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Episiotomy

When I was younger I remember hearing the word episiotomy in relation to childbirth but never really knew what it meant.  As I got older, I heard the word less and less often.  That is until my senior year of college when I got to know the meaning of the word quite well without actually experiencing it myself.  In one of my seminar classes, a classmate (a midwife by day) was telling the class about the term paper she was writing.  It was about the birthing practices of rural Nicaragua.  She worked in a tandem network of midwives both here in the US and in Nicaragua.  She said that the practice of episiotomy in the US was almost completely extinct but that it was still commonly used in Latin America.

In a class of about 11 women and 1 man (poor guy!), we all wanted to know more about this “episiotomy.”  So, in the spirit of that midwife taking her time to explain this practice I hope to impart a better understanding of the practice on you.

I have heard an episiotomy rather brutally and frankly described as cutting the vagina to make it wider for a baby’s head to pass through more easily during birth.  This is basically true but is not necessarily as barbaric as it may sound.  The cut is actually a type of surgery and it is done under anesthesia.

Most Western countries (United States, Australia, and Europe in particular) have moved increasingly away from using the episiotomy because of the complications it can cause.  A birth may progress without any need for the vaginal opening to be wider or the perineum (skin at the back of the vagina) may tear on its own.  This, too, is not as gruesome as it may sound.  A natural “tear” is often much shallower than an episiotomy.  Thus an episiotomy may take longer to heal and cause more complications.

There are two main types of episiotomies:  one is basically a straight, lateral cut from the vagina backward–this is called midline.  The other kind is is called medio-lateral and is cut at more of an angle away from the anus.

While there is certainly a time and a place for an episiotomy (as there is for a Cesarean section), I believe that natural tearing is preferable to episiotomy if possible.  The midwife I mentioned earlier explained this in an example I will never forget.  She took a piece of notebook paper and cut it halfway through with scissors.  “This is an episiotomy,” she said.  She took another piece of paper and tore it half way.  She said, “This is a natural tear.”  The torn piece of paper had all sorts of fibers and extra edges to it that the cut piece of paper didn’t have.  These overlapping bits provide a better opportunity to heal.  (Imagine trying to glue the cut piece of paper back–you couldn’t!  But you could with the torn piece of paper.)

Some studies show episiotomies, especially midline, cause greater complications even after the healing has occurred.  For instance, a woman can have trouble with sexual intercourse–it can be painful due to scarring and her vaginal walls can have trouble becoming lubricated.

There are certain therapies (such as massage and perineal dilation) than can help give the vagina preparation for birth that will make it less likely that a doctor will perform an episiotomy.  In any event, it is yet another complicated decision that a mother must make in the birthing process.  Hopefully this sheds a bit more light on it.  Have questions or comments?  Don’t be shy–dive right in!

I read in the news today about a report released a few days ago by the Centers for Disease Control (CDC).  The headline that emerged in numerous articles as a result of this report was that the use of the rhythm method to prevent pregnancy by teenagers rose from 11% in 2002 to 17% in 2010.  This is quite a jump.  The report was made to investigate why the teen pregnancy rate has risen markedly in recent years.  In fact, the United States has the highest teen pregnancy rate of any developed country in the world and one of the highest teen abortion rates.  So, I have decided it is time to tackle the issue of the rhythm method.

So, what is the rhythm method?  If there is such a great leap of teenagers responding that they have used it, it is pretty important for young women (you, the reader!) to understand what it is.  In general terms, the rhythm method is a means of birth control by which the female avoids sexual contact during the supposed window of fertility based on a calendric monitoring of her menstrual cycles.  In other words, if a young woman has a consistent 28 day menstrual cycle, she can estimate the days she will be fertile by following the “rhythm” of her menstrual cycle.  Here is an example of what a menstrual calendar would look like (with menstruating days in red and fertile days in green):

