Professor, Department of Obstetrics and Gynecology

Paula J. Adams Hillard, MD

Via Zoom, participants viewed plenary sessions that profiled some of the most topical issues in treating this patient population. The topics included a focus on telehealth in PAG with Veronica E. Issac, MD; the latest research in our surgical field from Peter C. Minneci, MD; and an update on COVID-19 with Denise J. Jamieson, MD, MPH. Tanya L. Kowalczyk Mullins, MD, MS, presented on pre-exposure prophylaxis (PrEP) for the prevention of HIV among adolescents and young adults. 

Ob/gyns who are interested in learning more about the gynecologic care of girls and adolescents may wish to save the date for next year’s NASPAG ACRM—

, in Chicago. I anticipate that it will be another wonderful opportunity to take a deeper dive into the topic of PAG. 

Ted L. Anderson, MD, PHD, provided an overview of adnexal masses in the PAG population; Jennifer E. Dietrich, MD, MSc, reviewed Müllerian anomalies and their management nationally and internationally; and Sophie Soares and Lisa Polen of the Population Council presented on “Intentional Design: Employing a Global Evidence Base to Promote the Space, Access, and Agency of Adolescent Girls and Young Women.”

Open discussions with our LGBTQ patients remain more vital than ever, especially as overreaching state governments are passing laws that affect how practitioners can care for these patients. One of the most notable workshops was titled “LGBT Health: The Need for Sexual and Mental Health Screening.” M. Brett Cooper, MD, and May Lau, MD, talked about the risks for sexually transmitted diseases, as sexual minority individuals who have sex with different and same-sex partners have higher odds of sexual risk-taking behaviors. 

Both transgender males and females were noted to have risks related to engaging in condomless sex. According to the presenters, the Youth Risk Behavior Survey (YRBS) revealed we are not appropriately testing sexual and gender minority youths for HIV and other sexually transmitted infections (STIs). The American College of Obstetricians and Gynecologists, the US Preventive Services Task Force, and the Centers for Disease Control and Prevention all recommend gonorrhea and chlamydia testing annually for sexually active females and from adolescence through the mid-20s for those possessing a vagina. 

The presenters discussed recommendations regarding HIV testing for youth at increased risk (unprotected sex, multiple partners), and noted that rapid (20-minute) oral swab testing is more adolescent- and youth-friendly than tests requiring blood samples. According to the presenters, the components of a supportive environment in caring for adolescents and youth include asking patients their preferred name and pronouns, making sure to spend time alone with the adolescent, providing assurances of confidentiality (within the legal confines of each state), avoiding heteronormative questions, normalizing behaviors, and asking patients to clarify if they used terms the clinician didn’t understand. 

The presenters also emphasized that anxiety and depression screening is critical among transgender and gender nonconforming youth, as the 2019 YRBS found that more than two-thirds of LGBT students felt sad or hopeless most days, about 47% reported that they had considered attempting suicide, and 23% actually had attempted suicide.

Another valuable workshop addressed how to incorporate trauma-informed care (TIC) into a clinical setting, and was presented by Heather C. Millar, MD, with Sharon Lorber, LCSW, and Heather Farina, NP. Our understanding of childhood abuse and trauma comes from a seminal report of abuse, neglect, and household dysfunction that described adverse childhood experiences (ACEs). These have subsequently been found to be highly correlated with such conditions as depression, early sexual activity, IV drug use, smoking, and an increased risk of having an adolescent pregnancy. Within our field of gynecology, ACEs and childhood trauma are associated with an increased risk of chronic pelvic pain, dysmenorrhea, dyspareunia, STIs, pelvic inflammatory disease, and premenstrual syndrome or premenstrual dysphoric disorder. 

Thus, we will all see patients with a history of trauma, emphasizing the need for TIC in our practices. TIC has been associated with increased adherence to medications, reduced substance use, improved physical health outcomes, and decreased burnout for staff. Trauma memories can be triggered by a number of components of our gynecologic practices, including vaginal exams and childbirth. But they can also be triggered by seemingly innocuous medical exams such as blood pressure evaluation and measurement of height and weight.

