Month: August 2016

So far we’ve talked about what to expect from the first visit to the gynecologist’s office, when your first period might arrive, and fun and interesting ways in which puberty is celebrated (or not) around the world.  Now it’s time to talk about what’s normal (or not) with menstrual cycles and some products that can help you go with the flow.

What’s a Normal Period?

According to textbooks, a normal menstrual cycle is counted from day 1 (the first day of full flow bleeding) until the next episode of bleeding, and on average, there are about 28 days between those two events.  Normal, however, can be anything from 21 to 35 days, meaning you could have a period every three weeks or every five weeks and still be healthy.

For girls who are less than two years out from the first period, cycles can be even longer; up to 45 days, as her body gets the hang of ovulating.  On the other hand, if there are more days with a heavy flow every month than there are days without bleeding, something is wrong, and it’s time to see the doctor.

If you suddenly realize you haven’t had a period since the Oscars, and now it’s Teen Choice Award season, then that’s way too long.  More than two months without a period (when you’ve had them regularly) is cause for concern.  One missed period may be something that happens every now and again because of stress or other factors.  Obviously, if a period doesn’t show and there’s ANY chance of pregnancy, don’t put off a pregnancy test or seeing the doctor.

A normal flow should not last longer than seven days, and usually, only the first 2-4 days will be “heavy”.  Knowing what’s too heavy can be tricky, especially if there’s a family history of heavy periods or bleeding problems.  If you need to change your pad or tampon because it’s soaked every 2-3 hours, then that’s probably too much.  If you are passing clots (solid, congealed blood) larger than a dime, soiling clothes or bed sheets despite regularly changing your pads or if you have a “flooding” sensation when you get up or walk around, then there may be a problem.  If you are soaking a pad every hour or feeling lightheaded:  call your doctor right away.

What about symptoms?

Almost anything is possible, but some broad categories include headaches, pelvic and back pain, breast tenderness and swelling, bloating and skin changes.  As tiresome as these physical irritations can be, the psychological effects of being on your period can sometimes be more challenging.

Mood swings or changes that tend towards depression, irritability, feeling exhausted or in a mental fog, appetite changes including a craving for carbs; these are all typical complaints and are often referred to as premenstrual syndrome (PMS), because they generally start before bleeding does.  Managing all of these problems, especially if they are severe and causing you to miss out on life, is exactly what your gynecologist is there to help with (so call her, already!).

Managing It all & Going With The Flow

For some non-medical therapy that can help you cope with these symptoms (and a whole lot more), I recommend trying some mindfulness practice, which is so much easier said than done.  There are about three thousand years of meditation history to consider, but all you need is to set aside some time (even 5 minutes to start), check in with your body and mind, then try to recognize your thoughts and feelings without judging.  Easy right?

So much of our discomfort-both mental and physical-arises from how we magnify a thought or a feeling into “the worst case scenario”, giving it so much more imaginary power than it has.  Learning to recognize this moment-to-moment and then translating that into self-regulation takes lots of practice.

It may seem counterintuitive to recommend an electronic device to unplug and connect to your inner calm, but apps that help with mindfulness practice can be useful.  The Insight Meditation Timer is fun because you can see where people are meditating the same time you are worldwide.  Smiling Mind has programs for ages as young as 7, with a special option just for teens.

So what’s the best way to stay on top of your period timing, flow, and symptoms?  Yep, there’s an app for that! New period tracker apps are coming online all the time, but if you are an iPhone or Android user, check out Period Tracker:  it’s easy to use and has lots of cute emoticons to represent a broad range of period-related symptoms.

Another good option is Life; it’s a bit sleeker than Period Tracker and has the ability (with an upgrade) to help monitor and provide reminders for more than just your period.  Finally, Monthly Gift makes getting your period almost a special treat.  The app has a fun, design-y interface to track cycles, the website has links to all kinds of girl-power blog pieces, and it offers a subscription service that delivers a little black box of tampons, pads, liners and even some chocolate.

There are several subscription services that deliver period care necessities right to your door, along with fun treats (why didn’t we think of it?).  HelloFlo is special in that it has a “Period Starter Kit” complete with both a parent’s and a girl’s guide to period basics.  And mom, check out The Period Store or Le Parcel, because, until menopause hits, you may as well get a monthly treat too. The Period Store has an extensive selection of both drug store and more environmentally conscious options for period care, along with teas, stain-resistant underwear, and treats.  Le Parcelis a good choice if you aren’t going to stray from your tried-and-true brand and love the option to customize the number of tampons, pads, and liners that go into your box.