With perfect use, meaning that a young woman meticulously keeps track of her period without fail and strictly avoid sex on possibly fertile days, pregnancy still happens 9% of the time.  If you wanted to avoid pregnancy, would you really want to take a 1 in 10 chance?  But, keep in mind that virtually all forms of birth control are not used perfectly.  So, with typical use (a slip up here and there), the rhythm method results in pregnancy 25% of the time.  That is 1 in 4!  So, needless to say that the rhythm method is not a terribly effective means of preventing pregnancy.  Other factors make the rhythm method less reliable, especially for young women.  In particular, a woman’s period does not become regular (and therefore predictable) for quite some time after the first period, called menarche.  Hormones are in flux during adolescence and early adulthood, so the monthly time of fertility is particularly unpredictable for young women.  Other times in a woman’s life when the rhythm method is especially ineffective include just after giving birth (as hormones are again in flux), after discontinuing the use of a oral contraceptive (“the pill,” which manipulates hormones), and around the time of menopause when, yet again, hormones are in flux.  Hormones can be affected by a variety of factors including stress and emotions.  So, the rhythm method can never be 100% effective.

The rhythm method has generally been rejected as a useful means of birth control [page 375] (except, notably, by the Catholic Church) in the past few decades, so it is eyebrow raising that teenagers are suddenly reporting a significantly increased use of it.  The rhythm method was first proposed in the early twentieth century.  Before this time, the function of ovulation as the key to fertility was not yet understood.  When science could finally understand these processes, it was determined that in the normal menstrual cycle a woman ovulates once occurring about 14 days before the beginning of the next period.  When this was discovered, gynecologists promoted it to patients as a means to help promote pregnancy.  Some years later, in 1930, a Catholic physician in the Netherlands began to promote this as a means to help avoid pregnancy.  Catholic organizations in Europe and America also began to advocate this means of birth control throughout the 1930s.  By the 1960s, the popularity of the rhythm method as a means of birth control had begun to wane, especially with the introduction of the birth control pill in 1960.

Avoiding pregnancy is generally the point of using the rhythm method, but it extremely important to point out that the rhythm method in no way stops the spread of sexually transmitted diseases (and neither do birth control pills).  Condoms are the safest and most effective way to avoid spreading or getting a disease during sex.  Abstaining from sex altogether is the only 100% effective method of avoiding both disease and pregnancy.  So, if you are a young woman considering using the rhythm method, please keep all of this in mind.  If you have any comments or questions, I’d be glad to hear from you!

Something that has always stuck with me since Intro to Biology years ago was something my professor said: females are the prototypical human sex. In other words, we all start out as females in a sense. It is not until around the 8 week benchmark in fetal development that a fetus starts to develop distinct sex characteristics. Generally speaking, from the moment of fertilization the embryo has an innate genetic sex (XX in a female; XY in a male). However, if you were to see a fetus before the 8 week mark, you would see that the genitalia is undifferentiated between XX and XY. That means that a female fetus and a male fetus look the same between the legs, so to speak.

So, why is that?  Why do female and male genitalia not differentiate from the moment of fertilization?  And what causes the differentiation when it happens?  And what did that professor mean by saying that females are the prototypical humans?  Well, it all has to do with the Müllerian ducts and hormonal reactions during pregnancy.

The Müllerian ducts are a set canals in the urogenital region of an embryo (that is, where the urinary and genital structures develop).  Depending on which way sex differentiation goes, the Müllerian ducts develop into the Fallopian tubes, uterus, and upper part of the vagina or they will begin to disappear leaving only small vestigial remains.  (The male reproductive organs develop out of the adjacent Wolffian duct.  These ducts begin to disappear during sex differentiation in females.)  Here is a diagram:

For reference, here is a list of homologous human reproductive structures (for instance, before sex differentiation, the scrotum and the labia majora are one and the same).

