Amy Kelley, MD - Sanford Health News

Benefits of birth control for teens

Dr. Amy Kelley:

We call it birth control because that’s what it originally was marketed for but because like more than half of people use these things for other reasons, it really is more accurate to say hormonal management.

Courtney Collen (host):

Hello and welcome to “Her Kind of Healthy,” a health podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. We want to start new conversations about age-old topics, from fertility to managing stress, healthy living and so much more.

“Her Kind of Healthy” is designed to bring you the honest conversations about self-care, happiness, and your overall wellbeing with our Sanford Health experts. We’re so glad you’re here.

In this episode, we are talking about why birth control can be beneficial for teens. Dr. Amy Kelley is a board-certified OB/GYN at Sanford Health in Sioux Falls, South Dakota, and a specialist in pediatric and adolescent gynecology. Dr. Kelley, welcome. Thanks for being here.

Dr. Amy Kelley (guest):

Yeah, of course.

Courtney Collen:

Always glad to have you. If you’re a parent or if you’re caring for a teen and just aren’t sure where to start, we’re here to help you take a step back and look at the bigger picture so we can approach this topic with confidence. Birth control isn’t just about preventing pregnancy and Dr. Kelley, I’m glad you’re here to correct me if I’m wrong, but it can be used as a powerful tool to support overall health and quality of life for teens. Am I right?

Dr. Amy Kelley:

Yeah, absolutely.

Courtney Collen:

The name birth control can be somewhat misleading. So let’s start with this. What are the most common medical reasons teens would be prescribed birth control?

Dr. Amy Kelley:

Yeah. So common medical reasons would be painful periods, especially if they are interfering in a teenager’s life. They’re missing school or they’re missing their sports activities or just not feeling their best.

Also, sometimes for adolescents who maybe have really heavy periods that are hard to manage, if you have to change your tampon between every class period, there is like two to five minutes between class periods and that’s just like impossible for some people to do. Sometimes it’s just way too heavy or you’re bleeding through your clothes because you can’t change it often enough. Those are things that birth control methods can help a ton with.

Courtney Collen:

Dumb it down for me for a moment. Why would birth control help with a painful period? What is it doing in your body to help with a period?

Dr. Amy Kelley:

Yeah, so there’s really kind of two big groups of birth control. One is things that you have to take a lot, really common, like you have to take often. So pills you take every day. A patch, you change once a week. The Nuvaring, which looks like a hair tie and goes in the vagina and you change it once a month.

Those all work to give you just a little bit of estrogen and a little bit of progesterone every day. And so they actually kind of keep your hormones the same throughout the month and they make the lining of the uterus thinner so that your periods can be lighter, less heavy, less painful.

And sometimes they help with mood issues too because you’re not getting a big surge of hormones right before your period. It kind of just turns the volume down on all of that.

The other big kind of birth control is things that just have progesterone in them, like the shot, the implant, and IUDs and those things don’t have estrogen in them, but they also, progesterone kind of just turns the volume down on your period and makes the lining thinner and can really help make periods less painful and less heavy.

Courtney Collen:

How often would you say you prescribe birth control for reasons that have nothing to do with preventing pregnancy?

Dr. Amy Kelley:

Oh, easily more than half the time, especially for teenagers. And honestly, a lot of times it’s for both things. I mean, and that’s particularly true for adult women is they need contraception, but also they need this to help with their period.

The other big group of reasons why we help people with their period is actually sometimes to stop their period. Especially for teenagers with extra challenges or disabilities. That’s a decent segment of what we see as well. If you have autism or have sensory issues or maybe you have cerebral palsy and it’s really hard for you to actually deal with the reality of changing a pad or you know, you’re in a wheelchair. You already have these challenges and then like you throw puberty in, a period in there, and it’s like a bomb going off. It’s too much.

Some kiddos in that situation do great with their period. They’re fine. Other kiddos not so much and other teenagers not so much. So, that’s another really big segment of what I see probably because I’m a specialist.

Courtney Collen:

That makes sense.

Dr. Amy Kelley:

Kids with complex issues that need period management.

Courtney Collen:

So we talked about how birth control can help regulate or reduce painful periods. In what ways can birth control support teens who maybe struggle with acne or hormonal symptoms?

Dr. Amy Kelley:

Yeah, so there are some side effects, and they really are kind of side effects from certain kinds of birth control that can be helpful. Already mentioned the one about helping with PMS (premenstrual syndrome), they can definitely help with some of those moods. Sometimes PMS isn’t just moods; it’s also like stomach aches or headaches. And they can definitely help with those things.

Also, acne. Helping with acne can be a side effect of some kinds of birth control and honestly, especially if acne’s way worse around the time of a period, it can really help a lot with it. So sometimes those side effects are actually one of the reasons why we choose one type versus the other. Sometimes it’s the whole reason somebody’s on it.

Courtney Collen:

Well I’m so glad there are so many options. At least you can decide what route you want to take based on the condition that you’re living with or the issue you’re having. How does birth control help manage conditions like PCOS (polycystic ovary syndrome) or endometriosis in younger patients?

Dr. Amy Kelley:

We don’t typically diagnose PCOS until people have had their period for like four years. So some teenagers can be diagnosed but some are too early in kind of their period life.

Courtney Collen:

Why would you wait to diagnose that?

Dr. Amy Kelley:

Because actually normal puberty looks a lot like PCOS and so there’s so much overlap there. And it often takes several years to really know what somebody’s period pattern is because it’s normal for it to be a little more variable for the first couple years. And a lot of things in puberty, like acne in particular, which some people know can be symptom of PCOS, is totally normal in puberty.

Courtney Collen:

How do you help teens choose the method that fits their lifestyle or their comfort level? Let’s talk through some of those options and maybe which might be best for this specific age group.

Dr. Amy Kelley:

Yeah. So I think honestly it really depends on your teenager and what their goals are. I don’t think there’s a specific birth control that’s perfect for everyone out there. I think it’s a very individual decision. I kind of have people think about usually like two or three things. One is, can you remember medicine every day or every week or are you going to forget it all the time? And that’s a little bit of a personality thing. You can work on remembering things, like it can be a skill that you learn, but some people just inherently have that skill already without having to work.

Courtney Collen:

Yes. It does not go away.

Dr. Amy Kelley:

Yeah. And some people are just really not good at that.

The other one would be what you want your period to be like. So things that have a little bit of estrogen and a little bit of progesterone in them, you do have to remember a lot, but they keep your periods really regular. So like pills, the patch and the ring. And if you really want a regular period – that’s important to you – you want to be able to move it around for like prom or something, then those can be good methods as long as you remember them.

Other methods like the shot and IUDs can actually make the lining of the uterus thin enough that you really don’t even have periods. Or if you do, they’re super, super light, but some people don’t like that and other people that is their whole goal is they’re like, yes, please get rid of my awful period. So I think those are two kind of ways to, two things to think about. Like, can I remember to take something or not? What do I want my period to be like?

And I think the last thing is do I need contraception? You know, we don’t use it just for that reason, but especially in teenagers who are maybe going off to college in a year, that might be something that they are pondering maybe they’re going to need. And so I think that that’s the other thing I encourage people to think about because there are some that are better for preventing pregnancy than others.

The best things for preventing pregnancy are the things that you can’t screw up. So what I mean by that is you’re not going to forget them. So IUDs that go in the uterus and implants that go in the arm have the lowest failure rates. They’re right along with getting your tubes removed.

So the one in your arm has a failure rate of about a half-a-person in a thousand and IUDs have failure rates of about one in a thousand. Whereas if you look at all comers for the pill to patch and the ring, it’s like 50 to 70 in a thousand. And that includes people who forget it too. So it can be better if you’re really good at remembering it, but it’s not anywhere near as effective as those other things.

Courtney Collen:

Do you find that this age group nowadays is going towards a certain method of birth control versus others? Are people going to less daily oral pill form and more, you know, something else in the arm, whatever it may be? Or is it really situational?

Dr. Amy Kelley:

I think it’s a big mix and it’s really situational. A lot of younger teens may not need contraception, but they really want good acne control and they’re going to lean more towards the ones that help more with that which is like the pill, the patch, and the ring.

And some people are like, I can’t remember to take my vitamin, there’s no way I am going to remember to take a pill. And so they lean towards doing something like an IUD. IUDs and implants are a lot more popular now than they were when I first started, you know, 15, 20 years ago. We do them a lot more, especially with teenagers. The youngest person that I’ve ever had do one for bleeding disorder was like 11. They’re very safe in teenagers and we have many different ways to help with discomfort and pain with insertion.

So I think a lot of teenagers are more likely to have heard about them and maybe be willing to talk about them, but they’re not always what they want. They’re not always like to have the side effects or have the features that are what they’re looking for.

Courtney Collen:

How would you talk with teens or maybe encourage parents to talk with teens about using birth control responsibly and consistently for those who may go with the oral or some of those that you take more regularly?

Dr. Amy Kelley:

It’s a habit. You can develop the habit. But if you aren’t consistent about taking especially pills, then it’s going to make your period really wonky. Like you’re going to have breakthrough bleeding all over the place and stuff when you miss them. And so, it’s not going to help with what you want it to help with.

So it is important to take it regularly. And some tricks that I have for people is there is a website where you can sign up and it will send you text reminders. And I think that works really well for the ring, which is monthly, or the patch, which is weekly. But I don’t think it works great for daily pills because eventually you just, we just start ignoring those reminders on our phone. Right.

Courtney Collen:

Yep. Naturally.

Dr. Amy Kelley:

So, I usually for daily things I think it’s really good to pair it up with something else that your teenager is really good at. Is your teenager really good at brushing their teeth every night? Does your teenager have a skincare routine that they’re like religious about? Well then, you’re going to put that right in with that because they’re not going to forget it if you pair it up with something that they’re really good at remembering.

Courtney Collen:

Sure. That makes sense. What noncontraceptive benefits do you think are often most overlooked?

Dr. Amy Kelley:

Probably relief from pain, decreasing the heaviness of periods. Those are probably two big ones, but birth control can be very helpful for things like mood swings around your period, acne, and honestly sometimes just with life in general.

If your periods, even if they’re technically normal, where your period is every like three to five weeks, if it varies within those three to five weeks and sometimes it’s 25 days apart and sometimes it’s 35 days apart and sometimes it’s 30 days apart. As a teenager, that can be super annoying and it can be really difficult to manage, especially in younger teens if it’s kind of all over the place. And so sometimes just the regularity of it and the predictability of it can be helpful for people’s lives.
I also think that people who have medical issues or teenagers who have medical issues like seizure disorders, diabetes, or if they’re anemic, it can sometimes help with those things. Some birth control methods actually can lower or can increase the seizure threshold. So sometimes it can actually help decrease seizures, especially if you notice more seizures around periods.

And sometimes diabetics have more issues with their period. There’s like a lot of medical things that sometimes have it being on something for birth control, hormonally managing your period sometimes can help with some of those medical things.

Courtney Collen:

That’s good to know. How do you involve parents, or guardians, while still respecting a teen’s privacy and autonomy? I bet this is a really tricky, delicate line that you’re on constantly as a pediatric and adolescent gynecologist.

Dr. Amy Kelley:

Yeah. And honestly, it can be really easy sometimes because sometimes parents are very aware of giving their teenagers some more autonomy and they’re like, yes, I’m going to leave the room now. So some parents are very aware of trying to build up their teen’s ability to deal with medical issues on their own.

And it’s not about keeping things from you about your child. That is not the point of teenagers having confidentiality. I cannot order any tests. I cannot give your child any medicines without your permission because you’re their parent. So I think that it’s important to know that.

But I do think it’s also important for your teenager to maybe have someone they can ask questions that maybe they’re just not quite ready to ask you. And usually it’s just because they’re embarrassed. It’s not because they’re trying to keep something from you or they don’t know how to ask you about something.

So it’s a very fine line to walk and I usually just am very clear about the boundaries at people’s first visits when I first meet them. I’m like, “This is the confidentiality that your daughter has with me. These are the exceptions.” And I tell the daughter and the mom when they’re both in the room. So they both hear me say that. We also do have an obligation where mandatory reporters, so if a teenager tells me that someone is hurting them or they’re going to hurt themselves, that is when I can break their confidentiality for that to get them help and help protect their safety. And so I always make sure and mention that.