The workshop presenters’ recommendations for a TIC approach to clinical care included: acknowledging the trauma, giving the patient choice and control in their care, building a relationship with the patient, avoiding having the patient retell their story, and providing coping strategies (including a focus on grounding and distraction techniques, referral for mental health services, and exploring models of peer support).


Quick take-home messages from a sampling of oral abstracts included the following:

At least 30% of females with unilateral renal agenesis or dysgenesis also have a Müllerian anomaly. Thus, screening is justified in this population (and also in those with a prenatal diagnosis of renal anomalies), with screening ultrasound around the expected time of menarche.

The average delay in diagnosis of endometriosis is greater among adolescents than among adult women. A confirmatory diagnosis with laparoscopy could be performed earlier in adolescents with chronic pelvic pain to diagnose the condition.

Lichen sclerosus occurs in premenarchal girls and is frequently misdiagnosed, with a delay of 1 to 2 years prior to appropriate diagnosis. SWIFT (Soreness/pain, Whitening, urinary Incontinence, Fissures, and clitoral hood Thickening) symptoms and findings on examination are predictive of this diagnosis; interestingly, the addition of pruritis symptoms does not improve the predictive value.

Among adolescent girls presenting to the emergency department for an evaluation of heavy menstrual bleeding, the American Academy of Pediatrics’ recommendation that they be screened for iron deficiency is infrequently followed. In addition, few of these girls are discharged home on oral iron, representing missed opportunities for both the diagnosis and treatment of iron deficiency.

Articles

Contemporary OB/GYN® Editorial Board Member Paula J. Adams Hillard, MD, reports on  the Annual Clinical & Research Meeting (ACRM) of the North American Society for Pediatric and Adolescent Gynecology (NASPAG), which was held virtually on March 18 to 21. The meeting drew gynecologists who specialize in pediatric and adolescent gynecology (PAG) and pediatricians who practice adolescent medicine, nursing and advanced practice nursing professionals, and various other clinicians who take care of girls and adolescents with gynecologic problems.

NASPAG 2021: Hillard’s Highlights

As ob/gyns, we care for patients with a variety of gynecologic and reproductive health issues that can be emotionally charged and intensely private. Although gynecologic health issues are medical issues as are headaches or sprained ankles, the extent to which individuals want to talk openly about them varies. In our offices, patients share their fears, their pains, and their hopes, and discuss their sexuality, their gender identity, and their sexual behaviors. We talk with preteens about puberty, with teens about their periods, with women who are excited to be pregnant, and with those who are not. We talk to women who have never told anyone about a past sexual assault. We talk with women who are facing infertility or the need for a hysterectomy. Our patients know we will listen to and treat them with dignity and provide accurate health education that enables them to be a partner in their health care decisions.

Three recent pieces of legislation highlight a threat to the physician-patient relationship. The proposal of laws that interfere with this complex and intimate relationship is a step too far. These pieces of legislation illustrate this overreach by the state: dictating medical care for transgender adolescents (Arkansas and 18 other states),

 mandating medically inaccurate information about abortion (18 states),

 and requiring resuscitation for newborns with fatal diagnoses (New Hampshire).

As Frank Bruni pointed out in his recent 

 op-ed column, politicians are currently demonizing trans people in a new culture war, similar to the way in which they vilified gays and lesbians, charging that gay marriages would somehow undermine straight marriages.

 Politicians, including former President Donald Trump, assert that trans equality would “destroy women’s sports.”