It is around this 8 week period that hormones are released from within a male fetus from the testes (from cells called Sertoli cells).  This is called the anti-Müllerian hormone.  The chromosomes of a male fetus receive this hormone and react by impeding the development of the Müllerian ducts.  In a female fetus, the chromosomes do not exist so the Müllerian ducts continue to develop.  From time to time, the necessary chromosome to inhibit the development of the Müllerian ducts in the male are missing.  (Remember that human chromosomes are incredibly complex, so when DNA is being “written” sometimes it can make a “typo.”)  When this happens, the fetus continues to develop the Müllerian ducts.  So, the genetically male fetus begins to grow a uterus and sometimes other female reproductive structures.  Usually, the testicles do not descend but a penis will still be present because it does not develop from the Müllerian ducts.  This is one of the many complications of determining sex at birth.  It may not be immediately clear what the child’s sex is.  This is called Persistent Müllerian duct syndrome (PMDS) and can also result as a failure of the testes to ever secrete the hormone.

So, going back to the words of my professor, all humans begin as embryos with the same “feminine” appearing genitalia.  This is why he says, with glee, that females are the prototypical humans.  Keep in mind all that the ancient Greek philosophers argued (and Freud, for that matter) that men were the essential human form and that women are defective versions of males.  Turns out, that all men start out as women in a manner.  There is a lot more to be said on this topic, but I will stop here for now.  Use the information you have learned here to impress your friends and put any obnoxious men in their place.  Please feel free to leave comments and questions.

Endometriosis

In the past two weeks, I cannot tell you how many times I have heard someone mention in conversation “endometriosis.” I have several friends and family members who have endometriosis, so it is not an altogether unfamiliar subject to me. However, I have never given much thought to endometriosis.   So, in writing this blog entry I hope to educate both myself and my readers a bit.

To start with the root, the word endometriosis comes from the Greek words meaning “inside” and “womb.”  Remember that the endometrium is the layer lining the uterus.  Here is a diagram:

The endometrium is where the embryo implants after it has been fertilized, so it is an integral part of reproducing.  Without a healthy endometrium, an embryo is not likely to implant successfully.

Interestingly, too many endometrial cells are a bad thing, and this is what endometriosis is:  the proliferation (spread) of endometrial cells outside of the uterus, especially common on the ovaries.  These cells respond as the endometrium does to hormonal changes over the course of a menstrual cycle.  So, imagine that you have endometrial cells throughout your pelvis and not just in your uterus.  Menstrual cramps would be amplified–the pain difficult to bear.  So, if you have particularly unmanageable menstrual pain during your period, please visit your doctor.  You may have a disorder such as endometriosis.  Only investigation by a medical professional can determine the source of the pain.

It is estimated that between 5-10 percent of women are affected by endometriosis.  Its effects generally do not manifest until menarche (first menstrual cycle) and usually diminish following menopause, though not always.  A large number of women who are infertile are infertile because of endometriosis (about 20-50%).  The proportion of women with chronic pelvic pain who suffer from endometriosis is much higher (about 80%).  There seems to be an increase in incidence of endometriosis in families that affected by it.  Women with an immediate relative with endometriosis has a higher risk of having endometriosis.  There is some association between endometriosis and certain types of cancer (especially ovarian), so it is important to know if you have endometriosis or if you have another malady with similar symptoms.

Endometriosis usually appears in patches within the pelvis that are often visible to the human eye during surgery because they can appear as darkened bluish-black spots.  Here is a diagram example of endometriosis:

Not all endometriosis appears as darkened spots, so it is necessary sometime to perform biopsies to be certain.  Endometriosis causes an inflammatory response that often causes scar tissue.  This scar tissue is frequently problematic in a variety of ways, including being the cause of infertility.  The cause of endometriosis is, so far, unknown but it is believed that there is more than one possible cause.  Hopefully, further research will uncover causes that can help in management and treatment of the disease.  Symptoms, too, can vary widely across endometriosis sufferers.  Abdominal pain being the most common symptom, others include:

