“Work with parents is necessary”: the main children's gynecologist in Moscow spoke about the problems of young patients

- Which patients and where do they most often come from?

- Our department provides planned, and not emergency assistance to residents of Moscow and all other regions. Most of all in our department are teenage girls, but there are many young girls (up to 3 years old) and preschool girls.

As for geography, they come to us from all over the country, from Kaliningrad to Khabarovsk. Orel and Yaroslavl regions I would like to note separately: local doctors do not start the situation, consult with us, send difficult children. And they constantly invite us to give lectures and train specialists.

- Are there regions where doctors, on the contrary, trigger diseases?

- Unfortunately, this also occurs. A girl from Stavropol came to us in a serious condition, because at the place of residence she could not find therapy for two months, but they were not sent to us either. We have such examples almost every day.

Or, let’s say, a glaring story. The 14-year-old girl came from the suburbs.

The patient’s tumor was such that her stomach corresponded to the stomach of a pregnant woman with a full-term twin pregnancy. Mom repeatedly appealed to the pediatrician with a complaint about an increase in the size of the abdomen, but the pediatrician prescribed a hypocaloric diet and jogging in the morning. And I would not have believed if my mother had not shown me a polyclinic card.

By the time the girl came to us, she was barely walking. Thank God that this tumor did not degenerate into a malignant one, but it was on the verge. The patient had high tumor markers, that is, the tumor was borderline.

I believe that the situation in which such cases arise should be changed centrally and legally. Let's say that with such a list of diseases, doctors should be sent for treatment to a specialized federal institution. While this is not happening and parents are not aware that they are entitled to free medical care for their daughters in large centers, many doctors think that it is better to leave patients to be treated at their place of residence. Yes, the money from the compulsory health insurance fund will go to the clinic that treated the child, but still, the child’s health must be our priority.

- What does the patient need to do to get to you?

- The situation with the coverage of the child population is not bad, but only in large million-plus cities.

I travel around the country a lot and I realized that there is a kind of informational vacuum. Many do not know where to send the girl with gynecological problems. That's why I started blogging for moms on Instagram: a third of the department’s patients come through this social network.

• © Photo from the personal archive

In the department of pediatric gynecology of the Russian Children's Clinical Hospital, we accept children from 0 to 18 years old from all regions of Russia, and getting to us is very simple. You only need a referral No. 0557 from any doctor of the clinic, no upholstery of the thresholds of the Ministry of Health.

If the pediatrician begins to say that he cannot give a referral, since patients supposedly have to be treated at the place of residence, then he violates federal law. According to Federal Law No. 323, any resident of any city in the country has the right to be treated in Moscow.

Many doctors still refuse to issue referrals to the capital. Then you need to demand a written refusal from the chief doctor of the clinic and go to the Ministry of Health with him.

When I give lectures, I hear the question of how much treatment costs in the RCCH. And I'm tired of saying that it’s free. It is necessary to convey this information to people, because they have lost faith in free medicine. And it exists, and at a high level.

- What problems are most often addressed to you?

- There are a lot of problems, and their prevalence depends on the age of girls. Based on the practice of our department, violations of the menstrual cycle come first in adolescents, both in the type of bleeding and, conversely, in the absence of menstruation, as well as tumors and tumor formations (cysts) of the ovaries.

However, tumors and cysts are also found in babies. We have passed several patients with intrauterine cystic torsion, that is, these girls were still fetuses, and they already discovered one or another pathology. A cyst is a kind of tumor, but it is always benign and can often even go away on its own. There are so-called functional ovarian cysts, which often do not need to be operated on at all, but just need to be observed. But observe with a specialist - a pediatric gynecologist.

Next come inflammatory diseases, malformations, sexual development disorders, diseases of the mammary glands and so on.

- What diseases can be at an early age?

- In very young girls, synechia pathologies are very common - fusion of the labia minora. Further inflammatory diseases, the same cysts and tumors.

The age from 3 to 7 years is called the neutral period or the period of sexual rest, therefore, during this period, diseases associated with the physiological deficiency of estrogens, for example, atrophic vulvar disease, which is often confused with vitiligo, are often found.

At this age, vulvovaginitis, that is, inflammation, comes first. This is due to the fact that a girl of this age does not have enough female sex hormones and her epithelium is easily damaged and vulnerable. Children do not always follow the rules of hygiene, so microorganisms quickly enter the genitals, penetrate the epithelium - and diseases arise.

- What symptoms should a mother pay attention to?

- This is a very important issue, and I even have a memo for my parents. In general, the girl should be examined by a gynecologist at the age of three, six, 14 years old and then annually even in the absence of patient complaints. But if at any age one of the listed in the memo is manifested, then the parents should write the daughter to the gynecologist or ask the pediatrician about the appropriate direction.

When is it time for parents to sound the alarm? Any item from the memo, but especially the change in the size of the abdomen.

Often a patient comes with an advanced education, and it happens that it is malignant. Then the most difficult surgical treatment is ahead - the removal of female reproductive organs with subsequent chemotherapy. Such cases are quite rare: annually we have several people, despite the fact that we are not an oncological institution.

