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Introduction: Down-there healthcare by the Gynae Geek

It’s three o’clock on a Wednesday afternoon and I’ve just performed a surgical evacuation on a woman who was nine weeks pregnant before she miscarried. I’m in theatre, writing an operation note, when my bleep goes off. It’s A&E. I speak to a worried-sounding nurse who asks me to come urgently and see a patient: ‘Forty-one years old … bleeding very heavily … not pregnant … haemoglobin is four and—’

‘What did you say? FOUR?’ I jump in.

‘Yes, Doctor, four—’

‘OK, I’m coming. Put her in resus. And put in a large cannula if you don’t already have good IV access. Oh, and what is her pulse?’

‘One hundred and seven.’

‘OK, I’m coming, I’m coming.’

I’m worried. Why is this patient’s haemoglobin level almost one third of what is normal for a healthy female? I scrawl the rest of my notes in my best ‘I’m-in-a-rush-but-I’m-trying-to-make-this-as-legible-as-possible’ handwriting, a skill that’s almost second nature now. I grab a disposable green paper gown to cover my theatre scrubs and run down the corridor to A&E. I enter the resus department, my gown fanning out rather dramatically behind me, and rush into the patient’s cubicle.

She is hooked up to a machine that is beeping wildly because of her racing pulse, and there is a lot of blood on the bed. The nurse I spoke to on the phone looks concerned, standing over the patient who seems surprisingly calm, albeit slightly clammy. I ask her if she’s sure she isn’t pregnant; she laughs and tells me it’s impossible, and the nurse confirms the pregnancy test is negative. She tells me she’s having her period, but it’s much heavier than normal. I ask her how many pads she’s been using.

‘Pads?’ she asks. ‘Oh, I don’t use those until Day 2 or 3 when things have settled down. I normally take the first day or two off work and sit on folded-up bath towels because there’s so much bleeding. Today it was so heavy though that I was just sat in the shower for a few hours, washing away the blood as it came out. But I didn’t feel well, and I think I might have passed out, so I called an ambulance.’

I look at the patient, who is slightly obese and of South Asian descent, which, along with her symptoms, makes me begin to suspect she has a cancer. I ask her how long she’s had this bleeding.

‘Probably about twenty years.’

Twenty. Years. No wonder her haemoglobin is four. In fact, I’m surprised she made it this far without ever having had to come to hospital, especially as she has been losing iron at the speed of sound for two decades.

I perform an internal examination and blood clots the size of my palm begin to fall out of her vagina. Then, miraculously, the bleeding seems to stop. I wait for a few seconds to see if more blood will come out. Nothing. I wait some more … and some more … and then there’s another steady trickle. I instruct the nurse to get me some IV tranexamic acid (a drug to stop bleeding) urgently, which she does, and I administer it myself. I prescribe a blood transfusion and tell the nurse to give some IV fluids to stabilise the patient, while we wait for the blood to be cross-matched in the lab. I also prescribe tablets to slow down the bleeding.

As I wait to give the tranexamic acid time to work, I ask the patient – trying not to sound patronising – why she has never sought help for her heavy periods. She tells me she had come to think it was normal, and even a few years ago when she began to suspect it was not, she was too embarrassed to discuss it with friends or family, or to go and speak to her GP. As we talk, her bleeding slows down, and I arrange for her to be transferred to the gynaecology ward. She will be observed and receive a blood transfusion, though I have no idea at this point that she will need four units of blood.

Walking away from A&E, I can’t believe what I have just seen. And I realise I will never get over the shock I feel when patients drop this kind of bombshell; nor will I ever truly understand the extraordinary things some people accept as ‘normal’.

* * *

If you’re still with me, and are not feeling too queasy from my casual Wednesday-afternoon bloodbath, let me introduce myself. My name is Dr Anita Mitra, B.Sc., M.B.Ch.B., Ph.D. I’m a London-based doctor, qualified in 2011 and I’m now training to be a specialist in Obstetrics and Gynaecology (O&G). I have almost fifteen years of clinical and lab-based research experience under the belt of my oversized NHS tie-top scrubs. An interesting fact is that my surname is the Greek word for ‘uterus’ – although I’m not actually Greek, and I didn’t always want to be a gynaecologist.