For those awake at night thinking about the giant mass of trash in the ocean, there are now many safe options for eco-friendly period care.  The Diva Cup is a silicone vessel that when inserted into the vagina, collects rather than absorbs menstrual flow, and can be used for up to 12 hours.  It’s reusable, which is fantastic, but does mean you’ll need to be prepared to empty and wash the cup.  You can’t just flush it down the toilet to join all the other trash in the sea.

Speaking of the sea, you may have heard about using sea sponges as tampons.  While it sounds like something a mermaid might use, humans should NOT use sea sponges for period care:  they have been associated with dangerous infections and toxic shock syndrome.

If a reusable cup sounds a bit too messy, you can consider natural or organically sourced tampons and pads, such as those from the Honest Company.  If you are all in for our planet, then reusable pads are the next step, as long as you are prepared to spend a little time in the laundry room. GladRags and Lunapad are both excellent options.

Last, but certainly not least, we need to remember how incredibly lucky we are to have all of these fantastic options because so many girls and women around the world have next to nothing to help them manage menstrual realities.  In some places, everything from leaves, rocks, and even cow dung are used to try and stay clean.

Take a look at Days for Girls and learn what you can do to help keep girls in school and women involved in their work and families.  In our own backyard, most homeless shelters and women’s centers are chronically low on period care products and would welcome them in a donation.

Here’s to having the best possible period experience for ourselves, our sisters around the corner and all across the globe!8

One of my favorite stories about the arrival of maidenhood (a lovely euphemism for getting your first period), involves shoes. “Tina” is now a bubbly, vivacious mom of 2 teens, who doesn’t recall any conversation whatsoever from her mother or anyone else about what puberty was going to do to her before it happened.  She’s sure there wasn’t any formal sex education in her small-town Texas middle school. She does remember a gym teacher who was always warning against “getting stinky”; lecturing in the locker room about the disgusting odors that start emanating from girl’s armpits, feet, etc., and the need to combat them with soap, deodorant, and powder.  So a few months later, just around the corner from her eleventh birthday, when she opened up the cabinet underneath her bathroom sink to find a pretty pink box of “feminine protection,” she knew what those little oblong cushions were!  Yes, Tina’s shoes were a bit tight, but she walked taller on her pillowy shoe inserts, knowing she was fighting the war against unseemly odor.

The First Period Celebration

Not all girls around the world and throughout history have been greeted by silence in response to their changing bodies.  There is the Jewish tradition of being slapped across the face by one’s mother, possibly signaling to the newly forming woman that fertility is no walk in the park.  There are families less bound by the current cultural taboo against menstruation that celebrates with a round of champagne or sparkling cider when a daughter gets her first period.

If you’re reading this, then you’ve probably either given or received several books about “your changing body”, or plan to attend fun and informative events that explain puberty in all it’s glory (like Be You Girls!).  Then there are places still, where ancient customs and elaborate ceremonies mark the occasion of a girl’s first period as a momentous rite of passage.

Various tribes in West Africa hold celebrations each year for all of the girls who have started to menstruate, after which intensive mentoring begins to teach them about their bodies, intimacy and the special powers of a fertile woman.

One Bangladesh religious sect performs a special ceremony involving a cocktail of menstrual blood and coconut milk, which is drunk by the celebrants to provide restorative powers.

More appealing to our Western palate, the Navaho tribes have a ritual called kinaalda, involving a four-day celebration and an enormous corn cake.  The new maiden wears a traditional buckskin dress and is sprinkled with flower pollen, giving her a golden sheen and symbolizing her new fertility.  She starts each of these special ceremonial days by running as fast as she can towards the sun and is mentored and massaged with oils by the older women in the tribe who take her aside to teach her about being a woman.

The Period Secrecy

While these exotic rituals can give us ideas about how we might design a meaningful ceremony for our daughters to mark her first period, many customs were designed to protect the rest of the community from the perceived dangers of a menstruating woman, or to protect menstruating women from harm.  Many cultures have prohibitions against menstruating women having relations with men, including Orthodox Judaism, Rastafarians, and Islam.

In some places, such as Nigeria, parts of South India and Bali, women are still separated when they are on their periods, living in “menstrual huts” where they can be relieved of their regular duties and avoid cooking so as not to contaminate their families.  An idealized vision of a place to which women can retreat for mutual support and comfort which was popularized by the book “The Red Tent” (1997) by Anita Diamant. In the book, biblical characters were required to sequester themselves during menses or childbirth.

