Victoria C  00:00

Health and Wellbeing Queensland acknowledges the Jagera and Turrbal people, the traditional custodians of the land on which this podcast was recorded, and the traditional custodians of the lands and waters on which you’re listening. We pay our respects to the Aboriginal and Torres Strait Islander elders past and present, for they hold the memories of the traditions, cultures and aspirations of Australia’s first nations people

 

Elle  00:21

When it comes to starting conversations about family planning and contraception, there’s lots of different reasons why people access contraception, not always, necessarily, because someone is sexually active.

 

Victoria C  00:33

Hi, I’m Victoria Carthew, a journalist, presenter and your host of this series, the Clinician’s Guide to Women and Girls’ Health brought to you by Health and Wellbeing Queensland, in partnership with the Queensland Government’s Women and Girls Health Improvement Program.

 

Victoria C  00:47

From menstruation to menopause and all things in between, including sexual health, wellbeing and ageing, the Clinician’s Guide to Women and Girls Health podcast series speaks to leading Queensland experts about how health professionals can have effective, empathetic conversations with female clients, empowering them to take control of their health journey. Welcome to our first episode of the Clinician’s Guide to Women and Girls’ Health. Our journey through health and lifespan begins with adolescent girls and to focus on reproductive and sexual health through puberty. I’m joined by Elle Blackburn and Professor Rebecca Kimble. Elle Blackburn is a school-based health nurse based at Children’s Health Queensland, whose passion for reproductive and sexual health literacy has empowered young people to access care and diligently spearheaded self-advocacy skills for navigating their health journey. Elle, I’m so pleased you could be part of the conversation.

 

Elle  01:42

Thank you so much. It’s a joy to be here.

 

Victoria C  01:44

Professor Rebecca Kimble is the clinical lead of the Queensland statewide Paediatric and Adolescent Gynaecology services based at the Royal Brisbane and Women’s Hospital and Queensland Children’s Hospital. Rebecca, welcome to our first episode.

 

Rebecca  01:57

Thanks. Thanks, Victoria. Thanks for inviting me.

 

Victoria C  02:00

You are such a wonderful combination of health professionals to begin this series and to give insight into women and girls’ health and the places that help can be sought in both a clinical and a school setting. Professor, the very best place to start is usually at the beginning. Can you describe the the usual? And when I say usual, it’s in inverted commas, as we know it, the usual progression of puberty in girls and girls at this young age.

 

Rebecca  02:25

Yes, so puberty is actually a journey, and it’s a very sensitive journey. It can be a very turbulent journey. It can impose on the quality of life of the child as they’re transitioning from being a child to an adult person, right? So it’s actually five to eight years of a journey that can really impact enormously on all sorts of things. Physically, puberty is the changes that come in a very stepwise progress from the onset of breast development, which is the very first thing in girls. It’s at about eight to nine, and then following that is pubertal changes to hair growth, so pubic hair kicks in. So all of these are substantial changes to a child’s body, and they can be quite thrown off balance with and quite anxious and quite sometimes scared about what’s changing in their body, right? So we’re, we’re flat chested, and suddenly we’ve got boobs growing and we’ve and we’ve got pubic hair coming on, and then,

 

Victoria C

Particularly when they’re younger, on the younger end.

 

Rebecca

That’s exactly right. And so, so precocious puberty, which is the onset of puberty, which we see quite a lot, starts even earlier than that, and that can be really, really distressing for children and parents and carers. So we do need to be conscious of the onset of puberty and the potential onset of puberty much earlier, which is precocious puberty or delayed puberty, which is much later. All of these can be quite nerve wracking, because if they don’t start on time, then you can imagine the anxiety in parents in relation to my child’s development is either too early or too late. However, if we assume that everything’s on track, so if we’re talking about somebody who’s on track, that too is quite an important, sensitive journey in relation to all these body changes, we then have our period starting, which is in medical terms, called menarche. And periods tend to kick in about two years after the onset of breast development. So generally, when we’re when we’re assessing girls, when we advise parents, when we when we’re making a determination on whether this is appropriate pubertal development or early onset, precocious or delayed, we sort of look at the series of the onset of the various parts of puberty. And so then periods kick in, and then after periods, and kind of over the whole time, gradually and gently, there’s the additional components of puberty, which is called the adrenarche. And the adrenarche is when the androgenic hormones come in. So you have your girly hormones, you then have the androgenic hormones, which kick in.

 

Victoria C

I love those two terms – girly hormones and androgenic hormones.

 

Rebecca

Which we all girls will have both, and that’s just part of normal development, and that’s when acne kicks in, right body odour kicks in, armpit hair kicks in. So these are, these are quite you can imagine a child who’s just playing around, carefree, innocent. Suddenly, all these things start happening to their body, and they can withdraw from society, because it can be quite a burden to them watching their body change and not understanding what’s going on, and then suddenly the burden of bleeding every month or two or three times a month. And so puberty can be really quite a turbulent phase in anyone’s life, but the child is still a child, and they’re still a child, even as all of this is happening,

 

Victoria C  05:43

Absolutely and Elle, for you, you’re seeing those young women, those girls, children, into young women in the school setting, where that can be quite shocking, because they’re seeing their peers, perhaps going through those things at the same time. What are some of the biggest issues that you are confronted with in the school setting?

