Diseases of the reproductive tract in the individuals assigned female sex at birth can occur at any stage in life, starting as early as during the prenatal period. Gynecological problems require specific diagnostic and therapeutic approaches in pediatric and adolescent patients to ensure that their unique healthcare needs are met, including psychological, social, and cultural aspects [1]. General gynecology practitioners may not be sufficiently prepared to take care of this specific population, which may lead to suboptimal care and long-term reproductive health consequences [1].

Due to the global shortage of Pediatric and Adolescent Gynecology (PAG) providers, innovative educational strategies—extending beyond reliance on expert specialists—are crucial to enhance training, increase exposure, and guide appropriate referrals for patients in underserved areas. A 2022 The North American Society for Pediatric and Adolescent Gynecology (NASPAG) survey of 120 North American PAG practitioners (39.2% response rate) revealed uneven distribution: 89.2% in the US (concentrated in populous states like Texas, California, and New York) and 9.2% in Canada (mainly Quebec, Ontario, and Alberta), with 14 US states and 10 Canadian provinces/territories lacking any PAG surgeons. Most providers operate in academic settings (68.3%) and focus full-time on PAG (60.4%), offering services like surgery for ages ≥ 12 (> 95%), ambulatory care (> 95%), and multidisciplinary care (> 85%) [2]. However, survey limitations (e.g., response bias) suggest underreporting, and in Canada, > 50% of OBGYN generalists—who handle most PAG care—prefer to avoid it. This access gap stems from limited PAG content in medical training, its under-recognition as a distinct OBGYN subspecialty in most countries, and reliance on PAG societies for education. Drawing from other OBGYN subspecialty fields, broader tools like curricula, guidelines, and referral protocols are essential to bridge disparities and improve outcomes for adolescents.

This gap in healthcare is due to many factors, including limited exposure to pediatric and adolescent gynecology (PAG) content during pre and postgraduate medical training and the lack of acknowledgment of PAG as a distinct subspecialty of Obstetrics and Gynecology in most countries. In general, PAG education is under-recognized by general medical curricula worldwide, and is primarily driven by local, regional, and international PAG societies [3]. PAG has taken note of efforts from other OBGYN subspecialties. An important consideration for the subspecialty of PAG is the need to address the unique reproductive conditions in this underserved population, which differ significantly from those in adult women and require care distinct from routine adult OB/GYN practices.

PAG related health issues may manifest as common, bothersome symptoms in children and adolescents, who may present to a wide variety of specialists including general practitioners (family physicians, nurse practitioners, advanced practice providers, etc.), pediatricians, pediatric endocrinologists, pediatric surgeons, pediatric urologists, nephrologists, adolescent medicine specialists, gynecologists and emergency medicine doctors. PAG competencies should be acquired by learners not only during fellowship, but also at the pre-graduate and post-graduate level of education. Teaching PAG in clinical settings is extremely challenging due to the small number of specialized centers, specialists and patient access limitations [4].

For these reasons, it is essential to use modern educational techniques that may overcome these difficulties which can include using simulation techniques, virtual patient and provider education tools, and artificial intelligence.

Current State of PAG Education and Training of OB/GYNs

PAG fellowship programs are growing in numbers in developed countries, but many patients still lack access to a PAG provider in both developed regions and low resource settings. While education has expanded at the fellowship level, educational opportunities are still quite limited when it comes to residency programs and medical student education exposure. A 2022 study of Canadian Ob/Gyn Residency Program directors found that most Ob/Gyns, not PAG specialists, care for PAG patients with minimal training, and only feel comfortable with managing adult-like pathology [5]. Over half report not wanting to treat this population and more than two-thirds felt ill equipped to care for this population as they had no PAG training during residency [5, 6]. Residency training in Canada, the United States, Europe, and other countries in the world have objectives, entrustable professional activities (EPAs), standards and/or milestones related to PAG [7,8,9]. A summary of available societies with their respective website and courses/conferences can be found in Table 1 and details are found in the sections below.

