It's Not Hysteria

1. Gynecologic Health: A History of Misunderstanding and Neglect

Women’s bodies and medical concerns have been misunderstood, mismanaged, and outright dismissed since the beginning of recorded history.

Historical roots of dismissal. From the "wandering womb" theory to the witch trials and the rest cure, women's health has been plagued by inaccurate theories and outright dismissal. This historical context continues to influence how gynecologic issues are perceived and managed today, often leading to delayed diagnoses and inadequate treatment.

• Ancient Greeks attributed many problems to a uterus moving around the body.
• Hysteria, once considered a physical malady, became a psychological one, further stigmatizing women's health.
• Black women were subjected to unethical medical experiments, highlighting racial biases in healthcare.

Systemic issues persist. Even today, research on gynecologic conditions is underfunded, and women are often excluded from clinical trials. This lack of data leads to treatments based on opinion rather than evidence. The healthcare system itself is often broken, with low insurance reimbursements, physician shortages, and provider burnout, making it difficult for people to get adequate care.

• Racial biases lead to undertreatment of pain in Black patients.
• Lack of funding for gynecologic research means limited treatment options.
• Overwhelmed doctors have limited time to address complex health issues.

Call for change. A revolution in our medical systems is needed to provide high-quality gynecologic care for all. This includes increased research funding, equitable access to care, more extensive training for healthcare providers, and basic health education for the public. It's time to break the cycle of misunderstanding and neglect.

2. Understanding Your Body: Anatomy and the Menstrual Cycle

Sex and reproduction are considered so taboo that people who are old enough to vote, get married, and become parents themselves may not have basic knowledge of their own body parts.

Basic anatomy is essential. Many people lack a basic understanding of their own reproductive anatomy, including the ovaries, fallopian tubes, uterus, and vagina. This lack of knowledge can hinder effective communication with healthcare providers and prevent people from recognizing when something is wrong.

• Ovaries release eggs and produce hormones like estrogen and progesterone.
• Fallopian tubes are the corridors from the ovaries to the uterus, where fertilization occurs.
• The uterus is a muscular organ that holds a developing pregnancy.

The menstrual cycle explained. The menstrual cycle is a complex interaction between the brain, ovaries, and uterus, preparing the body for possible pregnancy each month. It is controlled by a pattern of hormone signals that travel between the brain, the ovaries, and the uterus.

• The cycle involves the release of an egg (ovulation) and the thickening of the uterine lining (endometrium).
• If pregnancy doesn't occur, the endometrium sheds, resulting in menstruation.
• Hormones like GnRH, FSH, LH, estrogen, and progesterone play crucial roles in the cycle.

Conception and pregnancy. Understanding how fertilization and early pregnancy normally proceed is necessary to discuss topics such as infertility, miscarriage, ectopic pregnancies, and contraception. Fertilization occurs in the fallopian tube, and the developing embryo travels to the uterus for implantation. Knowing the facts about menstrual cycles and pregnancy is important to understand if something is going wrong and provides a foundation for discussing these issues with your healthcare provider.

3. Self-Assessment and Effective Communication with Healthcare Providers

The most important question to ask yourself as you reflect on your health is whether your experience is causing suffering or distress.

Recognize abnormal symptoms. Many people suffer for years because they think their symptoms are normal, often because they were told this by society or healthcare providers. It's crucial to recognize when symptoms are affecting your quality of life and seek help.

• Track your periods, noting cycle length, duration, and flow.
• Keep a pain diary, noting location, quality, triggers, and severity.
• Pay attention to bowel, bladder, and mood symptoms, as they can be related to gynecologic conditions.

Prepare for appointments. Organize your thoughts and concerns before meeting with your healthcare provider. This will help you communicate effectively and make the most of your time.

• Identify your greatest concerns and priorities.
• Determine what you need from your healthcare provider (diagnosis, treatment options, education, reassurance).
• Reflect on your personal goals for your health.

Advocate for yourself. If you feel your doctor isn't listening or isn't able to meet your treatment needs, seek a second opinion. You are the expert on your own body, and you deserve to be heard and respected. Don't be afraid to ask questions, express your concerns, and advocate for the care that you need.

4. Fibroids: Common, Benign, and Treatable

Up to 80 percent of Black women and 70 percent of white women have fibroids by age fifty.

Fibroid basics. Fibroids are benign tumors of the uterine muscle that are extremely common, particularly among Black women. They are stimulated by estrogen and progesterone and can cause a range of symptoms, including heavy bleeding, pain, and bulk symptoms.

• Fibroids are also known as leiomyomas or myomas.
• They form when cells in the uterine muscle multiply rapidly.
• They can grow until menopause, after which they often shrink.

Symptoms and location. Fibroid symptoms depend on the size, number, and location of the tumors. They can cause bulk symptoms (bloating, urinary frequency, constipation), bleeding (heavy or prolonged periods), and pain (with periods or sex).