But if we’re just chatting and she’s telling me some things that she doesn’t need medicine for, we don’t need to look into, just questions or things that she’s asking me, I’m not going to talk to her mom about that if she doesn’t want me to. I think that’s just part of learning how to be an adult and speak to medical providers. Like that’s a skill that everyone needs to learn.

And I think it’s also a way for her to advocate for herself but sometimes it’s tough. Sometimes teenagers and parents are on totally different wavelengths and then we have to kind of thread that needle about like, OK, so the teenager wants one thing, and the parent wants another. And sometimes it takes a couple visits or some time to do that honestly.

But I actually, one thing that I think both Dr. Miller and I are very clear about is that we will not do something against your teenager’s will. So if you are like, I want you to get an IUD, I am not going to put that in without your teenager saying that’s OK. And that doesn’t happen very often where people ask me to do that. But you know, we can’t do anything without your consent. But also I need your teenager to also consent to that because I’m not going to do something against their will except in very specific circumstances.

Courtney Collen:

Yeah, that’s fair. And this is why we’re grateful for you and for Dr. Miller, and for all specialists in this region, because it is such a learning process. Like parents are doing this in most cases, if it’s, if they’re listening to this, maybe they have, you know, their first girl or they’re caring for a teenager and this is their first journey kind of through puberty and we’re all learning together.

Dr. Amy Kelley:

I mean, me too. I’m a parent of teenagers. Now my two oldest are technically adults, you know, you’re looking surprised. But yeah, they are, they’re going off to college next year and it is like hard to navigate. And the one thing that I was most surprised about, I mean I knew it was coming, but I didn’t realize it was going to happen at 12:01 a.m. Is when your teenager does turn 18, suddenly you are, you do not have any MyChart access unless they sign something and give it back to you.

But like that’s also a really hard transition for some people, especially if you have a medical, a kiddo with some medical issues is when that summer before they go off to college or whenever they’re like right before 18. Sometimes you gotta do a little planning for that. Like how are they going to get their meds? Like are you going to be allowed to have their MyChart access so you can still help them? Are they going to take it over completely?

I think that that’s one thing I try to prepare parents and teenagers for too as they get closer to graduating is I’m like, now look, you’re going to not have access to this anymore. And that’s another reason why it’s super important for your teenager to be able to talk to their health care provider by themselves is that at some point they’re going to have to do that.

The goal with teenagers is you want them to be able to do things on their own. As much as we don’t want them to grow up, that’s the goal is like they need to be productive members of society and be able to take care of themselves eventually. And health care is part of that so that’s part of teaching your teenager to be an adult.

Courtney Collen:

But something that we probably wouldn’t expect unless we’re told, you know, we need to start. Like that’s a big like reality hitting you.

Dr. Amy Kelley:

Yes.

Courtney Collen:

I didn’t even think about having to do that and I’m sure a lot of our listeners didn’t either.

Dr. Amy Kelley:

No, even me, I was like, I thought I had a little bit of wiggle room. No, there’s no wiggle room and 12:01 a.m. It’s gone on their 18th birthday. One of my kids has chosen to let me have some access mostly because to pay bills to be honest. But that kiddo has a few more issues and my other 18-year-old is like, nope, I can do it. And has kind of taken over for himself.

So, you know, I think that it just depends on the kiddo, but yeah, that’s one. There’s a lot of stuff when you’re trying to launch your teenagers that it’s not an easy process for anybody really.

Courtney Collen:

This could be a whole separate conversation.

Dr. Amy Kelley:

Oh, it could. Just around the launch.

Courtney Collen:

Oh, Dr. Kelley. OK. What myths or misconceptions about teen birth control do you encounter most often? I do want to ask you first, do you find that birth control encourages sexual activity?

Dr. Amy Kelley:

Absolutely not. And there have been studies going back decades that show that being on a contraceptive does not increase sexual activity. Just like getting the HPV vaccine does not increase sexual activity either. There’s actually lots of data showing that.

In fact the more informed you are about your reproductive health, you’re more likely to delay sexual activity actually. So the more you know, actually the better choices you make.

I would say there’s so many misconceptions and social media has not helped in this regard. But I think one of the big ones coming up more recently is that being on contraception or hormones are bad for teenagers, like they’re bad for their health. There is no evidence that that is true. There’s lots of evidence that it’s very safe for teenagers and can really improve their quality of life.

I think the other things that I hear a lot are it’s going to make me gain weight or I’m going to be crazy when I’m on it like it’s going to affect moods. And I would say that those side effects can happen. Those side effects do happen, but they’re like in the 1% range. So that means 99% of people don’t have those side effects.

And the good thing is we have lots of different options. So if you do have those side effects with something, we can switch you to something else. It doesn’t mean that all of those options are going to cause those things for you. Every pill has a slightly different progesterone. Every method is slightly different and if one doesn’t work well for you, a lot of times another one will.

The only method of hormonal contraception or hormonal treatment that we know is associated with weight gain is the birth control shot in about a quarter of people. But all the other ones are right around the 1%. So those are like very common myths I get.

The one that moms always ask me about is “I don’t want this to affect her fertility long term.” Sure. Which absolutely understandable. And none of them do. So none of them increase the risk of infertility. There are a couple things that do increase the risk of infertility, but none (of the hormonal contraceptives) will increase the risk of infertility. They all are out of your system fairly quickly. The birth control shot can take six months to a year to wear off. So that’s one that like, it takes a long time to wear off, but it does. But I think a lot of moms and sometimes teenagers are really worried about that and there’s no evidence that it affects fertility long-term.

I think the things that do affect fertility are if you get gonorrhea, chlamydia, then it scars your tubes. And then some medical things can – endometriosis can affect fertility and actually hormonal management of endometriosis can help protect your fertility. So it’s easier to have babies later. So sometimes it actually is protective and not harmful.

Courtney Collen:

I like that we say “hormonal management” versus birth control.

Dr. Amy Kelley:

Yeah. I always try to say this is hormonal management, like lay people, we call it birth control because that’s what it originally was marketed for. But because like more than half of people use these things for other reasons, it really is more accurate to say hormonal management. Yeah.

Courtney Collen:

Makes perfect sense. Is there anything you would want parents to know or to feel reassured and ease any fears or anxieties around their teens starting this hormonal management or birth control?

Dr. Amy Kelley:

Yeah, I would just say feel free to ask questions. It’s OK if you’re worried about it. You’re just being a parent. Like we’re trying to make the best decisions we can with the information we have, so just make sure you have the information.

I think that especially some of these were not available or were not recommended for teenagers when maybe the parents were young. Like IUDs, it used to be like, no, you can’t have those until you’ve had a baby. But we have a lot, we have different IUDs now and we also have a lot more data that is very safe. So I think just asking lots of questions and being open to having a conversation is a good idea.

I also think that watching your social media consumption is not a bad idea and watching your teenagers’ social media consumption is also important because there are amazing, good things on social media. There are health care providers who have a social media footprint who are giving really, really good information out there. And there are websites that are not owned by companies that make money from birth control, that have really nonbiased stuff on there. We know that what those websites are, we can give them to you.

But I think when you’re looking like sometimes it’s really hard to know, is this person actually a doctor? Does this person actually have any criteria whatsoever to be giving me medical advice? Oftentimes the answer is no. And so I think you really have to take anything with a grain of salt, right? That’s in social media, particularly if they’re trying to sell you something or if they’re telling you just this one thing is going to fix everything. Anybody who is making money by selling you something and encouraging you to do that, and you just have to have a little bit of suspicion around that.

As a physician, we are paid because of our expertise and our time, but we don’t make any extra money because we did so many IUD placements or whatever. We don’t get money from the company that makes IUDs. We don’t get kickbacks from that or anything. We just make money based on the time we spend with people and our expertise. And so I think that’s just a little different.

And hopefully I’m not throwing anybody under the bus. They’re not like selling supplements, but I just don’t, as a physician, I just don’t think that’s actually ethical either. That’s my personal opinion, so.

Courtney Collen:

Well, I think it’s important that we clarify like what our position is here at Sanford Health and what our physicians are doing as board-certified specialists in this area and why it’s important to, if you have questions, like skip the Doctor Googles, skip the social medias, and just go straight to your trusted provider. Absolutely. When something comes up, especially if it’s, you know, for your teen, for your adolescent, for your child.

Dr. Amy Kelley:

Absolutely. I definitely recognize that people Google things. People want or maybe look at some of that stuff. But like I will give you actual websites that I feel have good information on them or that I know somebody who’s board-certified, this is their handle and I know they actually have the expertise they’re talking about. Because sometimes it’s real hard to tell.

And it’s real hard to tell who owns websites. And who’s getting paid for what on websites. And so I think that it’s also a skill to teach your teen, you know, you want, if they’re looking at those things, you want to be like, now you’re listening to this person – is this person a doctor? What credentials does this person have? That’s a skill that your teen is going to have to know too.

So I think it’s also just like a learning experience for all of us as we navigate kind of that new, not new, but like ever expanding social media presence.

Courtney Collen:

Absolutely. Yeah. Do you have any top of mind handles or websites that you want to quickly share?

Dr. Amy Kelley:

I watch a wide variety actually in different specialties just for my interest.

Courtney Collen:

Specifically on this topic of birth control for this age group.

Dr. Amy Kelley:

So the website I really like is bedsider.org because it is actually run by a nonprofit who does not make any money from hormonal management or from birth control. And so I feel like it’s really not biased. It’s very like the good, the bad, the ugly. Like it has everything in it and I think it’s really good. And it kind of is specifically tailored for teenagers actually, too.

Or like the American College of Obstetrics and Gynecology. I think those are also good places to go if you’re looking for medical information as well.

Courtney Collen:

Well thank you as always for the insight and for all that you do in this space of adolescent and pediatric gynecology and talking about birth control and all the things. We’ve had so many great conversations. This is just another one of those. Thank you for your time.

Dr. Amy Kelley:

Yeah, of course. Thanks.

Courtney Collen:

This was part of the “Her Kind of Healthy” podcast series by Sanford Health. For more, listen wherever you get your podcasts or online at news.sanfordhealth.org.

Get more episodes in this series

Understanding gynecologic care for teens

Dr. Amy Kelley:

I think that this is not always the easiest thing for parents to talk about. And so having someone who’s super comfortable talking about periods, talking about body parts, that is something that is really nice for teenagers to have. I often tell teenagers, I’m like, if you have embarrassing questions, I’m the girl to ask. Yeah, I don’t get embarrassed. Really. It’s hard to embarrass a gynecologist.

Courtney Collen (host):

Hello, and welcome to “Her Kind of Healthy,” a health podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. We want to start new conversations about age-old topics from fertility to managing stress, healthy living and so much more.

“Her Kind of Healthy” is designed to bring you the honest conversations about self-care, happiness and your overall well-being with our Sanford Health experts. We’re so glad you’re here.

In this episode, we are talking about OB/GYN care for teens. So, if you are a parent of, or caring for, a teen and just aren’t sure where to start, we’re here to help kind of take out some of the guesswork and make this feel a little less intimidating. Maybe you’re asking things like, is it too early? Is something wrong or is this just a part of a young woman growing up?

Dr. Amy Kelley is a board-certified OB/GYN and a specialist in pediatric and adolescent gynecology at Sanford Health in Sioux Falls, South Dakota. She is the perfect person to help us dive right in. Dr. Kelley, welcome. Thanks so much for being here.

Dr. Amy Kelley:

Thanks! It’s lovely to be here.

Courtney Collen:

We’re always glad to have you and your insights for conversations like this. So, let’s set the stage first and talk about what makes adolescent gynecology different from general gynecology care.

Dr. Amy Kelley:

Yeah, I think there’s two big things that make it quite different. One is that we typically have parental involvement in adolescence, and obviously when you’re an adult woman it’s just you and the doctor and that puts kind of a different dynamic on things sometimes, both for parents but also for teenagers because sometimes this stuff isn’t very easy for teenagers to talk about in front of their parents.