  • nausea, vomiting, fainting, dizzy spells
  • frequent or constant menstrual flow
  • chronic fatigue
  • heavy or long uncontrollable menstrual periods with small or large blood clots
  • mood swings
  • pain in legs and thighs
  • back pain
  • mild to extreme pain during intercourse
  • mild to severe fever
  • headaches
  • depression
  • Again, it is important to remember that other disorders can have similar symptoms to endometriosis.  It is crucial to consult a doctor if you are experiencing problems in order to accurately determine what you have.  Never rely on an “Internet diagnosis.”  This article is just scratching the surface of this topic (maybe I will write “Endometriosis:  Part 2”), so please feel free to leave comments and questions!

    Vulva

    I live!  I apologize greatly for such a prolonged absence, but it was important for me to focus these months on school.  It has paid off because as of today I hold a Master of Arts degree in Bioethics and Medical Humanities.  Hurrah!  Now, I hope to devote the proper amount of time to this blog.  I began writing an article about the vulva before my hiatus and decided to finish it for my return.

    So, what is the vulva? What’s the difference between the vulva and the vagina? Isn’t it all just one, connected thing down there? Why are there different names if it’s just a vagina, after all?  What does the vulva do?  All good questions. All questions I hope to answer.

    The word vulva comes from Latin and was used to mean “womb” or, more generally, “female genitals.”  In modern usage, the word vulva refers specifically to the the external genitals of the female.  The word vagina is often used as a catchall term to refer to both the internal and external reproductive organs of a female; however, to be completely correct, the vagina is an internal structure only and the vulva is the external structure only.  These external components that make up what we call the vulva include the clitoris, the labia majora and minora (outer and inner lips), the pubic mound (mons pubis), the vestibule of the vagina (the area inside the labia minora that includes the openings for the urethra and vagina), and the vaginal orifice (the actual opening of the vagina).

    Here is a diagram:

    Its development occurs during phases, particularly the fetal and pubertal stages.  As the entrance to the reproductive tract, it protects its opening by a “double door”:  the labia majora (large lips) and the labia minora (small lips).  The vagina is a self-cleaning organ with an environment that promotes healthy microorganisms that balance each other out and guard against invading, unhealthy elements.  Cleaning your vulva is important to gynecological health.  Simply use warm water and mild soap on a daily basis.  (Remember, this is for external use!)  It is unwise to use heavily perfumed soaps as they can irritate your vulva.  It is also unnecessary to douche unless a doctor specifically recommends it.  Douches can cause irritation and flush out those healthy microorganisms allowing for infection to set in.  The vulva is more vulnerable to infections than the external genitalia of males.  So, take good care of it.

    The vulva is key to sexual functioning.  The external structures of female genitalia are very full of nerve endings allowing for pleasure when properly stimulated.  When aroused, the vulva undergoes several physical changes it making it one of the external signs that a woman is aroused.  First, moisture from the vagina reaches the vaginal orifice, moistening the vulva.  The labia majora become enlarged and spread apart somewhat and can change color somewhat (darkened from increased blood flow).  The labia minora and the clitoris also increase in size.  During orgasm, the various muscles contract, though most of these contracting muscles are not located in the vulva.  Following orgasm, stimulation of the vulva may be uncomfortable or even painful.  The increased blood flow slowly dissipates until the vulva returns to normal.

    The vulva performs different functions than the vagina, thus it is important to know the difference between the vulva and the vagina.  Especially if you are talking to a medical professional, be sure to clarify whether you mean the internal structures (vagina) or the external structures (vulva).  Have anything to say about vulvas?  Have you say and leave a comment!