Table 1 Summary of available societies with their respective website and courses/conferencesNASPAG Curricula

NASPAG has long been an advocate of resident PAG education since the inception in 2012 of the NASPAG Residency Education Committee which has recently published its fourth edition of the Short Resident Education Curriculum [10, 11]. This manuscript is designed as a 2-week residency curriculum that introduces key pediatric and adolescent gynecology concepts using NASPAG online resources and identifies supportive PAG book chapters. It complements, but does not replace, the comprehensive Long Curriculum which is in its 3rd edition [12]. The Long Curriculum is comprehensive covering all PAG objectives from formal training guidelines (CREOG, ABP, RCPSC) and includes surgical topics for OB/GYN, expanded content on sexual and gender-diverse youth, COVID-19 care, and the most updated references for further education and expertise. Table 2 demonstrates the key differences between the short and long curriculum.

Table 2 Comparison of NASPAG pediatric & adolescent gynecology short vs. long curriculumPAG Education in Europe

The status of PAG education varies throughout Europe. The recent literature provides information on few European countries; a formal assessment of PAG education across Europe has not been investigated. According to available data, the Czech Republic and Ukraine are the only European countries which recognize PAG at a national level as a sub-specialty of Ob/Gyn [13, 14]. In the United Kingdom specialist PAG training, called Advanced Training Skills Module (ATSM), exists with the status of an elective module for senior trainees, which also requires maintaining an electronic portfolio [13, 14]. An electronic portfolio is a digital, structured collection of a learner’s work, achievements, reflections, and assessments that demonstrates their progress, competencies, and professional development over time. It usually includes cases managed by the learner. In other countries including Germany, Netherlands, Italy, Poland, Latvia, Lithuania, and Serbia there are no standardized PAG training curricula, however, provision of training exists in the form of PAG courses, annual meetings, national seminars, or focused courses within OB/GYN residency [14].

In 2014 the European Board & College of Obstetrics and Gynecology took an initial step to formalize the delivery of PAG care by including a PAG section in the document on Standards of Care for Women’s Health in Europe [9]. The section on basic PAG competencies was then included in the EBCOG-PACT project, the first curriculum for European trainees in Obstetrics and Gynaecology containing the postgraduate knowledge and skills required of general European gynaecologists [15]. Following the publication of the two documents, EURAPAG developed a post-specialty PAG training curriculum aiming to unify and standardize PAG education at the subspecialist level across Europe [13]. The curriculum uses a Delphi method, a structured technique involving anonymous, iterative expert surveys to build consensus on key elements like educational priorities and competencies in PAG training. The curriculum consists of 17 chapters covering all aspects of PAG and has been divided into three sections: baseline, medical, and surgical skills. Such an approach allows for flexibility in teaching and involvement of allied pediatric specialties providing opportunity for both pediatric and OBGYN specialists to participate. The curriculum recommends several workplace-based assessment methods, like direct observation (DO) of clinical task performance, Objective Structured Assessment of Technical Skills (OSATS), mini-clinical evaluation exercise (Mini-CEX), or case-based discussion (CBD). The process also requires the trainee to maintain a clinical portfolio, which includes a section for each of the 17 chapters of the curriculum, otherwise known as the 17 entrusted professional activities (EPA’s) [13].

