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The Gynae Geek: Your no-nonsense guide to ‘down there’ healthcare
Dr Anita Mitra


Information is everywhere and yet many women still don’t truly understand how our bodies work and. specifically, how our lower genital tract works. Dr Anita Mitra, AKA The Gynae Geek, believes that we can only be empowered about our health when we have accurate information. This book will be that source.This book takes you from your first period to the onset of menopause and explains everything along the way. From straightforward information about whether the pill is safe, which diet is best for PCOS, what an abnormal smear actually means, if heavy periods are a sign of cancer, right through to extraordinary tales from the Clinic. This straight to the heart, sharp shooting guide will become the go-to reference book for all young women seeking answers about reproductive health as well as a way to dispel the swathe of misinformation that’s out there.Dr Anita Mitra shares her personal experiences with stress and anxiety and her learnings about how the gynaecological health of women can be influenced by lifestyle choices.













Copyright (#ulink_fc4893f9-40ed-51f6-a0e8-884b7d301ec1)

Thorsons

An imprint of HarperCollinsPublishers

1 London Bridge Street

London SE1 9GF

www.harpercollins.co.uk (http://www.harpercollins.co.uk)

First published by Thorsons 2019

FIRST EDITION

© Dr Anita Mitra 2019

Illustrations © Nicolette Caven 2019

Cover layout design © Ellie Game 2019

A catalogue record of this book is available from the British Library

Dr Anita Mitra asserts the moral right to be identified as the author of this work

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Source ISBN: 978-0-00-830517-8

Ebook Edition © March 2019 ISBN: 978-0-00-830518-5

Version 2019-02-21


Dedication (#ulink_f21c0f95-bec6-5d82-ac21-37cb2a116f03)

For Menelaos, Achini and my mum


Contents

Cover (#ub4cfacfd-f7c6-5db5-b8cc-cb20647de21a)



Title Page (#u427d4fc4-a31b-5586-98d1-1a337cc73162)



Copyright (#ulink_9ea794b4-6677-5d9c-84c3-67445414eb8b)



Dedication (#ulink_9ef47df8-6ef4-569d-91a4-81849ed95114)



Acknowledgements (#ulink_db65e309-a105-5274-ac91-b8f9b8f15e12)



Introduction: Down-there healthcare by the Gynae Geek (#ulink_58693100-7c10-547e-bda4-5f9bfab681f8)

PART ONE: Anatomy (#ulink_90574921-0231-58a3-b2cb-739b010a2bd2)



Chapter 1: External female genital anatomy (#ulink_6dcc1560-d71e-5cce-9aa5-a2cfe07184f4)



Chapter 2: Internal female genital anatomy (#ulink_9fa52496-9638-5196-9235-ddd271226cec)

PART TWO: Periods (#ulink_15fe3481-7b23-5fd2-8a2d-7161209a5fea)



Chapter 3: Periods – the basics (#ulink_229842b4-53bb-57f0-9b10-1967dbec21e3)



Chapter 4: Irregular and absent periods (#ulink_13d20aad-d21e-59b6-b275-62edddc791ad)



Chapter 5: Heavy periods and other period-related frustrations (#ulink_7d8d64f2-dc02-5c78-aafd-51b800a494bd)

PART THREE: Sexual Health and Screening (#litres_trial_promo)



Chapter 6: Vaginal discharge (#litres_trial_promo)



Chapter 7: Contraception (#litres_trial_promo)



Chapter 8: Emergency contraception and termination of pregnancy (#litres_trial_promo)



Chapter 9: Sexually transmitted infections (#litres_trial_promo)



Chapter 10: Cervical screening and HPV vaccination (#litres_trial_promo)

PART FOUR: Fertility and Getting Pregnant (#litres_trial_promo)



Chapter 11: When you are thinking about trying to conceive (#litres_trial_promo)



Chapter 12: Fertility and egg freezing (#litres_trial_promo)

PART FIVE: Lifestyle and Women’s Health (#litres_trial_promo)



Chapter 13: Stress (#litres_trial_promo)



Chapter 14: Food (#litres_trial_promo)



Chapter 15: Exercise (#litres_trial_promo)



Chapter 16: Sleep (#litres_trial_promo)



Final thoughts (#litres_trial_promo)



Resources (#litres_trial_promo)



Notes (#litres_trial_promo)



Index of Searchable Terms (#litres_trial_promo)



About the Publisher (#litres_trial_promo)


Acknowledgements (#ulink_d35cbe1f-9467-5fa6-b115-12dc1e01498b)

It is such an honour to write something for the whole world to see. But I couldn’t have done it without the support of some incredible human beings who deserve huge thanks.

To Dr Rupy Aujla, my brother from another mother, for being the one who forced me to put myself out there to talk about something I believe the world needs to know.

To Dr Laura Thomas, for taking a chance on The Gynae Geek and inviting me on her podcast to discuss vaginas before that was a ‘cool’ thing to do.

To Dr Hazel Wallace and Alice Liveing, who both gave me a massive leg-up by collaborating with me on their social-media channels and giving me valuable advice about how to survive in the online world.

To Carly Cook, for her sass and support throughout the book-writing process and for hydrating me with many a mint tea. To the wonderful HarperCollins team – Carolyn Thorne, who saw the potential in my idea, George Atsiaris, Josie Turner and Julie McBrayne, who brought the campaign to life – thank you all!

To Adam Willis, my strength coach, but most of all my friend, for always being a voice of reason.

To my best friend, Achini Wanasinghe, and my mum, who listen to my moaning on a daily basis and support me no matter what. And all my other friends who have put up with being ignored for the time that I’ve spent writing the book.

To both of my parents for giving me the education that enabled me to be in the position to write this book.

To all the patients and my social-media followers who shared their stories and asked the questions that inspired it.

And finally, to Menelaos Tzafetas, aka ‘Mr Gynae Geek’, for being the one, in so many ways.


Introduction: Down-there healthcare by the Gynae Geek (#ulink_4bb47637-c25c-5d6e-900d-09aa4853c4fb)

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!





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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 (#ulink_8af625c4-7a73-5f0a-9c63-9248369b6617)

External female genital anatomy (#ulink_8af625c4-7a73-5f0a-9c63-9248369b6617)



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 (#ulink_f35432ea-2119-5775-b4c1-6a5e59bab4c9) 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 (#litres_trial_promo) 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,


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 (#litres_trial_promo)), 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.


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!



THE GYNAE GEEK’S KNOWLEDGE BOMBS

The female vulva can generate a great deal of anxiety, but I hope you now feel more comfortable with describing the different areas should you ever need to talk to a doctor about it.

The following are the key facts that I would like you to take away from this chapter:



Your vulva is on the outside; your vagina is on the inside.

Your vulva looks normal. Don’t let anyone tell you otherwise.

Pubic hair removal is safe but doesn’t carry any health benefits, so don’t feel you have to do it.

You do not need a labiaplasty if it’s purely for appearance reasons. It’s normal for your labia minora to hang below the labia majora and for one to be longer than the other. It’s Barbie who got that part wrong, not you.

Your pelvic-floor muscles are the lifelong friends that you need to get to know. Kegel exercises (see here (#litres_trial_promo)) are the most underrated workout that we should all be doing, not just in pregnancy.



CHAPTER 2 (#ulink_5802d11d-7558-5916-b302-8df6a8d35bb4)

Internal female genital anatomy (#ulink_5802d11d-7558-5916-b302-8df6a8d35bb4)



(While I’m performing a vaginal examination to look at a patient’s cervix):



‘Doctor, do my ovaries look healthy?’

To be clear, I can’t see your ovaries when I’m looking up inside your vagina. Yet I’ve been asked this question on multiple occasions, which tells me that many women may need a refresher of that uninspiring biology class that we all sat through at school. I’ll tell you about the cervix – what even is that? And a cervical ectropion, which is actually very common and completely healthy, yet one of the most anxiety-provoking things that I find myself explaining again and again. I’ll also tell you about a few of the interesting lumps and bumps that I spend a lot of time talking about in clinic that can cause a lot of confusion, usually made worse by my rogue friend Dr Google.