 This is a political strategy that ignores the realities of the patients in our offices. It ignores the transgender individual who has found puberty blockers to be immensely helpful or the trans persons who had previously been suicidal when attempting to fit in to a gender-binary world. It ignores the parents who have wrestled with their child’s affirmed gender identity, done extensive research and reading about the issue, and who love their child and support therapy and potentially medication to help alleviate their child’s gender dysphoria. It ignores our medical judgment and recommendations after we have listened to the patient and their parents. It ignores the expertise of our colleagues in endocrinology, psychology, adolescent medicine, adolescent gynecology, urology, and social work who work with transgender youth. As Bruni describes, these lawmakers are stunningly arrogant, and are “getting between physicians and patients.”

As many state legislatures across the U.S. introduce or have in process bills that could directly impact the physician-patient relationship and how treatments are administered, several professional organizations issued position statements. 

In its statement, the North American Society of Adolescent and Pediatric Gynecology stated that it has nearly 470 members consisting of physicians, advanced practice providers, nurses, and professional health care trainees. “Our mission is to provide multidisciplinary leadership in education, research and gynecologic care to improve the reproductive health of all youth, inclusive of children and adolescents who are gender diverse. 

We advocate for the provision of unrestricted, unbiased and evidence-based practice of pediatric and adolescent gynecology. We stand with national medical organizations supporting comprehensive care of adolescents and the confidential relationship between patients and their physicians.

 We support the positions that `physicians must be able to practice medicine that is informed by their years of medical education, training, experience, and the available evidence, freely and without threat of punishment. Patients, their families and caretakers in partnership with their physicians, not policymakers, should be the ones to make decisions about what care is best for them.’”

The other organizations included the American College of Obstetricians and Gynecologists; the American Academy of Family Physicians; the American Academy of Pediatrics; the American Psychiatric Association; and the American Osteopathic Association.

Frontline physicians oppose legislation that interferes in or penalizes patient care. American Academy of Pediatrics. April 2, 2021. Accessed April 26, 2021.

https://services.aap.org/en/news-room/news-releases/aap/2021/frontline-physicians-oppose-legislation-that-interferes-in-or-penalizes-patient-care/

It is not controversial to agree that our obligation as physicians is to care for our patients in a way that best meets their needs. We should also agree that legislatures do not have a role in dictating specifics of medical care. The Coalition to Protect the Patient-Provider Relationship is comprised of nonpartisan, nonprofit organizations united in the “opposition to inappropriate interference in the relationship between a patient and health care provider.”6 Member organizations include the American College of Obstetricians and Gynecologists (ACOG), American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Medical Association, American Medical Student Association, American Medical Women’s Association, American Nurses Association, American Osteopathic Association, American Public Health Association. The coalition states that “patients deserve accurate information, high-quality care, and the treatment options that best meet their needs. Physicians and other health care providers should be able to follow the best medical science and training based on available evidence, and adhere to their ethical obligations.”

It’s not just in areas of women’s health that we must protect that relationship. Other health and safety issues for which politicians are passing laws that stand between us and our patients include gun safety and environmental hazards. Resources for clinicians include a report, “Politics in the Exam Room: A Growing Threat,” by the National Partnership for Women & Families, National Physicians Alliance, Natural Resources Defense Council, and Giffords Law Center to Prevent Gun Violence.

According to ACOG’s policy statement on legislative interference with patient care, medical decisions, and the patient-physician relationship, “laws should not interfere with the ability of physicians to determine appropriate treatment options and have open, honest, and confidential communications with their patients. Nor should laws interfere with the patient’s right to be counseled by a physician according to the best currently available medical evidence and the physician’s professional medical judgment. ACOG strongly opposes any governmental interference that threatens communications between patients and their physicians or causes a physician to compromise his or her medical judgment about what information or treatment is in the best interest of the patient.”

When state legislators try to come between our patients and us, we must speak out strongly. We must not let politics trump science or interfere with our hallowed patient relationships. Our patients must be able to rely upon us to provide appropriate and confidential care, based on science and our medical judgment. 

Legislative tracker: anti-transgender medical care bans

. Freedom for All Americans. Accessed April 13, 2021. 

https://freedomforallamericans.org/legislative-tracker/medical-care-bans/

2.Cox C. As Arkansas bans treatments for transgender youth, 15 other states consider similar bills. 

