The dirty 'M' word: Miscarriage

This week is National Baby Loss Awareness Week. The campaign runs every year from 9-15th October, and aims to start a national conversation about pregnancy loss due to miscarriage, stillbirth and infant death. 

Miscarriage still seems to be on of the biggest social taboos, yet affects about one in 4-5 pregnancies end in miscarriage; around 250,000 in the UK every year, with 80% occurring before 12 weeks. Yet a surprising number of women do not talk to their family or friends about their experience. Many patients I meet feel so alone because they think it's only happening to them. In a society where people are willing to go on TV programmes to talk about their sex lives and their labia, why is a topic such as miscarriage such a taboo?

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Every week I meet countless women who are going through a miscarriage, or who have had one or more in the past. Each and every women has a different reaction and coping mechanism. A patient I saw recently gave me an interesting insight into how she was coping...whilst preparing her for theatre for surgical management of her miscarriage I asked her why she had opted for an operation over medication to help the body complete the miscarriage. She told me in a very matter-of-fact manner that it meant she could go back to work straight away and therefore wouldn’t have to tell anyone what had happened. And not because she didn’t want her colleagues to know she was trying for a baby, but because she ‘didn’t want anyone to feel uncomfortable’. It struck me as an ironic situation that this woman, going through probably one of the worst experiences of her life, was so concerned about upsetting anyone around her.

Why do we as a society flinch so much at a natural, and quite frankly frequent occurrence? Why should these women, and in fact men as well, feel they have to hide their experience like a dirty secret? A greater proportion of women can look me in the eye and tell me they’ve had Chlamydia than a miscarriage. Of course it is painful to talk about, especially to a relative stranger. But from my experience, I believe that some of these women feel ashamed, and many have a lingering doubt that they may have done something to cause their miscarriage, even years and years after the event. It’s probably the question I get asked the most...”What could I have done to prevent this?”. The honest answer: absolutely nothing. In the vast majority of cases, miscarriage happens due to an abnormality with the pregnancy, rather than a problem with either parent or any kind of wrong-doing. So it’s usually natures way of sorting out a pregnancy that would not be healthy. In a world where we are so in tune with our bodies and our health, I often find it quite difficult to explain to women that I can’t tell them exactly why their miscarriage has happened, because even with the most advanced technology it's impossible to determine the cause in most cases. But I always try to take the time to reassure them that they are most certainly not to blame. Until we can support these women and their partners to remove this feeling of guilt, and explore other factors preventing them from speaking out at the point that they feel ready, we are not going to be able to break the taboo and talk openly about miscarriage.

Tonight you can join the wave of light at 7pm local time and light a candle and leave it burning for at least an hour to remember all the babies who left us too soon.

What is endometriosis?

"en- doh – mee – tree – oh – sis"

It's not a song, it's a very common, and often debilitating condition that is not commonly talked about but is finally getting some airtime today, because the National Institute for Health and Care Excellence (NICE) finally issued the first ever national guidelines on diagnosis and treatment.

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But what is this disease? It is defined as the growth of endometrial tissue (lining of the womb/uterus) outside of the uterus, on areas such as the ovaries, bowel, bladder, pelvic side wall and even liver and lungs, known as ‘endometriotic deposits’. During a normal menstrual cycle, the endometrial tissue thickens in response to female hormones and is then shed as a period. The endometriotic deposits still respond to these hormones, so also grow and shed with your cycle, however the blood cannot escape, and causes irritation and inflammation of the inside of your abdomen – think lemon juice on a papercut, times it by several hundred and do it every month….it’s no wonder that centuries ago women were diagnosed with ‘hysteria’ because the pain can be so extreme that even the toughest cookie would be understandably hysterical at times. As well as incredibly painful periods, they tend to be heavier, and can cause anaemia due to the heavy blood loss. With this ongoing cycle of inflammation, scar tissue can develop inside the abdomen, resulting in ongoing pain even when it’s not ‘Ladies Week’. This is because the scar tissue can cause the pelvic organs including uterus, bladder and bowel to get stuck together, which can result in pain on going to the toilet (for a number one and/or two), and also dreadful, deep pain during sex. I was listening to Radio 5 live this evening, and a total legend of a guy called in and was talking so openly about his sex life with his wife who has endometriosis, and how he felt so responsible for her pain. I don’t have endometriosis, but I’m just depressed writing about it, and therefore it’s unsurprising that women with the disease have a much higher chance of depression, but that awesome guy on the radio highlighted that endo can have psychological implications for men too. Most shockingly though, endometriosis is INCREDIBLY common; it affects 1 in 10 women.

 

As with many medical conditions, there were a couple of blokes squabbling over who was the first to describe in around the 19th century, but there is even mention of the condition and its symptoms in the Hippocratic corpus which contains works from the 4th and 5th centuries BC. So if it’s not a new condition which affects 10% of women, why are many of you hearing about it now? The report highlights that the disease is poorly diagnosed. This is due to several reasons, including absence of any national guidelines (which is what has thankfully been published today) but also due to lack of awareness amongst both patients and I’m ashamed to say, doctors. It’s quite difficult to change peoples opinions, as I hear many unfortunate stories of women being dismissed, but it’s easier to raise awareness, increase knowledge and empower women to actually stand up and say ‘something is not right…’ Some women will have symptoms of endometriosis right from their first ever period. I’ve met patients who came to the hospital after years, if not decades of dreadful symptoms, and I’m always so saddened when they say ‘I just thought periods were meant to be like this…’ We need loose the shame of talking openly about periods so that women realise their body is trying to tell them there’s something funky going on inside. It's refreshing to see lots of people opening up about their endometriosis today on social media, in light of the media coverage, so hopefully even more women will feel more confident to go and speak to their GP about their symptoms. There are also lots celebrities who have the disease, and Lena Dunham in particular is refreshingly open about it.