The uterus

The uterus is also known as the womb, and we often use the terms interchangeably. I’ll use the word uterus from now on, you know, in the name of being proper and all.

The uterus is a muscular structure found in your pelvis, behind your bladder and in front of your bowel. It’s roughly pear-shaped, although I often describe it to patients as an upside-down wine bottle, with the large part of the bottle representing the body of the uterus and the neck representing the cervix (or neck of the womb), which acts as a passage for sperm to enter the uterus and menstrual blood or babies to exit. The wall of the uterus is made of smooth muscle, which moves in a ripple-type motion as opposed to striated muscle, which is the type you flex on demand in the gym. You might think that your uterus only contracts during labour, and while this may be the time when it performs its most vigorous workout, it also contracts during your period, helping the menstrual blood to escape, and during female orgasm. Given that these contractions are what cause you to have period pain, it’s not unusual for some women to experience a similar kind of pain for a few hours after sex, either due to orgasm-induced contractions or just because their uterus actually gets a bit irritated from being poked about.

Endometrium

The endometrium is the lining of the uterus, and is at its thinnest around your period, gradually thickening throughout the month to make a nice, soft, juicy landing for a fertilised egg. If this doesn’t happen, the lining is shed when you have your period. The thickness of the lining at the end of the month will determine how heavy your period is, and also, to some extent, how painful it may be – because the more there is to shed, the more the muscle of your uterus may need to contract to help move it out through the cervix and down into the vagina.

The cervix

The cervix or ‘the neck of the wine bottle’ is the gatekeeper to the uterus. Not only does it have a mechanical function of keeping your uterus shut during pregnancy, it also has a pretty complex immune function. A large quantity of the vaginal discharge that you produce comes from the cervix. Discharge is clever and anxiety-provoking in equal measures, which is why I have given it its own chapter (see Chapter 6 (#litres_trial_promo)). But until you get to that section, be aware that it’s way more than just a lubricant and contains loads of ‘natural antibiotics’ that protect you against infections, and that changes in the texture and qualities of the discharge throughout the cycle can determine whether sperm is able to enter.

If you feel your cervix (for non-squeamish readers, this involves inserting your finger into your vagina and feeling right at the top), it usually feels like the tip of your nose, because there is a little indentation in the middle. This is called the ‘external os’ and is the entry into the cervical canal; the small tunnel that runs through the cervix up into the cavity of the uterus. The canal is usually only a couple of millimetres wide, but during labour it opens up to 10cm, which is what we call ‘fully dilated’. Prostaglandins are the chemical messengers that cause contraction of your uterus during your period, and they also cause your cervix to soften slightly, opening a tiny bit to allow blood to escape with ease.

Cervical ectropion

An ectropion is an exposed area of the glandular lining of the inside of the cervix. Not everyone has one, but those who do are often terrified. And understandably so, because it is not something that is usually described clearly. So let me give it a go … Normally, the outer cervix is covered entirely with a smooth lining that’s quite tough and similar to the skin lining the inside of the vagina. But the glandular lining is a bit rough in texture, yet more fragile, and produces most of the protective discharge that I’ll cover in Chapter 6 (#litres_trial_promo). It’s most common to have an ectropion when taking the combined oral contraceptive Pill, or during pregnancy, but loads of women just have one for no particular reason. They’re not associated with a higher risk of abnormal smears, or with any other disease. They can be bloody annoying though – literally. They tend to bleed on contact, such as during a smear test or during/after sex due to the fragile nature of the glandular lining. It doesn’t mean anything is wrong, it’s just that the lining isn’t really designed to be exposed in such a way.






Having said that, lots of women have an ectropion and never know because they don’t all bleed. If you do have one it can go away on its own; especially if you’re on the Pill it will often disappear when you stop taking it. But if the bleeding is really annoying, there are things that can be done to treat it, such as having the exposed glandular layer burned away, which is what a lot of websites will recommend. Many women come to clinic insisting they want it removed; we generally advise against it unless it’s really problematic, and the vast majority change their mind once I’ve explained that it’s not harmful. As one patient once said to me, ‘If it’s nothing sinister, I’ll take a few harmless drops of blood over a barbecue on my cervix any day.’

Cervical polyps

These are little ‘skin tags’ that can be found in the cervix. Many women have them and never know, but in some they cause symptoms of abnormal discharge (a change in colour, texture, amount or bloodstained), bleeding in between periods, after sex or after a gynaecological examination, which makes them super annoying, and a potential source of worry. They may also be found by chance during a routine examination such as a smear test. They can be removed easily in clinic, and it’s quick and painless, but if they’re not causing symptoms this is unnecessary, as they are always benign (non-cancerous) and don’t increase the risk of any kind of disease or trouble in the future.




Nabothian follicle

Also called mucus-retention cyst, this is where the mucus that is made as part of the healthy function of the cervix becomes trapped underneath the surface of the cervix. Most often, these cysts are just an incidental finding when you’re having a speculum examination, and they’re usually too small to be felt, although if you touch your cervix, you may be able to feel the little lumps. They are completely normal and don’t increase the risk of any kind of gynaecological disease, nor are they anything to do with sexually transmitted infections. A patient once told me that another doctor described them as spots/whiteheads on her cervix, and she had thought it was because she wasn’t washing her vagina enough; so she went to town with various feminine-hygiene products, which didn’t make them go away and just gave her terrible vaginal irritation. If you have them, you can’t do anything to make them go away and you don’t need to either.

Fallopian tubes

You have two fallopian tubes – one on the left and one on the right, coming off the top of your uterus like long ears that flap around and pick up eggs from the ovaries. I recently scanned a lady who was ecstatic to find out she was seven weeks pregnant. I showed her the pregnancy in the uterus with a heartbeat and told her I could see the egg had come from the left ovary. She looked baffled and said it wasn’t possible because she’d had her left tube removed three years before due to an ectopic pregnancy (where the fertilised egg implants itself outside the uterus, usually in one of the tubes). However, your tubes are incredibly mobile – like a motorbike courier, they’ll pick up from any location if the goods are ready and waiting. So even with one tube, eggs can still be picked up from either ovary. The tubes contain tiny little finger-like projections called cilia, which help to sweep the eggs along into the uterus. However, they are not directly attached to the ovaries, and open into the pelvic cavity, which can serve as a route for infections to spread from your vagina, which is how sexually transmitted infections in particular can spread and cause pelvic inflammatory disease (see Chapter 9 (#litres_trial_promo)).

Ovaries

You have two ovaries, which are held close to your uterus by two ligaments – one that attaches to the wall of the inside of your pelvis and one that attaches to your uterus. The ovaries are home to a woman’s egg supply, which is complete at birth (about 2–4 million). The number of eggs decreases gradually as we age, with about three to five thousand ultimately making it to the point of being released. This is called ovulation and usually happens about once a month. The eggs live in little sacs called follicles, which go through several days of maturation to eventually form a cyst: a fluid-filled sac which bursts and releases an egg which may or may not then be fertilised.

Your ovaries are also a major site of hormone production, making the following:



Oestrogens Oestrogens, of which there are three types (oestrone, oestrodiol and oestriol), are not only responsible for your menstrual cycle, but also play a role in memory, heart health, bone strength and even the immune system.

Progesterone The major site of progesterone production is from the corpus luteum – this is the ‘shell’ that is left behind in the ovary after ovulation. If you don’t ovulate, very little progesterone will come from the ovaries themselves and the adrenal glands. (These glands sit above your kidneys and are responsible for making small amounts of progesterone along with a whole host of other very important hormones.) Levels are highest seven days after ovulating – that is Day 21 if you have a twenty-eight-day cycle – so if you’re having blood tests to see if you’re ovulating, this is what will be checked. If your level is low, you either didn’t ovulate or the timing of the test was wrong. The latter is surprisingly common, and a lot of scared patients come to clinic worried that they’re not ovulating. On further questioning, they do describe all the signs of ovulation (see Chapter 3 (#ulink_229842b4-53bb-57f0-9b10-1967dbec21e3)), and I’m then able to help them work out when to do the test, after which they come back very happy with a nice high progesterone reading.

