is on them, do you have resources for them where they can go to get good information, not information from let's say the manufacturer of a given IUD or from TikTok.
- [42:47]
Dr. Nicole Tyson
I. I mean, I think no matter how we. How we want to slice or dice that patients come in having already done their AI searches, their chatbots. It used to be just talking to, you know, it's like talking to moms and aunties and friends, and now the expanse is much, much broader. So I don't think we're going to say, don't read about it. And I actually think we know that there's this lurking population out there, right? They don't really get involved with the chats, but they read and they lurk, and those patients actually come in more empowered and with less anxiety. The lurking's not a bad thing, but we kind of need to know where they're lurking and help them find the good data and it's out there. So, I mean, some of the great websites for, like Joe said, NASPAG is a great one. Our own website, we have great patient handouts, Bedsider, Planned Parenthood actually has a pretty darn good website with a lot of videos. If we email afterwards, I can give you guys an extensive list. As you would imagine, I share with my patients routinely because it is important to find good resources. But I mean, some of the hard and fast tricks is if someone's selling something, it's not going to be helpful, right? Like, you need to take this turmeric before this. Like, that's not half the time you look at it. It doesn't even have turmeric and we don't even know if turmeric helps iud. So, like, be skeptical of the people selling and making crazy promises. And I think it is okay to go to the doctor, and your doctor should explain what they're doing and what it's about and the pros and cons and taking that time. It's hard, right? Sometimes visits are tight, but you need to find a fit if you're going to have someone do something to you. It's just like getting your wisdom teeth. You wanna know what's going on in my mouth? You should also get to know what's going on in your vagina and have that conversation with your doctor. I think you're entitled to that.
- [44:31]
Kara
That's right. I mean, asking for what you need as a young person is extraordinarily important, and it's a skill that needs to be built. I just wanna close the loop on this and then we'll move over to pcos, Joe, and get into that. But I wanna close the loop on this. And circle back to a comment you made earlier, Nicole, about how information actually delays experimentation, which is something that Vanessa and I. It's like the most common sentence to come out of our mouth with regard to almost everything that we talk about, but sex being one of those things. We know that the more information people have, the more empowered they feel. You bring up an excellent point that there are lots of different places they can get that information. Some is good, some, some is not good, and it's teasing it apart that makes all the difference for these kids. And if you're listening, wondering, well, I don't even know where my kid is getting their information. The advice that we would give is just start getting into conversation. Ask them, where are you getting your information? Tell me what you're learning. Like, I'm so curious. I would love to know. And it's. It's an amazing thing when kids actually, when they walk into your office, Nicole, and they have all the Reddit threads up there, you know, parents and trusted adults at home can get that same information if they just ask. And then you can start to get curious about what they're learning and how reliable the resources are. And you can also come to understand where they're getting this really wrong information, because they, they do. They need that from us. It's like. So, anyways, okay, enough of that. Joe, take us to pcos.