    Haiti

    Dear readers,

    I know that most of you have been inundated recently with the news of the earthquake in Haiti and appeals to send aid, especially in the form of monetary donations.  Normally, in such a case, I would leave well enough alone–but Haiti is different.  Haiti is usually designated the poorest nation in the western hemisphere.  Haiti has had a long and sordid history with other nations that has usually left Haiti worse off than previously.  The world has not been kind to Haiti and now a crippling earthquake has destroyed much of Haitian society.

    I am especially interested in Haiti because of the work of an organization called Partners in Health.  I read a life changing book called Pathologies of Power a few months ago by Dr. Paul Farmer.  He co-founded Partners in Health, is a professor at Harvard University, and is the United Nations Deputy Special Envoy to Haiti.  His work (written and and on-the-ground) is inspiring to me as a student of Bioethics.  Partners in Health administers 10 health care facilities in Haiti (outside of Port-au-Prince) based on a model of critical consciousness.  In other words, the aid provided is that which they (the locals) decide they need rather than what outsiders deems appropriate.  This is a highly successful and respectful means of ensuring the dignity of individuals and their culture, and the success of care provided.

    Now that this earthquake has devastated Haiti, the facilities run by Partners in Health are still standing and functioning–and, indeed, they are likely the largest single provider of health care at this point in Haiti.  Because their facilities are located outside of Port-au-Prince they stand to be able to do more for the thousands of injured in Haiti than virtually anyone else.  I myself have donated to Partners in Health because they need supplies now more than ever.  I implore of you to please follow the link below and spare what money you can–even if it is only a few dollars!–to a very worthy organization.  Please help your fellow man out in such a terrible time.  Thank you for reading–and please donate!  Tell your friends!

    http://act.pih.org/page/outreach/preview/haitiearthquake/sjbodell

    Temporary Hiatus

    Due to several unforeseen circumstances I have not been able to update this blog since the semester began. Unfortunately, I think that pattern will hold until the semester ends in December/early January. Hopefully, I will be able to update more regularly then. Until then, I apologize for the lack of time that prevents me from bringing you any new posts. Although, if it gives you something to look forward to, I plan to write the next blog post about endometriosis. Keep your ears and eyes open! Feel free to leave any comments you might have. See you on the flip side.

    Doula

    I worry sometimes that because I myself have not experienced pregnancy that I might ignore the “obstetrics” portion of this blog. I hope that is not the case because many young women are dealing with pregnancy (before, during, and after). So, to try to balance this blog I am going to write about a very important topic to childbirth–doulas.  (And I dedicate this article to all my friends who have given their time to serve women as doulas.  We all thank you.)

    A doula is person, most often a woman, who provides support to a woman during pregnancy, during delivery, and/or after birth.  A doula does not act in a medical capacity in supporting the mother.  Rather, it can be said that a doula’s main role is to provide informational, physical, and emotional support.  A doula is usually a person trained to be knowledgeable about the entire process of birth. The history of the word “doula” is interesting and points to its current meaning and usage.  It is an ancient Greek word that means “woman of service,” but in its historical context connoted “slave-woman.”  (For this reason, some modern-day doulas prefer to use terms such as birth companion to avoid this negative connotation.)  So, essentially, a doula is there to help the mother in any capacity but is not there to make decisions for her.

    Studies show that doulas play a very positive role during delivery and in postpartum circumstances.  Births in which a doula is attendant are shorter than those births unattended by a doula and are also less-likely to use or need pain medications such as epidurals.  Babies born to mothers assisted by doulas are more likely to be born healthy, without complications, and are more likely to successfully breastfeed.  In most countries, there are no formal or legal certifications required of doulas, though most doulas do go through training and are aligned with a doula registry.  In the United States the most prominent doula registry is DONA International (Doula of North America).  From their website, you can read much more about doulas and their services and look up doulas in your area.  If you are looking for a doula, I also recommend searching the web with your town’s name and “doula” in the search phrase as many doulas have formed smaller, local organizations.