Inhibin This hormone sends a message from the ovaries back to the brain saying, ‘We’re being stimulated enough, thanks’.

Relaxin This is a hormone which causes the joints and ligaments to soften during pregnancy to prepare the body for labour. It’s also responsible for the joint pain that pregnant women often experience.

Testosterone This is usually associated with men, but believe it or not, women need it too – not just to promote sex drive, but also for bone and muscle strength, as well as brain function.


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

What is a retroverted uterus and will it affect my chances of getting pregnant?

Also known as a tipped/tilted uterus, it means the uterus points backwards (retroverted) instead of forwards (anteverted). Between 20 and 30 per cent of women have this and in many cases, it is just how they were born and bears no impact on their health. In some women, however, it may be due to conditions such as endometriosis (see here (#litres_trial_promo)), fibroids (see here (#litres_trial_promo)) or the presence of scar tissue that pulls the uterus backwards. The actual position of the uterus does not affect your chances of getting pregnant because sperm is able to swim in all directions; however, any one of the underlying conditions above may cause problems. It also doesn’t cause pain, but again, if it’s due to an underlying disease, that may do so.

A retroverted uterus can make your cervix a little trickier to find when you have a smear test, which can be slightly uncomfortable. But we know plenty of tricks to make it easier and less painful. I often use the ‘make-fists-and-put-them-underneath-your-bottom’ position – if you know, you know! But the smear itself shouldn’t be any worse than normal.

As the uterus increases in size in pregnancy, it will gradually flip forward, and by twelve weeks – when most women are having their first scan – a retroverted uterus may have corrected itself, so that many women never even find out they had one.

Why do I bleed after sex?

Also called post-coital bleeding, bleeding after sex can have many causes, including:



cervical ectropion (see here (#ulink_2868db2d-727d-5abe-ba64-134f6579e36c))

cervical and endometrial polyps (see here (#ulink_8c4d38b0-8c16-5b1d-99d2-c6baae1bb1ef))

infections such as chlamydia, or even something simple like thrush, which causes irritation of the vagina and cervix and the added friction of sex can be enough to make it bleed

vaginal dryness (lack of lubrication, which can make the vaginal tissue more sensitive to friction in particular)

skin conditions such as psoriasis or lichen schlerosus – these can make the skin more delicate and increase the chance of getting small skin tears

cervical cancer – the one that everyone worries about, but is actually the least likely cause, which is why I’ve put it at the bottom of the list; the risk ranges from 1 in 44,000 cases of post-coital bleeding in women aged 20–24 to 1 in 2,400 in 45–54-year-olds.6 (#litres_trial_promo)


Does removing a fallopian tube affect my fertility?

Sometimes fallopian tubes may need to be removed in cases of severe infections (see Chapter 9 (#litres_trial_promo) on STIs) or due to an ectopic pregnancy (a pregnancy in the tube). You can still get pregnant with one tube (see here (#ulink_260969ac-8c9e-527b-a482-def365827994)), but if both are removed it does mean that you would need IVF to get pregnant. Removing either one or both tubes also does not affect the function of your ovaries and does not cause you to go into the menopause.

Why do I have a cyst on my ovary?

Ovarian cysts are very common and about 1 in 10 women will need surgery for one at some point in their lifetime. Most arise as a result of the normal workings of the ovary (see here (#ulink_df8cd656-6b11-58b6-95d1-3ca665e164ad)). We get tonnes of referrals to the gynaecology clinic for ovarian cysts that have been found incidentally during a scan for something else. Ultrasound is the best way to look at your ovaries initially, preferably an internal scan using a small probe inside the vagina because it gets closer to the action. Most cysts will disappear on their own within a couple of months. You may need a follow-up ultrasound, depending on the size and type of cyst.

Larger cysts may need to be removed because there is a greater risk that they may twist the ovary which cuts off its blood supply, and if not untwisted will cause the ovary to die. This is called ‘ovarian torsion’, and you’ll definitely know if you have it because it is incredibly painful, to the point where even morphine won’t touch the pain. It requires emergency surgery to untwist the ovary and remove the cyst. In most cases the ovary itself can be saved if the blood supply returns on untwisting.

The biggest ovarian cyst I’ve ever seen was in a young woman and was 24cm across. She was supermodel-slim, and finally went to her GP after spending a fortune on pregnancy tests, because she couldn’t understand why they were all negative, yet she looked seven months pregnant. A big tummy is a slightly unusual way for a cyst to present. More common symptoms include:



abdominal pain – this may be constant, occasional or during sex

constipation – due to pressure on your bowel

wanting to pass urine more often – due to pressure on your bladder

a change in your periods – irregular, heavier or lighter.

The risk of a cyst being cancerous in a pre-menopausal woman is very low, ranging from 1 to 3 in 1000.7 (#litres_trial_promo) (See Chapter 4 (#ulink_13d20aad-d21e-59b6-b275-62edddc791ad) for more about polycystic ovaries.)


Should I be worried about ovarian cancer?

Ovarian cancer is so rare before the menopause and ovarian cysts do not increase your risk.

An estimated 5–15 per cent of ovarian cancers are inherited, most often caused by mutations in the BRCA1 and 2 genes, which are also associated with breast cancers. If you have close family members (e.g. mother, sister, grandmother) affected by ovarian cancer, particularly at a young age, you may be eligible for genetic testing, which should be discussed with a genetic counsellor.

An estimated 21 per cent of cases of ovarian cancer are directly related to lifestyle factors including smoking, poor diet and lack of exercise,


so keeping active and eating well is one of the best ways to prevent the disease.

There isn’t currently any screening for ovarian cancer, as there isn’t yet a test that is accurate enough. Remember that screening means identifying women who may have a disease but do not have any symptoms.

If you experience any of the following symptoms more than twelve times per month, you should be investigated:



Persistent bloating

Feeling easily full after eating and/or loss of appetite

Pelvic or abdominal pain

Needing to pass urine more often, or as a matter of urgency

Change in bowel habit




THE GYNAE GEEK’S KNOWLEDGE BOMBS

I hope you have found this chapter more fascinating than when you studied female anatomy in that awkward biology lesson at school. These are the key facts that you may not have learned back then that I want you to keep in mind:



Your uterus can face forwards or backwards and contracts during your period to help the blood get out, which is what causes period pain.

It also doesn’t like being poked very much, which is why it can be normal to get a bit of an ache after sex.

Bleeding after sex is rarely caused by the big C.

Your fallopian tubes are pretty flexible guys, flapping around like a Mexican wave, so that they can pick up an egg from either ovary.

Ovarian cysts are very common (often a result of the normal functioning of your ovary) and do not increase your risk of ovarian cancer.






(#ulink_c0d29fc9-abc2-5493-9803-d6de3b82668f)

Periods are one of society’s biggest taboos. Over half of the population has had or will have one at some point during their lifetime. Yet we barely talk about them.

I’ve noticed an interesting three-way split in the way women feel about periods. In the first group are women who are ambivalent; they don’t mind either way whether they come or not. The second group hate them and would do anything to make them go away (‘Give me anything you’ve got to make them stop!’). The third group love them and are horrified at the thought of not having their period every month – some, because they see it as a sign that their bodies are working, and many because they feel like it’s ‘cleaning their body from the inside’ (although I’m always quite keen to point out that having a period doesn’t clean your body of germs or toxins; in fact, I think period blood often has a ‘dirty’ connotation, which is probably one of the reasons we’re so reluctant to address the issue).