- [46:20]
Dr. Joseph Sanfilippo
Absolutely. So now I have to put. Take off my pediatric adolescent gynecology hat and put on my reproductive endocrinologist hat. And I have a lot of hats, but that's another story. Okay, So I think, again, your audience should know when it comes to polycystic ovarian syndrome, there is so much new research, and, and it's, it's refreshing in a wor. So let's take the scenario of a teen who has acne, cystic acne. And obviously, you know, psychologically, that that takes its toll. Right? So one of the things, whether it's pediatric adolescent gynecologists or OBGYN or whomever or pediatrician, you need to understand, I always say, put yourself in that teen shoes. You know, what does it feel like now? The important thing is that a lot can be done for polycystic ovaries and acne. Okay. Now, sure. Frequently we work with a dermatologist, and they have many great things, everything from topical, et cetera. Accutane comes to mind. The fact that if you go on Accutane, you don't want to get pregnant because it's so called teratogenic. That's Important. And birth control pills per se can be beneficial. And the reason for that is it lowers the blood circulating levels of male hormones, testosterone. Okay, that's a bad guy. So if you can take a birth control pill, you lower the so called free testosterone level and have a beneficial effect on the acne. And by the way, while we're talking about birth control pills, I always emphasize to the students, you know, I always say you're a salesman, okay? You have to sell the patient that the pills are worth taking. So they need to hear that your chances of ovarian cancer are cut in half. Your chances of endometrial uterine cancer cut in half. There's some data about colon cancer, maybe not 50%, but lower incidence in addition to preventing ectopic pregnancies, anemia and painful periods, all those kind of things. So, sure, there are potential complications on the pill, but there's also some benefits. So back to the story. So the polycystic ovary teen can benefit from things like birth control pills and spironolactone. Spironolactone is really. It's a blood pressure medicine, but we use it off label because it too seems to have a beneficial effect on lowering that circulating male hormones, androgens. Okay? So all of these things are rays of hope for that, you know, distressed, if you will, teen. So if you have acne, sure, you want to work with your dermatologist, but one more time, the pediatric adolescent gynecologist or your OB gyn, again, the NASPAC members can help you, okay. Because you want to come full circle. So that's something that I would have them think about.
- [49:24]
Vanessa
Joe, can you talk about ovarian cysts and torsion? We talked about it early in the episode and people may not be aware of how common it is, what causes it, what kind of treatment to seek, and why it's so important to get good help.
- [49:44]
Dr. Nicole Tyson
Right.
- [49:45]
Vanessa
The right help when dealing with these issues. Because there's a knowledge base that specialists like you may have that other healthcare providers may have less depth of knowledge.
- [49:57]
Dr. Joseph Sanfilippo
Yeah. So the scenario would begin with pain, usually unilateral. And occasionally there's radiation down the involved extremity. Okay. But that's not always the case. So the scenario becomes pain relief of pain. And the relief of pain is. It twists and it untwists. It twists and it untwists. So that scenario, hey, I got a really extenuating pain, but now it's a little bit better. But now it's back. Red flag, okay? Very important red flag. To think about. Okay, so what's going to happen? The teen or whomever is going to go with their mom, probably, or parents to the emergency room or go to mom's obgyn, et cetera, et cetera. Well, here you want to conduct a conversation with the potential operating surgeon. What are you going to do? Why? It's more commonly associated with a cyst. It twists. Can't untwist. Okay. That kind of scenario. Now, where I'm leading with all of this conversation is untwisting. A torch, ovary or ovary and tube is usually almost always. Almost. Almost. Almost always not detrimental. We used to think, oh, it's going to dislodge a blood clot and it's going to be terrible. Forget that. That's. I don't want to say it's nonsense, but it, it's not. Not valid. Okay, so you want to have a surgeon who's going to be conservative and untwist that perhaps remove the cyst and kind of go from there. I mean, that's the ground level.
- [51:29]
Vanessa
Okay, how do you know, like, couldn't it be appendicitis? How do you know to even go to a gynecologist to begin with?
- [51:37]
Dr. Joseph Sanfilippo
So there'll be several aspects to that. One could be an ultrasound. Number two, we look at white count. Okay. And certain blood parameters. And then you look at the whole clinical situation. That's usually the way it unfolds.
- [51:50]
Vanessa
If it is torsion or if it is a cyst, what happens if it's a bur cyst versus, like, how do you then make a determination about what to do?
- [52:01]
Dr. Joseph Sanfilippo
And the best answer is? It depends. Okay.
- [52:04]
Vanessa
Always the best answer. And the least satisfying. Yes, continue.