 

Elle  05:59

Yeah, that’s exactly right. So it’s really fortunate that we do have school bases, school nurses available in state high schools. I think predominantly, a lot of young women come and seek out health care with me, specifically to do with accessing contraception and also painful periods. But I think a lot of the consults that I have with young people are often underpinned by that lack of knowledge, and there’s so much assumed knowledge and so much shame and stigma around not knowing their bodies in the way that they feel like they should know it, or stigma around being proactive about seeking help around sexual health related things, and again, like puberty is such a confronting thing for young people to experience because their brains are still developing, their prefrontal cortex is going into overdrive, and when you have puberty with attending high school, participating in family life, having a part time job, playing sport, these are all things that absolutely can create just a whirlwind of experiences for young people when they are trying to receive an education. So it’s that lack of knowledge that I find probably the most confronting thing that young people, specifically young women and girls, come and speak to me about.

 

Victoria C  07:05

Because it is the most natural thing in the world. It happens to everyone. But it’s not an it’s something you still need to be educated about isn’t it?

 

Rebecca  07:18

That’s exactly right.  And like Ellie was saying, it’s sufficiently confronting that people withdraw and don’t talk about it, and yet that that is exactly the phase of life. We need to be totally proactive and provide support and proactively, actually reach out and check in because of the impact on the quality of life there onwards. You know, in terms of periods per se, periods particularly, you can imagine if somebody’s bleeding two or three times a month, and that tends to happen when periods are kicking in, the brain is still developing. That frontal cortex is developing. We’re not producing eggs, so the ovarian function kicks in almost five to eight years later in terms of regular ovulation, and in that phase when we’re waiting to go from non ovulation cycles where we’re not producing eggs to producing eggs. The cycles, the period cycles, can be really, really heavy, really, really irregular, and have a huge impact.

 

Victoria C  08:10

Which is interesting because we talk about routine and expectations with young girls, and they you can’t, you can’t have that can you in this situation?

 

Rebecca  08:16

That’s exactly right, and, and this is an important part of my life, educating the clinicians as well as parents and carers and the children themselves when they come to clinic is putting a picture in front of them of the ovulation cycle and walking them through how when we’re in the first five to eight years when we’re not producing eggs. And that’s the natural thing, because your brain is developing the hormones that actually activate ovulation come from the brain, from the pituitary gland in the front, and that whole activation cycle is also maturing, so the brain actually is in charge of the menstrual cycle. And as the brain is developing and triggering ovulation, and the trigger for ovulation is maturing, and we’re gradually going from ovulating once or twice a year to 10 or 12 times a year as an adult. So as a child, we are only producing eggs twice a year or even that. And when we’re not producing an eggs, we’re not producing both hormones. So the girly hormones I was talking about, there’s oestrogen, progesterone. Oestrogen kicks in, thickens the lining of the womb, which is what comes out as a period. And progesterone only kicks in when an egg comes out right. And so you can imagine the role of progesterone is actually to stabilise the lining of the womb. And so if there’s no progesterone when we’re not ovulating and and so no ovulation, no progesterone, unopposed oestrogen. Means that that lining of the womb, what we call the endometrial lining, just gets thicker and thicker and thicker, and consequently, girls will then have a very unpredictable, heavy and prolonged menstrual cycle because there’s such a lot of endometrial build up that when they have a period, it’s heavy, prolonged, and then it’s unstable, and then it’s irregular. And so the period itself is a massive burden. And you can imagine, if you’re bleeding 7, 8, 9, days a month, and then you stop, start and bleed again, you’re just not getting a break.

 

Victoria C  10:22

And isn’t it extraordinary to think that that irregularity, that uncertainty, you have to say to them, that’s normal

 

Elle

That’s right.

 

Victoria C

And that’s the challenge isn’t it to be able to say to a young person. Are there particular red flags in a clinical setting, but also in a school setting, that for young girls to be coming and seeking medical help, or perhaps their parents and carers for doing so?

 

Elle  10:37

I definitely think so. So if I have a young person who’s seeking out my help for severe period pain, and what that looks like in a school setting is period pain that is so debilitating that they cannot attend school, they can’t play their sports, they can’t attend their part time job. That is a time when I would suggest going and doing a GP referral or going and see like a pelvic pain physiotherapist, for example. Having a period is normal and regular for most people. However, it’s that debilitating level of pain is what gets in the way of young people accessing their education. And periods are painful, but they shouldn’t stop you from living your day to day life,

 

Victoria C

Even in those earlier years?

 

Elle

That’s right, yeah, even in those earlier years.

 

Rebecca  11:15

So you actually see the end impact in schools, which is exactly what happens. We have one in four girls missing school in Australia because of periods. That’s a lot of girls. Those are the ones that that are on the pointy end of really debilitated. But then all the other children will come in and grin and bear it, right and then try and get through but they’re missing sports. They’re too tired, concurrent with a lot of bleeding. And you can imagine, if you’re bleeding out, you’re actually bleeding out your iron stores, right? And so you’re constantly running on an empty tank of iron stores. So you you haven’t got that iron level in your system, which has a huge impact on your ability to perform, to function, right on a day to day basis.