There are some types of contraception – for example, the hormonal coil – that will stop your periods (see Chapter 7 (#litres_trial_promo)), and if that happens it’s not a bad thing. It doesn’t mean your uterus will become ‘unclean’. The medication is simply preventing the lining from building up, so there’s nothing to shed. I once offered the hormonal coil to a lady whose periods were so heavy that she’d had several blood transfusions. However, for her the possibility of having no period at all was unacceptable and she declined, explaining that she ‘wouldn’t feel like a woman any more’. I really like the fact that some women appreciate their period as a sign that their body is working. This is so true, and I always tell my patients that their period is a reflection of what’s been going on in their bodies for the last month, even slightly longer.

The next three chapters will cover the basics of periods, the menstrual cycle and what can, and commonly does go wrong.


CHAPTER 3 (#ulink_f07ef2f7-9dd2-56b3-8cba-d662148b4b3e)

Periods – the basics (#ulink_f07ef2f7-9dd2-56b3-8cba-d662148b4b3e)



Me: How long is your menstrual cycle?



Patient: Three to four days.

Many people think that the length of a cycle is how long you bleed for, but this is a common misconception. Your cycle is actually the number of days from the start of one period until the start of the next.

Education about periods is pretty mediocre at best. In fact, at my school it was so dire that I genuinely thought a period was the contents of an egg cracking and being released through the vagina, which often makes me laugh when I think of the irony that I now spend my life explaining periods to others. But rest assured, I’ve done my fair share of reading since then.

In this chapter I want to start with the absolute basics, so do bear with me if you’re a period pro, although I hope there will be something to be gained for you geeks too.

If you fall into the ‘I’m-in-need-of-period-101’ group, you are not alone. A recent survey by ActionAid UK revealed that one in four women in the UK does not understand her periods, and that 20 per cent feel embarrassed to talk to their friends about them. If we can’t talk about periods, we will never work out what is normal or abnormal. And this results in so many women suffering unnecessarily because they don’t realise that there are things that can be done to help the problems they experience on a monthly basis.

What is a period?

A period is what happens when the lining of the uterus (the endometrium) falls away. Even though most of us are not trying to get pregnant the majority of the time, the entire reason for having a menstrual cycle is to prepare your uterus for a fertilised egg to implant. When this doesn’t happen, your uterus chucks out the lining it had prepared. But in order to actually have a period there is a lot of work going on behind the scenes throughout the menstrual cycle.

‘Day 1’ is the first day of your period. If you have a textbook twenty-eight-day cycle, Day 28 is therefore the last day before your next period. We are, however, humans, of course, and not everyone goes by the book, with only about 15 per cent of women actually having a twenty-eight day cycle,


and anything between twenty-one and thirty-five days being considered a ‘normal’ cycle length.

The menstrual cycle: more than just a bit of bleeding

Let me take you through the different stages of your cycle.






Follicular phase: fifty shades of period blood

It all starts on ‘Day 1’ – this is the first day of your period – and the bleeding usually lasts for three to eight days (on average five). Bleeding is classically heaviest on Day 2.

The blood during your period can come in a huge range of shades and hues. It won’t look the same as the blood you see when you cut your finger, because it’s not just plain blood. It’s mixed with mucus and cells from the inside of the uterus and the reason there is blood in the first place is because the juicy lining that’s built up over the month contains an intricate network of blood vessels that were meant to feed that elusive pregnancy it was planning on accommodating. The colour also depends on the time taken for the blood to come out. Just as an apple goes brown when it is cut and left exposed to the air, so blood starts to darken and, ultimately, go brown or almost black if it’s left to hang around for long enough.

It’s not uncommon for a period to start as spotting. This means light bleeding that’s not really enough to need a pad. It can be pinkish, which is usually due to the lining starting to fall away, or various shades of brown, which means it’s coming out very slowly or could even be old blood from your last period. Don’t be overwhelmed by this; it’s normal. New red bleeding tends to be thinner and often a bit watery because it’s the freshest. It can get a bit thicker and more crimson in colour because it has had a bit of a wait before show itself. Then normally it becomes quite light and turns brown to black before it stops completely. A wide range of colours is completely normal and to be expected.

The blood that’s being shed will clot in the uterus, so your body has to make anticoagulants – chemicals to break them down – in order to re-liquify the blood, so it can flow out. Many women tell me that ‘pieces of liver are coming out’. Admittedly, clots may look pretty sinister, but it’s not always something to worry about. If the amount of blood present exceeds the speed at which your body can make these anticoagulants you may experience clots, which can escape through your cervix, which softens slightly to allow the blood to escape. Clots tend to be small, usually no bigger than the size of a fifty-pence coin. However, larger clots, and lots of them, are a sign that there’s heavy bleeding going on, so it’s worth visiting your GP to check it’s not causing anaemia, to consider treatment and whether there’s an underlying reason, many of which are covered in Chapter 5 (#ulink_7d8d64f2-dc02-5c78-aafd-51b800a494bd).

While you’ve been busy concentrating on the outward manifestations of your period, you may not have realised that your brain has been busy making hormones: GnRH (gonadotrophin-releasing hormone), LH (luteinising hormone) and FSH (follicle-stimulating hormone). GnRH is produced first by the hypothalamus and then signals to the anterior pituitary to release LH and FSH, which then stimulate the ovary to prepare an egg for release (ovulation) and to produce oestrogen, which starts to rebuild the endometrium, in preparation for the hope of a pregnancy during this new cycle. Eventually, there is a massive surge in LH release, which triggers ovulation. LH is what you are trying to detect with the ovulation sticks that you can buy if you’re trying to get pregnant and want to work out when you’re ovulating. A patient once proudly told me that she usually ovulates about three times per month because her ovulation sticks told her so. You cannot ovulate more than once during a single menstrual cycle, although you can release more than one egg, which is how you get non-identical twins. This is one of the quirks of ovulation sticks; they tell you when you have had an LH surge, which can happen several times in one cycle, but they don’t confirm you popped out an egg.

Luteal phase: eggs and shells

Eggs live in sacs called ‘follicles’ which undergo several months of maturation before they can get to the stage of being released. Ovulation marks the start of the luteal phase and is like a Hollywood audition; at the start of your cycle there may be ten eager, willing candidates, but as time goes on, only one is selected to go forward and become the ‘dominant follicle’, which grows and grows, forming a cyst which pops on about Day 12–16 of the cycle, throwing it on to the main stage in the hope of being fertilised. It’s not unusual to get a bit of pain at this point. Ovulation itself is an inflammatory process and the ovary producing the ‘star egg of the show’ can get slightly enlarged which itself causes pain; then, when the cyst bursts, it leaks a little bit of fluid into your pelvis which can be uncomfortable. This ovulation pain (also called ‘mittelschmerz’, German for ‘middle pain’) can be sharp or like toothache, really low down near your hip bone on one side, but it usually lasts only twelve to twenty-four hours. Many women are quite anxious about this kind of pain and are horrified by the idea of a cyst bursting in their tummies. But it’s a positive sign that their bodies are working the way they should, which reassures most people. There may also be a little bit of bleeding at this time; ovulation bleeding only happens in about 3 per cent of cycles,


but it’s certainly nothing abnormal that you need to worry about. It happens due to a momentary drop in oestrogen.

After the egg is released, a shell of the original follicle, called the ‘corpus luteum’ is left behind in the ovary, which starts to release progesterone – the pro-pregnancy hormone. One of its main roles is to ensure the lining is fully preened and plumped up for the arrival of a fertilised egg. Progesterone levels are at their highest seven days after ovulation, and if fertilisation has not occurred, the corpus luteum eventually throws its hands up in the air and says, ‘I can’t do this any more. I’m bored of pumping out all this progesterone to no avail. I’m out of here!’ It then slowly starts to degrade, and this causes a drop in both oestrogen and progesterone, which means the growth of the endometrium is no longer supported, so it begins to fall away. This is your period and the cycle starts again.

Variations in cycle length

It’s normal for there to be some variation in the length of your menstrual cycle on a month-to-month basis.

A lot of mums of teenage girls contact me online, worried that there is something wrong with their daughters because they are only having periods every two or three months. But this is quite common when your periods start because the hormone cycles are still synchronising, and also coming up to the menopause when you have fewer eggs left, meaning you’re less likely to ovulate as easily. Cycles are typically shortest and most regular in your twenties and thirties. Any variation in the length of the cycle at any age will be due to changes in the follicular phase because the length of the luteal phase is pretty standard being dictated by the lifespan of the corpus luteum.