- [52:09]
Dr. Joseph Sanfilippo
Okay, so if it's a cyst and it spontaneously ruptures and there's no bleeding, it may be a self limited problem. Okay. That certainly can occur. Bleeding. Well, that can be. That's more of a surgical, I have to say, emergency or emergent intervention. And by the way, the surgery we're talking about is laparoscopy. We're talking about a little belly button incision with a telescope in the abdomen and maybe one or two, I always say, quarter inch incisions in the lower abdomen to get the job done. We're not talking about, you know, days gone by where it's a laparotomy. No, this is going to be minimally invasive surgery. You look at the clinical situation again, maybe pain, relief of pain, pain reoccurs those red flags. Okay. And then the clinician Would initiate the evaluation, ultrasound, lab tests, figure it all out and so on. But emphasizing that chances of removing that ovary are low. Okay. And I would have that conversation a priori with the operating surgeon. Now, that may not be possible. Don't get me wrong. Okay. But usually untwisting provides the viability back to the ovary. And you can save it.
- [53:25]
Vanessa
Right. The danger. Can you just be really explicit about the danger of a twisted ovary that is not addressed?
- [53:34]
Dr. Joseph Sanfilippo
Well, then the blood supply is cut off. Okay. And then that ovary, basically necrosis, it could die. Okay. That. That would be the worst case scenario kind of thing. Sometimes we think some of that business rarely occurs in utero. Okay. All right. That's another whole story. But suffice to say, the important things for your audience is if you're. Your teenager shows up with a lot of pain, okay. With any of those scenarios, get them to the emergency room, get them to your ob gyn, prompt them, okay. Because the sooner the better for intervention. And again, Nicole is front and center with this too, if you want to add to that in any way.
- [54:18]
Dr. Nicole Tyson
Yeah, I mean, I would say all of that is very true. It's just a little confounding sometimes because we make an ovarian cyst every month. Our little rai specialist Hill would tell us, right. Because that's how we ovulate. And so ovarian cysts are very normal. Anytime we do an image of someone who's ovulating, you're going to capture a cyst forming, rupturing, resolving. And so that's a little bit confusing. And we also have taken, I'm sure Joe and I combined many, many girls to the operating room for really bad constipation. So I think some of these pictures can be really cloudy, and ovarian torsion is really bad pain. So, you know, when boys towards their testicles, there's like noises you just have never hear in the normal world. And so girls tend to be like in the fetal position, sobbing. So it's not like, oh, my tummy hurts. It's like they tend to throw up. Because that's kind of how girls respond to pain. It's. It's miserable. Those ones, you don't want to be like, oh, it's a tummy ache, you know, I mean, those things can happen. And children contours. You don't have to be having periods. But I think those are situations that if your doctor just thinks this is a torsion, after the emergency room evaluation, tell them not to take that opium Just, just flip it. Say, I listen to this podcast. Just flip it. They can take the cystic fever. Just untwist it. We'll work it out. Like, that is a really great answer because there are a lot of places in the world where they still take out the ovaries. And sometimes girls who twist will have a propensity twist again. Then you're out of an ovary, right. And then you've got problems. So we're double built, which is great, but we don't want to compromise those ovaries.
- [55:59]
Kara
And just to explain your constipation comment, because I think it's really important for people to understand. Constipation can cause tremendous pain. Kids can be doubling over in the emergency room in the corner, sobbing, crying, and we have all these wonderful imaging techniques out there, but you can't always see what's going on. And if you think, think there's a risk of losing an ovary, a surgeon may say, we've got to take this kid to the operating room to make sure that we're doing the right thing. This is analogous to getting your appendix out. And, you know, when I was in training, you know, there was always taught that between 5 and 10% of all patients who went to the OR to get their appendix out should have a normal appendix. And if that's crazy to you. No, think about it like, right, it's the way that doctors can gauge am I over calling or under calling? What's going on. So if you have a kid who went to the operating room because of a torsion and it turned out to not be a torsion, do not be mad. I mean, I get it, it's frustrating, but, like, that's why, that's why you hear it.
- [57:10]
Dr. Nicole Tyson
You're full of poop.
- [57:15]
Kara
That is not the sentence, Nicole.
- [57:16]
Vanessa
I was going to say that. That's so refined, Nicole. So let's end with a little endometriosis. Not because it's so little. It's a very important big topic, one which we're continuing to hopefully learn more and more about, but because people may not realize at what age it starts to affect young women and how they can or should get help or support. So give our audience a little bit of baseline knowledge about that.