Global PAG Educational Resources

Pediatric and adolescent gynecology is supported by a robust network of professional societies promoting education, research, and clinical excellence on a global scale. In North America, NASPAG provides foundational resources such as its Annual Clinical & Research Meeting (ACRM), monthly webinars, podcasts (PAG over Pastries) and online learning platforms [16]. In Europe, the European Association of Paediatric and Adolescent Gynaecology (EURAPAG) organizes biennial congresses and offers specialized trainee programming and published curricula [17]. The British Society for Paediatric & Adolescent Gynaecology (BritSPAG) in the UK conducts annual updates and contributes to wider European and international initiatives [18]. The Israeli Society of Gynecology of Girls and Adolescents (ISRAPAG) was established in 1995 as a national pediatric and adolescent gynecology society under the umbrella of the Israeli Medical Association [19]. ISRAPAG organizes annual scientific meetings, continuing-education courses, and clinical update days focused on PAG, and develops Hebrew-language educational resources for both clinicians and patients. It collaborates closely with the national obstetrics and gynecology society and contributes to international PAG initiatives through congress participation and invited lectures. Within Latin America, the Asociación Latinoamericana de Obstetricia y Ginecología de la Infancia y Adolescencia (ALOGIA) hosts continental congresses (e.g., Buenos Aires, 2024) and partners on educational activities such as FIGIJ-recognized webinars [20]. Additionally, the Sociedad Argentina de Ginecología Infanto Juvenil (SAGIJ) and the regional Pediatric and Adolescent Gynecology Committee of the Federación Latinoamericana de Sociedades de Obstetricia y Ginecología (FLASOG) deliver structured courses, conferences, and clinical guidelines [21, 22]. In Australasia, the Australian and New Zealand Society of Paediatric and Adolescent Gynaecology (ANZSPAG) fosters clinical excellence through targeted tutorials, webinars, podcasts, and structured training pathways including fellowships and observerships [23].

Internationally, the International Federation of Pediatric and Adolescent Gynecology (FIGIJ) convenes the World Congress of Pediatric & Adolescent Gynecology triennially and regional scientific meetings to facilitate global collaboration [24]. The FIGIJ is a global non-profit organization dedicated to advancing evidence-based gynecological care for children and adolescents, with a strong focus on sexual and reproductive health. Central to its mission is fostering international collaboration among national societies, individual practitioners, and allied organizations to promote education, research, and service development. FIGIJ works inclusively across regions and cultures, partnering with societies worldwide to uphold sexual and reproductive rights, share best practices, and support clinicians, particularly in resource-limited settings, through joint initiatives, congresses, and training programs. The newest addition to the global PAG network is the International Federation of Gynaecology and Obstetrics (FIGO) Adolescent and Young Adult committee building and sharing PAG focused curriculum at their every 2 year global conferences, developing internationally minded PAG focused online cases for OB/GYNs, the FIGO adolescent gynecology health care passport and podcasts pertaining to key PAG topics [25].

Table 3 summarizes the North American, European, and Global educational resources which are available in different formats to meet the needs of a variety of learners.

Table 3 Educational resources: from textbooks, to podcasts, and other on-line toolsCurrent Innovative PAG Educational Approaches

Historically, PAG trainees, as with most other specialists, would learn PAG education via didactic courses and “on the job” or apprentice-like training. Over the last decade, however, advances in medical education techniques have infiltrated the education of PAG trainees to better optimize and standardize learning. In 2022, Dumont and Torres performed an impactful systematic review of PAG simulation [26]. It was clear that simulation-based education (SBE) in pediatric and adolescent gynecology (PAG) is essential for improving patient safety and addressing gaps in clinical exposure, particularly for rare or sensitive conditions. Simulation training encompasses both technical and non-technical skills (see Fig. 1), guided by educational theories and is structured through phases of preparation, briefing, simulation, debriefing, and evaluation. Various models, from low-fidelity, part-task trainers to high-fidelity, hybrid simulations, have demonstrated positive impacts on learner confidence, knowledge, and procedural competence [27,28,29,30]. The Global Library of Women’s Medicine chapter on Pediatric and Adolescent Gynecology Simulation has a table that summarizes simulation research through 2022, providing an excellent resource for educators in the field (Fig. 1) [26]. Future directions include research on knowledge retention, integration of interprofessional training, and exploration of advanced technologies such as screen-based simulation and virtual reality. SBE should be embedded within PAG curricula and tailored to institutional resources to ensure sustainable, high-quality training.