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There is so much to cover on this topic, and I haven't even touched upon ways of diagnosing or treating the disorder, which I will be doing over the coming weeks and months. But for now my take away message is that having painful periods or pain during sex is not something that you have to put up with, and something you should definitely go and talk to your GP about. These symptoms do not always equal endometriosis though, and other conditions need to be explored which is why you need to go and talk to a professional. It breaks my heart when I see so many women saying they were dismissed by their GP. Again, a lot of this may be due to poor awareness of the disease by doctors, but we have to remember that GP’s do an amazing job at diagnosing and treating so many conditions. All GP’s will have had a slightly different education and experience, so some doctors will be great at recognising the possibility of endometriosis, whereas others may not. Therefore you must remember if you’re not happy with the outcome of your consultation, you can always go to see another GP in your practice. It’s very difficult to be confident and stand up when someone tells you it’s fine and you know it’s not. But you just have to.

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And as always ensure you’re getting information from the right place. A recent study of the reliability of information obtained from googling the term ‘endometriosis’ was carried out by some gynaecologists in the UK and found many websites to be of poor quality, or inaccessible to the non-qualified reader. So always make sure you got to a reputable source if you want more information. Endometriosis UK is a favourite of mine.

The humble condom

This weekend is the last official weekend of the Summer, plus it’s carnival, but what could this possibly have to do with condoms? If you’re looking for some last minute summer fun, a condom should be one of your top 3 accessories.

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They are the most effective way of preventing sexually transmitted diseases, which coincidentally are at the bottom of the ‘hottest summer accessories’ list. Many people seem to forget about STI’s and only focus on preventing pregnancy when thinking about contraception. However, the number of people getting STI’s is sharply on the rise, and you trust me you don’t have to be promiscuous to get one. I always say to my patients ‘you have to remember that you’re not just sharing germs with the person you are sleeping with, but also with every person they’ve ever slept with, and the people they slept with too…’ I get a lot of grossed out faces, but it’s food for thought, isn’t it? Whilst many STI’s are quite simple to treat they’re often asymptomatic, so can go untreated for a long time, and can have major long-term health consequences, particularly where future fertility comes into question. Condoms do of course also prevent pregnancy though. On the effectiveness scale for pregnancy prevention however, they’re pretty mediocre on paper. Male condoms are 82% effective with typical use, and this rises to 98% with perfect use. This is compared for example to the pill which with typical use is 91% effective and over 99% with perfect use. But how can this be if I’m singing their praises?

It’s all about how you use them.

 

According to a study in the US, the commonest condom-related error was putting the condom on upside-down and then flipping it over, closely followed by taking it off too soon, and then putting it on too late. Disregarding the second factor of taking it off too soon, which slightly baffles me because its seemingly obvious it won’t work, the reason the first and the last factors will reduce the efficacy of condoms is because pre-ejaculatory fluid from the penis, that can be so small you might not even notice it can actually contain semen. A pretty interesting study was performed to demonstrate that 31% of pre-ejaculatory fluid contains healthy, motile sperm (ie. the type that is ready and willing to brave the river rapids of the vagina and cervix to make it to an egg that’s floating along the lazy fallopian tube river, fertilize it and implant in the lush, pillowy lining of the womb to make a baby), so using the ‘condom flip’ or the ‘sorry I’m a bit late to the party’ condom are essentially like not bothering with one at all on one in three occasions. This is another reason that the withdrawal method is so darn ineffective. From my experience of patients, and also acquaintances I have come to realise that a surprising number of people use this contraceptive method, even people that I would have regarded as ‘too sensible’, and I do wonder whether many people realise it’s only about 74% effective. A pretty shocking study in the US recently showed that 60% of teenagers in the US were using it as their primary form of contraception, and even 30% of older, probably should know better, women. Maths isn’t my strong point, but over half of teenagers, using something that only works 3 out of 4 times…sounds like a lot of unplanned pregnancies to me. Whilst some news websites were writing stories along the lines of 'withdrawal method as effective as condoms', this again relates to the fact so many people are using condoms incorrectly, so their efficacy rates could be greatly improved with greater awareness of this.

 

So why are so few people using reliable contraceptives? A lot of people lately don’t want to use hormonal contraception due to fear of short- and long-term side effects, so condoms strike me as the obvious hormone-free, side effect choice. There is a lot of embarrassment surrounding their purchase, and there doesn’t really seem to be any consensus on whose role it is to buy them. Is it the man, or is it the woman? If you’re in a responsible adult relationship then contraception should be something that you should be able to discuss openly. It’s quite clear that it continue to be a taboo subject in society, and I know a lot of people blush when I ask this question at work for medical purposes.

 

Some very forward thinking people are doing a great job at taking the embarrassment out of buying condoms, and doing monthly subscriptions, so you can now get your condoms delivered alongside your organic veg box (oh too many aubergine emoji jokes…) Hanx is the new cult condom brand, run by a dynamic female duo who were fed up of buying condoms aimed at men so set about making a condom designed by women. The result; a sleek and discretely packaged 100% natural Fairtrade vegan latex condom that is now available from Coco De Mer, Wah and online at hanxofficial.com, including as a subscription. I didn’t even realise that normal latex contains animal products; casein, a protein derived from cows, is used in the production, so these vegan condoms are great if you want to steer away from animal products for ethical or sustainability reasons. Plus the natural latex doesn’t have that traditional condom smell that can also be quite off-putting. Sounds intriguing right? Give them a go using the discount code “GG20” for a 20% discount.

 

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And being vegan doesn’t make them any less effective. We all know what happened in the film Bridget Jones’s Baby, but remember her vegan condom was expired, so don’t forget to check the expiry date.

 

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Now I’m going to let you go and get on with your bank holiday weekend. Have (Safe) fun!