 

Elle  11:59

Yeah Professor Kimball, I see that on the floor regularly. We have this expectation that women and girls are built with pain in our bodies, and there’s this, we’ll just tolerate it. We’ll get on with it. When the reality is, if your pain isn’t resolved by over the counter paracetamol or ibuprofen, and you’re still not able to engage in your daily activities as you usually would, that’s not regular, and you shouldn’t have to endure that.

 

Victoria C  12:21

So what is that process? How do we teach our teenagers that what is normal is just a bit of discomfort and what is something so much more? How do we get that message across?

 

Elle  12:28

I think we start with knowledge is power, and when we can share our knowledge with young people, that is the first step to getting them to recognise what is normal versus what’s not normal.

 

Rebecca  12:37

That’s right. So school based education is really, really important. I think that’s where we can target our children and empower them. It’s really important to empower them so that they can understand that they actually, physiologically, they don’t need to have a period till they need to have a baby. So we’re having the burden of periods for almost a decade and a half before we even need the cycles for the purposes of reproduction, and in all those years, we’re on the back foot. Girls are on the back foot because they’re chronically iron deficient, they’re chronically tired, their life trajectory goes off on a tangent that might not be their full potential. Physiologically, we’re tired. We we are missing school. We can’t perform. We’ve got iron deficiency anaemia. Brain function is also dependent on normal iron stores, and if we don’t have enough iron, the brain neurotransmitters aren’t produced and so surprise, surprise, there’s so much anxiety, depression and mental health distresses that come with when periods kick in. So you can imagine when you look at the mental health side of things for adolescents, periods kick in, and mental health issues kick in as well, right? But also what happens is, so we are maturing anatomically, so the uterus is actually growing. The uterus has three parts to it. It’s got the uterine body, it’s got the fallopian tubes and the cervix, right? And so all of that is also anatomically growing from a child’s uterus, which is half the size of an adult uterus, to becoming an adult size uterus in those five years, five to eight years. And so you can imagine we’ve got this tiny little uterus, which is just jam packed full of endometrial lining, and a tiny little cervix that’s very, very thin and very narrow and very tight. And so as blood is trying to egress out of the cervix, for a normal period to happen, blood also goes back the way into the fallopian tubes, what we call retrograde menstruation. And this happens. This is a normal phenomenon. It happens in most people, most girls. And what happens when the endometrial lining Retrogrades back through the fallopian tubes into the pelvic and abdominal cavity, is what sets off endometriosis. So we’ve got this endometrial lining sitting in the pelvic cavity every month, several times a month, 20 times a year. We’re setting ourselves up for endometriosis. The endometrial lining and blood in the pelvic cavity will cause bladder symptoms and irritation, bowel symptoms and irritations. And so our girls are not just copying the period. They’re also, on top of that, having chronic abdominal non specific pain. You go to the toilet, you have pain. You can’t empty your bladder properly because you’ve got pain.

 

Victoria C  15:15

You’re painting, and I wish for our listeners, you can see Professor Kimble because she’s drawing some amazing diagrams with her hands, but you are drawing and painting quite a picture for us of the bigger issues surrounding this. And if we look at the Queensland Women and Girls Health Strategy 2032 consultation outcomes, the report highlighted, teenage girls do often feel dismissed by healthcare professionals and because of their gender or because they’re not able to express it well. That’s a huge role in schools and for nurses and for all health professionals isn’t it?

 

Elle  15:41

Yeah, that’s right. And unfortunately, that is echoed from the young people that I see in schools, is that they don’t feel heard, they don’t feel seen, and they don’t feel listened to when they do try to advocate for their health, which is so devastating, because these are skills that we need to embed in young people to ultimately prevent the burden of disease later in life. The thing is, it’s really simple stuff that we can do to help support young people when they are accessing healthcare. It’s things like using validating language. It’s things like asking them this or stating this, must be really tough for you. I’m really grateful that you told me and that you really shared this information with me. I’m sure it was really tough. Also involving the young person in the decision making is so integral for success as well, because I feel more often than not, adults think that they know better than the young person themselves, and they’re living their bodies and they’re living their experiences. And the reality is, we are to walk with them and to complement their journey and give them the skills to make the best choices that they possibly can. Because the reality is, if we don’t get in now to kind of support young people on their health journey, we are seriously diminishing their futures in terms of feeling empowered in their bodies and being able to succeed and live the best and most brightest life that they possibly can.

 

Victoria C  16:50

Are they feeling comfortable as well talking about not just that reproductive health, but also sexual health?

 

Elle  16:54

I think I am able to work in a really interesting space, and I find that when I communicate my limitations with confidentiality with young people, they feel a lot more empowered to share. There’s a lot of fear from young people that when they open up with an adult or maybe a healthcare professional, that that information is going to go everywhere when it’s not and when you can communicate what your limitations of confidentiality are. So in a school setting, everything that we talk about is private and confidential. Obviously we still have mandatory reporting, which we can communicate but the reality is, I’m not going to go and tell your teachers. I’m not going to tell your parents unless there’s identified risks, of course, but just having that space for them to feel like they can be vulnerable and they can be honest about their experience is absolutely everything. Also really important is to not assume anything at all. I think as adults, we again assume that we know what’s going on for them, and the reality is it’s possibly not representative of what they’re actually experiencing. So giving them the space to actually talk and share their experience is so valuable because you don’t know what they’re going to come out with and say, and you don’t know what they know, or they don’t know, and it’s through that assumed knowledge that you can miss massive, really integral stuff that they need help with.