(See Chapter 4 (#ulink_13d20aad-d21e-59b6-b275-62edddc791ad) for other factors affecting cycle length besides age.)

Menstrual cups, tampons, pads … ?

There are an overwhelming number of ‘menstrual-hygiene’ products on the market; I’m not hugely keen on the term because I think it perpetuates the myth of periods being ‘dirty’.

Menstrual cups, tampons, pads … I’m constantly asked which are ‘the best’, and, to be honest, from a health point of view there is no shining star – so I’d advise you to use whichever makes you feel most comfortable.

Menstrual cups

There may be a few furrowed brows at the mention of ‘menstrual cups’. If you are wondering, they are small and egg-cup-shaped and made of a soft silicone, which you insert into your vagina, where they sit collecting blood as it comes out of the cervix. There’s only one small study that has ever compared tampons and cups head to head and actually found greater satisfaction with cups compared to tampons, but it didn’t find any difference in terms of infections


and there don’t appear to be any clear health benefits. The main advantage is that they are probably better for the environment and will definitely save you money in the long run. But don’t feel you have to use them. I don’t recommend them for the squeamish, as you have to be quite cool about putting your fingers into your vagina to insert them (they don’t come with an applicator like tampons), and it takes a bit of patience to learn how to remove them. After writing an Instagram post on menstrual cups I received a flurry of messages from women sharing the horror stories and proud moments of their first time. The most common initial problem seems to be difficulty removing it. Do not underestimate the strength of the vacuum that a menstrual cup can make with the cervix. However, you’ll quickly learn how to break the vacuum and remove it like a pro.

I’m frequently asked if it’s OK to use them with a contraceptive coil. Different manufacturers have different ideas on this, some saying it’s OK, others saying it should be avoided. This is because theoretically you could dislodge your coil with the aforementioned vacuum effect – something that has, in fact, been confirmed by several women who have contacted me via social media saying they managed to suction out their coil: ‘Anita, I’ve saved my coil, can you put it back in?’ was one SOS message I recently received from a friend. But while I’m all for recycling, you can’t reuse a coil, so I promptly replied, ‘Sorry, darling, you need a fresh one!’ If you do choose to use a cup with a coil, I would advise checking the strings at the end of your period. If you feel they are lower than normal, you can feel the rod of the coil or you can’t feel any strings at all, I would use condoms until you’ve had it checked by a doctor to ensure it’s still in the right place to give you full contraceptive protection.

Tampons

Just as menstrual cups may not be for everyone, the same goes for tampons. Some women just don’t feel comfortable putting something inside themselves. Others find it too painful. This may be due to tight pelvic-floor muscles or not being relaxed enough or, in my experience, endometriosis, probably due to inflammation and scarring in the pelvis. One study suggested that tampon use is protective against endometriosis,


but I think this finding is skewed by the fact that a lot of patients with endometriosis don’t use tampons because it’s too uncomfortable to put them in or because their period is so heavy that a tampon isn’t going to cut it.

Toxic-shock syndrome

Toxic-shock syndrome (TSS) is caused by bacteria and has nothing to do with any kind of chemical that is in the tampon itself. Staphylococcus aureus is a type of bacteria commonly found on the skin, and a particular form can produce a toxin called TSST-1. On entering the bloodstream, this can cause a massive inflammatory reaction, usually characterised by a really high fever, vomiting, skin rashes and aching muscles. But, unhelpfully, it doesn’t always lead to any symptoms ‘down there’ which would make it easier to identify the cause. It can be life-threatening and requires urgent medical attention. It’s also incredibly rare, with only about forty cases per year in the UK, around half of which are thought to be related to tampon use (the other half are seen in children, men and older women, and are typically associated with skin burns and infections).

The ways that tampon use can potentially increase the risk of TSS include:



collecting blood and increasing vaginal pH to create a breeding ground for bacteria

causing tiny little micro-tears in the vaginal wall on insertion and removal, which allow bacteria to enter the bloodstream (it has been suggested that menstrual cups are safer in this regard, although I disagree; there has been a reported case of TSS with menstrual-cup use,6 (#litres_trial_promo) probably because it too can cause vaginal abrasions and potentially create the right bacterial breeding ground.


On balance, I don’t think there’s any reason for the social media-based frenzy related to tampons, or enough evidence for changing your practices, especially because TSS is so rare.

Pads

Let’s not forget pads now. They might not be the sexy option these days, but they’re still incredibly useful, especially for light days, and a godsend to the many women who don’t like tampons or cups. To be clear, you don’t need the scented ones, which some women find cause irritation to the delicate vulval tissue. Reusable pads, as well as periods pants, with an inbuilt absorbable pad, are also increasingly popular. These are better for the environment, and there’s no difference between them and disposable pads from a health perspective.

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

Should I track my menstrual cycle?

I’m a massive fan of cycle tracking and usually recommend the Clue app (see Resources (#litres_trial_promo)). It stops you being caught short without pads or tampons and can be really useful in helping you to recognise patterns in symptoms that you might get at particular times of the month. I breathe a sigh of relief when a patient gets her phone out to tell me all about her periods because it makes things so much easier to pinpoint; and if you haven’t been doing it, we will often give you a menstrual-cycle tracking chart to fill in for the next few months.

I started tracking my period as a way of reassuring myself that the pain in my side every month was ovulation pain and not some dreadful case of appendicitis; all doctors are hypochondriacs to some extent. I did my medical-school elective on a tiny island in Fiji, where I had what I now realise was terrible ovulation pain, but at the time I was panicking and planning how I would get airlifted out to get my appendix removed because I didn’t want to undergo surgery in our operating theatre, which was essentially a shed with a bright light. It was the worst twelve hours of my life! (And I’ve also seen the occasional woman arrive at A&E with the same fear.)

What is a fake period?

I’ve heard people referring to periods on the Pill as ‘fake periods’, which can cause a bit of anxiety. What they mean is that the bleeding is due to the hormones in the Pill, unlike a ‘true period’, in which the bleeding is caused by your body making the necessary hormones. When you stop taking your Pill it mimics the last few days in your cycle where the corpus luteum is dying away, so the levels of synthetic hormones from the Pill are dropping, which causes the lining to fall away.

I’m often asked: ‘If it’s a fake period, does that mean I could still be pregnant?’ And the answer is, ‘No’. If you have a bleed on the Pill when you have your week-long break, then you are not pregnant.

Are organic tampons better?

Many concerned women have contacted me asking if they’re harming themselves by using conventional tampons, which, if you believe the hype, contain bleach plus cancer- and endometriosis-causing toxins. These claims are entirely unfounded, as very sophisticated lab techniques have failed to pick up any of these compounds in non-organic tampons.


Dioxins are a type of toxin that seem to get the most attention, but you actually ingest way more of these through your diet than you ever could through a humble tampon.


At present there is no scientific evidence to show organic tampons are better for health or any less likely to be associated with TSS. But they’re definitely more expensive.

Some people have said they find organic tampons less irritating, and while there’s no specific mechanism for why that might be the case, if you do find you’re not satisfied with your current brand, you have nothing to lose by changing to an organic brand to see if it makes a difference. But my medical (and non-medical) opinion is: if it ain’t broke, don’t try to fix it.

Can I stop my period if I’m going on holiday?

Yes, and there are two ways to do so.

If you’re on the combined oral contraceptive pill (COCP) The COCP is the type you take for twenty-one days and then have a break for seven days, during which you would have your period. If you want to stop your period, it’s OK to take up to three packs in a row without a break. You won’t have a bleed because you maintain a constant hormone level, although some people will find they get some cramping and spotting, especially towards the end of the third pack.