Please note, this is not a sponsored post and all views are my own.

Vaginal seeding after Caesarean Section

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About one in three babies in the UK are born by Caesarean section; half of these being planned and half being performed as an emergency, due to concerns for the wellbeing of the mother or the baby during labour. Over the last decade there have been concerns raised that children born by Caesarean section are at a higher risk of immune-related diseases such as asthma, type 1 diabetes and inflammatory bowel disease, as well as obesity.

Whilst there may be many confounding factors explaining these associations, one of the plausible mechanisms may be that babies born by C-section are not exposed to vaginal bacteria in the same way as babies born vaginally. The vaginal microbiome is one of my main research passions (yep, that’s right, I love exploring vajayjay bugs), and something I have previously written about if you want a refresher. It’s thought exposure to this bacterial population colonises the baby, which has an impact on the bacteria that it subsequently goes on to carry, and can in turn programme its immune system, hence the impact on future disease outcomes for the baby.

A very simple way of overcoming this would be to use vaginal seeding, which involves putting a swab into the mothers vagina to collect bacteria and then lying it over the nose and mouth of the baby during the first moments of life, to simulate the inhalation and swallowing of vaginal bacteria that takes place during a vaginal delivery. Sounds pretty simple and harmless? We’re not really sure. Whilst there is currently one rather encouraging published study describing the use of vaginal seeding, the authors only describe its use in four patients. That’s right. FOUR. In spite of this, there has been a wave of future parents requesting vaginal seeding to be performed by their obstetricians and midwives, which was highlighted in a paper that was published in the British Journal of Obstetrics & Gynaecology this week. Whilst the paper doesn’t add any new data, it is a pertinent reminder to expectant mothers and healthcare providers that we really don’t know enough about the safety to be able to give any evidence-based recommendations. The main concern is that seeding could introduce disease-causing bacteria, such as Chlamydia, group B Streptococcus and E.coli, which can live harmlessly or without symptoms in the mother but cause major infections and life-threatening sepsis in the newborn. Of course, potential mothers could be screened for these bugs, but we have to remember that we still don’t fully understand the role of certain common vaginal bacteria in mothers, nevermind their effect on the health, and immune programming of the baby. Lactobacillus iners springs to mind at this point. Lactobacillus is generally regarded as a ‘healthy’ group of bacteria, but there is a lot of debate as to whether the L.iners variety fit in with the rest of the healthy gang. As you can see, there are knowledge gaps to fill. There is currently one clinical trial underway in the US exploring the safety and efficacy of vaginal seeding, and there are countless other studies underway aiming to try and understand the role of the vaginal microbiome in the short- and long-term health of babies, so I’m sure there will be plenty of really interesting answers coming over the next few years.

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The paper in the British Journal of Obstetrics & Gynaecology also highlights that other studies have shown maternal diet during pregnancy, breastfeeding and early skin-to-skin contact can also have a major impact on health outcomes, so mode of delivery is probably just one part of a bigger picture. Of note, Caesarean section does not rule out early skin-to skin contact as many people may think. As soon as the baby has been delivered and a midwife or paediatrician has determined there are no immediate health concerns for the baby skin-to-skin contact can begin, and I’ve certainly closed a lot of Caesarean wounds with babies rustling in the drapes above, probably looking for some of that oh so intoxicating boob juice.

For now though, if you have to have a Caesarean section

1.     please don’t see it as a failure on yourself as a woman

2.     remember that the type of delivery is one part of a big picture that dictates health outcomes for your child

3.     the data is lacking regarding whether or not it’s safe to do vaginal seeding, so it’s probably best avoided until that data is available.

Natural contraception: does it actually work?

Now I’ll be honest, I know nothing about clothing fashion, but I know a thing or two about contraceptive fashion. And it’s fair to say, in central London at least, the contraceptive pill really seems to have had its day. This is of course my anecdotal evidence only, but lots of people say it’s because they want to consider hormone-free options. There are several hormone-free methods of contraception out there including the copper coil and the good old condom, but it’s natural family planning methods that is getting a lot of social media attention. There is also a particular app, called Natural Cycles that has a lot of bloggers and influencers singing its praises. But is natural family planning actually any good?

 

Natural family planning, also known as the fertility awareness method (FAM) is not a new concept at all and it’s been around for centuries. The aim of the game is to understand your menstrual cycle to begin to predict the fertile period, and avoid having sex at that time. You’ll probably remember from biology classes at school that the menstrual cycle is 28 days long according to text books. That means of day one is the first day of your period, your next period will start exactly 28 days after that. In this scenario, ovulation should occur on day 14, and when the egg is released it can survive for up to 24 hours and if its isn’t fertilised it dies. However, the fertile period technically begins 5 days prior to ovulation, because sperm can survive for up to 5 days in the human body, and therefore this fertile window is actually 6 days long, from day 9 to day 15 with a 28 day cycle, and if you want to avoid pregnancy you would need to either abstain from sex, or use condoms during these 6 days. Using this method alone, about 25% of women will get pregnant in a year. Errrrrrm…One. In. Four. As you can see, the odds of getting pregnant are about the same as the bookies favourite winning the Grand National.

 

So what about Natural Cycles? It’s the only ‘certified contraceptive app’ and if influencers with tens of thousands of followers are saying it’s the way forward it must be legit right? Well, in my opinion, it’s not wrong but there are some caveats that I want you all to be aware of.

