Bridging the Gap

Children and adolescents have unique gynecological needs often overlooked by pediatrics and adult OB/GYN.

On a February evening just weeks before her 17th birthday in 2021, Michelle Tang was rushed to the hospital in excruciating abdominal pain. Several months prior, the San Jose teenager had learned she’d developed a mass on one of her ovaries. Though she was surprised by the diagnosis, Tang didn’t approach her treatment with urgency. “It’s a bad habit of mine to downplay situations,” says Tang. “I don’t want to think the worst of anything.”

She lived with painful cramps and heavy periods for months. But on the night that she was admitted to a local community hospital, the pain was so acute that she could no longer ignore it.

The doctors who evaluated Tang knew her ovarian mass was the cause but did not have specialists on staff to treat such a young gynecologic patient.

They referred her to Pediatric and Adolescent Gynecology (PAG) at Stanford Medicine, a small but growing subdivision of Obstetrics and Gynecology (OB/GYN) devoted to care for girls from birth to early 20s. Tang saw Clinical Professor Nichole Tyson, MD, — one of three PAG faculty and the subdivision chair— as well as gynecologic oncologist Elisabeth Diver, MD. It turned out that Tang’s mass was Stage 1A: early ovarian cancer. And given her tender age, preserving her reproductive organs was of paramount concern.

Tyson removed Tang’s right ovary because it was malignant, but fortunately, since the cancer had not spread beyond that, she left Tang’s uterus and remaining ovary intact. “We were able to provide minimally invasive surgery with optimized reproductive preservation,” says Tyson.

Tang’s case is representative of the intersection between pediatrics, gynecology, and oncology that makes the PAG service so unique and vital. “GYN care for young people is really not discussed or talked about in medical schools. Clinical and surgical pediatric GYN care is not something that pediatricians, adult OB/GYNs, or pediatric surgeons are really trained for,” says Clinical Assistant Professor and PAG faculty member Stephanie Cizek, MD. “There is a huge gap in care that we fill as PAG providers.”

“It's a small specialty that has not yet trained as many scholars and clinicians to go to all of the academic centers across the country.

For Professor Emerita Paula Hillard, MD, — who began building the PAG program at Stanford when she joined the OB/GYN faculty in 2007 — the fact that patients like Tang are now commonly referred to the subdivision demonstrates the increasing visibility of Stanford’s PAG service. “The PAG program at Stanford is now in its adolescence,” she says.

An Era of Outreach

Hillard has been involved in PAG since the 1980s, when the North American Society for Pediatric and Adolescent Gynecology (NASPAG) was first established. In 2000, she founded a PAG fellowship program at the University of Cincinnati, where she taught for 23 years. When she arrived at Stanford, former chair Jonathan S. Berek, MD, charged her with growing PAG to support the creation of a fellowship program.

“For many years, until two years ago when we recruited our second faculty member, Dr. Cizek, I was the PAG subdivision,” says Hillard.

Some gynecological problems that fall under the PAG umbrella, such as uterine and vaginal anomalies that obstruct menses, are unique to adolescence. Others are associated with complex medical conditions. As such, Hillard sought referrals by doing outreach with pediatricians, gynecologists, and pediatric subspecialists at Lucile Packard Children’s Hospital Stanford.

She consulted with pediatric neurologists whose seizure disorder patients had worse seizures during menstruation and pediatric oncologists whose leukemia patients benefitted from menstrual suppression during chemo, as well as with virtually all the other subspecialists at the hospital. “These are partnerships that have really grown quite organically from the needs of the kids with these issues,” she says.

Hillard also made herself available to community pediatricians all over California via Stanford Medicine Children’s Health’s consultation service. Up until recently, she was the only full-time pediatric and adolescent gynecologist practicing in the state outside of the Kaiser Permanente system. “It‘s a small specialty that has not yet trained as many scholars and clinicians to go to all of the academic centers across the country,” she says.

Tyson (left) and Cizek (right) provide compassionate custom care for those typically overlooked.

Expanding the Faculty

After more than a decade of building referrals, patient volume increased to the point that Hillard could no longer handle it alone. In 2020, Cizek was hired straight from the PAG fellowship program that Hillard had founded at the University of Cincinnati, followed by Tyson, who had over 20 years of clinical PAG experience at Kaiser Permanente.

All three faculty cover the full breadth and depth of medical and surgical PAG. They enjoy collaborations across disciplines, cover PAG and gynecologic calls, provide PAG consult service for our inpatient referrals, and care for patients who are referred from as far away as San Diego and Yreka, California.

With the trio of faculty in place, Hillard says, it was finally time to turn their attention to launching the PAG fellowship. In July 2022, Olga Kciuk, MD, began as the inaugural fellow. The hope is to be approved for a second fellow soon.

Hillard, who transitioned to working part-time in May 2022 and plans to retire in 2024, is pleased that the fellowship will be part of her legacy. “It’s the second time around,” she says, referencing the first fellowship she founded at the University of Cincinnati. “But like a second child, you’re always excited.”

Future Directions

PAG is now part of several multidisciplinary teams, including the teams for Differences of Sex Development, Fertility Preservation, Hematology-Gynecology, Colorectal-Urology-Gynecology, and the pediatric Gender Clinic. “We really have all these spokes to our wheel,” says Tyson.

Tyson, who began serving as section chief in March, hopes to grow PAG’s surgical services and hire an additional full-time faculty. Other goals include establishing a menstrual pain clinic to care for young patients with endometriosis, a multidisciplinary polycystic ovarian syndrome clinic, increasing the subdivision’s onco-fertility presence, and expanding referrals for Müllerian anomalies.

Research is another direction for expansion. Cizek is currently working on several research projects, including one involving vulvovaginal graft-versus-host disease (a complication that can happen after stem-cell transplantation) and another that looks at disparities in access to fertility-preserving treatments. Tyson is studying the parent and child dyad when the latter is coping with a chronic illness, diving into when and how the pair discuss sexual health. “What we see is a lot of these kids with chronic illness, they‘re just the chronic illness,” says Tyson. “They don‘t really talk about … pregnancy planning, periods, any of that stuff.”

Human papilloma virus vaccination research and a collaborative research project on adolescent contraception are in the pipeline.

Supporting the Next Generation

Prioritizing psychosocial needs is a guiding light for the PAG faculty, who are sensitive to the fact that talking about private issues like your period and developing body can be uncomfortable for young people. “They just really need a trusted adult,” says Tyson, “and it‘s an honor and a privilege to get to be that trusted adult.”

Tang, for one, found Tyson to be an ideal confidant. “She has that approachable energy, and it‘s just very easy to talk to her,” she says. “I always felt a sense of comfort with Dr. Tyson, like a mother figure.”

Now 18 and in her freshman year at UCLA, Tang continues to see Tyson for follow-up care and surveillance. She says that her brush with ovarian cancer and experience at PAG has shaped the way she will view her gynecologic care and general health care going forward. Whereas before she took a wait-and-see approach to her health, she now sees the value of screenings such as Pap smears. “It really emphasized the importance of proactiveness,” she says.

The opportunity to shape young people’s health journeys over the long haul is a key part of what the PAG faculty find so fulfilling about the specialty. “You“re seeing our future right in front of us,” says Tyson. “And it“s both inspiring and motivating.”

Rachel B. Levin is a Los Angeles–based freelance writer and editor.

Nancy Rothstein is a San Francisco Bay Area photographer specializing in commercial lifestyle and portrait photography.

Stanford Ob/Gyn Magazine: Winter 2023

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