There are reverse situations: the girl had a benign education, but at the place of residence she had her ovaries removed from both sides, fearing that it was cancer. Although now there is every opportunity for emergency intraoperative cytodiagnostics (during the operation, doctors take tumor cells for research. - RT ), which allows you to accurately determine the nature of the tumor. I understand that this is not used in all hospitals in the country, but then you should not be shy to send a complex patient to specialized institutions where they are doing this - you will save your child’s health and life.

- What changes in the health of girls in the country can be noted in recent years? For example, have the pace of sexual development changed?

- No, the average age of the onset of the first menstruation (menarche) in central Russia is still the same as, for example, ten years ago: 12.5 years. A little earlier this age occurs in the southern regions and a little later in the northern regions, because the maturation of the reproductive system directly depends on genetic, national factors and the amount of solar energy.

- Are there any new diseases caused, for example, by physiological changes or changes in the environmental situation?

- According to statistics, the incidence in pediatric gynecology is growing, but this is not so much associated with a true increase in the incidence, but with an improvement in diagnostic capabilities. Now we are beginning to examine the child when he is still in the womb. That is, the fetus has become a patient for us. And supposedly "new" diseases existed 30 years ago, they simply were not detected.

The state has set a priority task - the preservation of the reproductive health of the nation. A healthy girl is a healthy expectant mother, which means the reproductive health of the nation as a whole. If we do not treat a girl under the age of 18, then after coming of age the treatment will be difficult. And we get a sick mother with many already chronic diseases.

• © Photo from the personal archive

In many regions, there is such a statistical paradox: until 18 years, all girls are healthy, and after 18 years, their health is deteriorating. And after all, not because they fell ill at the age of 18, but because before that they had not seriously dealt with them. In addition, there is no separate specialty "pediatric gynecologist."

- That is, gynecologists should receive additional education?

- Yes, pediatric gynecology is a sub-specialty. We are all obstetrician-gynecologists, and then we go through continuing education courses and become pediatric gynecologists. And there is an actively promoted opinion that pediatric gynecology should be distinguished as a separate specialty.

A simple example: we have a specialty “pediatric urology”. Why are boys examined so thoroughly until they are 18 years old? Why is there a pediatric urology, but no pediatric gynecology? Most likely, because the boys are conscripted, and by the age of 18 they should be fully examined and treated.

- At what age do girls now begin sex life?

- The average age in Moscow is 16 years and 1 month. In the regions about the same.

- In this regard, how do you assess the situation with educational activities, sexual education of minors, informing about the need for contraception?

- Of course, it is necessary. But here, as far as I know, this is prohibited in schools. There are pros and cons here. On the one hand, if we actively promote this in schools, we will still reduce the age at which sexual activity begins. On the other hand, we will avoid unwanted early pregnancies. We must weigh what is better and what is worse.

I see a solution to the issue of raising the moral and cultural level of each family.

Work with parents is necessary, because as long as I saw early pregnancies during my practice, the girl always had contact with her mother.

- Do doctors take on this responsibility?

- This is not an obligation, but it is advisable that the doctor conduct educational work. In practice, it is very difficult, because we have a clinic appointment time of 12 minutes. While the girl came, talked, undressed, dressed, 15 minutes had already passed. What kind of educational work?

Perhaps we need some kind of seminars, webinars, work with a psychologist, with parents, with teachers. I see this work not within the school with a child taken out of the family, but through activities aimed at working with the family.

Even if we teach a girl at school to protect herself, we can’t avoid any serious problems with her reproductive health. Yes, we will avoid early pregnancies or reduce their number, but the earlier the sexual life begins, the greater the number of problems and diseases a girl gets by the age of 18.

- Returning to sexual education, do people come with sexually transmitted diseases? Is it possible to get them not through sex, but through everyday life, for example, in the pool?

- No, now all the pools are very well disinfected, at least in Moscow. Therefore, many would like to attribute the infection to the pool. But more often it is sexual contact or gross violation of hygiene rules.

- How often do patients with HIV, AIDS and hepatitis come to you? Do these diseases occur at an early age?

- We do not have that often, fortunately. We rarely detect people living with HIV and children with hepatitis. There are, but then they, of course, go to specialized institutions. According to the law, we are obliged to assist them, and they have no restrictions.

- Another issue discussed is the human papillomavirus (HPV). There is a widespread belief that vaccination can be done only up to 15 years, while in the West the vaccine is given up to 40 years.

- It is a myth. It is recommended to be vaccinated before the age of 15, before the onset of sexual activity, but does not mean at all that it is impossible later. We officially registered up to 25 years inclusive. Abroad in most countries - up to 40 years. Moreover, before vaccination, you do not even need to be tested for HPV. If he is, no - it doesn’t matter. It will not be worse. There are ardent anti-vaccines, but our patients listen to the recommendations of doctors.

- Irina, what would you like to tell mothers?

- Do not be shy to contact a pediatric gynecologist with any problem, we will always help you, we are available and it is easy to get to us.