 

Victoria C  18:02

And this is a, you know, a school environment where they are spending a lot of time so they’re theoretically a little more comfortable in the clinical setting. Professor Kimble this could be so much more daunting for young women.

 

Rebecca  18:11

Absolutely. And Elle has alluded to how disempowering and scary all of this can be, and knowing that you’re in a safe environment is so important. So from a clinical perspective, I see children come in generally, they’ll have seen their GP, they might have seen a paediatrician or a general gynaecologist, and then eventually the adolescent, the Paediatric and Adolescent Service. I spend a lot of time educating all of the above, the primary practitioners, GPs, nurse practitioners, emergency physicians, general gynaecologists and paediatricians, precisely for that reason that we want to see children early. So we’re developing education resources for school-based education, specifically around periods and what’s normal, what’s not normal, and I think which we almost need to sort of get away with the distinction between normal and abnormal to what’s impacting you, impacting your life and the quality of life impact. Because what’s normal for one person is not normal for another person. And so the definition of heavy menstrual bleeding, for instance, has gone from specific, quantifiable, measurable amounts of bleeding, which is the old, archaic way of looking at it like if you don’t meet this target, you don’t have a problem. We’ve moved on to if it is a quality of life impact on the woman and girl, then that’s sufficient. And that’s really where we need to go. We need to just validate the suffering, because periods really do cause a lot of suffering in so many ways, not just the pain, not just the bleeding, but the overall inability to perform at top level, right? So we’ve got girls who have normalised or been or been made to normalise what is actually not normal, because they quietly suffering. And so when they come to the clinical setting, I actually have appointments that are an hour. I make sure. That I have a full hour per patient, and longer if they need to, but I spend the time educating not just the child, but also their parents and carers on basic physiology of periods, right? And of course, they always have the opportunity for mum and dad to step outside and so they can open up and talk to me about everything else.

 

Rebecca  20:20

Because I was wondering in a school setting, obviously the parents are generally not there. But for you, is that, is that tricky to navigate at times?

 

Rebecca  20:21

No, it’s not tricky at all. I just, I just politely ask the parents to please wait outside.

 

Victoria C

I can imagine you doing that.

 

Rebecca

And I think we have to, we have to, we have to advocate on behalf of the child, because oftentimes they’re terrified to actually ask the parents to to wait outside so that they can actually speak to us freely. And we know that we need to advocate on their behalf. And so I give them all as soon as they arrive, I give them all the opportunity to speak with me, with their parents, and then the parents can wait outside, and then I’ll call them back in. But the education part, I make sure everybody’s around the table so that the child doesn’t then have to explain her physical condition to the parents in relation to the understanding that the health literacy component.

 

Victoria C  21:02

I kind of love that thought as well, because you’re giving the child some power, aren’t you over their own bodies. You’re already instilling that quite early on.

 

Rebecca  21:09

Yep, absolutely. And so just about every girl, able and disabled who walks through the doors of my clinic, once we’ve had the education, I look at them and say, would you like to have a period? Would you like to have a lighter period? Would you like to have a period every few months and not every month? Or would you like just not to have a period until you have finished school and you know, ready to move on? Almost invariably, the children will tell me they’d rather not have a period, and then they look at their parents, and the parents would look at them, and this is after I’ve just provided basic physiological education about why we have periods and how we don’t actually need to have periods until we’re ready to have a baby, and we really need to prevent that endometriosis and prevent the suffering, and get back and get that those iron stores back so we’re performing well after that education for both parents and carers and children. Oftentimes the children will look at their parents seeking permission in relation to, should I just not have a period? Or am I allowed to not have a period? That option has just been put forward by me to the child to say, Would you like to have a period? You don’t have to have a period. There’s no right answer or wrong answer. You know. You just decide what you want. If you just want to be period free until you finish school, that’s quite okay, and most parents, after they’ve received the education would actually they can relate to that. Mums particularly can relate to that, and would generally say, but I wish I had this information when I was a girl.

 

Victoria C

Sounds revolutionary.

 

Rebecca

Most, most moms can relate to that because they’ve suffered as well, and they wish they had that option when they were teenagers. And so the vast majority of parents will actually go along with what the child wants. And the vast majority of children will choose not to have a period until they need to, and that’s quite easily achievable so

 

Victoria C  22:52

And we’re talking, I guess, just to clarify, we are talking about some extreme, you know, severe situations here. This is not, you’re not saying to any girl on the street,

 

Rebecca  23:02

Not at all.

 

Victoria C  23:02

This is extreme  situations.