If you’re not on the COCP In this case, your GP can prescribe Norethisterone, a synthetic progestogen tablet that you take three times per day, starting about ten days before your period is due and continuing for the duration of your trip/the time for which you want to stop your period. Your period will usually start about two days after stopping the tablets. Again, they can cause cramping and spotting and your period might be heavier than normal.

There isn’t a ‘non-hormonal’ way of stopping/delaying your period.



THE GYNAE GEEK’S KNOWLEDGE BOMBS

I love a good ol’ period chat. I always find that it’s something everyone wants to talk about, but no one wants to be the first to bring it up, whether in clinic or socially. One of my biggest missions is to help start this conversation, so that you can understand what’s normal and when something might need medical attention. Here are the five key points that I’ve covered in this chapter that I find myself repeating over and over:



A period is what happens when the lining of the uterus falls away, containing blood, mucus and old cells. It’s not your body detoxing itself, it just means you didn’t get pregnant.

Your period blood can be like a rainbow – pinks, reds, browns, blacks; they’re all normal.

It’s common to have irregular, often quite long cycles at the extremes of your menstrual life – as a teenager and before the menopause.

Menstrual cups, tampons, pads – there isn’t one outstanding product. Use what makes you feel comfortable.

Toxic-shock syndrome is exceedingly rare, so again, use whichever product you prefer.



CHAPTER 4 (#ulink_93f022ca-fdeb-5b32-b5c2-47f5549e001a)

Irregular and absent periods (#ulink_93f022ca-fdeb-5b32-b5c2-47f5549e001a)



I used to dread the time when my period arrived, but now I’m desperate to have one … what can I do?

Irregular periods are something I hear about frequently in clinic and get a lot of messages about online. Sometimes absent for months on end, they can cause a lot of stress, often because women worry they’re going to struggle to get pregnant eventually. There’s been a lot of media interest in polycystic ovarian syndrome (PCOS) lately, and while it’s a common cause of a disrupted cycle, many people don’t realise the impact that our hectic lifestyles can also have on periods. Most women tell me that they always had a regular cycle right from the word go, but that more recently they’ve gone completely haywire.

This is something that happened to me, and I had absolutely no idea of why. I’d thought my body was normal, so why had it started misbehaving? What I didn’t appreciate (and was never taught in medical school) was that my body was warning me that my intense exercise regime, lack of sleep and through-the-roof stress levels were putting it under incredible strain and destroying any hope of a normal menstrual cycle. Let me explain how and why these things alter your period and, while I’m at it, I will also give you a good rundown of PCOS.

How irregular is irregular?

Many people believe that anything that is not a twenty-eight-day cycle is irregular, but if your period comes, for example, every twenty-six to thirty days, that’s regular for you. As doctors, when we use the term ‘irregular’, we are talking about a cycle that has no rhyme or reason. This means you generally cannot predict when your period is going to come, and the variation in cycle length is usually more than ten days (i.e. If your shortest cycle is twenty-five days and the longest is sixty, the variation is thirty-five days). ‘Amenorrhoea’ is the term used when you don’t have a period for at least three or six months (depending on your source). It is also very common and something that causes a great deal of anxiety.

‘Lazy ovaries’ are not ‘a thing’

I’ve heard of people being told they are not having periods because of ‘lazy ovaries’, which is a bit unfair, as those poor little ovaries are trying their hardest to ‘keep calm and carry on’. Your menstrual cycle is not just controlled by your ovaries; they rely on getting the appropriate signals from the brain – the hypothalamus and anterior pituitary gland being the two areas that make the hormones that communicate with the ovaries to stimulate oestrogen and progesterone production. Many things can interfere with this communication, changing your menstrual cycle as a result.

Causes of irregular or absent periods

I’m sure a number of the issues outlined below will resonate with a lot of you, and if they do, I suggest you hotfoot it to Part Five (#litres_trial_promo) for a more thorough insight into these factors.

Note: it may sound obvious but the first thing you need to check for when you’re not having a period is … pregnancy.

Hypothalamic amenorrhoea (HA)

Also called functional amenorrhoea, this is one of the most common topics I am contacted about via email and social media, usually by women who say things like; ‘I haven’t had a period for over a year and I just can’t understand why. I exercise five times a week and I’m on a really healthy diet.’ Although I have no statistics to back this up, I would estimate that it is more common in young, fit women heavily invested in a healthy lifestyle. Unfortunately, the current fashion for an athletic physique, combined with the ‘more-is-more’ attitude of society and our hectic lifestyles leave little room for the simple things in life – like hormone production. That is why women get HA; and I can usually tell this straight away from the Instagram profiles of the many women who message me about this problem – their bodies have quite simply run out of steam.

While we may not be very good at consciously prioritising the essentials, our bodies do this automatically as a way of helping us to survive. As over-the-top as it sounds, your body would prefer to keep your heart beating, rather than give you a period, so your brain shuts off production of the hormones that stimulate your ovaries, which stops ovulation. And since the entire purpose of your menstrual cycle is for you to get pregnant, Mother Nature is particularly clever, recognising that a stressed-out woman does not need the added stress of having a baby. From an evolutionary point of view, this is a survival tactic for both mother and baby.

The main triggers for hypothalamic amenorrhoea that I see on a recurrent basis are stress, diet and overexercising – or, usually, a combination of all three.

Stress

You’ve probably heard of cortisol, the stress hormone. It influences production of female hormones by telling your brain that you’re under stress (even if you don’t realise it) and to halt ovulation until you’ve overcome it. Unfortunately, we are so used to living our lives in ‘turbo-power mode’ that we’ve forgotten what it’s really like to press the pause button, or even that it exists. I frequently meet real-life superwomen. They typically have several children, a zoo-worth of animals and a husband who isn’t very domesticated. And often an irregular cycle. Recently, I called one of these superwomen into my room and apologised that the clinic was running late. She said, ‘Oh, don’t worry; it’s been lovely to sit and read a magazine and have some time to myself …’ So before she’d even sat down I was pretty certain of what the problem was, although it can be a tricky one to solve because so many women have lost sight of how important it is to take that critical time for themselves.

Dietary factors

If you’re not eating enough to be able to provide the energy requirements of your own body, you’re not going to be able to sustain a healthy pregnancy. So here again, your brain shuts the system down, saving the energy and nutrients that would otherwise be used on ovulation. Fat tissue is one of the sites of oestrogen production, so women with very low body fat may not produce enough oestrogen, which is made from a specific type of fat called cholesterol. Fat tissue is also able to send signals to the brain to tell it whether there is enough of the stuff to maintain a pregnancy. Female hormones are made of fats, so if your diet is devoid of good, healthy fats, your body doesn’t have the right ingredients to make the goods.

I recently had a difficult conversation with a patient who had become a vegan right around the time that her periods stopped, but she was convinced that couldn’t be the reason why, because to her, veganism was the healthiest diet out there. However, any extreme change in diet can lead to nutrient deficiency (see Chapter 14 (#litres_trial_promo)).

Overexercising

Adrenaline is the ‘fight-or-flight’ hormone that is going to save you from that wild bear. Nowadays, there are very few bears or other life-threatening mammals running around, but your body doesn’t know the difference between thrashing it out on the treadmill or running from said bear. Your body senses this exertion as a stress and says to your ovaries, ‘Hold your horses! This woman is in danger – do not ovulate.’ It’s common for long-distance runners to lose their periods, but it’s not just running that can be a problem. Any intensive exercise can have the same effect. Many women that I see are training like athletes, then running off to their full-time jobs, families and social commitments and it can be too much for their bodies to cope with. They can also be putting themselves in a calorie deficit if they’re not eating enough, which takes us back to dietary factors. All of this – and how to address it – is discussed further in Chapter 15 (#litres_trial_promo).

Post-Pill amenorrhoea

After stopping the contraceptive Pill you will have your usual bleed, assuming you stopped at the end of the pack. But when is your next period going to come? That’s the million-dollar question. Some people will go back to having a regular cycle pretty much straight away. Others sit and wait … and wait … and wait some more. And in my experience, this is much more common than the textbooks say. But if the Pill is out of your system after a day or so, why does this happen? There is no single answer. It’s likely to be a combination of three factors:

The Pill essentially takes over your natural hormones, so it can take some time for them to get back into sync to the point where they can resume ‘business as usual’.

