02/13/08

 

BY LOUIS BERGERON

	Steve Fisch Photography
	Judy Lacy is one of about 400 doctors in the United States who are pediatric and adolescent gynecologists, providing care for young girls not yet adults.

"I had no idea that somebody actually did this!"

It's a comment that Judy Lacy, MD, often hears when a patient walks through her office door for the first time, though usually it's the patient's parent making the remark. The reason? Lacy is a pediatric and adolescent gynecologist, and while a few of her patients are still too young to talk, the parental remark generally stems more from the fact that her medical specialty is so rare that most people have never heard of it.

Lacy, who sees patients at both Stanford Hospital & Clinics and Lucile Packard Children's Hospital, estimated there are perhaps 400 doctors in the United States who practice her specialty.

Even more impressive is the fact that the hospitals now boast two such specialists. Lacy was joined last year by Paula Hillard, MD, professor of gynecology and obstetrics at the School of Medicine and chief of gynecologic specialties.

The gynecologic needs of infants, children and adolescents are often unmet. Clinicians may not ask about menstrual function or gynecologic complaints, and families or girls themselves do not always know what is normal.

Children generally go to pediatricians for medical care until they turn 18, which is when many girls first see a gynecologist. But Lacy said that approach to care can create problems for a lot of girls because gynecologic issues may not be recognized for what they are and could go without proper treatment.

"The thing that's hard is that pediatricians are not trained in gynecology, and gynecologists are not trained with children," said Lacy, who is also a clinical instructor of obstetrics and gynecology at the School of Medicine. "So there's this void, a lack of knowledge, for kids and adolescents, in terms of gynecologic needs, and that's where I come into play. I have expertise in gynecology and was trained to take care of children from a gynecologic perspective."

Lacy said it's not uncommon for her patients to have already been seen by pediatric specialists, but even the best-trained physicians in the world can have a hard time diagnosing an ailment that's outside their realm of expertise.

One example she cited was the case of a 1-year-old referred to her with a diagnosis of enlarged genitalia. The child had already seen three different pediatric specialists and undergone ultrasound exams of her pelvis and abdomen, as well as an endocrine and urologic evaluation. But, upon examining the girl, Lacy realized there was a mass in the area that appeared to be associated with the girl's genitalia.

An ultrasound of the area confirmed that the mass was a separate lesion, which Lacy surgically removed. The pathologic diagnosis was neurofibromatosis, an extremely rare neuroendocrine disease that can have serious ramifications. The girl will have to be monitored for the rest of her life because the masses often recur. Although the masses are benign, depending on the form of the disease, the consequences of having it go untreated could have been severe.

"It's one of those very rare conditions that you do not want to miss," said Lacy. Being able to diagnose such cases is part of what makes a pediatric and adolescent gynecologist so valuable. "Something I see frequently may be something an adult gynecologist may see once in their career," Lacy said.

Another complicating factor in treating girls is that the problems they experience vary with their ages. "A newborn is going to have a different problem than a prepubertal child," said Lacy.

That's also true for teens of different ages. "What makes it fascinating as a practice, but also challenging for clinicians, is that there is so much going on developmentally during the teenage years," said Hillard. "A 13-year-old is very different from a 15-year-old, who is very different from an 18-year-old."

Regardless of the age of a girl, communication between the patient and the doctor is a huge factor in providing proper care, both Hillard and Lacy agreed. Neville Golden, MD, director of the Center for Adolescent Health at Packard Children's Hospital, said the advantage of having adolescent health specialists on staff is that "we're able to provide much-needed consultation. This helps us to get to the bottom of any problems they face, and also offer a comprehensive range of services."

Among the issues an adolescent has to wrestle with is simply getting used to how their body is changing. Hillard said that's another good reason for a girl to see a gynecologist trained to work with teens. "Your average gynecologist doesn't understand how shy and private a 13-year-old is," she said. The American College of Obstetricians and Gynecologists recommends that girls should see an ob/gyn for a visit (not necessarily an exam) sometime between the ages of 13 and 15.

In addition to the exotic problems and emotional aspects of their work, Hillard and Lacy deal with a lot of problems that are more mundane, but are no less important and, too often, can be overlooked.

"Things like bad cramps and heavy periods, those are things girls just don't have to put up with," said Hillard. She noted that some popular over-the-counter medications for menstrual cramps don't have scientific support as to their effectiveness, despite being marketed to teens. But other medications, such as ibuprofen and naproxen, do work well when used in the proper doses, she added.

The growing childhood health problem of obesity also carries gynecologic ramifications not always recognized.

"Obesity is having profound effects on girls' reproductive health," said Lacy. "They have problems with irregular menses." It can increase their risk of uterine cancer and may also be a factor in developing polycystic ovarian syndrome, a condition characterized by irregular menses, atypical hair growth or difficult to manage acne, and often obesity. It can also lead to infertility.

With all the potential medical problems girls can face, both Lacy and Hillard were adamant about improving the health of girls any way they can.

"When I was a resident, I didn't know that there was such a thing as adolescent gynecology. I don't know where these girls got their care," said Hillard, who earned her MD from Stanford in 1977. "I think they just didn't, for the most part."

"I want to get the word out that Dr. Lacy and I are available," she said. "A lot of times we talk to pediatricians on the phone and help them handle the problems themselves and that's great.

"But, if primary clinicians don't feel comfortable with gynecologic problems, we're here and we can see girls," Hillard said. "We want to take good care of young girls and teens; we want them to be healthy."