When you subscribe to the app, you are supplied with a thermometer. By taking your temperature every day and putting this into the app along with the dates of your last periods this improves the accuracy of predicting ovulation, based on the rise in basal body temperature of around 0.3°C that happens at the time of ovulation. Based on this information the app with give you a result for that day; either green (safe to have sex) or red (don’t have sex, or use a condom). For the average user, with an average 28 day cycle, the manufacturers state that you should eventually get about 10 red days, because the app uses a very conservative estimation in order to improve the effectiveness at preventing pregnancy, which with typical use is 7.5% in a study of 4054 women. It’s important to note here that the typical use pregnancy rate for the pill is 9% and condoms are 15%. So if Natural cycles is numerically better, why do you get the feeling I’m about to tell you proceed with caution? Firstly, if you actually take the pill properly the failure rate is only about 0.5%, and if you put a condom on before you have any genital-genital contact and it doesn’t slip off or break the failure rate is about 2%, and this is called perfect use. The studies on natural cycles state with perfect use the failure rate is also 0.5% like the pill, but that’s only based on estimates of how often the app would wrongly attribute a red day as a green day. But you have to remember, we are humans, and not mathematical algorithms. So why would the app get it wrong? Many reasons. These include; not taking your temperature at the same time every day, having a temperature due to illness, being on a different time zone that affects your circadian rhythm, or you just happen to ovulate on a day the app didn’t predict. And the latter may be surprisingly common. There are plenty of reasons why ovulation doesn’t occur on the predicted day, and that may be because you’re stressed, you overtrained, you have a poor diet, you had a disrupted sleep cycle, you were jetlagged….the list is endless. Or maybe you have an irregular cycle, which isn’t a contraindication to using these types of fertility awareness methods, but it means that natural cycles for example would give you a LOT of red days. So that’s lots of days when you’re keeping those legs closed, or popping out to stash up on rubber johnnie’s (do the kids even call them that these days?). Basically if you ovulate earlier than expected and you’ve had unprotected sex within 5 days you are at risk of pregnancy because the rise in temperature only happens on the actual day of ovulation so the app won’t be able to protect you.

 

So in summary, the app will work as contraception if it correctly calculates the day that you ovulate, and you either use a condom, or don’t have sex on the red days. I also truly believe that it’s only really suitable as a contraceptive for women who would not be devastated if they did get pregnant. I certainly don’t criticise anyone who does want to use these apps as their contraception, but I do believe in helping people making informed decisions. Personally for me it would not be reliable because I work nights, am frequently stressed and have terrible sleep hygiene.

 

One thing I do really think Natural Cycles is great for is helping you to get to know your menstrual cycle, which can be really empowering for women and also really helpful if you’re thinking of trying to get pregnant in the near, or medium-term future. Plus if you’re actively trying to get pregnant, you can use the app the opposite way round and use it to help you work out when you’re fertile, so that you can arrange plenty of date nights during the red times (*insert winking emoji).

 

On a final note, there are other contraceptive apps out there (although most are far less effective, and an interesting study showed exactly how ineffective they can be), but Natural Cycles is the one I’ve seen people talking about most on social media, which is the reason I chose to talk about it, mainly to reinforce my final message is that you have to be careful who you trust on social media. Always check people know what they’re talking about and remember just because it works for one person doesn’t mean it’s the best option for you. Bad fashion advice is easier and less heart-breaking to rectify than an unwanted pregnancy.

Contraception: What's all the fuss about?

Contraception: it’s not a sexy topic (…too many puns…eye roll…), but it’s important.

Information about contraception is usually a bit dry, and a lot of people seem to have obtained most of their sex education from Cosmopolitan magazine and whispered conversations with friends. So here is the first in a series of posts on all the things you wanted to know but were too afraid to ask, and also a few things you may not have even thought to ask.

Here’s a pretty standard conversation I have with patients on almost a daily basis…

Gynae Geek: ‘I need to ask you quite a personal question now; are you currently sexually active?

Patient: ‘Yes, I am

Gynae Geek: ‘And what contraception are you using?

Patient: ‘I don’t use anything…’

Gynae Geek: ‘Are you trying to get pregnant at the moment?’

Patient: ‘No….but…erm…I think it's going to be fine’

 

There are no ‘buts’ FACT: If 100 women have unprotected sex for one year, 85 will get pregnant, even in the face of plummeting male sperm counts.

A lot of people think ‘it won’t happen to me’, but let me tell you: it does, it can, and it will.

The commonest form of contraception used in this country is the contraceptive pill, which has now been available to all women in the UK for 40 years. I do feel like the pill has gone out of fashion a bit over the last few years (more on that another day), but there is a surprising array of other methods, so there has to be something to suit everyone.

 

Last week I heard of a rather disturbing new addition to the long list; a penis sticker called 'JifTip the Diktip'. I kid you not, someone actually made what is essentially a piece of ergonomic duct tape for men to stick over the hole at the end of their penis to stop semen from coming out. According to their website the concept is “Feel Your Partner, Feel Freedom, Feel Smart”. Can someone point out what is ‘smart’ about using something that the manufacturers clearly state further down on their website is ‘not approved for anything anywhere’ and is ‘for novelty, pleasure, convenience, fun or entertainment’. They’re certainly not my first choice of adjectives.

Lets be clear, this willy sticker could well be as effective as a dried up roll of 1990’s sellotape when it comes to preventing pregnancy ie. It’s totally never been tested.

Secondly it will not protect against sexually transmitted infections (STIs), which is often only seen by most people as a secondary indication for using contraception. With antibiotic resistant Gonorrhea currently doing the rounds, STIs are not something to be taken lightly.

 

If you currently fall into the category of ‘it won’t happen to me’, or are intrigued about other potential options available, keep your eyes peeled over the next few weeks (again, no penis pun intended).

What is a cervical ectropion?

Prepare yourself for overshare (which in my mind doesn’t really exist, but in medical school we were always taught in communication skills workshops to ‘fire a warning shot’ so don’t say I didn’t tell you…)

I went for a smear test yesterday, cos you know, got to practice what you preach and all that. And as the nurse finished taking the sample I saw her putting the sampling brush into the pot and I saw there was blood on it. I was not having my period so why was there blood? It’s actually incredibly common to have bleeding after a smear test and loads of people freak out and think it means the worst. Well, in the vast majority of people, myself included it’s due to a completely benign condition called an ‘ectropion’. In fact, I don’t know why I even just referred to it as a ‘condition’, because it’s actually a variant of normal.