. April 8, 2021. Accessed April 13, 2021. https://www.usatoday.com/story/news/politics/2021/04/08/states-consider-bills-medical-treatments-transgender-youth/7129101002/

3.An overview of abortion laws. Guttmacher Institute. Updated April 1, 2021. Accessed April 11, 2021. https://www.guttmacher.org/state-policy/explore/overview-abortion-laws

4.Bruni F. Republicans find a cruel new culture war. 

. April 10, 2021. Accessed April 11, 2021. https://www.nytimes.com/2021/04/10/opinion/sunday/transgender-rights-republicans-arkansas.html

5.Ennis D. What Donald Trump’s transphobia really means for women’s sports. 

. February 28, 2021. Accessed April 13, 2021. https://www.forbes.com/sites/dawnstaceyennis/2021/02/28/what-donald-trumps-transphobia-really-means-for-womens-sports/?sh=3fac76545e66

6.About the coalition. Coalition to Protect the Patient-Provider Relationship. Accessed April 13, 2021. 

7.Politics in the exam room: a growing threat. National Partnership for Women & Families. October 2015. Accessed April 13, 2021. https://www.nationalpartnership.org/our-work/resources/repro/politics-in-the-exam-room-a-growing-threat.pdf

8.Legislative interference with patient care, medical decisions, and the patient-physician relationship. ACOG. Updated July 2019. Accessed April 13, 2021. 

https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2019

Three recent pieces of legislation highlight a threat to the physician-patient relationship.


Keeping Politicians Out of the Exam Room

Sexual violence continues to be a major public health problem affecting millions of adults and children in the United States. Medical consequences of sexual assault include sexually transmitted infections; mental health conditions, including posttraumatic stress disorder; and risk of unintended pregnancy in reproductive-aged survivors of sexual assault. Obstetrician-gynecologists and other women’s health care providers play a key role in the evaluation and management of sexual assault survivors and should screen routinely for a history of sexual assault. When sexual violence is identified, individuals should receive appropriate and timely care. A clinician who examines sexual assault survivors in the acute-care setting has a responsibility to comply with state and local statutory or policy requirements for the use of evidence-gathering kits. This document has been updated to include model screening protocols and questions, relevant guidelines from other medical associations, trauma-informed care, and additional guidance regarding acute evaluation of survivors and evidence-gathering kits.

Why and how to perform trauma-informed care

Violence against women, including intimate partner violence and sexual violence, has been characterized by the World Health Organization (

) as a major public health problem, and a violation of women’s human rights.

 The Committee on Health Care for Underserved Women of the American College of Obstetricians and Gynecologists (

 This document recognizes the frequency of sexual assault as a public health problem, exhorts ob/gyns and other women’s health care clinicians to screen all women for a history of sexual assault, addresses the issues that must be addressed in the acute evaluation of survivors, highlights the short- and long-term health consequences of sexual assault, and emphasizes the need to provide trauma-informed care when assessing the needs of sexual assault survivors.  

Because sexual assault is so common (nearly one in five US women have been victims of a completed or attempted rape during their lifetime), all of us as ob/gyns will see women who have been sexually assaulted, even if this event occurred in the distant past.

 Thus it is imperative that we be familiar with the issues addressed in this Committee Opinion. The acute consequences of sexual assault include acute traumatic injuries that may be severe and life-threatening, as well as pregnancy and sexually transmitted infections.  

In today’s world, myths about women’s reproductive health abound and are being perpetuated by misinformed politicians and others with a political agenda. It has been inaccurately claimed that “legitimate rapes” (whatever that hot-button term means) don’t result in pregnancies. The statistics from a longitudinal study on the prevalence and incidence of rape found the national rape-related pregnancy rate to be 5.0% per rape among victims of reproductive age, with approximately 32,000 pregnancies yearly in the United States resulting from rape.