 

Rebecca  23:02

So, so the children that go through what Ellie was talking about, you know, you tried the over the counter medication, you’ve tried your non steroidals, you’ve tried your Ponstans for pain, and nothing’s happening. So you haven’t quite become pain free. You’re still suffering, but the amount of bleeding hasn’t reduced, right? It’s a very simple concept, and it’s understanding it makes a huge It relieves people of the mystique and the lack of knowledge around basic physiology of periods, right? It’s very much back to when we’re not ovulating, when we’re not producing eggs, we’re not producing the second really important hormone called progesterone, and therefore the period is going to be heavy because we’ve got a thick lining. And the treatment is supplementation of progesterone to just try and stabilise that endometrial lining, stop it from overgrowth and stabilising it to the point of either having lighter periods or infrequent periods. You can choose to have your periods, two monthly, three monthly, six monthly, or no periods. It’s just adjustment of the progesterone levels. So you can take progesterone to lighten the period and then have regular monthly cycles. Or you can take progesterone to have lighter periods and have regular two or three monthly cycles. Or you can just continuously take progesterone to stop your cycles.

 

Victoria C  24:18

Don’t go anywhere. Our conversation continues after these messages.

 

Advertisement  24:22

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Victoria C  24:57

Thanks for listening now, let’s return to our Clinicians Guide to Women and Girls’ Health.

 

Victoria C  25:02

Such an important conversation. And I’m joined by health nurse Elle Blackburn and Professor Rebecca Kimble in this episode, our opening episode of the Clinician’s Guide to Women and Girls’ Health and we’re discussing teenage, adolescent reproductive and sexual health. And if you hear something you’d like to explore further, or perhaps any links or sites that we mentioned, they certainly will be available to you in our show notes. You touched off the top of Professor Kimball about there’s so much else going on in terms of hormones and other things. So of course, the other when is around when it’s an appropriate time to start talking about things related to sexual interactions and contraception and family planning. Elle, you are in the front line.

 

Elle  25:37

I am. I really, really am. I think it’s appropriate to start conversations about respectful relationships and family planning and things like consent very early on. It’s never too soon to start talking about consent and respect and healthy relationships, especially at the start of adolescence.

 

Victoria C

Is that almost at the forefront of it now?

 

Elle

I would say, yeah, it absolutely is. So in Australia, we have respectful relationships education embedded in Queensland state high schools, which is an incredibly valuable initiative that we’ve got put in to help young people learn about power, control, consent, coercion, and embed skills like empathy and challenge things like gender norms. And it’s very, very valuable for kids to have those skills moving forward, to navigate the rest of their lives. The thing about these sorts of conversations, though, they can’t be one offs. They need to be ongoing and continuous, and it needs to be led through role modelling as well. When it comes to starting conversations about family planning and contraception, there’s lots of different reasons why people access contraception, not always, necessarily, because someone is sexually active. Professor Kimball was just talking about for young people who are experiencing debilitating periods, accessing contraception to manage those symptoms is so valuable. So I think in terms of things to reflect on, on clinicians and parents as well, is that if you have a healthcare professional coming to you, talking to you about your young person having contraception at, say, 12 or 13, some knee jerk reactions can be my child isn’t sexually active, I don’t want them to be at that space yet. And accessing contraception is only a really small drop in the ocean in terms of, is it because that they are sexually active, or is it because we need to manage ongoing chronic health conditions? So really, really valuable to I guess, keep an open mind when it comes to accessing medications to support your young person.

 

Victoria C  27:21

And for healthcare professionals that are listening as well, who aren’t necessarily talking about reproductive health directly, how would they, how would you encourage them to speak to families and initiate these conversations so that it is you, because you are removing that stigma aren’t you?

 

Elle  27:32

That’s exactly right. So you don’t need to be a healthcare professional to have conversations like this. You just need to be a respectful adult. That’s legitimately it. And it’s through role modelling those conversations, I think using healthcare checkups is a really good way to prompt these conversations with young people about how they’re going with their period and with their bodies. I also think normalising these conversations regularly about your own personal experience as a parent is also so valuable in terms of what your young person’s going through. I think Professor Kimble can probably speak more to the dynamics in which parents are navigating young people accessing health.

 