And so sometimes it’s one of the first times that they’re seeing a doctor and maybe we don’t have their parent in the room for the whole time. Or maybe it’s the first time they’re really talking to a doctor about things like, you know, their genitalia or their periods and so it’s just a little bit different, a different dynamic.

I think the other thing is that adolescents and young girls are not the same as adults. Their brains are not fully developed, and also their reproductive system isn’t fully developed. The first couple years after your period, that immature system can behave just a little bit different than it does when you get, you know, 3, 4, 5, 6 and beyond years past your first period.

Courtney Collen:

In a little bit, we’ll talk about what that first appointment might look like with or without an adult. And what those conversations, how they might flow. But first, what are some of the most common reasons or concerns that you see an adolescent going in for OB/GYN care? Why would they need that?

Dr. Amy Kelley:

Yeah, I think there’s kind of two big things that people come in for. One is the am I normal? Which is either like an anatomy issue or just a period issue where either Mom or the teenager for some reason is worried that something is wrong. And sometimes that’s true and sometimes it’s not. So that’s kind of, I call those the am I normal visits.

The other one is when they, the teenager or the mom or both of them really feel like there’s a problem like where something having to do with their period or reproductive health is interfering with their life and they need something done about it.

Courtney Collen:

What age or milestone – you talked about period, am I normal? So talk about like what age are we talking about and what age would you recommend a teen’s first visit?

Dr. Amy Kelley:

Yeah, so ACOG (American Congress of Obstetricians and Gynecologists) actually recommends that adolescent women be seen between the ages of 13 and 16 for their first visit. And I think that that first visit often just depends on if things are going well for the teenager or not.

So, you know, really people can get their period even as young as like 9, especially in non-white populations. And so sometimes we’re seeing adolescents and people who are going through puberty and they’re not even really teenagers yet. So anytime that there’s a problem or a perceived problem, we are happy to see someone.

I think you can always ask your pediatrician or your family doc first because sometimes parents just are not as familiar with what’s normal in puberty and what isn’t. They kind of only know what happened to them. So that’s a good reason to come in is if your family doc or you are worried that something is kind of going awry during puberty or afterwards or you’re having issues.

But if it’s just like I think that my daughter needs to have a gynecologist, then sometime between age 13 and 16 is a good time to just get established even if things are going well for her.

Courtney Collen:

Sure. So you say maybe you call them like, am I normal appointments? Those kind of routine 13 to 16 age group. Walk us through what that kind of appointment might look like. Who needs to be there? Is this you one-on-one with the teen? Walk us through what that might look like.

Dr. Amy Kelley:

Yeah, so if it’s kind of I’m getting established, like having some questions appointment, really it’s us sitting in a room and talking. It’s not very common that a teenager has to get undressed for us unless they have a specific concern about a specific body part. Most of the time we’re just talking about, you know, when they got their period, what their period is like now, are they struggling with other things in school. It’s really more of like getting to know them as a person, particularly if they’re doing well.

I think a big part of gynecology, especially for younger women is trust. Because you’re talking to somebody about periods when you get older. You might be talking to us about sex, about contraception. And those are things that a lot of people really feel like they have to have trust in the person.

And then when you get to 21, you have a Pap smear, and it’s super nice if you’ve seen us, even if it’s only every year, every other year, you kind of like know our face. You’ve talked to us a few times and by the time we’re actually doing some of those more invasive exams, people feel like they already know us.

And that’s really kind of the whole point of it is having access to someone who could, they can talk to you about things that maybe they don’t feel comfortable talking to parents about or honestly sometimes parents are like, I don’t really know. You know, and that’s fair, right? We are not always taught these things about our bodies.

But I think it’s really important and empowering for teenagers to know what’s normal and what isn’t and when they should call and talk to us. Because sometimes teenage years can be kind of a scary time, especially those first couple years after your period.

Most of the time parents are there, especially for that first visit. If I get the feeling that maybe the daughter or the teenager has a couple of questions that maybe they feel a little weird about asking, sometimes I’ll kick Mom out or I’ll ask, “Do you want to talk to me by yourself?”

And you know, sometimes if it really doesn’t seem like that then I won’t necessarily talk to her alone until her follow-up appointment. I feel like that’s something that kind of just really depends on the mother-daughter or the mother-parent –

Courtney Collen:

Dynamic.

Dr. Amy Kelley:

Yeah, dynamic. And also, a little bit how comfortable the adolescent might feel talking to me by herself because sometimes, you know, if you’re 10 or 11 and you’ve had your period for like a year and you’re having issues, you might not have ever really talked to the doctor just by yourself before. So it’s kind of intimidating sometimes.

I have everything from girls who are like telling me like what their blood looks like, you know, and all the nitty gritty details to someone who will like, barely even talk to me or like just doesn’t even want to even say the word period and you know, I think that just goes to like the fact that everybody’s individuals and this is a huge age range, you know?

If you’re 9 or 10 and getting your period, that’s a very different conversation. You’re still in elementary school. There’s different ways you look at the world than when you’re 13, 14. I mean there’s a huge amount of growth during that time and so it really can be quite widely different.

Courtney Collen:

Is there anything that a parent or caregiver can do before an appointment to help a teen feel prepared for a conversation with you?

Dr. Amy Kelley:

I think like just at least giving them the heads up of what kind of doctor we are. So like when we come in and start talking about periods, they’re not like, oh my god, what is this?

So I think at least them like knowing what kind of doctor they’re going to is probably a good step. Yes. It is helpful if people are having periods – especially if they’re having period problems with pain or irregular periods or feeling like they’re really heavy and unmanageable – I do think it’s helpful to maybe look and if you’ve been tracking periods or if you kind of have a calendar to look back on that so that you can answer some of those questions when we’re talking about some of that.

I feel like a lot of moms do that, but sometimes people come in with like their guardian, maybe like a sibling that has guardianship or foster parents or even like dad sometimes because that’s just the way it works out. And oftentimes those people maybe don’t have an idea of what that period pattern is. So just kind of either knowing that or making sure your kiddo knows that. Or your adolescent knows that. That’s very helpful.

Courtney Collen:

Even just jotting it down in a phone on a notes app or something.

Dr. Amy Kelley:

Yeah, absolutely.

Courtney Collen:

That makes sense. Can a teen schedule their own appointment?

Dr. Amy Kelley:

Typically, at least not in the state that we’re in (South Dakota) because we do have to have parental consent to see teenagers, to see people until they’re 18.

Courtney Collen:

Got it. How can parents or caregivers navigate normal puberty changes versus something that may need medical attention?

Dr. Amy Kelley:

I think that there is a wide variety of normal, which also throws a little bit of a wrench in it. But I do think that keeping track of periods when they first start to kind of know like what the actual pattern is. Is your teenager having issues with the period? Like, you know, is she bleeding through her clothes or onto her sheets at night? Are you noticing lots of clothes that have blood in them? Are you noticing like big mood changes around a period or that your kiddo is always missing a day of school because they feel like awful during their period or they’re throwing up? Those kind of things.

I think kind of just noticing that and kind of taking inventory of that I think is a good idea. Also being able to talk to them. You know, we’ve talked in the past about communication being really important during the teenage years even though they push you away and this is one of those times where you may have to pursue your kid a little bit, you know, and really make an effort to talk to them about these issues.

Because they may not always be super forthcoming about it. Especially if they’re embarrassed, like if they are kind of leaking into their clothes and things like that. That’s something that a lot of teenage daughters are like, you know, they kind of just don’t want anybody to know about. So sometimes you have to pursue your kids a little bit if you want to kind of know how they’re doing.

Courtney Collen:

Great insight. What should we understand about conditions like PCOS, which is polycystic ovary syndrome, endometriosis, or severe period pain in adolescents?

Dr. Amy Kelley:

Yeah, I think that the biggest thing is that if your kid is acting differently because of their period, like as far as missing school, not doing the things they normally do. You know, if they’re a runner and they never run during their period or if they aren’t going to their sports practice during that time because they don’t feel good. If it’s interfering with their life, it’s really time to talk to somebody about that because I think that sometimes if we had terrible periods as teenagers and nobody really did anything about it and they’re just like suck it up, then sometimes we’re like, oh well that’s normal and it might technically be normal but we can help so much.

And it’s really rough. Like teenagers, if they miss a couple days of school and you’re in high school, you’re behind. You know, it’s really hard to make that up sometimes. And so it can really interfere with their life even if you don’t necessarily always perceive it as being abnormal. If it’s interfering with life, it’s time to just come and see if we can help.

Courtney Collen:

And even if it would be normal and this is just kind of part of the routine, maybe you have some mild cramping but it’s new and it feels overwhelming. It’s still OK to come and say, “Hey, this is what’s going on.” Or a parent saying that, or the teen, and you just reassure them like this is part of this process.

Dr. Amy Kelley:

Absolutely. And I think if you’re not sure if it’s normal or not, then send off a message to your primary care provider if you haven’t seen us yet, you know to your pediatrician or to your family medicine person. They may or may not feel comfortable following up with you on period issues. I think it kind of depends on the person.

But they can, they do know what’s normal and what isn’t and what maybe you should come in for. PCOS is something that regular puberty can look a lot like. PCOS and regular puberty for the first two years after you get your period, there’s a wider variation in what’s normal. You can get it every 20 to 40 days. It can vary from period to period and how long it is and how heavy it is. And so PCOS in itself is not always something we diagnose until people have had their period for years.

And that’s really because some of the normal puberty like beginning of your period things are the symptoms of PCOS too. You know, like a lot of kids get acne and that can be a sign of PCOS but it can also just mean your kid just is going through puberty. So that is something that if you have concerns about, absolutely ask us about. But just know that it’s not something that we’re going to be like your kid has this right away because it isn’t something we typically diagnose in the first couple years after they get their period.

With something like endometriosis, that is something sometimes kids have symptoms right away. Really the thing I always tell people to look out for if you have endometriosis in your family is if right away periods are really painful and have painful or they have lots of GI issues around the time of their period.

Typically for the first couple years teenagers don’t always ovulate. And so actually, usually their periods aren’t painful. So if your kid, very first or second period, is already really complaining, pain, missing school, that’s not necessarily what I would expect. I think sometimes people watch that for a little bit and don’t realize that it, for kind of your typical puberty, it’s going to take two to three years before you have pain. That’s kind of what we expect is you don’t have pain right away. So if you do, that actually is a good reason to contact us.

Courtney Collen:

Could an adolescent gynecologist such as yourself be considered a patient’s primary care provider? Like talk about how you and other adolescent gynecologists might work with primary care providers, physicians?

Dr. Amy Kelley:

For most part, I really recommend that people still stick with their primary care physician, whether that’s a family medicine person or a pediatrician because there are some things that I think is better from them. And I don’t think that we completely can cover everything that a primary care doctor can cover. You know, certainly there’s lots of stuff that we can do. If you’re behind in your vaccines, we’ll catch up.

I think there’s value in still seeing your primary care provider. And that’s particularly true if your kiddo has any medical issues because we don’t really necessarily like take care of asthma. If your kid is sick, I’m not going to see your teenager to do a strep test. And so you still need your primary care doctor.

And both myself and Dr. (Elizabeth) Miller who are the two OB/GYNs here at Sanford who do a lot of pediatric and adolescent gynecology, both of us talk to pediatricians. If family docs have questions about something, we get messages from them all the time, and we will often kind of answer some of their questions. Or if they are wondering if someone should come see us, that’s a communication that’s often happening in the chart.

We are very happy to work with your primary care doctor, especially for kiddos who have like complex medical issues. Which is one of the things that we do a lot of is complex people, teenagers with diabetes, with like Type 1 diabetes or other significant medical issues. Sometimes periods are part of that, or they make it worse, or they need kind of some different kinds of care. And so that’s something that we really work well with primary care providers to make sure that we’re kind of covering the whole person.

Courtney Collen:

Sure. So you would really recommend starting there at your primary care provider, family medicine provider, and then it would essentially be a referral to you?

Dr. Amy Kelley:

Absolutely. You know, occasionally moms see us and they’re like, “Hey, my daughter – this is happening. Is that OK? Can she come see you?” And yes, of course. Like that’s also an OK time to ask. We may not have a lot of time to delve into it because we’re really there to take care of you if it’s your appointment. But many of my colleagues will see teenagers, especially older teenagers and often do when they see like the mom, you know, because then they kind of have that continuity too. And it’s somebody the mom trusts.