 It really should go without saying that we must counter this misinformation at every turn.  

The long-term health consequences of sexual assault can include physical symptoms, decreased social functioning, changes in health perception, and decreased quality of life. Many women with a history of sexual assault may not volunteer this history, but may present with chronic pelvic pain, dysmenorrhea, and sexual dysfunction. The psychological and mental health sequelae of sexual assault can be profound, from an acute disorganization phase to delayed symptoms such as nightmares, flashbacks, phobias, somatic symptoms, and post-traumatic stress disorder (PTSD), characterized by a re-experience of the trauma, avoidance, and hyper-arousal. Women with substance use disorders have very high rates of a history of rape or sexual assault, and thus it is particularly important to screen for this history when we detect substance use disorders, and conversely, when a history of sexual assault is elicited, to screen for substance use disorders that may result as a mechanism for coping with the history of trauma.   

ACOG recommends screening all women for a history of sexual assault by asking direct questions in a nonjudgmental manner, validating the patient, as well as providing appropriate referrals. The Committee Opinion provides examples of appropriate screening questions. When a history of sexual abuse is disclosed, medical procedures including pelvic, rectal, and breast exams, as well as transvaginal ultrasound exams, may be triggering and associated with PTSD. Women with a history of sexual assault are at increased risk for PTSD and depression after childbirth.

Trauma-informed care is essential for all women with a history of sexual assault, but I would suggest that we approach ALL women with these principles, including acknowledging the effects of trauma, recognizing its signs and symptoms, and practicing so as to avoid retraumatizing. To that end, we need to ensure every woman’s physical and emotional safety, assure patients of our trustworthiness, prioritize individual choice and control during examinations, and seek to empower individuals. We should also encourage peer support, including during gynecologic exams. I would suggest that we treat all women in this manner, given that women may not feel comfortable acknowledging a difficult past history of sexual assault. In addition, we must avoid doing exams that themselves can be traumatizing or triggering. Our performance of the gynecologic exam should be predicated on the principles of “catalyzing women’s empowerment,” as described by Wijma and Siwe.

Many hospitals today have implemented programs whereby acute medical exams for sexual assault victims are performed by Sexual Assault Nurse Examiners (

). When I was an intern, many moons ago, I learned how to assess the appropriate medical issues for sexual assault survivors, and to collect forensic evidence using a “rape kit,” which fortunately included a checklist of the appropriate steps and required documentation. The Committee Opinion lists a website that facilitates localization of a specialized sexual assault examiner, because for an assault victim, being examined by such an expert is much preferable to being in the hands of someone who is inexperienced. Today, many fewer residents in ob/gyn do these evaluations, which is likely preferable for individual survivors of sexual assault, but which means that many clinicians today have never done such exams. The ACOG document acknowledges that in some locations or situations, the ob/gyn may remain responsible for the acute exam. A detailed protocol for sexual assault medical forensic examinations is available online from the U.S. Department of Justice’s Office of Violence Against Women at 

https://www.justice.gov/ovw/sexual-assault

. ACOG has other resources on this topic, available at 

. When we do provide acute care for survivors of sexual assault, it is important to provide instructions in writing, and also critically important to arrange for both clinical and psychologic follow-up.  

As ob/gyns, it is our responsibility to screen all patients for physical and sexual violence, and to provide compassionate trauma-informed care for all women. This ACOG Committee Opinion provides basic information that can inform that care. 

The author reports no potential conflicts of interest with regard to this article

World Health Organization. RESPECT women: preventing violence against women. Available at 

https://www.who.int/reproductivehealth/topics/violence/respect-women-framework/en/

Sexual assault. ACOG  Committee Opinion No. 777. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2019;133:e296-302.

Breiding MJ, Smith SG, Basile KC, Walters ML, Chen J, Merrick MT. Prevalence and characteristics of sexual violence, stalking, and intimate partner violence victimization--national intimate partner and sexual violence survey, United States, 2011. MMWR Surveill Summ. 2014;63(8):1-18.