Time for some more terrible gynaegeek artistry... The doughnuts at the bottom are the cervix being viewed end on, as it is seen during a speculum examination (aka 'the fanny clamp of death' as my patient called it last week. NB. she agreed afterwards this was a gross exaggeration and I was actually really gentle...:-D)

Time for some more terrible gynaegeek artistry... The doughnuts at the bottom are the cervix being viewed end on, as it is seen during a speculum examination (aka 'the fanny clamp of death' as my patient called it last week. NB. she agreed afterwards this was a gross exaggeration and I was actually really gentle...:-D)

An ectropion is an exposed area of the glandular lining of the inside of the cervix. 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 and more fragile. Its 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 having abnormal smears, or with any other disease. They can be bloody annoying however…literally. They can bleed on contact, such as during my 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 lining isn’t really designed to be exposed in such a way. Lots of people have an ectropion and never know because they don’t all bleed. If you do have one it can go away on it’s own. But if the bleeding is really annoying there are things that can be done to treat this, such as burning away that top layer of skin. We generally don’t really recommend doing that unless it’s really problematic.

Having said that, bleeding after sex is abnormal until proven otherwise. Not all bleeding after sex is caused by an ectropion, and other more serious causes include infections and abnormal cells on the cervix. So please go and see your GP if you’re getting problems with bleeding and they can easily check your cervix and decide whether you need to come to the Gynaecology clinic for further assessment.

Do I need a labiaplasty?

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Why has Barbie not been taken off the shelves? When I was growing up everyone used to say that Barbie’s boobs were so big that if she was real she would topple over. Now I’m no good at physics so I’m not sure whether that’s really true, but the girl does love her stilettoes so I guess it could be. As well as her inconceivably tiny waist and never-ending thigh gap, the one thing that really irks me about this plastic woman is her unrealistic nether region. Is Barbie the reason that last year 156 girls under the age of 15 had labiaplasty performed on the NHS?

 

If you need to revise your female anatomy, or want a quick summary of what labiaplasty actually means, check out my latest YouTube video…

Did 156 teenage girls really need their labia trimming? And why has the number of these operations performed on women over 18 risen faster than any other cosmetic procedure in the last few years. There are several reasons to perform labiaplasty. Firstly to reduce the size of the labia minora because they cause discomfort during exercise, sex or other physical activity. Secondly to remove areas containing lumps, bumps or other areas of abnormal or diseases tissue. And finally for cosmetic reasons, which really are not meant to be done on the NHS, but appeared to be the focus of the BBC report on this procedure in teenage girls. The labia minora usually grow first during puberty, so it would be normal for these to suddenly appear to hang down slightly, before the labia majora catch up, which is a prime reason why teenagers should not be having this op performed. Secondly the size of the labia majora is largely dictated by the fat content underneath the skin, so someone who is very slim may feel their labia minora are over-sized due to comparatively smaller labia majora. The optimist in me would like to think that the number of cases reported by the BBC in teenagers, is in fact an over-exaggeration because it has been derived from computer coding, which would not differentiate the number of procedures according to the reason that they were performed, although it’s impossible to find out.

From my (ahem…sometimes excessive) time spent on social media I think that the sudden interest in ‘neatening up’ ones labia may be an unpleasant 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…’ As someone who sees more than her fair share of labia on a daily basis, I can tell you there is no such thing as normal, and certainly no such thing as symmetrical. Symmetry is overrated, as there is no other body part that is truly symmetrical. We’ve all got one foot that’s bigger than the other; 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, as this may be the only time women see other women’s labia, so the perception of ‘normality’ is grossly skewed. And trust me; it’s not like popping into the hairdressers for a quick fringe trim on your lunch break. This is proper surgery that very few women need to have done. I saw a very interesting BBC short documentary, which is definitely worth a watch if you want to know more.

There are also loads of great vulva/labia artists out there on instagram such as @the.vulva.gallery @joelizaharrison @vulva_portraits @vagina_museum…the list is endless, but I think these are definitely worth checking out, because understanding what is normal is the first step towards personal acceptance.

Three totally normal vulva from @the.vulva.gallery

Three totally normal vulva from @the.vulva.gallery

Cervical screening: what is it and what do my results mean?

I’ve been so humbled to receive so many messages over the last few weeks telling me you saw my social media posts about Cervical Screening Awareness Week and finally decided to go for your cervical screening appointment that you’ve been putting off for many moons.

I’m kind of known amongst friends and colleagues for banging on and on about cervical screening (a.k.a. smear testing) but it’s for one simple reason: it’s 2017, and with an excellent screening programme in the UK, no woman deserves to die of cervical cancer. No, seriously, I'm not being dramatic - cervical screening is THE single best way to prevent this disease.

So let’s get down to the cold hard facts.

Do I really need to go?

Anyone over 25 who has ever been sexually active, needs to attend screening. It doesn't matter how many men, or even women you've had sex with, how long ago the last time was, or if you've been in a monogamous relationship for years...you still need to go when you get invited. Read my last post to understand why #sorrynotsorry

What the test does…

It collects a sprinkling of cells from the cervix, also called the neck of the womb, which sits at the top of the vagina. These cells are then examined under a microscope to look for abnormal cells that have the potential to change into a cancer in the future, and therefore the test is NOT a test for cancer. Cervical cancer takes about 10-15 years to develop which is why we do the screening every 3 years from age 25 (every 5 years in over 50’s) to identify these abnormal cells and if needed to treat them before they turn into a proper cancer.