The triggers for hypothalamic amenorrhoea (see here (#ulink_2455729b-1949-50ff-b81d-0abd3bfb9833)), which I find to be very common.

The possibility of an underlying problem such as PCOS, which has been masked by the Pill.

Premature menopause

Also referred to as premature ovarian failure/insufficiency (POF/POI), premature menopause is actually a misnomer. You run out of eggs when you go through the menopause, whereas with POF/POI your ovaries stop responding, despite still having eggs on the shelf. I can’t even count the number of times I’ve had women come and cry in my clinic room, convinced this is happening to them when their period has gone AWOL. It takes a very simple blood test to confirm or refute the diagnosis (oestrogen levels will be low and FSH will be through the roof) and, thankfully, it’s pretty uncommon, affecting about 1 in 100 women before the age of forty, and 5 in 100 before forty-five (the average age in the UK for menopause being about fifty-one years). It tends to run in families, so asking your mum when she went through the menopause is helpful.

Hormonal diseases

PCOS is the most common hormonal disorder that can affect your periods and is discussed at length below. Diseases associated with hormones that seem unrelated to your ovaries can also have a dramatic impact due to the interconnection of the hormonal system as a whole. Thyroid disease (high or low levels) is particularly common in women, and changes in thyroid hormones have both a direct and indirect effect on female hormone levels, which can change the timing of your periods and also how heavy they are (see here (#litres_trial_promo)). A thyroid blood test can be done by your GP, and this can reveal thyroid problems in many women. Type 1 diabetes (where your body is unable to make insulin) and type 2 diabetes (where your body becomes less responsive to insulin) are both associated with irregular cycles due to the interaction of insulin and female hormone production.


Type 2 diabetes can also be associated with PCOS, as described below. There are, of course, other hormonal diseases which, although less common, will be checked with blood tests.

Polycystic ovarian syndrome (PCOS)

This is the most common hormonal disorder seen in women, with some studies suggesting that up to 1 in 5 of us is affected. It is diagnosed based on the presence of two out of the following three characteristics known as the Rotterdam Criteria:



Irregular or absent periods

Signs of excess male hormones including excess body/facial hair or acne or high levels on a blood test

Polycystic ovaries seen on an ultrasound scan


PCOS does not typically cause pain. Polycystic ovaries are often seen on scans to investigate lower abdominal pain, but are not the cause of this pain.

What causes PCOS?

PCOS is a syndrome (i.e. a collection of symptoms), so it’s not the same cause in everyone. It is a complex mash-up of your in-built genetics, epigenetics (which is how genes are turned on and off) combined with environmental aspects of how we live our lives now.

One of the key features of PCOS is insulin-resistance, which is found in about 70 per cent of sufferers. This is when your body is able to make plenty of insulin (one of the key hormones responsible for keeping your blood sugar under control), but your tissues are less sensitive to it, and therefore you have to ramp up production to maintain the same response. The problem is that insulin forces your ovaries to convert oestrogen to the male hormone testosterone, which stops ovulation (goodbye regular periods) and gives you all the fun hormonal side effects (hello acne, excess hair, mood swings …). Blood tests and ultrasound scans are carried out to confirm it and rule out other causes of the symptoms.

So what causes PCOS in those who are not insulin resistant? The adrenal glands. As well as making cortisol, and the fight-or-flight hormones adrenaline and noradrenaline, they also make testosterone and its precursors, resulting in the same effect on your ovaries.

Management of PCOS

A lot of women are understandably disappointed to hear that there is no cure for PCOS. But there are plenty of ways to treat the symptoms, both through lifestyle changes and prescribed medication:

Lifestyle intervention

Every guideline I’ve ever come across for PCOS cites ‘lifestyle intervention’ as the first-line treatment, although doctors have not always been famed for giving the best lifestyle advice. Thankfully, times are changing and there is a new wave of doctors coming on to the scene, led by the likes of my friends Dr Rupy Aujla, Dr Hazel Wallace and Dr Rangan Chatterjee (see Resources (#litres_trial_promo)), all of whom dish out great lifestyle tips via their social-media platforms and chart-topping podcasts, so check them out.

Several years ago, a hugely overweight twenty-two-year-old came to clinic for advice about PCOS as she was planning on getting pregnant in the next few years. I spent about fifteen minutes talking to her all about lifestyle interventions that she could undertake. I gave her so many in-depth, practical tips and tricks that she could use to improve her PCOS and, in turn, her long-term health in general, which is so important for anyone planning a pregnancy, with or without PCOS. My heart sank though when she looked at me and said, ‘But can’t you just prescribe me a tablet to sort it all out?’ Granted, these interventions are not easy, requiring some hard work and diligence at times, but you will reap the benefits in the long term because they can reduce the risk of the complications of PCOS, including type 2 diabetes and heart and vascular diseases, which are some of the major causes of death and chronic-health issues in the Western world.

Here is a summary of the advice that I give to my patients (see Part Five (#litres_trial_promo), here (#litres_trial_promo) for more details).



Weight loss Many patients are surprised when I tell them I’m not going to ask them to lose weight. Weight loss is one of the most effective ways to help the symptoms of PCOS (reducing fat reduces insulin resistance, which is the main driver of the condition), making your cycles more regular, increasing the chance of a healthy pregnancy, improving acne and reducing the risk of diabetes and heart disease in the future.11 (#litres_trial_promo) However, being told to lose weight is psychologically tough and, I believe, makes the whole disease much more traumatic to deal with. I prefer instead to focus on improving diet and exercise which, if done correctly, will result in both improved symptoms and weight loss without this being a depressing focal point.

Diet There are a lot of people pushing extreme PCOS diets online, particularly focused around low-carb/ketogenic (high-fat, low-carb) diets, which I don’t subscribe to at all. The rationale behind them is sound, and data supports short-term effectiveness.12 (#litres_trial_promo) But we don’t know for sure if these diets have a direct impact in the long term, and they’re hard to stick to, so I don’t recommend them unless a patient is insistent on trying. I also don’t want to promote faddy eating in young, impressionable women, who are already at a higher risk of eating disorders.13 (#litres_trial_promo) Low-carb diets also run the risk of resulting in a low-fibre intake, which is associated with a higher risk of PCOS.14 (#litres_trial_promo)To get enough fibre, you need to eat carbs. Carbs are not the devil, but the devil is in the detail. You need to eat good-quality, high-fibre carbs such as oats, brown rice and fruits and veggies that are also packed with other precious nutrients that your body needs for all the complex chemical processes such as ovulation. Good-quality fats (see here (#litres_trial_promo)) are also essential because female hormones are made from cholesterol that is a fat. If you don’t have the building blocks, you can’t make the goods. The Mediterranean diet really is the one that has it all (see here (#litres_trial_promo) for more on that).

Exercise Probably one of the questions I am most frequently asked online is: ‘What’s the best exercise for PCOS?’ And my honest answer is: the one you’re going to stick with – because dealing with PCOS is about being consistent. And exercise doesn’t have to happen in a gym either; so for many people, something as simple as going for a walk at lunchtime or getting off the bus a few stops early may be exactly what they need and what fits with their schedule. If you want to get geeky about it, one of the main aims of exercise for PCOS is to slightly alter body composition to increase lean muscle and decrease fat tissue (see Chapter 15 (#litres_trial_promo)). Muscle is much more sensitive to insulin compared to fat, and also needs more energy, so improves your metabolism.

Relaxation Life is stressful. Stress increases cortisol, which increases insulin resistance and testosterone levels. If you can remove the driver, you can break the cycle. Realistically, we can’t take all the stress out of our lives – and nor should we, as a certain amount of stress is good for us – but we have to look for ways to manage it. Depression and anxiety levels are also known to be higher in women with PCOS,15 (#litres_trial_promo) so self-care is very important. Exercise is a great way of addressing self-care and helping you to relax.