Now sit tight if you’re ready to hear the somewhat off-piste route that led me to become the turmeric-latte loving, dead-lifting doctor who removes disco balls from ‘you-know-where’ for a living …

From the age of about three, I wanted to follow in my father’s footsteps and become a surgeon. But at seventeen, I was far too cool for school and, as a result, the only A grade I got in my A-levels was in German, which didn’t do much for any of the medical schools I’d applied to. I ended up talking my way into a place on a Medical Biochemistry course at the University of Leicester, after the admissions tutor told me my grades were ‘a bit lower’ than they’d normally accept. During my time reading Medical Biochemistry I worked in a research lab, studying the anticancer mechanisms of plant-based chemicals (which is essentially the scientific basis for the current turmeric latte trend). This was the first time I truly appreciated the impact of diet and lifestyle on our health. I worked my socks off during my undergraduate years and graduated three years later with a first-class degree and a place at Leicester Medical School.

For the first few years of medical school, I still desperately wanted to be a surgeon, and spent the third and fourth years doing research in my spare time with a professor of kidney-transplant surgery. However, in my fifth year, I had to do my placement in Obstetrics & Gynaecology. I have to admit I was partly terrified and partly bored by the idea of spending eight weeks in the speciality. However, those eight weeks changed my life. I loved the interaction with the patients, both young and old, the diseases fascinated me and the surgery was often bloody and dramatic, but usually with great outcomes, which I loved. Suddenly, I knew this was exactly what I wanted to do for the rest of my life.

I graduated from medical school in the summer of 2011 and spent my first two years working as a doctor in the East Midlands, completing the mandatory Foundation Programme, which involves basic training in six different specialties. My first job was, in fact, in Obstetrics & Gynaecology, and it flew by in an adrenaline-fuelled, placenta-splattered blur. I had found my calling. But it wasn’t plain sailing from there. I wanted to move to London and O&G training was very competitive at the time, with nine applicants for every job, and unfortunately, I didn’t get one. There is only one chance to apply annually, so I needed to find something else to do for a year. Many doctors work as locums, filling gaps on rotas for very good money, but I have never been driven by cash, and after my initial disappointment, I saw this year as an opportunity to enrich myself and my CV.

Failure always feeds my hunger, but I needed to ensure that failure was not an option with my next chance at a training job. So to cut a very long story short, I decided that I would still try and move to London and pursue my love of research for a year. To make this happen, my plan was to email every single professor of Obstetrics & Gynaecology in London and beg them for a research job. And it worked! I got a prestigious position at Imperial College, London, where I started doing a Ph.D. – the most incredible, but challenging thing I’ve ever done. And during that time, I managed to bag myself one of those sought-after training jobs.

As much as I thrive on the thrill of operating and the honour of being able to help women bring their babies into the world, the thing I love most about my job is the chance to sit down with them to answer their questions about gynaecological health and calm their anxieties. Many concerns often stem from lack of knowledge and understanding of what is ‘normal’ – because very few women feel it is safe to talk about a topic shrouded in taboos and shame. While there is so much general health information available online, there is relatively little engaging and reliable material about female health. There are also lots of unqualified people selling their opinions as medical fact. I began to see the conversation opening up on social media, but when I looked closer it filled me with horror. Film stars talking about vaginal steaming, beauty bloggers talking about vaginal facials, wellness coaches telling women they had successfully ‘detoxed their body’ because their vegan diet had stopped their periods, as well as other unqualified people pushing products that women simply don’t need. But where were all the doctors?

Women drink in this information, unable to decide for themselves whether it is actually credible or evidence-based, distracted by the huge numbers of followers these ‘experts’ have and the glossy façade of the online world.

I saw the need for a sensible voice in this unregulated chaos, so I started an online blog and Instagram account called ‘Gynae Geek’. The positive response was overwhelming. I began to receive huge numbers of comments and messages from women desperate to know more, and I get a particular thrill from seeing them tagging their friends in my posts for them to read.