What the test does not do…

1. It does not check for sexually transmitted infections (e.g. Chalmydia, Gonorrhoea, HIV etc). You should go to your local sexual health/GUM clinic if you need a sexual health screen.

2. It doesn’t tell you anything about your ovaries/fertility/parties going on in your uterus. We literally only collect cells from the cervix which can be completely normal even if there’s something else going on further up in the reproductive tract. If you have symptoms or are concerned you should speak to your GP.

3. It does not hurt – we use a small plastic speculum to open up the vaginal walls, which can be uncomfortable initially, and then we use a brush with soft bristles to collect the sample. It literally takes 60 seconds. Most people feel very little, some say it’s uncomfortable, very few people say it’s painful, but either way its 60 seconds that could save your life…I’d say its worth it.

And if it’s abnormal?

We invite you to come to colposcopy clinic so that we can visualise your cervix directly under a microscope and make a decision about 1. whether there truly is an abnormality present (its only a screening test, so just says you are likely to have an abnormality, but the colposcopy will confirm it) and 2. Whether its an abnormality that we can watch to see if it’s going to go away on it’s own (As most do), or whether it needs removing straight away. But more on this another day.

cervical_cancer_drop.png

In summary, we know that cervical screening is very effective for preventing cervical cancer, but only when women actually attend. From the introduction of the national screening programme in 1988, you can see on the graph that there was a massive drop in the number of cases of cervical cancer. Unfortunately the number of eligible women attending screening has been dropping over the last few years, and when this happens we see an increase in the rate of the disease again. So make sure you protect yourself by going for the test.

Rather scarily a survey published last week revealed that 28% of women who did not attend their cervical screening were unaware of the test. Astounding! So I’m asking you, please: spread the word. You could literally save your best friend/sister/mum/colleague’s life…even your boss if you like her that much…

Check out the quick 2 minute video I made to explain the test results in more detail, or if you want to listen to my best Radio 4 voice…

“I’ve never had HPV….right?”

HPV.jpg

Having read the title you probably fall into one of 3 camps here…

1. “WTF is HPV?”

2. ”I’ve definitely never had HPV so I’m intrigued…”

3. “Finally someone is actually talking openly about HPV!”

So for all the people in the first camp, HPV aka Human Papillomavirus is the virus that causes abnormal cervical screening/smear tests and in a very small handful of people cervical cancer, as well as cancers of the anus, throat and penis. There are over 200 different types of HPV, but there are 15 types that the World Health Organization has identified as ‘high-risk subtypes’, which are most likely to cause cancers. All sounds pretty scary so far? So what if I told you that by the age of 50 years, 90-100% of women will have been infected? But in the UK, the lifetime risk of getting cervical cancer is 0.75%. If almost all women get HPV at some point, but only one in 135 get cervical cancer…something isn’t really adding up here is it? That’s because the immune system clears the infection in most women. In some people it’s cleared incredibly quickly – possibly within a few days, but can take weeks, months or even years. If it hangs about it starts to cause changes in the cells, because the virus is a bit needy and needs to make a comfy home in your ever so hospitable cervical cells to help it survive. It’s these cellular changes that we are looking for in a smear test; so you can think of it as a bit of a housing inspection. Are you sub-letting your cervix to HPV?

If HPV lingers for too long, it can, unfortunately, cause very severe abnormalities, which may eventually turn into cervical cancer. From getting the first infection however, this takes at least 10-15 years. If you’re in this very small minority of women, you will have been invited for between three to five cervical smears during which we would detect these abnormal cells and be able to treat you before they every turned into cancer. This means attending for your smear test is the single most effective way of preventing cervical cancer.

Girls: a brilliant show but needed some correcting...

Girls: a brilliant show but needed some correcting...

Most people think they’ve never had HPV because of the fact they have never had an abnormal smear test. HPV is all over the place. It is found in our environment and all over our skin. In fact, a study has even shown that high-risk HPV has been found on the hands of small children. So chances are, if you’ve ever been sexually active, you’ve probably had the virus, because that's how it gets to your cervix. You just don’t know about it because your body cleared the virus quickly, and you didn’t happen to have a smear during the time that HPV was setting up shop in your cervix.

To finish I’d like to quickly clear up a few common misconceptions about HPV that I commonly discuss with my patients

  • HPV infection is not a true sexually trasnmitted infection and is not a sign of promiscuity – the virus is everywhere, and sex is what gets it to the right place (your cervix), and even just having one partner will put you at risk. Finding out you have HPV just means you have a very hospitable cervix which enabled the virus to get a bit too comfy and then your immune system wasn’t able to get rid of it very quickly.
  • HPV is not a lifetime sentence – about 90% of infections detected as cervical smear abnormalities will be spontaneously cleared within 2 years. But you can get the same, or different type of HPV again, so you need to continue screening even if you had HPV and it went away.
  • Using condoms all the time, or having a same-sex partner do not protect you – if the virus is on your skin, it can still get into your cervix, therefore, you still need to go for smears.
  • There’s no medication for HPV – because it’s a virus that lives inside your cells it makes it very difficult to develop medicines that would kill the virus without destroying the cells of your cervix. In clinic we observe women with abnormal cells, and in the small number where HPV causes severe abnormalities because it doesn't go away, we remove those abnormal cells, thus removing the infection along with them.
  • You still need to attend for smears if you’ve been vaccinated – the vaccine doesn’t protect against all types of HPV so there is still a risk of getting abnormal cells although it is MUCH lower than people who haven’t been vaccinated.
  • You don’t need to disclose your HPV status to your partner – even if you got it from him, which you will never know because there's no test for men and chances are he doesn’t even have the infection anymore, even if you do…the honest reason is that penises are hostile places…HPV doesn’t like to stick around that long compared with the cervix!