Modern Day Period Taboos

In our modernity, as women have worked so hard to achieve some measure of equality with men in the world of work, keeping menstruation private has been critical.  When being on your period is seen as a potential weakness compared to men who don’t have to deal with PMS, cramps or feminine hygiene issues, it does make sense just to brush it under the rug, so to speak.

As we redefine feminism for ourselves and our daughters, it makes sense to let go of the secrecy and taboos that have kept us in the dark about our bodies.  So why not throw out the negative stereotypes about “the curse” and embrace pro-female rituals to celebrate our girls and create a community of women to support and mentor them through their journey into womanhood!

Please share with us your ideas or experiences with a maidenhood celebration or your version of a Red Tent sanctuary.

“Aunt Flo’s Coming to Town,” “Shark Week,” “Cousin Red,” “Ride the Cotton Pony”…..are we talking bad late night TV? No ladies, it’s that time of the month aka your menstrual period.  If you are a middle school girl in the US (or are deeply involved in caring for such a creature), then having some idea of when this momentous event will take place in your household may be helpful.  A lot has been made of the trend towards earlier onset of puberty in the U.S. and other developed countries.

Unfortunately good records for pubertal development are not available going back hundreds of years, so theories that the age of menarche has dropped dramatically (from say, 17 to 13 years of age) are mostly speculation.  The average age of menarche (the technical term for your first period-pronounced MEN-are-kee) when using good data over the past 50 or so years, does indeed show a decline, but only by a few months, and is likely due to the overall better nutrition and higher rates of obesity in our prosperous nations.

The Timing of Puberty

While the majority of pubertal timing is determined by genetics, we can’t ignore the possible role of environmental factors that may be leading to early maturity.  Other known risk factors for early puberty include obesity, inactivity, smoking/second-hand smoke and psychological stress.  Researchers have moved away from thinking that puberty starts when a critical weight is reached, and now believe it’s a significant body fat percentage that triggers maturation.

Obviously, the start of puberty is complicated, and there is very little that can be controlled about how and when it happens.  Compared to a lot of other systems in the human organism, the “switch” that turns on puberty is unknown. Puberty is still a profoundly mysterious process involving ancient areas of the brain synthesizing information from both inside and outside of the body to change a girl into a woman at (questionably) just the right time!

It’s common to think of a girl’s first period as the start of puberty, but menarche is one of the later milestones in the process.  One of the first visible signs of puberty is breast development or “breast budding”, and any suggestion of this before eight years in a girl should be investigated, as that could be abnormal.  We do know that different races mature differently:  African-American girls show the first signs of puberty at earlier ages than Caucasian or Hispanic girls, and Asian girls develop later.

In addition to breast growth, the appearance of underarm hair, pubic hair and then a growth spurt, are all things that happen (usually, but not always in that order) before the first period shows up, which is about two years after the start of breast budding.  The average age for starting periods in the U.S. is roughly 12 1/2, but what falls into the normal range is anything from 11 to 14 years old.  For girls (and their families) on the early end of the spectrum, it can be tough to adjust to a woman’s body when her life is still completely about being a child.  For girls on the later end of the spectrum, waiting for her period to start can feel like an eternity, and she can become anxious that something is wrong.

Early Puberty

In the case of early signs of puberty, it’s just the luck of the genetic draw mixed with her particular environment, and most of these cases are not treated with anything other than reassurance.  Cases, where something abnormal and/or treatable is discovered, can include such rare things as ovarian or brain tumors (or other central nervous system damage), genetic syndromes that include precocious puberty (the technical term for abnormally early puberty), or metabolic problems that lead to abnormal levels of hormone production.

Evaluating a girl with early puberty involves a physical exam, blood work, a special X-ray of the arm and hand to give a “bone age” that can be compared her chronologic age, a pelvic ultrasound (NOT done vaginally but with a full bladder), and a very thorough review of her history and growth curves.  Other, more specialized tests could include a brain MRI or stimulation tests, where a particular hormone is given, and then blood levels are checked at certain times afterward.

If nothing abnormal or otherwise treatable is discovered, but the child is determined to have early puberty, then she may be a candidate for an injectable treatment that can turn off the pubertal process. This allows her to catch up on some growth (which slows to almost nothing once menarche hits), and provides some more time for her to mature before having to deal with puberty.

Late Puberty

While most parents pray for a “late bloomer”, girls without any signs of puberty by age 14 or who have gone more than five years without starting their period since the breast development began need to be evaluated for delayed puberty.  In fact, parents or pediatricians don’t need to wait that long to check on the status of delayed puberty if the girl is anxious.  Most of the time, it’s just a matter of waiting for just a little longer and, voila, the cycle starts.  By age 15, only about 2% of girls will not have started their periods, so by that time, being a little worried is justified.