Courtney Collen:

Why is it important, Dr. Kelley to have specialized care for this early stage of life?

Dr. Amy Kelley:

I think that this is not always the easiest thing for parents to talk about. And so having someone who’s super comfortable talking about periods, talking about body parts, that is something that is really nice for teenagers to have.

I often tell teenagers, I’m like, if you have embarrassing questions, I’m the girl to ask. Yeah, I don’t get embarrassed. Really. It’s hard to embarrass a gynecologist.

A lot of this stuff is new to both parents and to teenagers. It’s a learning curve kind of to know how to address it as well as sometimes what’s normal. And I think a generation or two ago, like people didn’t talk about periods. You know, we hid when we were going to the bathroom, we were like, you know, did everything we could to hide those tampons. Like nobody should know that we’re having our period.

Courtney Collen:

Keep the wrapper quiet.

Dr. Amy Kelley:

Yes, absolutely. Like even in the stall you’re like, don’t make any noise.

Courtney Collen:

Coughing over the sound.

Dr. Amy Kelley:

Yes. So I think that has changed for the better, you know, for the most part. But it’s still one of those things that sometimes parents aren’t exactly sure how to address certain issues. And some things have changed. Period underwear was not around a generation ago. Like menstrual cups and discs and some of these things like moms are like, I don’t know anything about this. I need some help here. Which is totally fine and we are here to help.

Courtney Collen:

I mean we could go on and on about those products.

Dr. Amy Kelley:

Well yeah and we could go on and on about, you know, all of these things, about sex education and how, and you know, and you and I have talked before that unfortunately I don’t think we always get the greatest reproductive health education. And so, you know, I think that sometimes talking about these things isn’t easy for parents either. And we are here to help them out, but we’re not here to take their place. You know, like it’s still super important that you talk to your kids about these things and have that open communication. But we can help you with that. Especially if you feel a little bit unprepared for it.

Courtney Collen:

Yeah. At least helping lay the foundation and giving you a platform to go from there. And we’ve had so many conversations about how to navigate those conversations which has been super helpful for our audience.

Are there any misconceptions you hear, or I’m sure there are plenty you hear, but help us clear some up. What are some of the things that parents might not be totally clear on when it comes to adolescent gynecologic care?

Dr. Amy Kelley:

Sometimes people come in and they have prepared their teenager to have a speculum exam and to have a pelvic exam, and so one of the big things is we don’t do Pap smears until age 21 unless you’re a transplant patient. But we don’t have a lot of transplant patients in young people.

Courtney Collen:

Do you mean transplant patients?

Dr. Amy Kelley:

If you’ve had an organ transplant. If you’ve had a kidney transplant or a liver transplant, then we start them at 18. But that is a very, very small slice of the pie. Most people don’t need them until age 21.

And that’s a common question I get and sometimes people ask me why and we talk about the fact that most people if they have mildly abnormal Paps as teens, they go away. And that’s why we kind of wait and check at 21.

The other thing that I think there’s a misconception about is that I’m just going to talk to people about birth control and I’m just going to talk to them if they’re having sex and all we’re worried about like is preventing pregnancy, which yes, super important to prevent pregnancy. And there are teenagers having sex and that is a reality parents need to know. But that is not the only reason to come and see us.

Many people have period issues to the point where it is bothering them. It is interfering with their life. Sometimes, if you have other medical problems, it’s interfering with your other medical problems. And so we often do period management or menstrual management for many, many other reasons.

So your teenager can come and see us even if they’re not having sex, even if that’s not even like anywhere near their reality yet. And I think that that’s something that can sometimes like be misconstrued as well.

And then I think like just what the first couple years of having periods is like and how it can be a little bit more irregular than when you’re an adult, and I think a lot of moms don’t always realize that. So I talk to a lot of people about that as well.

Courtney Collen:

Thank you for helping us clear that up. That’s really helpful. How do early positive experiences with reproductive health care shape a teen’s long-term well-being?

Dr. Amy Kelley:

I think it can make a huge difference. You know, if you have a traumatic experience at 21 with a Pap smear with someone you’ve never met before, then how likely is it that you’re going to come back and get a Pap smear the next time you need one?

You know, maybe you won’t because it was super traumatic and weird. Having some comfort with somebody before we’re ever doing some of those things that are a little bit more tricky and it’s not that Pap smears – Pap smears should not be painful. They should not be difficult for people. But I think there’s this idea in culture that like they’re the worst things in the world so people are scared of them.

So it’s so much better if when they’re doing something that they think might be scary, that it’s with somebody that they have seen for a couple years and somebody that they’ve talked to about hard things already. Because if you have good experiences early on, you’re more likely to get routine gynecologic care. You’re more likely to talk to your doctor when something is going on and you’re not sure if it’s normal or not. And those are really important things to talk to your doctor about and to not be embarrassed to ask about.

And I think that the earlier we learn all our body parts, the earlier we learn how to talk to people about these things that can be a little more difficult to talk about, the better off we all are. And hopefully that will lead to your teenager becoming an adult that takes good care of their health, that knows they have somebody they can come to if they’re having these issues. And that they won’t be too embarrassed to ask us when they have issues.

As you know, I’m a huge vaccine advocate. Vaccines are one of the most important medical advances we’ve ever had. And one vaccine in particular that teenagers, or actually you can get it as young as 9, is the HPV vaccine. And I would just encourage parents if they have any questions about it, talk to your primary care provider. If you’re seeing one of the adolescent gynecologists and your kids have not gotten that yet and you have questions, please ask us.

HPV does not just cause cervical cancer. It causes head and neck cancers, it causes rectal cancer and it is transmitted skin-to-skin so you can get it without having penetrative sex. You can get it without having sex at all. And you can get it even when you use condoms consistently. Almost everyone gets exposed to it at some point in their life.

And I think there’s a lot of misconceptions about it and I often am like talking to people about it in their teen years because they didn’t get it when they were younger. And it works the best if you get (HPV vaccine) before age 15. It works, and you only need two shots if you get it before the age of 15. Hopefully soon, maybe we’ll only need one. But as of now we recommend two by the age of 15.

And so I would just really encourage people to talk to their doctor about that. I completely understand everybody wants to do the right thing by their kiddo and it’s OK to have questions. But definitely it’s also OK to ask us so we can tell you what we think and what we know.

The only other thing I would say is there are a couple of vaccines that your kids need before they go to college, their meningitis vaccines. One, which is one of the other reasons why it’s still good to keep in touch with your PCP and still go to annuals until your kiddos are adults. But those vaccines are really important, and you don’t want to be getting a ton of vaccines the summer before you go to college when you can start getting them when you’re 16. So also just remember that there might be some vaccines your kids need at age 16.

Courtney Collen:

Good to take note.

Dr. Kelley, thank you so much. This was such great information and so helpful as always to have your insights on this topic. This was part of the “Her Kind of Healthy” podcast series by Sanford Health. For more, listen wherever you get your podcasts or online at news.sanfordhealth.org.

Get more episodes in this series

How to have the ‘girl talk’ with your teen

Dr. Amy Kelley:

If you are willing to talk about those things and not judge their questions and you know, not get upset that they’re talking about those things, you are going to be their safe person and that’s what you want to be.

Courtney Collen (host):

Hello and welcome to “Her Kind of Healthy,” a podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford Health News. I’m so glad you’re here.

In this episode, we are having the girl talk. This conversation is all about puberty. We’re diving into what it is, but also how to approach, navigate and get through what can sometimes feel like an awkward or uncomfortable conversation with the daughter or preteen in your life.

I am so excited to bring in Dr. Amy Kelley, an OB/GYN at Sanford Health, who specializes in pediatric and adolescent gynecology. Dr. Kelley, good to see you.

We know this is a time of understanding yourself, your body growing and transitioning into the next phase of your life, but the conversation with a parent or caregiver can be awkward. So I want to start with this. What is physically or physiologically happening in our bodies during puberty, and what are some of the earliest signs in girls?

Dr. Amy Kelley (guest):

It’s interesting because I don’t think it’s awkward, but I suppose I do this every day and talk to people about it a lot. And I think that it’s definitely worth looking in the mirror if you’re going to talk to your kids and kind of say words that maybe you might have a hard time saying. Because if you look and feel awkward, then your kids will kind of look and feel awkward too.

And so the more comfortable you can get yourself versed in kind of the language that you need to use, which honestly is just like our body parts, but there are certain body parts and certain things that we’ve been taught are like really private. And it’s OK that they’re private.

But when you have a kiddo, it’s really important that they know the real words for things like their body parts. So I think that if those things like breasts or vagina or any of those things are hard for you to say without blushing, then looking in the mirror and saying them like a million times and making funny faces at yourself so that you really can say that without blushing will help make the conversation go better.

And if you really can’t do that, then I would maybe consider talking to your kids when you’re getting ready for bed and you’re like talking to them about a bedtime story or something because then it’s dark and so it doesn’t matter as much. Or if you’re in the car, then you don’t have to look at them if you feel really awkward. There you go. Those are a couple of like tips I have for parents.

Courtney Collen:

Good pro tips.

Dr. Amy Kelley:

But I think that you know, puberty is a time when basically your child is going from being a child to being an adult. And so their entire body, including their brain, changes a lot. And so it’s about maturing certain organ systems, the reproductive system in particular, but also other things.

Your kids grow taller, they start making pubic hair, they start smelling more like adults. And their brain changes quite a bit and matures. So, it really is kind of an all-encompassing thing. It’s not just about your reproductive organs.

Courtney Collen:

So when would we typically start to see some of these signs in young women?

Dr. Amy Kelley:

Yeah, so really anytime between about 7 and 13 would be pretty normal. African American girls and Hispanic girls often do go through puberty a little earlier. So sometimes they even will exhibit signs at like 6.

But typically I tell people if it’s before 7 they should probably talk to their pediatrician. If they haven’t started any puberty signs by 13, they should also talk to their pediatrician. But there’s a wide range of what’s normal.

Typically girls will, you’ll see breast development first. Although some girls will get underarm hair and pubic hair first. One of those two things is usually what comes first.

Courtney Collen:

How can parents distinguish between normal development during that kind of normal age range and something that might need medical attention that might be a concern?

Dr. Amy Kelley:

Yeah, so honestly, sometimes it’s hard to know. And so I think just being able to talk to your pediatrician about it is really important and making sure you’re going to your well child visits during those years to make sure things are developing normally is really important.

But really because of the wide age range that puberty happens, there’s a huge breadth of what is totally normal. And so it’s really hard to generalize that, but I would say if you’re concerned about it, you should just talk to your pediatrician. But average is between 8 and 13 for starting to get breast development or pubic hair.

Courtney Collen:

Talk through some of the biggest, most common misconceptions about puberty.

Dr. Amy Kelley:

I think that a lot of people are like, my kid is crazy or super emotional. And some kids are so, I mean, that’s not a complete misperception. I think that there are some kids who really do fine and don’t have mood issues going through puberty. And so, I wouldn’t assume it’s going to be this huge tumultuous thing for your kid because sometimes it is not. So I think everybody kind of goes through it a little differently.

I think the kiddos who have the hardest time are the kids who are really early or the kids who are really late. Because middle school is all about “am I normal? Am I lovable?” Those are like the things your brain is trying to figure out in middle school. And so, to have puberty happening at that time too is difficult. It’s a lot. It’s a lot.

Courtney Collen:

I know we’ll get to kind of the emotional and social development that someone might be going through during that time, so we’ll get to that in a little bit. But talk through maybe how do hormonal changes affect puberty?

Dr. Amy Kelley:

When you go through puberty, your ovaries turn on and you start making estrogen. And for some people estrogen is a huge mood changer. You know, like it will make them, it makes them a little bit more emotional.

But the other thing that’s going on is your brain is changing. And so the part of your brain that kind of functions to control emotions gets a lot bigger during puberty. And so, you know, something that was not a big deal, like I stubbed my toe, it hurts a little is not a big deal before puberty. But suddenly when your part of your brain that controls emotions is getting bigger and you throw some estrogen in there, then suddenly, I stubbed my toe, ouch and tears, or this person said something mean to me and tears, when normally maybe it wouldn’t have caused that.