On that note, I will leave you with my HPV mantra that I tell all my patients;

“everyone gets HPV no matter what you do, so trust in your immune system, eat your 5 (or 10) a day, don’t smoke and go for your smear test; that’s the way to cervical disease freedom”

I’m sure there are a lot more questions you may want to ask so feel free to leave your comments below and I’ll answer them in another post in the future.

Also my favourite HPV-related online resource is Jo's trust which is probably the most up to date and reliable information you will find online.

#MenstrualHygieneDay2017

"Damn it, I forgot to add my Tampax compak pearl tampons to my Ocado delivery…I’ll just pop into the Sainsbury’s local at the end of the road and get some on the way to work tomorrow"

Being able to walk into a shop and buy tampons or sanitary towels is something we often take for granted. Whilst the debate about taxation of these products in the UK and other countries rages on, many of us are not aware that in many parts of the world this is a luxury that many women do not have. This is why the international organization ‘WASH United’ initiated Menstrual Hygiene Day, which falls every 28th May with the aim of raising awareness of the fundamental role that adequate menstrual hygiene plays in the lives of women and girls worldwide.

 

In the absence of available sanitary products or the means to afford them, women are instead forced to use unhygienic substitutes such as old clothes, mattress fibres, and newspaper. Whilst many of you reading this may be shocked to realise that women are subjected to such conditions, you are unlikely to be surprised when I tell you that these practices can increase the risk of infections that may have serious implications for future reproductive and gynaecological health.

 

About a year ago I started working with an amazing charity called Raise the Roof, which works in partnership with the Kenyan Government, communities, and local organisations to establish sustainable community projects. Poor access to adequate sanitation and sanitary products is estimated to result in 3.5 million days of school absenteeism per month in Kenyan girls, which can result in disengagement and poor academic performance. Raise the Roof have been working with Days for Girls to supply over 45,000 school girls and women with menstrual hygiene kits containing sustainable, reusable pads and liners to ensure our girls can continue to go to school throughout the month with comfort and dignity.

Raise the Roof team educating our school girls about periods and the sanitary kits that they've been supplied.

Raise the Roof team educating our school girls about periods and the sanitary kits that they've been supplied.

However, it’s not just commodities that are needed to solve this problem. We need increasing awareness, to fight stigma and educate men and women on the importance of menstrual hygiene in order to implement policy changes.

Shockingly a recent poll by ActionAid revealed that 1 in 5 women in the UK feels uncomfortable talking about their periods, and 1 in 4 don’t understand their menstrual cycle. SO there’s only on thing to do…stay tuned for more period chat.

Vaginal microbiome: what grows down below

Grab your lab coat and safety goggles because we’re about to get geeky.

So, the word microbiome seems to have become a serious wellness buzzword these days. And arguably the human microbiome, which is a term used to refer to the bacterial population that resides in the body, is one of the most exciting areas of science and medicine to be discovered this century. It’s taken us a pretty long time to realise that not all bacteria actually cause disease, and in fact some actually help us to maintain a state of health and wellbeing.

In 1892 a German gynaecologist called Albert Döderlein identified bacteria in the human vagina, and of course, he named them after himself ‘Döderlein’s bacilli’. Some reports say he was the first person to introduce the use of rubber gloves in obstetrics and gynaecology too, so I think I’ll let him have that one, because I don’t fancy going barehanded at work and I’m pretty sure none of my patients would be that keen either. So it turns out this clever chap was describing Lactobacillus, which is the most common type of bacteria in the human vagina. Then everyone sort of lost interest in vaginal bacteria until the use of DNA sequencing helped us to discover what other things are growing down there.

The vaginal microbiome (but let's use the term VM for short...cos some of you are still wincing every time I write the word ‘V-A-G-I-N-A’) is pretty simple compared to that of most other areas of the body including the gut, skin, nasal passages etc. And by that I mean it contains far fewer varieties of bacteria; usually from one-five different species, although up to 25 in a small proportion of women, which is far less than the gut, with about 200. Lactobacillus species are the most frequently found in the vagina, Lactobacillus crispatus and Lactobacillus iners being the most common. In some women, however, there are no Lactobacillus to be found, resulting in an overgrowth of a huge variety of other bugs including Streptococcus, Atopobium, Gardnerella, Prevotella to name but a few. We don’t generally associate these bad boys with health, and these can cause a disorder known as bacterial vaginosis, which is associated with nasty smelling discharge and irritation and is pretty darn unpleasant for anyone that has it, although is not truly a sexually transmitted disease as lots of people think.

The vaginal microbiome structure as first classified by Ravel et al. Proc Nat Acad Sci 2011. Is it science or is it modern art?

The vaginal microbiome structure as first classified by Ravel et al. Proc Nat Acad Sci 2011. Is it science or is it modern art?

Now whilst the VM may be simple, it most certainly is not stupid…it’s pretty damn clever. Let’s think of the vagina as the entrance to a beautiful temple, and the Lactobacillus bacteria are the monks who protect it. These monks work day and night to keep the temple safe by stopping the growth of the ‘bad boys’ I mentioned above, and other heinous creatures including HPV and even HIV infections, and most importantly they produce lactic acid which again stops growth of the baddies, and also helps to keep everything clean by gently sloughing off the dead cells in the vagina (much like that acid face wash/toner/mask you just used on your face). The also keep the peace by preventing inflammation at bay by talking to the immune system and telling them that everything is all cool.

Ok, so these monks are a bit ‘out there’ since they’re willing to launch an acid attack, but that’s as violent as they get, and if they’re attacked, they tend to get afraid and run…in particular they don’t like douching because they don’t cling on to the vaginal walls very well and hence they get washed away and then bad bacteria start to grow and run amok causing inflammation and increase the risk of getting a sexually transmitted infection, cervical cancer, premature labour, failed attempts at IVF and are probably also associated with miscarriage too. Lactobacillus also hate smoking, but that’s a tale for another day.