I realise that I am in a privileged position, with over fifteen years of scientific and clinical training that have given me the ability to seek out information and decide whether it is credible or not. This is one of the reasons that I back up most posts with references to scientific studies – to prove to my followers that what I’m providing them with is reliable information and not just my opinion. It is also why I use the word ‘geek’: I want women to realise that knowledge is sexy, knowledge is power and that they should never be afraid to ask: ‘Why?’ and ‘How?’

So, what is this book about?

This is not your average healthcare book. While it’s full of medical and scientific facts, it’s also a collection of tales from the thousands of patients I’ve treated, who inspired many of the topics in the book. It is a back-to-basics guide to gynaecological health, covering what’s normal and what’s not. It’s sensible, no-nonsense and, most of all, evidence-based. Some parts might make you blush, others make you laugh and some might even make you exclaim, ‘Oh my gosh, that’s me!’ But it’s not intended for self-diagnosis, nor as an alternative to visiting a doctor in real life. Rather, it is designed to help you to decide whether or not you need to go and talk to a healthcare professional about something that’s bothering you.

I also hope this book will be a conversation starter for women of all ages – because we need to break the taboo around talking about what’s going on down there. The reluctance to do so often delays women in seeking the help they need, which can result in unnecessary suffering and poor health outcomes. I want women to see that there is no question that cannot be asked, no symptom that should be ignored and, most importantly, no need to suffer if they are in need of help.

As well as covering anatomy and the mechanics, sexual health and fertility, I’ve also included a section on lifestyle and women’s wellbeing, which form one of my favourite subjects. A lot of women do not realise there is a link between gynaecological health and how we eat, sleep, move and generally live our lives. There are a surprising number of simple things that can be done on a daily basis to help you and your health today and for the future.

Each chapter includes a section headed ‘Things you’ve always wanted to know, but were too afraid to ask’ – a collection of questions I’m most frequently asked in relation to the particular topic in hand. The chapters then conclude with a short summary – ‘The Gynae Geek’s knowledge bombs’ – which comprises the essentials that everyone should take away from the chapter.

* * *

I set out to write a book that would be engaging and entertaining at times (the opposite of most of the health information that is out there at the moment). And while there are areas where I’ve shared my opinion, as a scientist and a doctor I have been insistent that the information provided is evidence-based and that’s why you’ll see so many references everywhere.

The structure and content have been led by questions my patients, friends and social-media followers have asked me. You may decide to skip over certain sections because they don’t apply to you at the moment. But they may do in the future. Or they may apply to your friend/sister/colleague right now – and I would be honoured if you would share this book with other women who you think would benefit. But also share it with the men in your lives. Because women’s health shouldn’t be a mystery to them either. The health of the nation depends on the health of its women and, therefore, it’s something that everyone should be aware of.

My ultimate goal with this book is to ensure that every woman has access to the information she needs to understand how her body works, to empower her to seek help and thus ensure that no one suffers in silence.

Now go forth, learn, enjoy and don’t ever forget that it’s cool to be a geek!

Since we’re just getting to know one another, I want to share a fact about myself: I’m quite good at charades. Why is that? Because most people seem to use hand gestures, rather than actual words when it comes to their vagina/undercarriage/‘down there’/lady garden/private parts – whatever you want to call it. The fact is, most women I encounter don’t know the proper names for their genitalia. And some wince when I say the word V.A.G.I.N.A. But I want to shout it from the rooftops. It’s not a dirty word! And I think this difficulty with using the right language is one of the major reasons why people feel embarrassed to go and see a doctor when they’re concerned something is not right: because they don’t even know what to call the area in question. That’s why this section provides you with an informal anatomy lesson, with a few interesting anecdotes along the way. So don’t be shy, it’s time to learn the essentials.

CHAPTER 1

External female genital anatomy

Doctor, while you’re down there, can you just tell me if my vagina looks normal?

This is one of the questions I am most frequently asked by my patients, but it is also one of the most inaccurately phrased. What women actually mean is: ‘Does my vulva look normal?’