Fig. 1

Summary of current literature in SBE in PAG (reproduced with permission)

As few centers around the world have experience with SBE PAG education the international cooperation may facilitate organizing SBE-based courses. Experience from the COVID-19 pandemic era has shown that simulation-based teaching of patient encounter and management, including clinical reasoning process and communications skills, can be carried out remotely with facilitators, learners and simulated patients located in various parts of the world [31].

As addressed earlier, the limited exposure to pediatric and adolescent gynecology during medical training results in low awareness of the specialty among physicians and educators and may contribute to the global shortage of specialists. Therefore, incorporating core PAG content into undergraduate medical education is essential for expanding the workforce as well. This can also be achieved with SBE. High-fidelity scenarios, which incorporate PAG specific health problems (severe anemia/juvenile menorrhagia, abdominal pain/ovarian torsion), can be successfully implemented for large student cohorts and are well received and positively evaluated by learners (unpublished data).

Since 2022, while no new PAG simulation articles have been published, numerous workshops have been launched at the NASPAG ACRM, focusing on surgical simulation tools for PAG fellows and PAG surgery providers in practice. In 2025, workshops focused on both low fidelity models (Simulated Surgical Management of Vaginal Stenosis: Simulated Buccal Graft Patch and Tissue Reconfiguration Techniques with Z-plasty (Fig. 2)) and high-fidelity 3D-printed models (Surgical Simulation: Resection of the Transverse Vaginal Septum (Fig. 3)) [32]. Hybrid models, utilizing a task-trainer with a simulated patient, have also been designed for simulation education (Fig. 4). Institutional models have also been created specifically for fellows training. Examples of these range from laparoscopic oophoropexy in a child (Fig. 5), to more practical skills such as CO2 laser (Fig. 6) and laparoscopic trocar box (Fig. 7). With the creative approaches utilized for many of these low fidelity simulation models, there is also opportunity for further simulation model building with 3D printing and other innovative bioengineering strategies.

Fig. 2

Surgical Simulation Models for Vaginal Stenosis Management (A: Buccal Graft Approach, B: Z-Plasty Approach. Courtesy of Dr. Dietrich)

Fig. 3

3D-printed, silicone casted, transverse vaginal septum (TVS) (A: intact model, B: model with vulva removed demonstrating the TVS, C: model with TVS resection completed. Courtesy of Dr. Dumont)

Fig. 4

Hybrid model for adolescent gynecological examination with simulated patient sitting on the reduced size pelvic trainer. Courtesy of Dr. Torres

Fig. 5

Laparoscopic Oophoropexy Simulation Model. Demonstrates simulation doll and simulated laparoscopic pelvic structures. Courtesy of Dr. Dietrich

Fig. 6

Surgical Simulation with CO2 laser using a bell pepper to test various energy settings for coagulation and cut features. Courtesy of Dr. Dietrich

Fig. 7

Trocar Insertion Simulation Box. Courtesy of Dr. Dietrich

Educational Assessments are Critical

Although teaching and disseminating knowledge about PAG is essential, medical educators must not overlook the importance of assessment of learning [33]. This is particularly important given that PAG is not recognized as a separate subspecialty in most countries worldwide, resulting in little or no oversight of who practices in the field. Therefore, the international PAG community should work toward developing effective and standardized methods to assess not only theoretical knowledge, but also PAG-related clinical skills. Such assessments will help ensure that individuals who wish to practice in this field have mastered essential PAG competencies [34].

Entrustable Professional Activities (EPAs) have recently been advocated as an effective means of assessing competencies across many medical specialties and have been successfully implemented in numerous curricula [35]. At the medical student level, colleagues from Yale conducted a prospective evaluation cohort of 9 medical students based on their rotation in PAG comparing pre and post rotation knowledge assessments. Solotke et al. reported on the usefulness of EPAs in this novel approach to teaching PAG at the pre-graduate level, which was well received by both educators and learners. They noted that clinical knowledge improved significantly over the course of the rotation from 67% to 75.2%. They also noted that EPAs increased and rotation and faculty evaluation scores improved [36]. Although this approach has been implemented and reported by only a single center, EPAs are a promising tool for assessing PAG competencies. Therefore, the development of core PAG EPAs should be considered by the international PAG community as an essential step toward the advancement of future PAG curricula.