But it’s that filtering of everything through that emotional part of the brain that sometimes makes things very dramatic.

Courtney Collen:

Like exacerbates everything.

Dr. Amy Kelley:

Yeah. It’s like it puts an exclamation point on everything. And the hard thing is that your frontal lobe, which is the part that kind of controls like your actions, is not completely developed. So if you think about you have this emotional like machine in your brain that throws extra emotion into everything, but you don’t have the frontal cortex to control that emotion, that’s really why some teenagers get very, seem very “hormonal.”

It’s not necessarily even about the hormones. It’s also about the changing brain. And I always tell parents that that means that you are their frontal cortex. So, they are not going to think about the consequences. They are just thinking about the emotion of it right in the moment.

And so part of being a parent of teens is helping them slow down that emotional part and think through the logical. Like, that person is mad at me, but that doesn’t mean they’re not my friend. Or I’m really mad at the math teacher, but I still have to do my homework because I still want a good grade. You know what I mean? Like, so that is kind of the hard part of being a parent of teens is that you are their frontal cortex until they have developed it, but you can help them develop it by making them walk through the consequences of what they’re doing.

Courtney Collen:

That makes so much sense. And it’s such good insight. And you are in the thick of it with what, 18-year-old twins? Right now? And a 13-year-old.

Dr. Amy Kelley:

Well, he’s not quite 13. He’ll be 13 in a month.

Courtney Collen:

You are a seasoned pro at parenting, I’m sure, for this stage of life.

Dr. Amy Kelley:

Well, giving advice is different than taking it, you know. We’re very good I think at giving other people advice and sometimes it’s a little harder when it’s you. But yeah, I mean I understand the what’s behind some of those things. Yeah. It doesn’t always make it easier to deal with as a parent, just knowing that though.

Courtney Collen:

And of course we’re talking about, you know, you have boys and we’re speaking about girls and it’s a little bit different. But that kind of, that frontal cortex, that idea is it could be for both.

Dr. Amy Kelley:

The planning part of your brain isn’t fully developed until 25. And so, when we think about older teens and how sometimes they don’t make the best decisions too, that’s really kind of why – that frontal planning cortex isn’t completely developed.

But again, it’s our jobs to help develop that by making our teens and young adults walk through the consequences of their actions so they can make better choices. If they’ve thought about it, then usually they can make pretty good choices.

So I think the other thing I think’s really important with teens is talking about the things that you’re worried about. Like if you’re worried about there are drugs out there, there’s smoking, sex, whatever it is that you’re worried about – as your kids become teenagers, not talking about it doesn’t really help because it’s still out there.

But talking about it and saying, this is what we expect, you know, as a family, these are our values and this is the behavior that we’re expecting of you or the choices that we’re hoping that you will make. And talking about what are you going to do in the moment? Like, you know, what would you say to a friend? How would, if you want to say no, how would you say no? If you needed to call me, how would you call me? Because a lot of times if you’ve thought through a lot of those things beforehand or they’ve thought about it, they’ve made a pathway in their brain. If I need help, I can call my mom about this or I can say no to this friend. Or I can say no to my boyfriend if I don’t want to have sex.

If you’ve never talked about those things, they have no pathway in their brain to make a good decision.

Courtney Collen:

I feel like that’s just such a great approach to parenting this day and age because there’s so much going on. Yeah. And with social media at play, you know, having that conversation just authentically approaching conversations and talking through things and how we feel and what we’re concerned about. I feel like that’s just a great way to connect with your child and build that foundation. I mean, is that true?

Dr. Amy Kelley:

Yeah. And you don’t want it to just be like one talk. Like a lot of people talk about the sex talk, but really if you’re doing a good job with that, it’s not one talk; it’s over time. You may have a talk when they’re 8 or 9 about puberty, yes. And what to expect and maybe what sex is very basically.

And then as you get older you add more to it and you use things like, the neighbor is pregnant, how do people get pregnant? You know, and then talking about, or you watching a TV show and there’s a teen pregnancy on the show. Well that’s a great little in to be like, Hey, do you know how to prevent pregnancy? Yeah. And have we talked enough about that? Do you have questions about that?

Courtney Collen:

And it’s age appropriate.

Dr. Amy Kelley:

Yes. As you go through. But I think that sometimes people have a misperception about what age kids should know this stuff because unfortunately with social media, the average age that somebody runs across porn on the internet is 11 and usually it’s something silly like when will I have breasts? Or, you know, like it’s questions about things they want to know. Yeah.

But we all know if you Google, when am I going to get boobs? What are you going to get on the internet? We all know what you’re going to get. But when you’re 11, you don’t know what you’re going to get. And so I usually talk about 8 is great, 9 is fine, 10 is too late. Now it’s never too late. But usually by 10, kids know more than you think they know and then you have to reteach them some stuff.

So it’s so much easier when they’re 8 or 9 because they’re not embarrassed because they don’t really know that much. And it’s actually easier because you just approach it from a science standpoint and isn’t this cool how babies are made? And they might be like, “ew, gross.” But they might be like, “that’s cool.”

Courtney Collen:

Absolutely.

Dr. Amy Kelley:

And they’re not going to be as embarrassed about it. The longer you wait, the more embarrassed they’re going to be to talk to about it.

Courtney Collen:

And they might think they know and then you’re there to basically clarify what they think they know is right from their friends who have older siblings who may not know the full, you know, the full scope of things. So you have to juggle that too on top of catching them up.

Dr. Amy Kelley:

Yeah. And you want to be their safe person. You want to be the person that they come to with questions, not their like – yes, they’re going to go to their friends with things too. But if you are willing to talk about those things and not judge their questions and you know, not get upset that they’re talking about those things, you are going to be their safe person and that’s what you want to be.

Courtney Collen:

Let’s shift to having the talk now, Dr. Kelley. When is the best time for parents or caregivers to start talking to their daughters about puberty?

Dr. Amy Kelley:

So I would really say like around 7 or 8. And honestly, if you’re an African American and you’re seeing some signs of puberty in your daughter or your daughter is African American, whether you are or not, if you’re seeing some signs around 6 or 7, then you probably need to talk to them at that point.

And really the first signs are going to be pubic hair or underarm hair or some breast development. And because once that happens, you’re kind of on a time clock. So, most of the time after breast development, you’re going to get your period between two and three years after breast development starts. OK.

Now, sometimes for certain reasons it’s a little bit accelerated and it’s a little less than that. Sometimes it’s a little more than that. But the average is about two to two and a half years. And so you kind of know when you start seeing that, you’re like, “oh, I’m on my timeline now. So, we got to talk about that in time for the period.”

So I don’t think you have to tell them everything at once, but I do think like telling them, “Hey, have you noticed this? I’ve noticed that you have some dark hair in your underarms. Did you notice this? What do you think of that?” And kind of just asking them how they’re feeling and going from there. Like, do you know what that means? And talking about how they’re going to start going through what we call puberty, which is how you become a teenager and then an adult.

And girls, because they usually go through puberty first before boys, I think that it’s even a little bit more important to have that conversation on the early side. Schools, you can’t rely on the school to tell your daughter she’s going to get her period. And the reason why is because some schools will do it in fourth grade, some do it in fifth or even sixth grade. And if you’re 11 or 12 in fifth and sixth grade that your kid might already have their period by the time the school has talked to them. Particularly if you’re African American or Hispanic.

And so I think it’s really important if you see any signs to kind of start having that conversation.

Courtney Collen:

You had some great tips about ways to approach like body hair, underarm hair, specifically or growing breasts and then approaching that kind of age appropriately. Are there any other like good tips, age-appropriate tips, ways to explain that first period or body changes?

Maybe when we get a little bit older to 7 or 8, say, or 9, would you still approach it the same way, kind of like, “hey, have you noticed this? How do you feel about that?” Any other tips along those lines for parents or caregivers?

Dr. Amy Kelley:

Yeah, I think that I would just kind of start with the same kind of thing. Sure. And then, you know, talk about when, like if you’re a mom, you can say, “I experienced that too when I was going through puberty and these are kind of the things that are going to come next,” and talking about how breasts may grow enough that maybe we’re going to have to talk about getting a bra for you. And hey, once you have underarm hair, you might smell weird. Like you are going to sweat more and maybe we should think about deodorant and like doing something along those lines.

There’s great books out there to kind of help with that. So if you have kind of a more introverted kid who maybe wants to read about it, there’s lots of different age, good age-appropriate books. The American Girl Doll series is kind of a classic. But there’s, it’s called “There’s Something New About You” and it’s really made for like that 8-ish age range, 8, 9. And then there’s actually follow-up books to the American Girl Doll books. Like there’s two more for older kids, but of course sometimes kids outgrow dolls.

So, another great book series is called “Girlology.” It’s like biology but “girl” instead. And it’s written by an OB/GYN and a pediatrician together. And there’s three in that series and one of them is about puberty for like ages 8 to 11. There’s one that’s kind of a middle school book that’s a lot about like sex and consent. And there’s one that’s for older middle schoolers, early high schoolers that’s a lot about contraception and protecting yourself and making good choices.

So I really like that book series too because it definitely kind of grows up with your kids since there’s three different ones.

Courtney Collen:

Great resources. Thank you for that.

We kind of touched on this at the beginning of the conversation, Dr. Kelley, but what advice would you have for parents or caregivers who feel uncomfortable or unsure about how to start the conversation? And you kind of gave some great options, like if you feel this way or that way, maybe in the car, it’s casual or maybe before bed it’s dark, you know, less eye contact.

Dr. Amy Kelley:

Those are two ways to kind of, if you feel uncomfortable to kind of allow you to not look at your child or if it’s in the dark. Like you may, they may not see if you’re a little bit uncomfortable.

But I think just starting with the basics and let them lead the conversation a little bit. You know, a conversation at 8 about puberty and sex is very different than a conversation at 14 or 15. And when I talked to my kids about this, like we were laying down in bed and one of them had asked me a question about the neighbor being pregnant. And I’m like, OK, this is it. This is it. I’m going to do it.

Courtney Collen:

Your day has come.

Dr. Amy Kelley:

My day has come and they were like 8-ish, 8 and a half. And I was like, “Hey, you asked me how people get pregnant because you know, our neighbor’s pregnant or I think it was maybe even the dog, like their dogs were having puppies or something and somebody was with child or somebody was with child or puppy. And I said, so like, let’s talk about how that happens.” And I was just very scientific about it, you know, like, this is how babies are made. It’s like super cool. It’s, and you know, sex is something that happens only between adults. And I told them like the name, like use the names of their parts. You know, I use the word penis, I use the word vagina. Because actually unfortunately the age of sex, average age of sex abuse is 9. And so that’s kind of the other reason that I recommend your kids know the basics about sex at 8 or 9 is because it can help protect them.

Courtney Collen:

And it includes like the names of the actual body parts.

Dr. Amy Kelley:

It’s important because your kids have to know the names of their body parts because if something happens to them, they must be able to tell you what happened. And to tell someone else what happened. And if they don’t know the right names, that can lead to confusion and misunderstanding. If they tell like a teacher or something.

I actually had somebody who called their vagina pocketbook and told their grandma that someone was hurting their pocketbook and their grandma didn’t know that was the name and so it kind of delayed that being found out. And so I always tell people kind of that story, like you have to tell your kids the real names of things.

But also like if you tell them if they know what sex is and they know what makes babies and they know it’s only for adults, like literally that’s totally all they need until they’re like 11, 12. Then I think that it also helps protect them. Like if someone tries to trick them. They can be like, no, my mom said that’s only for adults. Like, why would I do that? They can kind of help protect themselves.

But puberty wise, that’s kind of how I cleared the fence over to puberty and I was like, remember you guys are talking in school of like, the girls are going to talk to the health teacher about periods. And I’m like, remember how we talked about what happens when you make babies and how the sperm and the egg have to meet? I said, you have to go through puberty before you can have sperm and eggs. And the way that girls get those is this, and I kind of talked about the menstrual cycle with them.

And some, some people are like, well, why would you tell boys that? But because they should know. Because they should know what happens.