The evaluation for delayed puberty is very similar to that described above for early puberty. Possible reasons for this could include disordered eating (anorexia nervosa/bulimia), metabolic problems related to diabetes (such as polycystic ovarian syndrome), early menopausal syndromes (which are common in girls who are cancer survivors), or rare anomalies of the reproductive organs.  Treatments will vary, depending on the cause, but most will involve some hormone replacement, to get the body to develop, have periods and get back on the developmental track.

Celebrate Puberty

Believe it or not, doctors treat “having a period” as a vital sign, like having a normal blood pressure or not having a fever; a regular, predictable menstrual period is part of being a healthy woman.  So whether it’s early, late or right on time, it’s something to be anticipated and appreciated!

The First Gynecology Visit

I’m a gynecologist who loves her job, but if someone came in for their first gynecological visit and said they were excited to see me, I’d be worried. No one enjoys a visit to the doctor!  Even so, many girls and even women are anxious and scared about going to see a gynecologist for the first time, and that may have to do with notions about strange metal instruments and awkward positions or the stories from the older women in their lives.  In my case, as for many of us in the (early) middle-aged generation, it was right before going off to college.

The Gynecologist’s First Gynecological Visit

The nurse told me to take everything off and put on the paper gown, then sit on the table and wait.  I sat there waiting and waiting, while my anxiety was growing and growing!  When the doctor finally arrived and gruffly introduced himself, I had difficulty focusing on his face because his shirt was unbuttoned to show off rows and rows of gold chains and massive amounts of chest hair.  I recall there wasn’t much discussion before getting down to business:  my first pelvic exam and Pap smear.

Afterward, I gingerly walked back to the waiting room, and smiled meekly at my Mom and thought, what was that all about?  Now I’m the one greeting nervous girls and moms, and it’s such a privilege to provide my patients and their families with an exceptional experience for their first visit to the gynecologist.  I know that if it goes well and they are able to let go of some of their fears about discussing and even looking at “yucky, gross private parts stuff”, they are one step closer to being able to take care of themselves and be as healthy and happy as possible.

First Visit to The Gynecologist

Since I was headed to college, thankfully, a lot has changed for young women embarking upon their first reproductive health visit.  Most importantly, it is recommended that girls see a provider to address their gynecologic well-being well before they go to college or plan to become sexually active.  The ACOG, or the American College of Obstetricians and Gynecologists, recommends girls see a gynecologist (or another qualified provider) for their first visit between the ages of 13 and 15 years old, sooner if there are any concerns or problems.  An accurate assessment of pubertal development and even menstrual problems also can be difficult for girls and their parents, especially if mom had heavy, painful, or irregular periods herself and views that as the norm.  Identifying pubertal or menstrual problems early on can prevent them from becoming serious issues in the future.

In addition to a shift in the timing of the first gynecological visit, there is now hardly any need at all for a pelvic exam using a speculum for an adolescent girl.  There is no need for a Pap smear for anyone under the age of 21, and testing for infections, including sexually transmitted diseases, can be accomplished with urine testing or self-collection of vaginal swabs.

For girls coming to see me, an examination happens after we have had ample time to talk in my office and they become more comfortable and relaxed.  After moving to an exam room, I do a focused physical examination that may involve a breast exam and visualization of the vulva, but I almost never need to use a speculum.  A tool that I almost always use, however, is a hand-held mirror for what I call the “anatomy tour”. It can feel seriously embarrassing, but learning the detailed ins and outs of your vulva and what exactly to call the various parts is critical to feeling like you can manage any problems that might come up.

The Goal of The First Gynecological Visit

The goal of the first gynecological visit is to start to establish a relationship and making sure the real questions you have are getting answered.  While there are pediatricians who are comfortable with gynecologic topics, it can be especially awkward to discuss extremely private matters with an adult that has known them since childhood.  Parents always want their children to feel comfortable coming to them with any problems or concerns, but in reality, the topic of puberty can be so embarrassing to discuss (for both sides) that the conversations are often avoided.

The first gynecological visit is an opportunity to make these issues less “icky”, and allow some time and space to get the communication going.  It’s also a chance for parents to ask questions and get guidance and support.  Graduating to see a gynecologist is a major step for every girl, as she transitions into womanhood, and begins to take responsibility for her body, health and choices.

If you have been looking for a Pediatric Gynecologist, I encourage you to give my office a call and then,  congratulations are in order for getting the first gynecologic visit scheduled, and I am looking forward to seeing you soon!