Holmes MM, Resnick HS, Kilpatrick DG, Best CL. Rape-related pregnancy: estimates and descriptive characteristics from a national sample of women. Am J Obstet Gynecol. 1996;175(2):320-324; discussion 324-325.

Soderquist J, Wijma B, Thorbert G, Wijma K. Risk factors in pregnancy for post-traumatic stress and depression after childbirth. BJOG. 2009;116(5):672-680.

Wijma B, Siwe K. Examiner’s unique possibilities to catalyze women’s empowerment during a pelvic examination. Acta Obstet Gynecol Scand. 2004;83(12):1102-1103.

Commentary on ACOG Committee Opinion 777: Sexual Assault, which discusses the role of the ob/gyn in caring for sexual assault survivors and includes information on screening.

ACOG Guidelines at a Glance: Sexual Assault

I know you’ve been there. Someone, somewhere, wanting to make conversation, asks you what type of work you do. Typically, I’ll answer that I’m a physician, and we all know that reply can trigger a long story from the questioner about their own latest encounter with the medical profession. Sometimes, if they are curious and ask for more information, “what type of doctor?”, I’ll respond that I’m a gynecologist. Before volunteering even this limited information, I’ll try to gauge their interest. If my questioner is a man, the conversation may quickly to turn another subject. This is certainly not always the case, and a man may choose to pursue a discussion, just as the subject may change when I am speaking with a woman. But more often than not, when speaking with a woman, the topic of gynecology or obstetrics leads to further discussion.

The conversation may then evolve to a discussion of my gynecology practice that no longer includes adult women, but which focuses on pediatric and adolescent gynecology (PAG). Here’s where I often see a puzzled look, and some variation on the question, “What on earth is pediatric and adolescent gynecology?”

 Many people are surprised that PAG is a “thing.” I may describe some of what I do as “preventive obstetrics,” which typically brings a smile or a chuckle, albeit often with a bit of lag time. 

Preventing unintended pregnancies in adolescents is indeed a major focus of my practice, but my practice is much broader than just contraception. I see girls, adolescents, and young adult women in my practice at the Lucile Packard Stanford Children’s Hospital in Palo Alto, California. My patients come from all around the San Francisco bay area, as well as from much further afield in California and other parts of the western United States. I care for these individuals with problems ranging from abnormal menstrual bleeding, abnormal puberty (too early, or too late), vulvar and vaginal symptoms, pelvic/ovarian masses, pelvic pain, differences of sex development, concerns about sexually transmitted infections, congenital utero-vaginal variants, and much more. 

I regularly provide preventive guidance to teens (and their parents), address anxieties about fertility and future reproductive health, encourage preventive services including human papillomavirus vaccinations, and talk about the benefits and risks of hormone therapies including oral contraceptives and hormonal intrauterine devices not only for contraception, but also for managing menstrual pain, irregular bleeding, or heavy menstrual bleeding. I talk about condoms, safe sex, responsible sex, abstinence, self-esteem, bullying, and uncover never-before-disclosed sexual abuse. I answer questions about normal anatomy-breasts of different sizes, or labia that may not look like the idealized images of porn stars on the Internet. Once you earn their trust with honest answers and sincerity, teens will confide a lot-including their hopes, dreams, fears, and foibles. And if I’m lucky and have the privilege of seeing an individual weather her teen years into young adulthood, I’m often witness to the amazing transformation of adolescent development. 