- [57:46]
Dr. Nicole Tyson
Well, I mean, I think that there, you know, there's period cramps and period pain called dysmenorrhea, and Joe is alluding to that. That's our uterus causing us misery. Probably 85% of us with uteri have this experience. It's prostaglandin mediated. And the first line treatment is hormonal birth control in all the different forms that it comes to. Either have fewer periods, lighter periods, skip periods. But it doesn't mean that you should just go off into the yonder and say, still suffer. So if you're using medical treatment and you're not getting better, adolescents for sure get endometriosis all the time. This keeps me in business until we have a better way to diagnose and treat. And most women who've had endometriosis look back and have suffered for 7 to 10 years. Right? Like that is the Moreau sad story. So missing school, missing life, missing out on activities, on the weekends, it's just. It's kind of paralyzing. But there's this overarching fear of hormonal treatment. Right? Like this. This is. The dichotomy is, well, this is normal. I had bad periods. I don't want her to take medicine. This is life versus, well, it's bigger than life sometimes because perhaps we could help mitigate the consequences down the road for them and get them back to their activities in life. Because chronic pain also elevates other chronic pain. And so once you kind of reach this pain platform of endometriosis pain, then there can be migraine pain and belly pain and back pain. And we don't like to manage all of these pains. And then the longer that goes on this cycle. So it's the real deal. And I would say absolutely, if there's these kind of issues where the kiddo is out or suffering or even using medicine for their period pain, like come talk to your gynecologist, pediatrician, us, and then when they're not responding to first line treatment, then come see a PAG specialist because we will diagnose them. We typically do the camera surgery in young peoples to get a diagnosis early, know what we're dealing with. We don't have great blood tests, we don't have salivary, we don't have an FDA approved in these other arenas. And some of the bigger gun treatments for older women can impact the development of young girls bones. So we don't launch into that in the same way. So it's a little complicated. But I would say the biggest myth out there we probably all have heard and can agree with is you can't get it as a teen. It's just not going to happen. You're faking it. Just stop being dramatic. Take your motion, you know, get a heating pack. And there are really great alternatives, right? There's Tens, units and maybe certain yoga poses. But, like, to a point, right? To a point.
- [60:24]
Dr. Joseph Sanfilippo
Yeah. But failure to respond to the medical therapy is, again, the red flag. And that we have to go to the next level. And that's. That's the problem where that doesn't happen. And the girl, the woman suffers before the diagnosis is made. The patient is seen. At least four physicians. Okay. I mean, all kinds of things. And so think about that. There is one other thing I did want to bring up, if that's okay, and that's the topic of fertility preservation. And in a nutshell, if anyone out in your audience has the. The misfortune of a cancer diagnosis, they need to think about, as soon as the diagnosis is made, is preserving their eggs or their ovarian tissue, et cetera. This is not always brought up.
- [61:13]
Vanessa
Okay.
- [61:14]
Dr. Joseph Sanfilippo
And you, the patient, or you, the parent, should bring it up. Well, what about her future fertility? Because one day she can have her own genetic, biological child if she froze her eggs, if she froze ovarian tissue. And that's something that I just think, you know, it's not. Not commonly discussed, but I just wanted to put that out there because, you know, your audience should put that on a back burner and hopefully never, ever have to go there. But that technology is here.
- [61:48]
Vanessa
Yeah. We did an episode with Dr. Jamie Notman, who's got a book coming out, actually, called Future Fertility, and she goes into a lot of depth. But it's really important in the context of this conversation and in the context of, God forbid, a cancer diagnosis, for example, that this is on our minds, even though we have so much else on our minds and so many other worries, just keeping it. Keeping it out there. I mean, really, I wish you could stay with us for many, many, many hours, and we can.
- [62:19]
Kara
She wants you to move in.