Courtney Collen:

Because then they get into their 20s and they start having a girlfriend and they’re like, what’s going on with your body?

Dr. Amy Kelley:

Yeah. Honestly, I really think when they’re young too, you don’t have to tell them all the details. And you can kind of let them ask you questions and let them lead you down what they think is important too.

And it’s interesting. Kids will react in very different ways. I had one twin who was like, “la, la la la, la I don’t want to even talk about it.” And then I had one who was very, very scientific. Like, he had a microscope and he was like, can I look at sperm and eggs under my microscope? And I was like not easily. Like, well, let’s put that on ice for now. It was just interesting. Kids do react different, and they might, they’re going to react a total, maybe completely unexpected from what you thought too. That was not what I thought my kid would say.

Courtney Collen:

Could your twins be any different?

Dr. Amy Kelley:

Right. They’re totally different.

Courtney Collen:

But at least they’re getting, and you know, it helps to have a mom who’s an OB/GYN. But I mean, any parent can really kind of fill their son or daughter in when they feel it’s appropriate.

And especially for young men, even though, you know, we’re talking specifically about girls. Informing them about what’s going on. I just went to a period pad donation drive where organizers were collecting tampons and pads and a dad brought his boys in. They were at that age where they were starting to learn about what happens as women go through puberty and they were proud to pass along their donations, a big case of tampons and pads.

And that’s awesome. Other people in the community. And I was like, yeah. Like, go dad. And or you know, whoever might be in their family having the conversation with them. But it’s a good thing. It’s OK to spread awareness about.

Dr. Amy Kelley:

Well, and I remember when I was in middle school and unfortunately your period isn’t regular a lot of times when it starts and it surprises you and like, yeah. We had girls who, you know, would have like red on their pants or obviously got their period when they weren’t expecting it and it’s like, can be really embarrassing. Then you’re known as the girl who bled on your seat.

And like, and I don’t want my kids to make fun of people for that. I just want them to help them. So I think that that was like one of the big reasons why I thought it was really important for everybody to know about periods. Totally. So they can have that empathy for other people. And, you know, hopefully not make fun of girls.

Courtney Collen:

Just be more aware and understanding. Yeah, absolutely. At the end of the day, kind at least. Yeah. Right.

Dr. Amy Kelley:

Absolutely.

Courtney Collen:

OK, you just brought up a good point. You don’t really know when your period’s going to come, right? Yeah. Between that age range, so it could just come in at school, you don’t know, you absolutely could find some blood in your underwear.

Do you have any advice for moms or caregivers sending their kids to school? Should they have a little Ziploc bag with an extra pair of underwear to stay in their locker? Or a, you know, maybe a pair of period underwear, which are fantastic. Anything that they can take and when should they start maybe thinking about that?

Dr. Amy Kelley:

Yeah, I think probably somewhere between 12 and 24 months after your kiddo maybe starts getting breast development. So typically, they’re going to get their period, like I said, about maybe two to three years after they start breast development. And so kind of when you start to get close to that two-year mark, it’s probably not a bad idea to have like a go bag. And if you’re not sure what to put in a go bag, like you can go to the internet. It will help you.

Courtney Collen:

As it does.

Dr. Amy Kelley:

There are plenty of companies that sell little first period like kits. But you can make your own too. I mean you don’t have to buy one. But having just, like you said, an extra pair of underwear or, like a pad, making sure they know how to use them. Like you know, where the pad goes in their underwear. And just kind of going through that with them really might help alleviate some anxiety.

Because hopefully you’ve talked to them and they know, hey, my period is going to come soon. Like probably in the next six months to a year. And so I’m just going to have this in my backpack just in case.

Courtney Collen:

And hey, if you’re like a crafty or Pinterest-y type of mom, maybe you get all the things and you decorate it and you put it in a little discreet box and you say, “Hey girlfriend, like let’s talk about this and I’m going to give this to you when you need it.” And it’s like, you know, it’s just like part of the conversation.

Dr. Amy Kelley:

Yeah, the other thing is, I think it’s not a bad idea to just have like a little kid at home that maybe has some period underwear, some different kinds of pads and maybe if you have a swimmer or gymnast or something, maybe a couple of different tampons just so they have like a variety of things that maybe they want to try.

Just a note for parents who have health savings accounts you can get reimbursed for period underwear and periods. So a couple companies, Thinx and Ruby Love, take HSA money. So just FYI parents, you know, I mean that or flex spending money, which is a super nice thing to know.

Courtney Collen:

Either way, insurance related. Yeah. Fantastic. Because I can’t say enough good things about it. And that’s a whole other conversation like the menstrual cups and the period underwear which have come so far in comfort and style and anyway. I’m sure perfect for those adolescent girls.

So we talked about the internet and being able to find resources there. Let’s talk about social media and peer influence. They have a lot to do with shaping our young people today, Dr. Kelley, which can be a good thing or a challenging thing. How is social media in influencing how girls perceive puberty and body image today? What are you noticing in conversations with your patients and their families?

Dr. Amy Kelley:

I would like to say it doesn’t have as much of a role, but I don’t know that that’s always necessarily true. But I’m a big proponent of wait until 8, meaning wait until eighth grade before getting a phone because we definitely know that it’s not good for mental health of teenagers now.

In all honesty, my twins got their phone when they were in seventh grade, so I kind of like jumped the gun a little bit there, but they did not have social media until they were 16. I would really encourage parents to do their best to kind of wait until their kids are older for social media.

Honestly, that’s hard because they can kind of sneak it in, you know, I mean unfortunately it’s – kids are smart. And even with barriers that you put up for them, like they figure out how to get around them. So, you know, that that can be a hard thing.

But I do think it’s totally reasonable to monitor your kids’ social media accounts and until they’re 16-ish if they have them. Because you want to know what’s going on there and that they’re safe. That’s the biggest thing. But I think that unfortunately it is really hard to figure out sometimes what is good information and what is not good information.

There’s influencers, particularly in women’s health who, you know, they’re trying to sell things to you. And they’re not necessarily giving you good information. They’re just trying to sell you things, whether that’s supplements to make your periods better or, you know, to make you feel better or whatever. And so I think that letting your kids develop a healthy dose of skepticism is not a bad thing. Or at least having them, like every time they’re getting information from the internet, thinking about who’s giving me this information? Who’s paying for the website? What are they trying to do?

Because if you have that mindset rather than “Oh, this influencer is telling me the truth and they’re a great person.” Maybe they are a great person, but they’re also an influencer trying to make money. And so I think that, you know, having the sense to go through those kind of things and sometimes adults aren’t very good about that either. We’re working on it. So maybe we all need to think about that a little bit more: if somebody is trying to sell us something they make money from, maybe be a little skeptical of that.

Courtney Collen:

Yes, a hundred percent.

Dr. Amy Kelley:

But I think that I’m hoping that with time and us knowing that social media is not great for mental health of young people. That hopefully we can continue to maybe put that off until middle-late teens.

But yeah, I think that you’ve just got to have your button in there all the time. If you’re letting your kids have some social media, you got to like, be following them in front of things, things you got to know of who their friends are and try to – it’s so, so hard because they’re always one step ahead of you. It’s rough.

Courtney Collen:

Especially when it comes to social media. And that was my next question about filtering out misinformation. How do we do that and help them develop a healthy self-image? But it really sounds like, you know, when it gets down to it, just making sure you’re having that open, honest conversation or at least keeping that line of communication open. To allow them to ask questions.

And then maybe when they do see something, they’re comfortable to approach you about it and then you’re getting in front of it to like clarify or kind of dispel some misinformation. Or at least helping them build that healthy dose of skepticism, like you said. Which is always a good thing.

Dr. Amy Kelley:

Well, and I always try to give my patients and my kids websites that I know are good because there’s, especially with reproductive health, there’s several studies that show at least 50% of reproductive health websites have misinformation on them. So you do have to be really careful.

So I usually am always trying to encourage parents to go to places that I know have good information and the people that pay for that website are people who are trying to help, not sell things.

So I really like Young Women’s Health, which is a website from Boston Children’s Hospital. And you can literally go to Young Women’s Health and you can like search almost anything you can imagine and they have a little blurb about it with other resources. You can type in eating disorder. You can type in periods. Or they have a really good tampon video that goes through anatomy and shows people how to put tampons in. Love it. So I really like that website. A lot.

And there’s some other really good ones out there as well. But I think that giving people good resources can be helpful because I know they’re going to Google stuff. So I might as well give them a good website to look at that I know is accurate.

Courtney Collen:

Absolutely. Which they can get in the same place that they’re getting their social media information too, so. Absolutely. Yeah. Good information.

Safety and awareness are so important in our youth, especially in women. We know that we talked about it a little bit at the beginning. Why is it important to include discussions about consent, boundaries and abuse in puberty type education? I mean, one of the tips you had was to use the actual body part names, which helps lay that foundation. But why is it important to include some of those other things and how would you include that?

Dr. Amy Kelley:

In today’s world, like consent is, is absolutely needs to be taught from the time your kids are little. So that is something you can start teaching them as soon as they can talk. You know, like they don’t have to give hugs to people they don’t want to give hugs to. That’s their choice. You know, like these are there when you’re teaching them to toilet train, you know, mom’s helping you wipe, but nobody else really needs to help you here. And if Mom’s with you and like we’re at the doctor’s office or something looking to see if there’s a problem, that’s OK. But otherwise nobody else needs to be touching or looking here.

And as they get older just talking about how this is their body and they get to decide what happens to their body that I think that that’s just a really important thing. But it’s definitely, you don’t have to wait to link it with sex. You can link it to like, everything in life you need consent for, you know? Yeah. So I think starting when they’re little is good for that.

But safety things. We had a couple of rules in our house, when my kids got access to the internet, if you find something scary, you come talk to Mom about it. Mom’s never going to be mad because sometimes you can end up in weird places on the internet. We couldn’t have internet in our rooms. Like it had to be in spaces that everybody could be in. So you know, they’re not looking at things that they wouldn’t want you to see as you walked by.

But also, like, you don’t friend people you don’t know in real life. You don’t play games with people that you don’t know in real life. Now as my kids have gotten older, that’s shifted because now they’re old enough that they can make some of those choices on their own and I’m not so strict about it.

But I think that those kind of rules are really important to keep your kiddos safe. And schools are doing a much better job with that than they used to. You know, my kid that’s younger, he knows you don’t give your real name on the internet if you’re talking to somebody. And I’m like, we only talk to people we know in real life, but you know, they have taught him at school, you don’t give your address to anybody. You don’t give your full name to anybody. You don’t give your phone number to people. You don’t tell them all these things. And so I think schools are starting to catch up a little bit with some of that safety stuff.

But I think having some parameters and boundaries around the computer, but also like having boundaries around yourself. Like what is acceptable behavior? Is it OK for people to say mean things to you that you’re going on a date with? No, it’s not OK. Definitely putting boxes around what behavior is OK with dating is I think an OK thing to do as they get to be teenagers too. Whether you have some rules about dating or whether you just have, you know, rules about this, like, I want to meet this person first. That’s OK. Or, this is what I want from a relationship.

It’s not ever OK for somebody to hit you. It’s not ever OK for somebody to call you names. And just kind of knowing that. But then we have to also, as parents, we also have to model that for our kids. And so our kids learn relationships from us. And so that sometimes means that you get a little microscope on your own relationships, which can sometimes be hard because then you’re teaching them, but maybe you’re not showing them some of that – how you should be treated or how you want to be treated.

So I think that like, it’s also really important to model those behaviors. And that can be a little bit harder. It’s much easier to be like, do what I say, not what I do, you know, but your kids will pick up what’s going on with your relationship. So I think that it’s also important if your relationship needs some work, as your teens get older, I also think it’s OK to be like, yes, you know what, you’re right. Dad spoke to me really meanly and we should probably talk about that and we will take care of that. But that’s an adult thing. It’s OK to be like, yeah, we’re not perfect and we’re working on it.

Courtney Collen:

Absolutely. Kind of like you can’t always control what happens in the situation, but how you react and respond to it and then look back on it is a great teaching moment.