Rebecca  28:05

You’ve touched on a really important concept there Ellie in relation to the contraception side of things. So the contraceptive pill has got hormones in it. So it’s got the oestrogen, progesterone. And oftentimes in primary care, these girls who have heavy menstrual bleeding will be started on the pill for that purpose, to try and regulate their cycles, to try and reduce the cycles. What works better, generally, is not in the first instance, the contraceptive pill, but progesterone alone, which is just one component of the pill. So when you understand that the deficiency in a menstrual cycle in the early phase is actually a lack of progesterone. Just giving the child progesterone, which is not the contraceptive pill, is what treats the deficiency and actually deals with the cycle. And it’s got fewer side effects, because the oestrogen side of the pill is where a lot of the side effects kick in. So when a child is growing, oestrogen can actually stunt their vertical height growth, right? It also increases the risk of getting thromboembolic disease. So VTE, where you can get a clot in your leg, and it can, it can. So it’s, it’s got a lot of unnecessary side effects for the purposes in that early phase of life, where all we need is the half of the pill, which is the progesterone only. So if you’re iron deficient, you take iron. If you’re progesterone deficient, you take progesterone, not oestrogen, and progesterone, because we’ve already got plenty of oestrogen. And this is what I spend time educating and reassuring parents and children about, is that we’re not putting you on the pill. We’re just giving you the half of the pill, which is the progesterone component only, because that’s all you’re lacking at the moment, and that’s got hardly any side effects. So we have oral preparations of progesterone, we have injectable preparations of progesterone, and they work really, really well in addressing the heavy, painful periods, and so 80 to 90% positive responses and we’ve got our own data from the Queensland Children’s Hospital, where progesterone only actually deals with not just the reduction of bleeding, but it actually deals with the reduction and resolution of pain. And so progesterone only is very, very effective, and it’s physiologically much better because this child is still growing, and what you don’t want to do is stunt the vertical height growth or add to the additional risk of venous thrombosis, et cetera. And this is education I provide. And so it is our role to make sure that our clinicians are aware that these options are available for all girls, able and disabled girls. But the other thing I wanted to just add is education around the very frequent occurrence of undiagnosed bleeding disorders. And so about 35 to 40% of girls will concurrently have a bleeding disorder which is undiagnosed and it first manifests through their periods. And so heavy, painful periods with iron deficiency or iron deficiency anaemia, has got a 35 to 40% chance that that child has also got a bleeding disorder. So it’s not just a hormonal thing, it’s a haematological thing where there’s a bleeding disorder that is extremely common, and it’s platelet function disorders and another thing called von Willebrands disease, both of which are extremely common in society, but under diagnosed because we don’t proactively go looking for it. And of course, the girl presents for the first time because she hasn’t lived life long enough to have bled through surgery or any other way. The first manifestation of this bleeding disorder is oftentimes that very heavy, painful period associated with iron deficiency anaemia. Girls will land in emergency departments needing blood transfusions with the haemoglobin dropping right down to 50s and 60s, which is very debilitating, but oftentimes it’s because we’ve missed the fact that there’s also a concurrent bleeding disorder that goes

 

Victoria C

With it as well

 

Rebecca

With it as well.

 

Victoria C  31:56

I think for our clinicians listening that is such a huge amount of information, but also important for perhaps what they haven’t been able to look for or known to look for before, and so certainly they’ll be able to look out for that study. I do want to get to talking about healthy behaviours and also support services as well. But I really wanted to have a conversation with you both around mental health, with regard to this, this issue, because it you’ve talked about the actual physical barriers and symptoms, and what will happen. How this impacts on mental health, you’re both seeing in huge numbers, isn’t it Elle?

 

Elle  32:24

Absolutely so having unpredictable or severe period pain plays a massive impact on how young people experience their lives, and I know we’ve touched on it a handful of times, but it really does impact the access to education and to knowledge, and it’s not fair that we have young women out there who aren’t receiving an education because of their bodies and that lack of information. And if you’ve got an unpredictable period, if you’re persistently bloated or in pain, you’re not going to want to come to school. You’re not going to be in the readiness mind frame to receive an education and be ready to learn. You’re not wanting to go out and socialise with your friends. You’re not going to want to go and play sport as well. So it’s such this cycle of pain period, pain period, and then trying to break out of that is so debilitating for young people, because as we said at the beginning, there’s this expectation that everyone’s just going to be in pain, and it’s just a part of being a woman, when the reality is it doesn’t have to be like that.

 

Victoria C  33:17

And I presume it could also impact on eating behaviours, et cetera, because you were saying before there’s you have bowel troubles and other things that can happen because that can happen because of that pain in the pelvic area.

 

Rebecca  33:24

That’s exactly right. So that retrograde menstruation will cause quite a lot of constant pain and quite a lot of bloating and quite a lot of bladder pain as well. So it’s a vicious cycle of we’re in constant pain, and so the easiest thing is to just stay at home and avoid life in general, right? And which is so unfair. You can imagine if we just compared this normalisation and acceptance of periods and the fact that it’s okay to bleed several days of every month or several times every month, with any other health matter, if we were bleeding from our legs every month, or if we were, if we had, you know, pain in our arms and legs and toes or anything, we’d be seeking care straight away for even minor pain. And yet, we’re debilitated by bleeding from our bodies several days of every month. It’s a chronic cycle. You’re just not getting a break, and it sets, sets you up on a trajectory that you’re not performing. You’ve got anxiety. You’re stuck with periods from from when they’re start.

 

Victoria C  34:29

And Elle that cycle in a school setting is incredibly traumatic.

 

Elle  34:33

Absolutely. And why would you want to go to school if you’re scared you’re going to bleed through your uniform, if you’re going to be in so much pain, you’re going to crawl out of the classroom, face the awkwardness of wanting to be sent home and also not wanting to, yeah, participate in learning. These can these symptoms of the pain that young people are experiencing. Healthy Habits can make a massive difference in terms of getting adequate sleep, having a good, balanced, nutritional diet. Moving your body as well is really great and releasing hormones to kind of manage some of that pain. Also, I like to talk to young people a lot about sleep, because that is something that is reoccurring in a lot of my consults, and how different circadian rhythms are for young people as well. Young people have a very different circadian rhythm to adults.

 

Victoria C

Do they understand that?

