Alyssa had come into the clinic just after New Year’s; although she was a patient new to us, it seemed she had been seen by everyone in the hospital over the past few years. She complained of chronic pelvic and lower abdominal pain accompanied by constant vaginal bleeding. Her first visit was an overbook appointment to get her a pelvic ultrasound and labs; she started on the heavy menstrual bleeding and pelvic pain protocol.
She was coming back today for her second visit, during which we would review her results—all normal and reassuring—then come up with a comprehensive treatment plan. We were busy in the newly expanded Adolescent Clinic and had several complex patients but the most senior pediatrics resident on Adolescent Medicine Service saw Alyssa first. She came out of the room 30 minutes later looking exhausted. Alyssa had complained of constant pain and bleeding for the last two weeks and hadn’t been to school in a month.
Reviewing her complete record, Alyssa had seen multiple specialties over the six years but especially in the last 12 months. She had seen gastroenterology and had biopsies of her esophagus, stomach, and small intestine. Surgery had opened her abdomen looking for a cause and found nothing. Ob/Gyn had put her on birth control pills briefly and done a laparoscopic surgical evaluation for endometriosis which was also negative.
When I entered the room I saw a young appearing and anxious 17-year-old. I reviewed the resident’s notes with Alyssa, her Mom, and her wonderfully supportive older sister. The resident had done a great in-depth interview and everything was as she had described. We re-reviewed the reassuring pelvic ultrasound and labs. Despite the description of the bleeding there was no evidence of anemia or symptoms of blood loss. I went into my usual spiel on treatment of somatic pain however couldn’t get over Alyssa’s vivid description of near constant pain and bleeding, but wasn’t affecting her now. I asked her mother and sister to leave the room.
I turned to Alyssa, “Have you ever been sexually abused or raped?”
“Yes,” she answered immediately, “When I was 10.”
She looked confused for a moment, and then shocked, quickly mumbling, “I haven’t talked about that or said anything since it happened and I had those counseling visits.”
I asked if anyone else had asked this question since she began with the pain. “No” she stated, “No one has.”
The pain began a few weeks after she discontinued therapy around 11 years old and had gotten so much worse in the last year. My resident pointed to the completed note documenting the results of the Adolescent Assessment of health issues that she had completed with Alyssa. There in the row designated “Sexual Health” she had written, “Patient identifies as heterosexual female, no oral, anal, or vaginal sex; but she has a boyfriend of two years and has discussed having sex. Is on Depo for contraception and bleeding.”
“When did you and your boyfriend start talking about having sex?”
“A year ago” she replied.
As a result of this valuable exchange, Alyssa’s health care team no longer includes a multitude of surgeons, but instead trauma-informed counselors and clinicians supportive of her most cherished intimate relationship and her desire to one-day bear children. As a provider, being able to comprehensively address this young woman’s sexual and reproductive health issues and assist her in moving from a place of constant pain to healing is a privilege and a gift.