Dr. Amy Kelley:

Yeah. In a lot of cases. So yeah. But it’s hard. I think if you look at relationships in general, like teen, there is some evidence that there is more violence both emotionally and physically in relationships under 20, when you’re under 20.

And so I do think that you have to be like on the lookout for that and make sure that your kids are safe in their relationships. But I also think that one of the other things I often just caution parents about is dating someone much older, especially for young women. So since women do go through puberty earlier, sometimes they get treated as older than they are. You know, a 12-year-old that’s gone through puberty could look like a 16-year-old too. And so they often get attention from older men who may or may not realize their age.

I think that it’s also teaching our daughters about boundaries with everyone is important. But also like letting them be kids. And so, you know, maybe your 14-year-old doesn’t need to date the 18-year-old. That’s hard to police, but I think you do have to just be aware that they’re more likely to have sex early if they’re dating someone who’s more than two years older than them. They’re at risk for an unplanned pregnancy.

So I think that us just being aware of what those risk factors are is important too. I mean, it’s so hard to be the parent of a preteen and a teenager, and there’s nothing that prepares you for it either. Like there’s not a class you can take. So I think that we all just need to also just be kind to each other as parents as well.

Courtney Collen:

I have a 2-year-old at home and I feel like I’m going to blink and then have this conversation in a few years with her. I’m going to be calling you to come in and like be my sidekick for this. And I have another little girl on the way, so I’m like, oh my gosh, this is going to be double trouble.

Dr. Amy Kelley:

We all need a village to help raise our kids. And fortunately, it is not us alone that is raising our kids. Right. You know, social media is, all of these other things are, and so I do really think parents get way too much of judgment.

And so, especially if parents are listening to this, they’re like, oh my God, I gave my kid a cell phone at in sixth grade. Oh my God, I’m terrible. No, you’re not terrible. We’re all just doing the best we can. And I think trying to, especially as a physician and primary care doctors, I think we have to also have lots of grace for parents. I think we all love our kids. We all want what’s best for them. And we’re all trying to do the best we can. So I try not to judge other parents. It’s just a hard world out there.

Courtney Collen:

So exclamation point. Yeah. For sure. We are doing the best we can and the world is changing every single day. And we never know what tomorrow’s going to bring. But again, when it comes down to it, having that line of open communication, keeping that open no matter what type of household you’re in, what type of situation you’re in that relationship with, you know, if you’re caring for an adolescent girl, or it’s your daughter, granddaughter maybe, you know, that’s important. What else would you say to parents as they kind of think and we wrap this up?

Dr. Amy Kelley:

I think I would say two things. One is that your kid is going to grow up and be an adult. And I think thinking about what kind of adult you want to help them become. They’re going to become an adult that maybe you don’t anticipate. Like your kids aren’t going to be exactly what you think they’re going to be. But I think helping them become what they want to be is really important.

I always tell parents that connection is what protects your kids. So connection equals protection. So I think we’re all so worried about protecting our kids from all these other things. But they’re going to get exposed to that. They’re going to grow up. They’re going to see all these things. So we need to teach them how to deal with all the things in the world. So connection allows you to help protect your kids because they will come to you. And you are their safety. And so, if you can be that, that’s how you’re going to protect your kids by having that strong connection to them.

Courtney Collen:

I appreciate this conversation. So valuable and such a great resource for our listeners. Dr. Kelly, thank you so much for your time and for all that you do in the OB/GYN space in the adolescent space and of course being a resource for us here. Thank you so much.

Dr. Amy Kelley:

Yeah, of course. Thanks for having me.

Courtney Collen:

This was another conversation in our series, “Her Kind of Healthy” by Sanford Health. A reminder you can find any of our Sanford Health podcast series wherever you listen and anytime at news.sanfordhealth.org. I’m Courtney Collen. Thanks for being here.

Get more episodes in this series

Choosing the right birth control

Courtney Collen:

There’s a lot of options. (Laugh)

Dr. Amy Kelley:

Yeah, totally. There’s tons of options. And I didn’t even talk about condoms. I didn’t even talk about barrier methods, which is kind of the other group.

Courtney Collen (Host):

Hello and welcome to “Her kind of Healthy,” a health podcast series brought to you by Sanford Health. I’m your host, Courtney Collen, with Sanford Health News. We want start new conversations about age-old topics from fertility to managing stress, healthy living and so much more. “Her Kind of Healthy” is designed to bring you honest conversations about self-care, happiness, your overall well-being with our Sanford Health experts.

On this episode, we are talking about birth control, or contraception, the use of medication devices or procedures to prevent pregnancy. And there are so many different types. For a lot of us, it can be very overwhelming. Let’s bring in Dr. Amy Kelley, who is an OB/GYN at Sanford Health, and a specialist in pediatric and adolescent gynecology. If you ask me, she is the perfect person to have this conversation with. Dr. Kelly, welcome. Thanks for your time today.

Dr. Amy Kelley (Guest):

Thank you.

Courtney Collen:

So let’s start with the basics. We have a lot to get to. What exactly does birth control do physiologically in the body to prevent a pregnancy?

Dr. Amy Kelley:

It depends a little bit on what method you’re talking about, on how it prevents pregnancy. Things that are fairly common and have been around for a while, like birth control pills or the birth control patch, they work by kind of taking the job of the ovary away. So they basically give you a little bit of estrogen and a little bit of progesterone every day. And that makes you not ovulate. So it kind of takes the ovaries’ job and says you don’t have to do anything right now. And he kind of keeps your hormones basically very similar from day to day.

Courtney Collen:

So how would a young woman or women of any age know what birth control is right for them and where do they even begin?

Dr. Amy Kelley:

Well, there’s actually a few really good online resources to kind of do a little bit of looking around on your own. The one I like the most is called bedsider.org, and it’s an app as well. And I like that one because it’s not from a company. It’s actually run by a nonprofit. So you know, they’re not trying to sell you anything; they’re just trying to give you information.

But otherwise I would say going to your physician is a great place to start as well. What you do for contraception I think varies a lot depending on what stage you are in your life and what you need. Some people you know, are using contraception more because their periods are bothering them, especially in the teen years. And they may want something different than what they want maybe when they go to college and their life is busy and they have to worry more about the contraception or the pregnancy prevention part, maybe then and they also, maybe their life’s a little crazy because they’re in college and they can’t remember their pill anymore.

So I think that what you do varies a lot based on your personality and also what stage of your life you’re in.

Courtney Collen:

Now let’s talk through some of the options. Yeah, like explain some of the various types of contraceptives that are available.

Dr. Amy Kelley:

Yeah, so I kind of put things into different categories. So I put things into high maintenance and low maintenance categories because that’s kind of how I roll. I like low maintenance things.

The things in the low maintenance category are also a little bit more effective to prevent pregnancy. So that’s kind of a good category for people who are most concerned about that. It’s also a great category for people who need low maintenance options where you don’t have to think about them very often.

So the two big ones in that category are the implant that goes in your arm. And I actually have one right here. You’re probably going to be kind of hard to see it since I have just such a little screen, but it’s very small. It’s really, really tiny and it goes under the skin in your arm. And that works for about four years. And it is the most effective thing for contraception. It has a failure rate of a half a person in a thousand. So it’s like right up there with getting your tubes tied or doing something permanent.

The other one that’s very similar in effectiveness is IUDs. There’s a couple of different kinds of IUDs, but IUDs stand for intrauterine device and it’s a T-shaped device that goes in the uterus. They’re also quite small, so this is an example of one right here. They’re not very big.

Courtney Collen:

Wow. That is small.

Dr. Amy Kelley:

Yeah, they’re pretty small. And intrauterine devices come in a couple different flavors. There’s one that doesn’t have any hormones at all and that has copper in it. That works by causing some inflammation in the uterus. But it also works because copper makes sperm unable to penetrate eggs. So it actually prevents the process of fertilization. The copper IUD is good for 12 years. It’s good for a very long time. That one doesn’t really change your periods. It can make them a little heavier and more painful sometimes because it causes inflammation, but otherwise you have regular periods with it.

The two hormonal IUDs that are used the most often there’s one called Kyleena and there’s the Mirena. The generic of the Mirena is called the Liletta. And those work for five years and eight years. And hormonal IUDs have just a little bit of progesterone in them, so they make the lining of the uterus really, really thin. And some people actually don’t have periods with them because they just don’t have a lining to shed very often because it’s so thin.

So Kyleena is smaller. They’re the five year one and they’re made specifically and FDA-approved for people who haven’t had children. The Mirena and Liletta are just a tiny, tiny bit bigger and it’s good for eight years. And it’s specifically FDA-approved for people who have had children.

Now we have lots of studies that show that people, whether or not you’ve had a child, can use either one of these. But the company just hasn’t gotten FDA approval for both of them, for both kinds of people. But those are all very low maintenance options and they work really well for contraception.

The downside to the hormonal ones is that they can make your period kind of wacky. And that’s a little bit different for every person. For IUDs, a lot of people don’t have periods at all and if they do, they’re pretty light, maybe a little sporadic. For the one in your arm about one in three women don’t have any periods and then everyone else has periods and they can be kind of crazy and long, but not usually heavy or painful. But they can also just be spotting every couple of months. So it varies a lot. And that’s, those are probably the main side effects that we talk about when we talk about using those for people. But those are, those are our low maintenance options where you don’t even have to think about them. We put them in, you’re done.

Our kind of medium range options that I think are pretty low maintenance, but you have to remember more often, is Depo-Provera, a shot and you, every three months you have a little wiggle room. It’s every 10 to 13 weeks. And most people it stops their period actually. Because it’s also a bunch of progesterone. So that lining gets really thin. Depo is kind of in that medium range because you only have to remember it every three months. For some people that’s great and they remember, it’s good. Other people it’s easier to remember things every day than every three months. Everybody’s a little different. So that’s kind of a medium range option.

The most high maintenance options are the birth control pill, which you take every day. The patch which you change once a week and something called the birth control ring. There’s a couple of different kinds of the ring. And you change that once a month. So those are a little bit higher maintenance because you have to remember them more and you have to go to the pharmacy and you have to get refills on them and if you move or if you’re in college, you have to figure out how you’re going to get those refills. So those are just a little bit more like time consuming and you have to think about them a little more. Those are the only ones that keep your period really regular, too. And a lot of times they have really nice side effects. Most of them help with acne. A lot of them help with, if we feel kind of moody around our period, a lot of them help with that.

So those are pretty popular ones and they’ve been around for a long time too. Those have a much higher failure rate though. The failure rate for those is about 70 in 1,000 versus like two for IUDs and a thousand or a half a person for the one in your arm.

Courtney Collen:

There’s a lot of options.

Dr. Amy Kelley:

Totally. There’s tons of options. And I didn’t even talk about condoms. I didn’t even talk about barrier methods, which is kind of the other group. Condoms are also definitely contraception because they prevent sperm from getting to eggs. But they’re kind of the most high maintenance option really. Because they don’t work in your drawer or in your purse or in your truck. They only work if you use them every single time. But they are also the only method that helps protect you from things like gonorrhea and chlamydia. And so they’re a super important option, particularly in our state that’s really having a surge of different STI infections right now.

Courtney Collen:

And a great way to get the partner involved too. I mean it, you know.

Dr. Amy Kelley:

Absolutely.

Courtney Collen:

They’ve got to do their part.

Dr. Amy Kelley:

Yeah, I mean it is unfortunate that there aren’t very many options for males, right? At least not reversible options for males. There’s always been talk of getting reversible options for males but they just never seem to let come to fruition.

Courtney Collen:

What are some factors, Dr. Kelly, that might determine what is right for each patient? I mean does age come into play? Health history, sexual activity, maybe having had previous children? Talk through some of that.

Dr. Amy Kelley:

Yeah, absolutely. I think there’s a lot of factors that go into it. Certainly what you want after children sometimes is different than what you want before you have children, but I tend to – and everybody’s a little bit different so of course there’s lots of different factors – but I tend to try to talk to people about two big ones to try to pick what they want to do. And those two big ones would be what do you want your period to be like or what can you handle as far as your period goes and how important contraception is to you. And I try to stick with those two things because there’s just so many other factors too.