 

Elle

Usually no, usually no. And I find that going back to, knowledge is power, when you can embed that yes, your circadian rhythm is different to others, and we are essentially asking you to attend school at what would be 3am for us with a smile on your dial and ready to learn. There are things that they can do to maintain a quality sleep hygiene and also to embed lifelong skills so that they can have those healthy habits. So it’s things like making sure that you have a bulletproof bedtime routine, so avoiding screens and schoolwork before you go to sleep, making sure your bedroom is as cold as possible, doing some light stretching and movement before trying to go to sleep also helps.

 

Victoria C  35:52

As cold as possible?

 

Elle  35:52

As cold as possible, yeah, absolutely. Well, not as cold as possible, a bearable amount of cold

 

Victoria C  35:53

Because you warm up and that helps you sleep?

 

Elle  35:58

It does. Yeah. I also talk about how young people love their screens, and the impact of dopamine dumping. So first thing in the morning, a lot of young people access their devices, and what that does is it spikes your dopamine first thing in the morning, because you have all this amazing stimuli. You’ve got these feel good hormones running through your body. But the reality is, if you spent the first 30 minutes of your day, getting that dopamine rush, everything else – so having breakfast, connecting with people, going to school – nothing is as exciting as those first 30 minutes. So you really are setting yourself up for disappointment for the rest of the day. So I encourage young people, if they can avoid it, try not to go on your screen for the first 30 minutes. Drink a big glass of water, move your body, do anything to stay away from that screen, because ultimately you’re going to have a much better day if you can just stop doom scrolling upon entry back into consciousness.

 

Victoria C  36:47

I really want to just pick up that bit of conversation and take it home to my family. And that makes so much sense for all of us, actually, not just for our for our young people as well. There’s a lot of messaging around health, particularly this age group, and as you say, they’re accessing a lot of it via social media and through their tech. It’s important they’re getting the right messages, isn’t it Professor?

 

Rebecca  37:04

That’s exactly right. And so having healthy sleep hygiene, being empowered to seek care and this, and this is something that I think we’ve got a lot of work to do still in society, in empowering and educating society in general, and just explaining to them the whole pubertal journey and how important and how much of an impact it has, and empowering our children to seek help. And I think that’s where our school based services are, so so important that we really need to support people like Elle to, and resource you guys better, so that you’ve got, actually got much more time to spend with children, so that they actually feel that they can seek care without the psychological barriers of the normalisation of pain and suffering, right? They need to know that it’s okay to seek care and to talk to somebody about it, and not to feel like you’re disempowered, because for generations we’ve normalised it, and so you’ve got to grin and bear it. I think we really need to get to that next level of societal threshold setting where we actually do proactively seek care, as opposed to just accept things, because the impact is so much the mental health side of things. So it’s my message to children in school, or just children in general, when they’re going through their pubertal cycle, is to understand their menstrual cycles, understand their pubertal development. And this is where we need to really empower them, provide education, but also be empowered enough to actually reach out and seek help and feel free to seek help and feel like it’s a health matter. It’s a health matter like any other health matter, which was what I was alluding to, if we had a broken toe, we would quite happily seek help and that’s not taboo. And yet periods, why are periods still so taboo? And we just need to snap out of that and educate society so that as a natural health matter, we are comfortable to seek help and to reach out at all levels, parents, carers, grandparents and the children themselves.

 

Elle  39:04

That’s where we come in as clinicians in this really valuable space. So we have this opportunity where we can ask those curious questions, we can believe the young people when they do, share what they’re experiencing and validate their experience. I often say when we have new staff coming through, that this is potentially the first time a young person is accessing health care. So we really want to try to make it a super positive experience, so we can capitalise on those help seeking skills, because ultimately, this will benefit young people for the rest of their life, if we can get in right now and support them and validate them and see them and say, look, I can see what you’re going through. This is really tough, and I’m so proud of you for coming here and telling me about it, right?

 

Rebecca  39:42

That’s right, yeah

 

Victoria C  39:43

Stay with us. We will be right back to continue our conversation.

 

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Victoria C  40:12

Welcome back. Let’s return to our conversation.

 

Victoria C  40:16

We always say there’s an app for that. You know, there’s most things in life, there’s an app, and we know that there are some valuable ones in health, like a period tracker. I’m just interested in your thoughts on really valuable ones, and then I guess further step of sharing that information that they’re tracking, perhaps with their GPS or their clinical people as well.

 

Elle  40:33

I love the use of technology and how it can complement healthcare. I’m a big fan of period tracking apps. I’ve specifically used Clue, which is great. It’s free, and it asks you to log things like how regular your cycle is, what sort of symptoms are you experiencing if you’re sexually active, what sort of contraception you’re using. And that’s information that young people don’t have to remember they are constantly asked to perform in so many different areas of their life, it’s challenging to keep on top of what their cycle is like. So if you can delegate that to a computer, I really advocate and encourage that, because it’s with that information, then you can get really valuable data about is your period regular? Are you bleeding in excessive amount? Are your symptoms persistent? Is everything where it needs to be? And then you can communicate this amazing information to your GP, and then they can do all the heavy lifting as well for you

 

Victoria C  41:18

And sharing those apps or information on those apps, it’s important and timely, isn’t it? That people who are using people who are using them do share them with their health providers as well.