While assessment of competencies in Pediatric and Adolescent Gynecology (PAG) is essential for ensuring high-quality training in OB/GYN residencies, significant limitations exist at the resident level in the United States.

Specifically:

PAG competencies are restricted to those outlined in the APGO-CREOG 13th Edition document, which exclusively addresses certain elements of gynecology ambulatory care.

No surgical aspects of PAG are defined as competencies.

Tables detailing achieved privileges do not incorporate any components of PAG surgical care [8].

However, the PAGWEBED tool, provided by NASPAG, offers a more comprehensive approach. It evaluates knowledge in ambulatory topics and extends to formative assessment of PAG surgical conditions [16]. During fellowship training, however, fellows can acquire PAG-focused surgical experience, develop the ability to serve as subspecialty consultants, pursue research and teaching opportunities and achieve competency in the subspecialty.

Growth of PAG Subspecialists and Educators

In the US, PAG has been a focused practice recognized by the American Board of Medical Specialties and the American Board of Obstetrics and Gynecology since 2017. Further steps toward full subspecialty recognition will undoubtedly result in expansion of the workforce and PAG educators with planned expansion of fellowship programs and PAG employment opportunities that fill gaps in PAG deserts. Initially, expanding PAG access may take the form of expansion of virtual learning opportunities and patient care. Telehealth and online platforms are currently enabling this expansion in many programs that lack a dedicated PAG faculty. They have significantly improved access for patients while also supporting providers without PAG expertise, helping to facilitate visit scheduling, overcome geographic limitations and address time constraints they may otherwise prevent obtaining PAG specialized care [37].

Artificial Intelligence and PAG

As the workforce expands, attention will be needed to ensure its sustainability. Artificial intelligence (AI) will certainly be a tool with unimaginable possibilities in this realm, including expanding provider access by handling simple instructional algorithms that benefit training teams and managing other administrative electronic medical record tasks that may lead to educator burnout [38].

As the subspecialty expands worldwide, practitioners experience- measured by years in practice, education, and patient volume – builds comfort in treating this population and secures hospital privileges. While fellowship programs offer formalized training, there is opportunity for enhanced summative evaluations to streamline credentialing. Current competency assessments rely on subjective performance metrics tied to written objectives. For example, a team at Stanford used simulation models with sensor-based haptic feedback to objectively evaluate clinical breast exams, an in innovative method PAG could adopt [39].

Looking ahead, the reimagined PAG skill assessment with technology may enable microcredentials to verify competencies in PAG.

Many surgical specialties and subspecialties have followed an apprentice model of education, where trainees gain skill and experience through surgical cases under direct supervision. There are certainly technical challenges and ethical challenges that this model poses. Pugh and colleagues thought of ways to improve this historical approach to better understand how residents approach surgery through use of motion sensor feedback on specific surgical tasks, using prediction models. These models were used to assess 96 learners, consisting of medical students, residents and attending faculty [40]. Using motion sensor data, they automatically identified surgical gestures and the tools used during an open surgery suturing simulation. The use of such kinematic tools, could benefit PAG surgical education as well, building confidence early on for all learners in sophisticated, complex surgical tasks [41]. Many medical educators have turned to video tools to augment learner feedback. However, this tool is time consuming as it requires expert review. Surgical experts from Stanford University, studied video feedback directed by AI algorithms to detect surgical workflows and technical approaches. Two hundred learners participated in a simulated bowel surgical task to identify an injury and perform a repair. Their AI algorithms identified performance of precision, injury identification and suture repair. This study highlights the potential of AI to automate surgical video assessments to evaluate both the procedural phases and technical approaches to surgical performance. These deep learning algorithms can effectively segment surgical workflows and identify techniques beneficial for both self-assessment and peer assessment [42]. As video-based and AI based assessments evolve, PAG educators will undoubtedly benefit.