    If you are more interested in seeing a doula in action both during  birth and postpartum, I recommend watching two television shows on TLC.  The first is A Baby Story.  Many of the women delivering babies in this series employ a birth doula.  The second show is Bringing Home Baby, which documents new parents bringing home their babies many of whom employ a postpartum doula who assists the mother in adjusting to motherhood often including lactation and breastfeeding advice.  Doulas are useful for all mothers, not just first time mothers.  Think about the assistance needed by a mother of more than one child when delivering a baby and bringing it home from the hospital.  In all, I think doulas are a integral tool to birth, providing valuable information often neglected by doctors and other medical staff.  They are immensely helpful after birth in helping the mother adjust to life with a new child.  If you are expecting, at least look into the idea!  Have questions, comments, or otherwise?  Please don’t be shy.

    Vaginismus

    My apologies for an absence! There were finals, work, a brief foray at an ivy league university, and two family emergencies–and my birthday was a week ago. Time marches on. Now I am back to talk about a subject I know quite a bit about–vaginismus.

    Vaginismus is a disorder of the muscles in the vagina, specifically of the pubococcygeus muscle or PC muscle. The PC muscle controls urine flow in both women and men and is the muscle targeted by the popular Kegel exercise. The PC muscle is also very important to childbirth.  With vaginismus, the PC muscle reacts to stimulus by becoming spastic and wildly contracting, which the woman cannot control.  Stimulus that causes this reaction can include any sort of vaginal penetration from sexual contact to the insertion of a tampon to a gynecological exam.  These spasms are completely involuntary and are said to be like an eye blinking when an object comes too near it.

    Vaginismus is most usually caused by trauma to the vagina or psychological trauma connected to the vagina.  For instance, an invasive and painful surgical procedure or childbirth could cause vaginismus.  Rape very often causes vaginismus because of the combined physical and psychological trauma.  Other, less personal forms of psychological trauma could cause vaginismus such as hearing that initial sexual activity is painful and therefore forming a fear (whether realized or not) of penetration.  Sometimes, vaginismus is a result of generalized trauma or stress that is unrelated to the vagina or sex.

    The PC muscle reacts to this physical-psychological impetus by forming an automatic response to all contact.  This reaction makes sexual activity for a woman painful and oftentimes impossible.  Estimates of how many women suffer from vaginismus vary widely because so many women who have it are unaware of it what it is.  In any event, vaginismus is more common that most realize probably affecting 5% or more of the female population.

    Treatment for vaginismus is most effective when it takes into account both psychological and physical factors.  In this treatment, the woman consults a therapist to work through feelings towards sexuality and vaginal penetration to remove the negative associations attached to them.  Additionally, the woman physically conditions her PC muscle to be less spastic.  These methods vary, though the most common is probably dilation therapy.  With dilation therapy, the vagina is slowly desensitized to penetration by inserting dilators that increase in size.  Dilators do not harm sexual sensitivity, but rather allow the PC muscle to build up a stimulus memory in which it does not spasm.  A relatively recent treatment for vaginismus is the use of Botox injections to relax the PC muscle to prevent spasms.  Studies have shown that it is highly effective against vaginismus but dilation therapy combined with psychological therapy is still the standard for most sufferers.

    So, whether you have heard of vaginismus before or not, it is an important and under-discussed gynecological subject.  Please take the time to talk to your girlfriends and family members about what you have learned about vaginismus.  By spreading the word, more women will feel more confident about seeking treatment for this disorder that, if treated, is highly combatable.  Have any questions or something to add?  I’d love to hear from you!

    Blog news

    Greetings all! I recently received an honor by being invited to be a featured HealthBlogger in the Women’s Health Community at Wellsphere.com. That’s quite exciting to me because I love being able to write a blog that might help someone out in some way. So, thank you all for reading. Being a HealthBlogger for Wellsphere won’t affect a thing in how I contribute to this blog–it just means the blogs I write here will be passed along to others in the Wellsphere community. Look at the cool badge I got:

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