Sleep Lack of sleep makes you more insulin resistant, as well as causing cravings for sweet, fatty, high-calorie, low-nutrient foods and caffeine, all of which spike cortisol. And the vicious PCOS cycle continues to turn. I find that exercise helps me sleep better, so as you can see, all the things in this section go hand in hand.


Medication

This isn’t an exhaustive list, but these are the three types of medication that I get asked about the most:



The Pill The combined oral contraceptive Pill (COCP) will not ‘balance your hormones’. While it is entirely acceptable to use the Pill to ensure you have a regular monthly bleed, or as contraception, it will not treat the underlying cause of your irregular cycle. Once you decide to stop taking the Pill your periods will likely still be irregular, unless you’ve made some serious lifestyle changes. I see a lot of patients in clinic who are very disappointed to hear this as they’re under the impression that by using the Pill, their PCOS is cured; it isn’t. The Pill just forces the body to bleed on the week off.Many women are not keen on taking the Pill, but it is advised to have at least four periods per year to reduce the risk of the uterine lining becoming too thick and irregular which can, in the long run, increase the risk of endometrial cancer. The other advantage of the Pill is that it helps your body to make something called ‘sex hormone-binding globulin’, which mops up excess testosterone, so helping with acne and excess hair.

Metformin This is a diabetes medication that reduces insulin resistance. A lot of women tell me they hate it though because it can cause awful stomach cramps and diarrhoea. While metformin can be effective for improving ovulation, body weight and composition, it works best when used in conjunction with lifestyle modification.16 (#litres_trial_promo)

Inositol This is a dietary supplement that can be bought over the counter. Of all the many supplements that have been proposed for use in PCOS this one seems to get the most coverage online and, thankfully, has the biggest evidence base, relatively speaking. I’ve seen a really positive effect from inositol in quite a few women; however, although lab studies suggest it may reduce insulin resistance, and there has been a handful of small human studies to show it can improve menstrual-cycle regularity, reduce testosterone and even increase the chance of pregnancy,17 (#litres_trial_promo) there haven’t yet been any big trials to prove exactly how effective it is, the best type to use or the optimum dose, so it’s not something that’s routinely recommended by many gynaecologists just yet.


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

When should irregular periods be investigated?

There is no hard-and-fast rule. A sensible approach would be to see your GP if you are having periods less often than every three months, or if you’ve recently started having an irregular cycle. A lot of patients say they’ve always had an irregular cycle, but this should still be investigated as there may be a correctable cause.

I frequently receive messages from concerned mothers, such as: ‘My fifteen-year-old daughter has had irregular periods ever since they started three years ago and her GP won’t do anything about it.’ While it’s bound to be worrying, remember that it can be normal for teenagers to have irregular periods and may take about five years from when they start to settle down into a more regular cycle.


So it’s not always wrong to leave things alone to see if they sort themselves out, but it very much depends on what else is going on and what other symptoms she may be having, so do discuss this with your GP if you are worried.

Are there any health risks associated with hypothalamic amenorrhoea?

First and foremost, the thing that most women are worried about is fertility. If you’re not ovulating, you can’t get pregnant. So if you want to have a baby in the near future, you need to speak to your doctor as soon as possible.

One of the biggest risks with HA, however – and many women are not aware of this – is the risk of brittle bones and heart disease that can arise due to a lack of oestrogen, which I would suggest is just as important as your fertility. I’m really passionate about ensuring this message filters through. We often tend to focus on short-term, tangible outcomes, forgetting the things we can’t see. ‘I’d rather look shredded now and deal with my bones when I get older,’ one patient told me. But that’s the problem. You can’t deal with your bones later. Peak bone strength in females occurs around the age of thirty, and if you’re not building it in those crucial teens and twenties you can’t catch up later. Build it now, for benefits down the line.

Does PCOS increase the risk of ovarian cancer?

This is the thing that everyone worries about. PCOS itself does not increase your risk of getting ovarian cancer,


but obesity and diabetes, both of which are associated with PCOS, may do so. It’s important, therefore, to try and implement some of the lifestyle changes discussed here (#ulink_14660ab5-18bb-5782-96d9-a303b304461a).

PCOS does increase the risk of endometrial cancer (cancer of the lining of the uterus),


the greatest risk being to women who are less physically active, regardless of obesity or diabetes.


So anything you can do to increase the amount of movement you do may reduce your risk, irrespective of whether you actually lose weight,


which is another reason why I prefer to steer away from concentrating on weight loss as a specific goal.

I had a scan that shows I have polycystic ovaries – what are the implications of this?

‘Polycystic’ means having lots of cysts. With regards to your ovaries, this means you have loads of follicles that are trying to mature and break free. Up to 25 per cent of women have ovaries with a polycystic appearance,


and it’s particularly common in younger girls who have started their periods in the last few years because their ovaries are literally bursting with eggs wanting to get out. However, it doesn’t automatically mean you have polycystic ovarian syndrome (PCOS), if you don’t have any of the other classic symptoms (see here (#ulink_cb2e2f86-5f8b-5d99-be2a-6717593396cf)).



THE GYNAE GEEK’S KNOWLEDGE BOMBS

Irregular or absent periods cause so much anxiety, so I hope this chapter will have put your mind at ease, giving you a few areas of your life to re-evaluate if this is a particular problem for you. The most important takeaways here are:



Lazy ovaries do not exist. If you stop having periods it’s because your ovaries aren’t receiving the right messages from the brain, or other hormones are influencing their activity.

Premature menopause is very rare and unlikely to be the cause of irregular or absent periods, but it is very easy to check for with a simple blood test.

Your body is very clever and is able to stop your periods if you are stressed, overexercising or not eating well, as a survival tactic to conserve energy for things that are more important than making hormones.

The contraceptive Pill will not cure PCOS. It will merely cause you to have a period every month, but when you stop the Pill, if you haven’t made any lifestyle changes, your body will resume the same cycle as before you started it.

Lifestyle changes including diet, exercise and stress management can have a massive positive impact on PCOS. They also reduce your risk of complications such as diabetes, heart disease and female cancers.



CHAPTER 5 (#ulink_2cf3601e-9b37-510d-9ff9-5b51dd99cab2)

Heavy periods and other period-related frustrations (#ulink_2cf3601e-9b37-510d-9ff9-5b51dd99cab2)



‘I hate leaving the house on the first few days of my period because I’m so scared of leaking through my clothes.’

If you skipped the introduction to this book you need to go right back there and read the story here (#ua14a5b70-2a7e-5b14-9139-7747e979ce0a), which illustrates how horrendous periods can be and the dramatic impact they can have on women’s lives.

I’m sure you know someone who has terrible periods, but they may not talk to you about it, and, as a result, many of us don’t know what other people’s periods are like, or even whether our own are ‘normal’. As a result, many women feel ashamed, and so they suffer in silence, not leaving the house for the first few days due to pain or needing to change their pads constantly, or through fear of leaking.

There are a lot of things that can be done to improve the situation, but your doctor has to actually know that you are having problems, so don’t be afraid to go and talk to them about it. As doctors, we’re not fazed by things you wouldn’t dare tell anyone else, nor do we expect you to use any complex medical lingo. I can usually tell when a patient is shy and embarrassed, and try and use all the awkward words in my first few questions, just to prove to them that it really is safe to say whatever they want to.

My advice is to keep it simple by giving a basic explanation of what’s going on in language that you feel comfortable using and your doctor will use their expertise to ask you for more info.

Heavy periods

One in five women will experience heavy periods, also known as menorrhagia – literally, raging periods. Let’s look at what this means.

How heavy is heavy?

The textbooks state that anything over 80ml blood loss is classified as heavy. But what does that even mean? No one sits over a jug and measures it, and it’s incredibly difficult to quantify the amount on a sanitary pad or tampon. A more helpful way of classifying a heavy period would be any of the following:



Changing pads/tampons at least every hour for several hours in a row

Needing to use a pad and a tampon at the same time





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