 

Rebecca  41:22

That’s right. So it’s very helpful, because then you’re not spending a lot of time sort of interrogating the child in relation to what their periods have been doing, because they often don’t remember. And so it’s helpful for us to just have cast an eye on the patterns or the irregularities of their periods. Very, very helpful, and it does. It does give them an opportunity to focus on themselves and focus on what might not be just right, without getting too burdened by it. You know. So most of the apps are created for adult women. And so adult women, ovulation cycles, regular cycles. And so are you comparing what is expected of you in the adult, mature cycle versus what you’re having. So for adolescents, paediatric and adolescent populations, they are never going to be having the same pattern, because these are adult cycles. But what it does help them determine is there’s something not right, and that’s really important to say, well, at some point in life, later on, I’m supposed to be having these regular cycles with ovulation. I’m not doing any of the above because I’m still a child, and so it might trigger them to seek help, which, which is probably helpful.

 

Victoria C  42:30

And we know that the Pelvic Pain Foundation, for example, they’re always talking about early intervention, and that is, I’m imagining, what you’d be advocating for all the way along.

 

Rebecca  42:38

Absolutely, I’m really grateful for the education that the pelvic pain foundation is providing, because that’s a first step toward providing that education. I think we need more education like that. The guideline we are developing is for our clinicians so that they too intervene early, so they don’t inadvertently dismiss the symptoms and things that are really, really important. And I’m sure every clinician wants to help the child, but they probably are also out of their depth in not understanding when to draw the line to refer to a specialist or that they can themselves commence progesterone treatment, for instance. And so we’re trying to empower through this guideline that’s going to be easily accessible on the Queensland Health, Queensland Clinical Guidelines website, and it’s also available just through Google for everybody, for clinicians, for children, for parents, for anybody who wants to access that. And it’s got a very detailed approach in relation to all of what I was talking about, in explanation of the cycles in the physiological differences, in what options you have for medication and non medication, all of those other healthy behaviours, and then recognising those other more rarer things, like bleeding disorders and when to investigate those or if they are uterine anomalies, for instance, they too can present as period pain in a slightly different pattern. So part of the education for everyone is the recognition and taking a proper history of their child’s pain and pattern of pain, as well as impact on their bladder function and bowel function, is if there’s constant pain or cyclically worsening pain, then get an ultrasound done to check to make sure that the the uterus is normal. Or if it isn’t, then I would like to see them as soon as possible and get an MRI done and make sure that if we’ve got a surgically correctable condition. And this is extremely common that we actually get the girls in, get an MRI, get a proper diagnosis, get on to the reconstruction of the reproductive tract. So there’s a lot of so that the uterus develops as two tubes coming from either side, joining up in the middle and becoming a single uterus. But in about one in 5000 girls, it comes from both sides the two tubes, and they don’t join up. And there can be two systems of variable development. And these are, again, rarer conditions that, if you’re not looking out for and don’t have a threshold to take a good history and get a baseline ultrasound done, then you’re missing it. And then four or five years goes from the time that their periods have started, and all that accumulated blood has flowed back into the pelvic system and caused a lot of endometriosis, inflammation and damage to the reproductive tract. So really important.

 

Victoria C  45:12

That early intervention that you’ve just given us an incredible reason why you need to really get focused on this early What a way to start our series, what a wonderful conversation to give insights into our young women and the challenges, but also the opportunity to manage and best deal with the health issues before I let you go, ladies, Elle, any final thoughts and insights?

 

Elle  45:31

Just never fear. Help is near. There are amazing Queensland wide services out there to support the young people that you are working with. You potentially have an amazing school-based youth health nurse in your local hospital and healthcare service. You also have amazing organisations like True Relationships and Reproductive Health that have amazing age appropriate sexual and reproductive health resources, along with counselling. Most Queensland Health clinics do offer sexual health services and reproductive health services, so reach out. There’s always going to be someone out there to give you the best advice to how to care for young people, so you’re not in it alone, and there’s resources there to support you.

 

Rebecca  46:05

Again, I think we’re we’re in a very curious time in life where we really need to improve education for society in general. Empower them, educate them, give them basic health literacy, on puberty, on menstrual health, so that everyone understands that it’s okay to have the conversation, it’s okay to seek help. The children themselves need to know and be empowered that it’s okay to talk about things and seek help, because, like I said, periods in the first instance, are designed for reproduction, having a pregnancy, and until you need to have a pregnancy, you actually can choose not to have a period, and that’s okay. It’s not harmful. In fact, it’s actually beneficial and it’s protective of your reproductive tract, because you’re not setting yourself up for that long term retrograde menstruation and damage and endometriosis, which so many women have gone down the journey of. I think it’s time that we actually re-instated the threshold of normalisation of what’s okay and what’s not okay in society in general.

 

Victoria C  47:03

Ladies, thank you both so much for your company and your time today.

 

Elle  47:03

Thanks for having us.

 

Rebecca  47:06

Thank you. Thanks for having us.

 

Victoria C  47:11

For more information and show notes from today’s episode visit the Health and Wellbeing Queensland website at www.hw.qld.gov.au

 

Victoria C  47:21

If you’ve liked today’s conversation, be sure to subscribe for future episode updates. We’ll see you next time on the Clinician’s Guide to Women and Girls’ Health.