Many people don’t know the difference between the vulva and vagina, and I think this is a major reason why women so often feel embarrassed to go and see a doctor when they’re concerned that something is not right: because they don’t even know what to call the area they are worried about. What’s more, women’s perceptions of a ‘normal vulva’ are usually inaccurately shaped by the pornography industry, and as someone who looks at vulvas (and vaginas) for a living, I feel appropriately qualified to suggest that this area is becoming a target for body dysmorphia.

It’s very common for women to feel embarrassed or ashamed to take their clothes off and a lot of women apologise as I begin an examination, but it’s important to remember that, as awkward as it may make you feel as a patient, as healthcare professionals we’re totally relaxed and at home. So with that out of the way, let me take you on a brief tour of your anatomy.

The vulva

Vulva, a word that makes a lot of people giggle or blush, is the term used to refer to the external genital region containing the following structures:

 Mons pubis Also known as the Mound of Venus, this is the fatty tissue that covers the front of the pubic bone and is covered in hair. A lot of women apologise for not shaving or waxing this area, but there is no evidence to show that hair removal improves hygiene or reduces the risk of infections, so you don’t actually need to (see here for more on this). Pubic hair also plays a protective role in cushioning the sensitive underlying skin, as well as collecting pheromones, the chemicals that play a role in sexual attraction.

 Clitoris and clitoral hood Your clitoris is shaped like the wishbone of a chicken. The clitoral head, about the size of a small pea, is the visible part of the clitoris, but is, in fact, just the tip of the iceberg, because extending down either side underneath the skin are two arms, each about 5–7cm long. The clitoris is made of the same kind of spongy tissue that is found in the centre of a penis, which fills with blood to produce an erection, and the same thing happens to the clitoris during arousal. The clitoral head has the same embryological origin as the head of the penis but contains about two to three times as many nerves, and might explain why it doesn’t need to be pressed like a doorbell with a dead battery, which many men don’t realise. The sensitive nature is also the reason that there is a fold of skin usually covering it, called the clitoral hood.

 Urethral opening The urethra is the tube that empties urine from the bladder. It’s much shorter in women, at only about 5cm, compared to 20cm in men, which is why women are more likely to get urinary tract infections (UTIs). This is also the reason why you should wipe front to back after using the toilet, and urinate after sex in order to avoid helping the spread of bacteria into the urethra and up into the bladder. Some women may be able to see their urethral opening, while others cannot, and that’s because it can be quite high up, sometimes even almost inside the vagina. I’ve seen many a medical student try to put a catheter into the clitoris, but it’s always the boys who blush the most when I politely redirect them to the urethra!

 Periurethral/Skene’s glands I’ve often been asked at parties by overexcited men about female ejaculation. Well, these are the glands that are responsible for this phenomenon, and they are the female version of the prostate gland. The fluid they make is thought to offer some protection against the bugs that cause UTIs. Infrequently, they can get blocked and swell up, causing a cyst, which can sometimes be confused with a vaginal-wall prolapse.

 Vagina This refers to the muscular tube inside that goes from your vaginal opening on the outside, up to the cervix. Your vagina cannot be seen from the outside (hence the inaccuracy of the question: ‘Does my vagina look normal?’), and at about 7–9cm long, it has an amazing degree of elasticity and can expand in all directions – enough to allow for the birth of a baby. Its expansive nature also means it can also accommodate many a foreign object.Possibly the most unusual thing I’ve ever removed from someone’s vagina was a disco ball. Not a massive one from the ceiling of a 70s club, but one that was golf-ball-sized and originally belonged on a key chain. It was 7 a.m., and the end of a particularly harrowing night shift in A&E, but having been told that the offending object was a key ring, I thought it would be a quick job. Then the triage nurse casually added: ‘Oh, by the way, Doc, the key ring itself has snapped off and it’s just the disco ball left inside now …’ Needless to say, it certainly was a challenge, largely due to the fact that your vagina can make a pretty impressive vacuum, but I got it out in the end. If the owner of said disco ball is reading this, I just want to say how much I still feel your pain and embarrassment to this very day.

 Labia majora These are the larger, skin-covered outer lips of the vulva. The skin here is usually darker than the rest of the surrounding skin and has a fatty layer underneath that plays a protective role.

