The Vagina Bible. Jen Gunter
is a biopsy for a persistent itch. A biopsy (a small procedure that removes a 3–4 mm piece of skin) may be recommended to rule out an early cancer. While the biopsy may help diagnose the cause of the itch, many times the results are nonspecific, so the best the biopsy did was rule out cancer (still very important).
Menstrual Cycle Primer
While this is The Vagina Bible and not the “Uterus and Ovary Bible,” having a good working knowledge of the changes that occur each month with the menstrual cycle will be helpful in understanding a lot of what follows in this book.
Menstruation is the shedding of the lining of the uterus (the endometrium) when a pregnancy has not occurred. The average age of menarche—the first menstrual cycle—is 12–13 years. The first day of the menstrual cycle, or day 1 of your cycle, is the first day of bleeding (so the first day of your period). Menstrual bleeding typically lasts 3–7 days (see chapter 17 for more on the amount of blood).
The menstrual cycle is regulated by several intricate hormonal circuits all working together in harmony. Sometimes I visualize this as three jugglers who occasionally have to throw one of their balls to another while they all continue to juggle. If everything is on point, then the system works flawlessly; however, one late throw or missed catch and everything gets out of whack. The three jugglers in the case of menstruation are the hypothalamus (a part of the brain), the pituitary gland (also in the brain), and the ovaries.
The hypothalamus releases a hormone called gonadotropin-releasing hormone (GnRH) and this process can be easily disturbed by stress, sleep disturbance, and weight loss or gain. GnRH triggers the pituitary gland to release the hormone follicle stimulating hormone (FSH), which tells the ovary to start developing follicles (eggs). The follicles produce estrogen, which makes the lining of the uterus thicken. The estrogen provides feedback to the pituitary gland. When estrogen levels are high enough, the pituitary releases a hormone called luteinizing hormone (LH), which triggers ovulation.
After ovulation the egg heads down the fallopian tube to the uterus, and the tissue left behind (like an eggshell, but soft), called the corpus luteum, produces progesterone. While estrogen thickens the uterine lining (think of it like stacking bricks), progesterone stabilizes the lining (a bit like mortar). The corpus luteum can only produce progesterone for approximately 14 days unless it gets a signal from a pregnancy. Without fertilization, the corpus luteum shrinks and the progesterone is rapidly withdrawn and this causes the lining of the uterus to come out as a period. And we are back at the beginning of the cycle, with day 1 being the day bleeding starts.
Estrogen and progesterone have wide-ranging effects beyond the ovaries, uterus, and vagina. The cyclic changes can affect mood, the immune system, and even sensitivity to touch.
When should I start seeing a gynecologist or other woman’s health care specialist?
Some women prefer a gynecologist; however, many prefer their family medicine doctors and nurse practitioners. Even some pediatricians are comfortable providing reproductive health care. Who you see for regular checkups and for symptoms, such as an itch or sexually transmitted infection (STI) screening, may vary depending on a number of factors.
A screening visit regarding reproductive preventive health care is recommended between the ages of thirteen years and fifteen years. This visit could be with any provider who is comfortable talking with teens about sex and reproductive health. This visit is an opportunity to discuss any reproductive health concerns, such as menstrual protection or safe sex. A pelvic exam (meaning checking inside the vagina) is not required unless there are symptoms, and for a teen who has not yet been sexually active a pelvic exam can almost always be avoided.
Screening for STIs should begin whenever a teen becomes sexually active and continue until the age of twenty-four (see chapter 28). Regardless of whether you have or haven’t been sexually active, cervical cancer screening starts at the age of twenty-one (see chapter 26). A “get to know you” visit before you may need to get reproductive health care of any kind is never a bad idea. This allows you to get comfortable with the person with whom you will be sharing intimate details before you need to share them. For women who have never been sexually active or never had a pelvic exam, this visit can be especially helpful to familiarize themselves with what the exam might entail and the medical equipment that is involved.
Any woman or teen twenty-four years or younger who is sexually active should be seeing a provider who is comfortable with gynecologic care for annual chlamydia screenings. Screening for other sexually transmitted infections may also be indicated. Urine screening is very effective, so taking a pelvic exam out of the equation often makes this screening easier for many women regardless of age.
What is a pelvic exam?
A pelvic exam has two components: looking inside the vagina with a speculum to see the vagina and cervix, and touching inside with gloved and lubricated fingers of one hand into the vagina (the other hand may press down on the lower abdomen to feel the uterus and ovaries). This second part of the exam may be called an internal exam or a bimanual exam. This evaluates the uterus, ovaries, pelvic muscles, and any masses or irregularities in the vagina or in the pelvis (meaning on or around the uterus and ovaries). Sometimes a rectal exam (inserting a gloved finger into the rectum) may be indicated. Whether an internal exam and/or rectal exam is needed depends on the reason for the exam.
A speculum is a medical tool for looking inside the body. There are many different kinds, and the type used for cervical cancer screening and STI testing is called a bivalve speculum. This is made of two blades (they are not sharp, just slightly curved).
A bivalve speculum is inserted closed, which makes insertion less painful, and then opened once it is deep enough. A screw or similar device keeps the blades open during the exam. When opened, the speculum allows the provider to see the cervix and the upper vagina. The sides of the speculum are open, and so if the speculum is rotated the vaginal walls can also be inspected.
Image 6: Speculum open (left) and closed (right). ILLUSTRATIONS BY LISA A. CLARK, MA, CMI.
There are several different types of bivalve speculums, all with minor modifications that can sometimes help make them more comfortable or practical, as every woman is shaped differently. The common speculums are Pedersen, Graves, and Cusco and are named after the men who designed the modifications. A Graves is wider at the tip (this is useful for seeing the cervix for procedures), but is almost never needed for a regular exam. The wider tip can make insertion more painful.
The speculums come in different sizes; a narrow speculum is approximately the width of a finger, and many times this can be used, reducing discomfort significantly. I liken this to trying on clothes at the store—I was always told to start with the smallest pair of pants that I think has a reasonable chance of fitting.
In general, someone who has used tampons or a menstrual cup successfully or who has been sexually active will do well with a speculum and pelvic exam performed by a provider who makes them feel at ease, proceeds at a comfortable pace, and is aware of physical cues that might suggest the exam has become painful and knows to stop and reaffirm that it is okay to proceed or make adjustments as necessary.
A speculum and pelvic exam shouldn’t be painful; there may be pressure or minor discomfort, but it should not hurt. If it does, speak up and ask your doctor to stop.
Annual pelvic examinations are no longer recommended, as screening the pelvic organs and vagina this way does not reliably identify any medical condition—in short, it is a poor screening test. If you have no symptoms, your exam is over after your cervical cancer screening.
DOES THE SPECULUM HAVE A RACIST LEGACY? Some women do not like the idea of a speculum because they have been told it was invented by Dr. Marion Sims, known to some as the father of modern American gynecology and to many others, including myself, as a shoddy doctor, a racist, and an all-around terrible man who experimented on enslaved women without consent and who was only in medicine for the money.
It is common medical lore that Dr. Sims reportedly developed the first reproducible surgical technique for vesicovaginal fistulas