There’s still so much to be learned about the VM, because it doesn’t seem to be a ‘one-size-fits-all’ kind of situation. Some women are completely healthy in the absence of these awesome Lactobacillus guys, whereas others have various complications as listed above. We’re also starting to realise that not all of the different types of Lactobacillus are equal in the health stakes because some species might actually be more protective than others. If we can work out which bacteria really are the most healthy and exactly how the dynamics of this community works to protect us from disease, then it would be possible to use pre- and probiotics to keep the VM healthy and prevent disease. So the VM has potentially massive implications for female and reproductive health and there’s going to be a lot of exciting research coming out over the next few years, which I look forward to sharing with you. The VM would definitely be my specialist subject on Mastermind!

I’ll write another post about how you can try and keep your VM in tip top condition soon. But for now if you’re feeling super geeky, then I’m leaving a link to the second half of the podcast I recorded with Laura Thomas about the VM, where we talk a little bit more about the scientific stuff.

Over and out,

Dr Anita

 

Go follow Laura @laurathomasphd and check out her website www.laurathomasphd.com

Podcast: All Adventurous Women Do, with Laura Thomas PhD

A few weeks ago I had the pleasure of recording a podcast with Laura Thomas PhD on 'Don't Salt My Game'. If you don't know this podcast then you need to. Check it out on iTunes.

Laura is a Registered Nutritionist and Wellness Advocate, and her mission is "cutting through the BS and telling people what they really need to know to stay on top of their game." Trust me, she's killing it!

We talk about lady bits: drawing them, cutting them off, the stuff that comes out of them and the stuff that's living in there. And of course we cover my favourite topic of cervical screening. Don't be shy, give it a listen...

And don't forget to follow Laura @LauraThomasPhD on insta and twitter and find her at http://www.laurathomasphd.co.uk/

Hello, World!

Vaginal discharge: it's the reason you exist...

I’m throwing you all in at the deep end by writing my first ever blog post about vaginal discharge. Yep, that stuff that no one wants to talk about… except when they’re in that little hospital clinic room with me, all on their own, with no one to hear or judge. So thank you to the hundreds of patients who inspired this post and opened my eyes to the mystery and confusion surrounding discharge.

Firstly, vaginal discharge gets a bad rep. It’s not actually a ‘symptom’ as many people believe, it’s something that everyone has, and is pivotal to a healthy female reproductive system. The consistency and character of your discharge changes throughout the menstrual cycle, dependent on the fluctuations in female hormones. Day one of your cycle is the day your period starts, and as the bleeding stops there is often very little discharge because of low levels of oestrogen and progesterone, often resulting in a dry, irritated feeling. It’s probably as close as you’ll get to feeling like a postmenopausal woman, so remember what you’ve got to look forward to. Thankfully, hormone levels start to rise, and discharge becomes thicker and then creamier in consistency with a white-yellowish colour.

By now it is getting on for 2 weeks after your period started, so it’s time for ovulation, which is when your ovary decides it's time to evict an egg or two in the hope of it meeting the sperm of its dreams. At this time, vaginal discharge becomes very thin and watery, and then stretchy with an egg-white consistency. This type of discharge seems to cause the greatest level of confusion. The oral contraceptive pill works by stopping ovulation, so if you’re using this form of contraception you’re unlikely to experience this type of discharge. I see hoards of women who have stopped taking the pill after many years, and aren’t used to this type of ovulation discharge and are really worried it’s something abnormal. But it’s not. It’s a real sign your body is working normally. And also a sign you need to a. stock up on condoms or b. schedule date night whichever way you are inclined on the pregnancy front. Because, this type of discharge folks, as I boldly stated in the title, is the reason we exist. It allows sperm to swim up through the cervix into the uterus (or the womb) and fertilize an egg. Shortly after ovulation, the discharge becomes very thick and sticky and even the Mo Farah’s of the sperm world aren’t going to stand a hope in hell of getting through that stuff. And if the sperm-egg dating game didn’t go so well, your period starts and the cycle repeats itself.

egg cracking.jpg

As well as ensuring an ongoing human race, vaginal discharge has many more important roles. Firstly, it contains peptides that we sometimes refer to as ‘natural antibiotics’ that protect us against sexually-transmitted infections, and other bugs that want to wreak havoc, causing abnormal discharge, pelvic inflammatory disease and pregnancy complications including premature labour. But we also have good bacteria in the vagina too, just as we see in the gut and the vaginal bacterial community is known as the vaginal microbiome, which I’ll be writing way more on in another post, but for now, just rest assured in the knowledge that vaginal discharge is a nice, warm and hospitable environment for the growth of these good bacteria, which also play a huge role in keeping infection and inflammation at bay.

Now for two unexpected functions of discharge. Number one – it prevents chafe, and number two it stops you from having a dusty vagina. I’m honestly not joking. Discharge acts as a lubricant to stop friction and irritation, and also provides a way of helping the dead cells from the vagina, cervix, and uterus to make their way to the outside world.

There are of course abnormal types of discharge, which I’ll cover another day. Until then, the ‘Red flag symptoms’ to watch our for are…

  1. Itching
  2. Blood-stained discharge
  3. Foul-smelling discharge
  4. Change in colour
  5. Associated with pain

For now, I will leave you with Dr Mitra’s top tips for healthy vaginal discharge:

  1. Get to know what’s normal for you throughout your cycle so that you can detect anything abnormal quickly and easily.
  2. Maintain a healthy, varied diet, including lots of good prebiotic-containing vegetables and probiotic foods such as greek yoghurt and miso to protect your good vaginal bacteria.
  3. Don’t douche. Especially if you’re doing it because you feel irritated or that your discharge smells. You will only make it worse. See your GP instead.