 Labia minora These are the inner, more fleshy-looking lips, that are usually quite red or pink and probably what cause the most concern with regards to what’s ‘normal’. Most women’s labia minora will be visible below the labia majora and it’s common for them to be asymmetrical. The average size ranges from 2–10cm in length and 1–5cm in width1 and consequently the appearance of the labia minora varies significantly from one woman to the next. It’s kind of ironic how teenage boys (and let’s be honest, most immature men) boast about the size of their penis, yet women are expected to have neat, tucked-in labia that never see the light of day. Why is this? Because they originate from the same embryological structure. It is normal for them to seem to enlarge slightly with age due to loss of collagen and oestrogen, both of which support the structure of the tissue.

 Perineum This is the area between the back of the vaginal opening and the anus.

 Pelvic-floor muscles Your pelvic floor is underneath the skin of the perineum and is made up of several muscles and pieces of connective tissue that act as a sling to hold your insides in. Pelvic-floor weakness can lead to prolapse of the vaginal walls, bladder, urethra or the uterus. A lot of people think you can only get a prolapse if you’ve had a baby, or if you’ve had a vaginal delivery, during which these muscles may tear or be cut to facilitate delivery. However, this is not the case, and it can happen to anyone – regardless of whether they’ve only ever had C-sections, or even if they’ve never had a baby. The pelvic-floor muscles also help you to maintain control of your bladder and bowel.

THINGS YOU’VE ALWAYS WANTED TO KNOW, BUT WERE TOO AFRAID TO ASK

Is ‘down-there’ hair removal safe?

Generally speaking, yes. Minor cuts, burns and ingrown hairs may occur as a result, but they’re rarely severe enough to require medical attention. The most commonly reported reason given for removing pubic hair is for hygiene purposes,² however there isn’t actually any evidence to show that it improves hygiene or reduces the risk of infections. I think this belief is perpetuated by the myth that your vulva and vagina are dirty and teeming with germs. As doctors, we don’t judge or have a preference about the terrain down there, so don’t feel you have to schedule a waxing/shaving session before an appointment. I’ll take it as it comes, thank you!

Will having lots of sex make my vagina loose?

No. Regardless of what the teenage boys in the playground may have said, this is not true. Your vagina is very elastic and can expand enough to let a baby out (and other objects in) but it always shrinks back. While having a baby may change the shape of your vagina slightly, having sex will not because a penis is not large enough to do so. Having sex will also not change the size or shape of your labia minora.

Do I need a labiaplasty?

Absolutely not! Labiaplasty is surgery to trim the labia minora and/or clitoral hood. It is largely performed for cosmetic reasons. I think that the sudden interest in ‘neatening up’ one’s labia may be an undesirable offshoot of the current obsession with aesthetic ‘perfection’. There are numerous plastic surgeons around the world advertising labiaplasty as a quick and simple procedure to make your labia more symmetrical/neat and tidy, etc. But symmetry is overrated – no other body part is truly symmetrical: we’ve all got one foot that’s bigger than the other, eyebrows that don’t match. And it’s the same with labia. It’s also normal for your labia minora to be visible on the outside, although Barbie and the porn industry may tell you otherwise. There is minimal evidence to show that the surgery actually improves pain, sexual function or how women feel about their genitalia, plus there is a risk of pain after the surgery due to nerve damage or resulting scar tissue, so it’s really not a decision to take lightly. And it cannot be reversed in the same way that you could, for example, have breast implants removed. As a famous professor once pointed out: ‘If you think your labia are too long, stop shaving off your pubic hair and you’re unlikely to think so.’

When should I start doing pelvic-floor exercises?

Right about … now! Also called Kegel exercises (see here), everyone should be doing them, regardless of whether they are pregnant or have ever had a baby, because that’s not the only thing that weakens them. They generally weaken with age, so you want them to be as strong as possible from a young age. Doing pelvic-floor exercises in pregnancy, especially from an early stage, has also been shown to reduce the amount of time it takes to push your baby out, and the risk of leaking urine after the birth.^{3, 4} Many people think having a Caesarean section prevents pelvic-floor weakness, but that’s not the case. Carrying around several kilos of extra weight for nine months will put extra strain on the pelvic floor whether you push out that watermelon or it comes out the sunroof!