YOSEMITE, CALIF. — Be ready to provide an opportunity for adolescent patients to ask questions about a sensitive topic like sex, Richard G. MacKenzie, M.D., advised at a pediatric conference sponsored by Symposia Medicus.
“Sometimes kids have questions in areas that they sometimes feel hesitant or embarrassed to ask [you about],” said Dr. MacKenzie, director of the division of adolescent medicine at Children's Hospital Los Angeles. “I'll say, 'If you don't feel comfortable asking me questions as your physician in a confidential way, then I think we need to help find another physician for you because you should be able to ask questions of someone that you trust and who knows of your personal and private life.'”
Building a trusting relationship that allows for confidentiality includes encouraging parents to talk to their kids about sensitive topics, “if for no other reason than to raise these as concerns so their teens can bring questions to you as their advised health care provider,” he said.
Dr. MacKenzie discussed common questions about sex that young women have posed to him over the years:
▸ Do my parents have to know if I go to the doctor for birth control or for a checkup? In most states the answer is no. In California, for example, “a minor may receive birth control without parental consent, and a minor may consent to medical care related to the prevention or treatment of pregnancy, except sterilization,” Dr. MacKenzie said. “The health care provider is not permitted to inform the parent or legal guardian, and the parent or legal guardian is not responsible for the bill that young person generates.”
For a resource, he recommended the “Adolescent Provider Toolkit,” a guide to treating teen parents. It can be found on the Web site of the San Francisco-based Adolescent Health Working Group (http://ahwg.net
▸ Can a girl get pregnant when she is having sex on her period? “For those of us who know the standard knowledge base about menstruation and pregnancy, the simple answer is no, but there are exceptions,” said Dr. MacKenzie, also of the departments of pediatrics and medicine at the University of Southern California, Los Angeles.
The biologic conditions for normal pregnancy are ovulation, a patent fallopian tube, motile healthy sperm, and a receptive endometrium.
However, he noted that about 10%–15% of a teen's menstrual cycles are characterized by midcycle bleeding, “which is ovulatory bleeding and is usually accompanied by a small amount of brownish-colored blood,” he explained. “To the novice, this may look like menstruation,” so the woman may mistakenly presume that she can't get pregnant.
Some investigators hypothesize that sexual arousal may actually stimulate ovulation, thus mimicking an estrus cycle, a phenomenon seen in rabbits.
“Menses is an evolution of the estrus cycle, a reproductive cycle in which ovulation occurs secondary to sexual arousal and stimulation,” Dr. MacKenzie explained. “Anecdotally, women have reported getting pregnant 'against all odds,' having coitus only during their menstrual period. Some clinicians feel that a woman may regress to the estrus cycle with stimulation. She may actually ovulate secondary to sexual stimulation. If the other conditions are right, she may become pregnant.”
▸ Can I get a sexually transmitted disease from oral sex? The answer is, “for sure,” he said. STDs that can be transmitted during oral sex include gonorrhea, herpes simplex virus, chlamydia, human papilloma virus, chancroid, and syphilis.
“The reason this question comes up is that there is this feeling amongst young people that oral sex is not sex at all,” he noted. “It's another way of sexual satisfaction, but it's not considered sex in their minds.”
▸ Can you be pregnant and still have your period? The answer is yes. This can happen during spurious menses, a condition in which pregnant women continue to have abbreviated menses for the first two to three cycles after fertilization. “I've seen a number of young women whom I thought on my history taking and my exam were not pregnant but ended up being pregnant [because of this condition],” Dr. MacKenzie said.
Implantation bleeding is another cause. “This occurs in 25% of females 5–12 days after ovulation, [which is] roughly the time of their menstrual period, so it can be seen as a period,” he said.
Ectopic pregnancy, blighted ovum, and molar pregnancy also may produce vaginal bleeding that is mistaken for menses.
▸ Can a girl get pregnant even though she hasn't had her period yet? This question “probably speaks to 13-year-olds who are talking about having premenarchal sex,” Dr. MacKenzie said. “It's extremely unlikely,” but there are occasional reports.