I am surprised that parents rarely question the repeated inspections of their children’s genital areas. No matter. I will get into this sometimes awkward but always important topic. Last week, we reviewed boys’ exams. This week, we will cover the female exam and why the doctor checks the perineal area at nearly every well visit, from birth to adolescence.
But First
In case you missed last week’s article, please take a minute to review privacy and safety. Busy parents are often on their computers or taking calls, understandably since doctor visits are in the middle of your workday. Although hectic schedules make multitasking tempting, it’s important to be fully present during your child’s exam.
The doctor or other health care provider must ALWAYS ask your (the parent’s) permission to do the genital exam, and frankly, they should tell you why they are doing the exam. If your child is school aged, a good pediatrician will address the child with something like, “No one is supposed to look under your underwear except your parents– not even the doctor unless your parent is in the room and says it is ok. I would like to make sure every part of you, including your genital area, is growing normally. Is that ok with you?” Similarly, teens should be offered a chaperone, typically a nurse or medical assistant. If the provider is male and your teen is female, a parent or chaperone should always be present. And unless very specifically indicated, no one should be inserting a finger or any instrument in your child’s anus or vagina. Rectal and vaginal exams are done in certain circumstances– even in babies– but you should be aware of the necessity and assent.
Babies
In newborns, the genital exam helps confirm biological gender and screen for congenital abnormalities. This article focuses on babies who are clearly female. Babies with ambiguous genitalia are managed on an individual basis, ideally with a multidisciplinary team.
The newborn exam generally confirms a normal appearing perineum, including labia, clitoris, urethra, and vaginal opening. Usually during this exam, I inform parents that a newborn girl often has white or even bloody vaginal discharge as maternal hormones leave her system. If your clinician is not explaining the exam or telling you what to expect, you have every right to ask.
As Girls Grow…
As girls develop, their exams may surface conditions such as labial adhesions, signs of trauma, poor hygiene, or early onset puberty (precocious puberty). While other, less common conditions do occur, I like to remind parents that their child is examined from head to toe throughout infancy and childhood, because, as she develops, so does her exam. Most of the time, we are examining to make sure girls are developing typically, or as expected. Girls ordinarily enter puberty between the ages of 8 and 13. Making sure the child’s pubertal development is aligned with her overall growth and development is part of the exam.
Similar to boys, female puberty is categorized on a 5 point Sexual Maturity Rating (SMR) scale, where Sexual Maturity Rating 1 describes newborn to prepubertal girls. Once a girl enters puberty, usually with breast development and fine hair growth in the genital and underarm areas, she is at SMR 2. A fully developed female is described as SMR 5 (Note: some clinicians use the term ‘Tanner Staging” instead of SMR. The 1-5 scale is identical).
Understanding a girl’s pubertal development is a great opportunity to have discussions about what to expect, from tween and teen moods to preparation for periods. If your doctor is not elaborating on your daughter’s development, please ask: In what stage of puberty is she? When can we expect her to get her period? How many more years do we expect her to grow? What can we do to help prepare her for her period? Or what can we do about her heavy periods?
Teens and Young Adults
Parents want to know: When does my daughter need a pelvic exam? In most cases, your teen does not need a pelvic exam until age 21, unless she has specific concerns, such as significant pain or discharge. Most testing– even for sexually transmitted infections– can all be done without invasive procedures.
Though your teen may not need a pelvic exam, your pediatrician may still check for normal anatomic development, especially prior to menarche, the onset of periods. For example, some girls are born without any opening in their hymens (imperforate hymen). In such a situation, blood from a period accumulates in the vaginal canal with no way out.
If your teen consents to visual inspection, a parent or chaperone can remain in the room. Your pediatrician is assessing hair growth, maturation of the clitoris and labia, appearance of any discharge, and potential signs of infections. If your teen has any concerns about her anatomy or menstrual cycles, please empower her to speak up.
Final Thoughts
Children and teens should know their personal space is theirs alone, with a right to request a chaperone during exams, especially if the provider is male.
Everyone wants to ensure their child is growing and developing normally, and if something is not going according to expectations, we want to understand and intervene, if necessary. This requires communication even when– and maybe especially when– it is uncomfortable.
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References:
Braverman, Paula K et al. “American Academy of Pediatrics. Clinical report–gynecologic examination for adolescents in the pediatric office setting.” Pediatrics vol. 126,3 (2010): 583-90. doi:10.1542/peds.2010-1564
Davis, Victoria Jane. “What the paediatrician should know about paediatric and adolescent gynecology: The perspective of a gynecologist.” Paediatrics & child health vol. 8,8 (2003): 491-5. doi:10.1093/pch/8.8.491
Gerber, J A et al. “Do pediatricians routinely perform genitourinary examinations during well-child visits? A review from a large tertiary pediatric hospital.” Journal of pediatric urology vol. 15,4 (2019): 374.e1-374.e5. doi:10.1016/j.jpurol.2019.05.007
Committee on Child Abuse and Neglect. “Protecting children from sexual abuse by health care providers.” Pediatrics vol. 128,2 (2011): 407-26. doi:10.1542/peds.2011-1244
https://www.acog.org/womens-health/healthy-teens