But the reason why I think those two play a big role is because these kinds of options vary a lot on how effective they are, and getting pregnant is a huge thing. Changes your whole life. And so you know how worried you are about that is a very big determining factor on what option you choose. And most of these affect your period.

Now, they usually affect your period in good ways with our high maintenance options like the pill, the patch, the ring – most people’s periods get shorter, they’re less crampy less and sometimes they’re a lot lighter as well. But you still have them every month.

There are ways to kind of skip and manipulate your period with them, but you have very regular periods and for some people that’s super important and that’s what they’re looking for. With our low maintenance options, you’re getting much better contraception, but you may have periods that are irregular and not as predictable. You might also not have a period at all. And sometimes that’s people’s goal is to not have a period maybe because they don’t like it. Like a lot of our autistic teenagers have – it’s a sensory thing that they don’t like or sometimes it’s because they’re super busy with a sport and they don’t want to deal with that period. Sometimes it’s because they miss school because it’s so painful or so heavy every time. And so we’re trying to have them have less periods.

There’s really good reasons to consider not having a period for some people. But if that’s their goal then I’m going to recommend different things than if they want regular periods or if they can handle a little bit of irregular bleeding. Sometimes that drives some people crazy. So I think knowing a little bit about how you’re going to feel is a good way to kind of figure out what might be a good option for you.

Courtney Collen:

Are there any risks that a patient should consider before choosing a birth control or any specific risks behind any of those types of birth controls?

Dr. Amy Kelley:

Yeah, so the ones that are high maintenance pills, the patch, the NuvaRing, and actually there’s more than just Nuva so I should just say the ring. But those three have estrogen in them. Estrogen does have the potential risk of blood clots. Which is, you know, a serious risk. It’s not a very common one. But there are some people who have medical conditions or who have certain genetic issues that make them too high risk to use estrogen. So there are some women who are not good candidates for those three options because they shouldn’t use estrogen.

The other ones have other risks. You know, certainly any medication has some risks. People can have things like stomach upset, headaches, nausea, but most of the time any of those types of side effects, you always have to compare them to what the alternative is too. So if the alternative is the potential to get pregnant, pregnancy has a lot of complications and side effects too. And so most birth control, if you’re comparing it to pregnancy, is much safer than pregnancy.

But there are some people who have some mood changes because with hormonal options or Depo is associated with weight gain in some people. And so those kind of side effects vary from person to person. But we always discuss that with people so that they know if they have them what to do and you know, if we think that they’re likely to have them or not.

Courtney Collen:

If an individual is planning to get pregnant but they’ve been on birth control for a period of time, be it the more high maintenance options, the pill or something more low maintenance like the ring or IUD. Is there a period of time that they would need to be off the birth control before successfully conceiving? And is it different based on the type of birth control? Can we talk through that for a moment?

Dr. Amy Kelley:

Yeah, you actually don’t have to wait at all. It’s a little bit of an urban myth that you have to wait a couple months when you go off of the pill or go off of really any birth control. I’ve had plenty of people who we pulled their IUD and they never even got a period they got pregnant instead. So it can happen rather rapidly. Almost all of our methods of birth control are once you take them out or once you stop taking them, your fertility comes back very quickly.

The exception to that is Depo-Provera, the shot. That can take six months to a year to wear off. So that isn’t a great option for people who think they’re wanting to have children soon because it can take a while to wear off. Now I’ve also had people who have gotten pregnant on it because Depo has a failure rate, so that’s not a universal truth, but it can take a while to wear off. The Nexplanon also can take a few months to wear off. But I’ve had people also get immediately pregnant with that. So it does vary a little from person to person. But yeah, that’s an urban myth that you have to wait. You can definitely start trying right away.

Courtney Collen:

Well thanks for clearing the air on that. I appreciate it. Now speaking of myths or misconceptions, are there any that you hear of about different birth controls? Either the types or things you’re seeing on social media? Any fear that you hear of? Talk about that.

Dr. Amy Kelley:

All the time. When you think about birth control is something that 90% of women take or use in their lifetime. Women make up more than 50%, you know, 50-52% of the population. It’s no wonder there’s all these myths because when so many people are using something like contraception, it’s very easy to blame contraception for lots of common things, whether it causes that or not.

One of the biggest concerns I get from parents a lot of times is: will this affect fertility in the future? There’s this myth that like you take the pill for 10 to 15 years and then when you go off of it, you can’t get pregnant anymore, or Depo or whatever it is that you’re on. And that really is very much an urban myth.

The biggest issue with fertility nowadays is actually age. So if you’re on the pill for 15 or 20 years, you’re trying to get pregnant in your thirties, maybe even your late thirties and it’s much harder to get pregnant as you get older. So I think that’s a common misperception and it really is just, it’s based on some other things. It’s not a crazy thing to think by any means. But I hear that a lot.

The other thing I hear a lot is that contraception, especially hormonal contraception, makes you gain weight or it makes you crazy. And there’s a kernel of truth to that as well because some people do gain weight with hormonal birth control and some people do think it affects their mood. But lots of other things in life do that to us too. You go to college, a lot of people gain the freshman 15. College is super stressful. People have a lot of anxiety when they’re at college, especially that first year. And so sometimes those things aren’t just from birth control, but it can be really hard to tell.

Regardless if you think your birth control is causing some of that, it’s not something that we hear very often. I would put it in the under 5% category. So if you look at all kinds of birth control, a small number of people might have those side effects. But really if that’s the case, switching to a different method usually will fix that. So it doesn’t mean you can’t have any kind of birth control if you have one that you don’t like or doesn’t work well for you. The one birth control that consistently is associated with weight gain in studies is Depo. And the average weight gain with Depo is five pounds. And about 10 to 20% of people gain weight with Depo. So, you know, if you think about that being the only one that consistently shows that, that’s kind of worst-case scenario. So really all the other ones are probably much better for most people.

Courtney Collen:

Yeah. Good to know the risks or side effects I guess before you go in.

Dr. Amy Kelley:

Yeah, absolutely. And we talk to people about those. I think that we’re very open with what people might potentially experience. On TikTok lately there’s been a lot of stuff about IUDs and how horrible they are. And so there’s quite a bit of fear around getting IUDs for some people too. And the interesting thing about IUDs is how much the experience varies from person to person. I do think that they can be uncomfortable and crampy. I myself have three IUDs and this is my third one. And I really don’t like getting them because they are kind of yucky to get, but it’s also like less than a minute. And you know, there are things we can do to make it better. There’s medicine we can give you beforehand if you’re anxious, there’s medicine we can give you that kind of helps the cervix be a little bit more open to putting an IUD in. And we even sometimes put people to sleep for IUD placements if they’re really anxious or if they have a history of trauma or for kiddos who maybe can’t cooperate with an exam like children or teens who have developmental delays and things like that.

But there are definitely things we can do to make it make it better. I had a teenager just the other day, 16, who did way better than I did with my last IUD insertion. So it does vary a lot from person to person. But most people can get through it.

Courtney Collen:

Yeah, good to know. Now how young is too young to start on a birth control and what to consider there because – and then you know, how old is too old to continue birth control? Can you talk to that?

Dr. Amy Kelley:

So really once you have your period, you could be on something for birth control.

Courtney Collen:

So as early as 11, 12 …

Dr. Amy Kelley:

You know, even nine, 10 because some young ladies do get their period as early as nine or 10, especially African American teens and Hispanic teens sometimes get theirs a little early. But there are some special considerations in young people. There’s the potential for a little bit of loss of height in that first year after you get your period. You can still grow a little bit. We don’t have great studies to prove that if you take estrogen that it makes you not grow as much. But there’s that concern. So sometimes we start out with things that don’t have estrogen in young ladies who just started their period.

But, if you’re having problems with your period or if contraception is needed, then it’s really as soon as you get your period, we can be helping you with that if it’s an issue. As far as how old you can be, it’s unlikely, but you can get pregnant all the way up until menopause. So I think it’s important for our perimenopausal women to understand that, you know, once you hit 40, it doesn’t mean you can’t get pregnant anymore. And so it’s important to still use contraception if you need it and it depends on what method you’re using.

As you get older, things with estrogen do start having a little bit more risk. But if you are someone who can still take estrogen, you can take it until menopause. You can take birth control pills until menopause. If you have a reason why we think estrogen’s not a good idea, you develop hypertension or you know you’ve had a blood clot or something, then there are other methods. There are those methods that don’t have estrogen that you can use.

Courtney Collen:

Different factors. Let’s talk through some of those that might affect the success or effectiveness of any method of birth control.

Dr. Amy Kelley:

Yeah, so there are some medications that do affect birth control and how effective it is for contraception. So it’s really mostly our estrogen containing birth control methods. So the pill, the patch, the ring that are affected by other medications. So some of those medications can include seizure medications and antibiotics.

But there’s actually only a couple of antibiotics that really affect contraception. And they’re actually antibiotics for tuberculosis. So one of them is called Rifampin. So most of your antibiotics you’re going to get for like an ear infection or strep throat or sinusitis or a yeast infection is not going to impact your contraception method, even if it is a pill, a patch or a ring. But again, there are some medications and those would be the two big ones that are common would be a couple, a handful of antibiotics and anti-seizure medications.

Courtney Collen:

How long should a patient be on any specific birth control before they might be able to switch or something’s not working out? Or are there some that are riskier to be on for a long period of time?

Dr. Amy Kelley:

The vast majority of them, it’s fine to be on for a long period of time. There is kind of this myth about Depo that you can only be on it for two years because there is a slight risk of some bone loss with Depo-Provera, however, that bone loss is not associated with broken bones or hip fractures, risk factors, anything like that. And in fact with Depo for two years you lose a little bit of bone and then it stabilizes.

So if you’ve already been on it for two years, there’s actually no really good reason to quit unless you just don’t like it or don’t want to use it anymore. And the amount of bone you lose is about the same as you would if you had a baby and then breastfed for a year because you lose some bone and some calcium from those things as well. So we don’t really consider it to be a risk that would make us not want to do it in most people.

Courtney Collen:

What are some questions that maybe a young woman and her mom or her parents or a woman and her partner should ask their OB/GYN or their provider during the appointment when they’re discussing these different options? And/or any questions that you get that you would suggest listeners consider before beginning a method?

Dr. Amy Kelley:

Yeah, I think it’s really important to be honest with the person that you’re seeing with your provider. And you know, that can be hard in front of parents specifically sometimes, like if you really need contraception, but maybe your parents aren’t aware of the fact that you need contraception. I always think it’s better to have parents involved in these conversations, but you know, it is OK to talk to your provider alone if you feel like that is appropriate and you need to in fact, most providers I think do talk to teenagers alone for at least a little bit.

We do need parental permission in South Dakota to give adolescents any medication. And that does include contraception. There are some ways around that, but in general that is required. So it, it can be a little bit of a little bit of walking a tightrope sometimes in my shoes when you’re trying to like not out a teenager that might be sexually active, but also make sure they’re getting what they need. And I feel like that’s a conversation between the parent and teenager.

My goal as provider is to be a person that can give someone information and make sure they have the information they need to make good choices for themselves. But I think that being honest is important because you want to be honest about are you at risk for sexually transmitted infections so that we can talk to you about condom use if that’s an important piece of this. And do you need contraception or really are we just trying to get your period better? Like what is your main concern and reason for contraception? I think that those are things that are really important is just being honest.

You also want to make sure that we know and are aware of all the other medicines that you’re taking to make sure that we don’t have any interactions. And also to make sure that what we’re giving you is safe and that you don’t have these risk factors that would make us not want to give you estrogen. But I think that really, there are no dumb questions. I think that if you have concerns or you’ve heard rumors about birth control and you are worried about something specifically, just ask us. I mean, that’s what we’re here for.

Courtney Collen:

Yeah. And we’re so thankful to have you and other physicians and providers and a whole care team to be there when we’re considering these big decisions. Dr. Kelley, thank you so much for your insight on this topic and all that you do for patients at Sanford Health. I appreciate you.

Dr. Amy Kelley:

Thanks so much. It was great to be here.

Courtney Collen:

Thank you.

Learn more about this topic

• Endometriosis is common, yet commonly undiagnosed
• What is preventive care and how can it keep me healthy?
• Family planning at Sanford Health

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