- [62:21]
Vanessa
So many questions, and I know our audience does, too, but we were lucky to get both of you on with us for even this amount of time. You are two very busy people doing incredible work in the world, and it's such a joy. It's kind of like when you get to hear your favorite musician live in a small bar. You're like, this is the best thing ever. So for me and Cara, listening to the two of you, it's the equivalent of like hearing Bruce Springsteen in a bar with, like, 50 other people.
- [62:53]
Dr. Nicole Tyson
Okay, so that's a big honor. Well, thank you. Joe and I hanging out feels like that's too. It's really.
- [63:00]
Dr. Joseph Sanfilippo
Amen.
- [63:01]
Vanessa
Yeah. I mean, it's like it's the allman Brothers. Just, you know,
- [63:05]
Dr. Joseph Sanfilippo
can I say one other thing?
- [63:07]
Vanessa
Yes, please.
- [63:08]
Dr. Joseph Sanfilippo
We have a book entitled Everyday medical miracles. And Dr. Tyson has a, has a story, and this is 60 all true short stories by healthcare providers. And your audience can get a lot of, again, a glimpse into what we do day in and day out and our most interesting and challenging patients. So for what it's worth, Everyday Medical Miracles, it's on Amazon. It's on book. Book, baby.
- [63:36]
Kara
We'll put a link in the show notes to that for sure.
- [63:40]
Dr. Joseph Sanfilippo
Thank you.
- [63:41]
Dr. Nicole Tyson
Thank you.
- [63:41]
Vanessa
So come come back and visit us when your schedules clear up in 2028
- [63:46]
Dr. Nicole Tyson
and oh, you guys are funny.
- [63:50]
Dr. Joseph Sanfilippo
We would be honored. I'm serious. This has been a delight. Thank you.
- [63:53]
Vanessa
And I know we're going to get a lot of questions from folks, so please share stories. Questions. This is a corner of medicine that many people don't know about. And we're really, really happy to help shine a very bright, joyful light on the amazing work that you both do. And everyone has a new acronym, Knapsack. I mean, it's like, you know, it's like knapsack, but not.
- [64:23]
Dr. Nicole Tyson
And we actually, I think mine's backwards. We have our own textbook too.
- [64:27]
Vanessa
Oh, that. It looks, I think it shows up the right way. Nicole naspect. Yeah.
- [64:35]
Dr. Nicole Tyson
Do you see the beautiful art on
- [64:37]
Vanessa
the COVID I was going to ask you about that art.
- [64:39]
Dr. Nicole Tyson
My daughter is actually an ENT resident and she's a gifted artist. Incredible. So I said I'll do the book with you all. So I'm one of the editors, but I get to design the COVID because I wanted a book that was more friendly to what the work is that we do.
- [64:55]
Vanessa
That's amazing.
- [64:56]
Dr. Nicole Tyson
Textbook, right? And that's fun.
- [64:58]
Vanessa
That's amazing.
- [64:59]
Kara
It does not look like homework.
- [65:00]
Vanessa
It doesn't look like homework.
- [65:03]
Dr. Nicole Tyson
But I think for those of us who have to take exams every year and do all that work, it is for sure homework.
- [65:09]
Dr. Joseph Sanfilippo
Amen.
- [65:11]
Dr. Nicole Tyson
Well, thank you guys, have been lovely podcast hosts.
- [65:14]
Vanessa
Thank you folks.
- [65:14]
Dr. Nicole Tyson
Thank you very much.
- [65:16]
Dr. Joseph Sanfilippo
Appreciate the opportunity.
- [65:18]
Vanessa
Thank you so much for listening. You can email us with questions, feedback or Episode requests@podcast.com if you want to
- [65:28]
Kara
learn more about what we do to make this whole stage of life less awkward for everyone involved. Our parent membership, our school health ed curriculum, our keynote time talks, and more are all at Less awkward. Com.
- [65:44]
Vanessa
And if you want products that make puberty so much more comfortable, visit myumla.
- [65:51]
Dr. Nicole Tyson
Com.