If you practice general obstetrics and gynecology, and if you enjoy taking care of teens, you likely do some or all of these things in your ob/gyn practice. I just do them every day. If you don’t like taking care of adolescents (and if you’re the parent of a teen, you’ll understand that they can be prickly at times, and that eye-rolling is par for the course), then you probably shouldn’t do much of it. Most teens are pretty discerning, and it’s hard to fake sincerity. But if you remember how hard it was to BE a teen, and how much you would have appreciated a caring physician who addressed your concerns about growing up (including menstrual concerns, if you identify as female), you may want to learn more about PAG and include more adolescents in your practice. I have no doubt that if you want to do this, and you start to ask your adult patients about their adolescent daughters, you will begin to build a practice that includes adolescents. The American College of Obstetricians and Gynecologists recommends that the initial visit for screening and provision of preventive health care services should take place between ages 13 and 15, and the Committee Opinion on 

provides guidance and resources for that visit.

 Most moms of teens are unaware of this recommendation-YOU may even be unaware of this recommendation.

The CREOG educational objectives include topics on pediatric and adolescent gynecology,

 and more and more residency training programs have faculty with expertise and experience in dealing with girls and adolescent young women, so that current residents are better prepared than ever before to care for this underserved population. For residency programs without PAG-trained faculty, or for individuals in practice who want to learn more PAG, two publications (dubbed the Short and the Long curriculum) provide a standard curriculum with resources and guidance for self-learning.

 The American Board of Obstetrics and Gynecology (ABOG) includes articles on PAG among the lifelong learning papers for Maintenance of Certification (MOC).

 For the first time, in 2018, ABOG offered an examination and focused practice designation in PAG. The North American Society for Pediatric and Adolescent Gynecology (NASPAG) website offers resources for clinicians, patient handouts, and the annual clinical and research meeting each May is a wonderful Continuing Medical Education (CME) opportunity for learning more about caring for young girls’ and teens’ gynecologic needs.

 The next NASPAG meeting will be held in New Orleans on April 11-13, 2019.  

 since 1992, and I am passionate about the clinically relevant articles that you and I read on a regular basis. 

 has published a number of excellent reviews of PAG topics, including eating disorders,

 heavy menstrual bleeding in adolescents,

 These reviews are great places to start reading if you want to become more familiar with care of adolescents and young girls. I thank Charly Lockwood for his leadership as Editor-in-Chief of 

, as well as my fellow editorial board members for their dedication to this publication. I’m grateful that they have allowed me this forum to be an evangelist for Pediatric and Adolescent Gynecology. My PAG practice is never boring. I would encourage you to add care for more adolescents and young girls to your practice of general obstetrics and gynecology. It is gratifying, and much appreciated by the girls and their mothers.

The author reports no potential conflicts of interest with regard to this editorial.

Adams Hillard PJ. What is pediatric and adolescent gynecology? 

ACOG Committee Opinion no. 598: Committee on Adolescent Health Care: The initial reproductive health visit. 

American College of Obstetricians and Gynecologists. CREOG 11

 edition of educational objectives. Available at 

https://www.acog.org/About-ACOG/ACOG-Departments/CREOG/CREOG-Search/CREOG-11th-Edition-of-Educational-Objectives

Fleming N, Amies Oelschlager AM, Browner-Elhanan KJ, et al. Resident education curriculum in pediatric and adolescent gynecology: the short curriculum. 

Loveless M, Amies Oelschlager AM, Browner-Elhanan KJ, et al. Long curriculum in resident education. 

American Board of Obstetrics and Gynecology. Why is MOC important? Available at 

https://www.abog.org/new/information.aspx?cat=moc&id=1

North American Society for Pediatric and Adolescent Gynecology. 

Snyder B. Eating disorders in adolescents and young adult women: Implications for reproductive health. 

http://www.contemporaryobgyn.net/obstetrics-gynecology-womens-health/eating-disorders-adolescents-and-young-adult-women-implications-reproductive-health

Heavy menstrual bleeding in adolescents. 

http://www.contemporaryobgyn.net/modern-medicine-news/heavy-menstrual-bleeding-adolescents

. 2013. http://www.contemporaryobgyn.net/endometriosis/pelvic-pain-adolescent 

Talking with patients about their daughters is one way to build a practice focused on caring for girls, adolescents, and young adults.