• Submucosal fibroids grow into the uterine cavity and can cause heavy bleeding.
• Intramural fibroids grow within the uterine wall and can cause bulk, bleeding, and pain.
• Subserosal fibroids grow on the outer surface of the uterus and can cause pain or bulk symptoms.

Treatment options. Treatment options for fibroids include medications to control bleeding and pain, and procedures or surgeries to shrink or remove the fibroids or uterus. There is no one-size-fits-all approach, and decisions should take into consideration symptoms, future fertility plans, and patient preferences.

• Medications include NSAIDs, hormonal birth control, tranexamic acid, and GnRH agonists.
• Procedures include uterine fibroid embolization and radiofrequency ablation.
• Surgeries include myomectomy (removal of fibroids) and hysterectomy (removal of the uterus).

5. Endometriosis and Adenomyosis: Invisible Conditions, Real Pain

People with endometriosis and adenomyosis often undergo multiple ultrasounds, CT scans, blood tests, and ER visits with perfectly normal results.

Endometriosis and adenomyosis defined. Endometriosis and adenomyosis are conditions where tissue similar to the uterine lining grows outside of the uterus (endometriosis) or within the uterine muscle (adenomyosis). These conditions can cause debilitating pain and other symptoms.

• Endometriosis can affect various organs, including the bowel, bladder, and nerves.
• Adenomyosis is confined to the uterus but can cause severe bleeding and pain.
• Both conditions are often difficult to diagnose and can take years to be identified.

Symptoms and impact. Symptoms of endometriosis and adenomyosis can include severe pelvic pain, heavy or irregular bleeding, bowel and bladder issues, muscle pain, nerve pain, and systemic symptoms like fatigue and migraines. These symptoms often worsen around ovulation and periods.

• Bowel symptoms include diarrhea, constipation, and pain with bowel movements.
• Bladder symptoms include urinary urgency, frequency, and pain.
• Muscle and nerve pain can radiate to the lower back, buttocks, and legs.

Diagnosis and treatment. Diagnosis of endometriosis and adenomyosis usually requires surgery, as there are no simple lab tests or imaging studies that can definitively identify them. Treatment options include surgery to remove the tissue and medications to manage symptoms.

• Surgery involves excision (cutting out) or ablation (destroying) the tissue.
• Medications include pain relievers, hormonal birth control, and GnRH agonists.
• Holistic options such as physical therapy, dietary changes, and mental health care can also be beneficial.

6. PCOS: A Complex Syndrome of Hormonal Imbalance

The most common endocrine (hormone-related) disorder among women of reproductive age, PCOS affects 10 percent or more of those assigned female at birth.

PCOS basics. Polycystic ovary syndrome (PCOS) is a common hormonal disorder that affects people with a uterus. It is characterized by an imbalance in hormones that regulate ovulation and periods, leading to a range of symptoms.

• PCOS is a syndrome, not a disease, meaning it is a group of associated signs and symptoms.
• Symptoms and features of PCOS can differ widely among patients.
• The exact causes of PCOS are unknown.

Diagnostic criteria. PCOS is diagnosed based on the Rotterdam criteria, which include at least two of the following: irregular or absent periods, clinical or biochemical signs of high testosterone, and polycystic ovaries on ultrasound.

• Oligo-ovulation or anovulation (infrequent or absent ovulation)
• Clinical or biochemical signs of hyperandrogenism (high testosterone)
• Polycystic ovaries (multiple small cysts on the ovaries)

Health risks and treatment. PCOS is associated with increased risks of chronic medical conditions, abnormal bleeding, uterine cancer, infertility, and mood disorders. Treatment focuses on managing symptoms and addressing associated health problems.

• Medications include hormonal birth control, ovulation induction drugs, and diabetes medications.
• Lifestyle modifications such as diet, exercise, and stress relief are also important.
• Surgery is rarely needed but may be an option for some patients.

7. Ovarian Cysts: Common, Varied, and Sometimes Dangerous

The majority of ovarian cysts are innocent bystanders.

Types of ovarian cysts. Ovarian cysts are fluid-filled sacs that develop on the ovaries. Most are normal and harmless, but some can cause pain or other problems.

• Physiologic cysts (follicular, corpus luteum, hemorrhagic) are normal and usually resolve on their own.
• Endometriomas are cysts filled with old blood and endometriosis tissue.
• Dermoids are cysts filled with hair, teeth, and other tissues.
• Cystadenomas are benign fluid-filled cysts that form from cells on the surface of the ovary.

Cyst emergencies. Some cysts can cause serious health problems, including rupture and ovarian torsion.

• Ruptured cysts can cause sudden, sharp pain.
• Ovarian torsion occurs when the ovary twists and cuts off its blood supply.
• Both conditions require immediate medical attention.

Diagnosis and treatment. Pelvic ultrasounds are the primary method for diagnosing and evaluating ovarian cysts. Treatment depends on the type of cyst, symptoms, and risk of complications.

• Physiologic cysts are usually monitored and resolve on their own.
• Endometriomas and dermoids may require surgical removal.
• Surgery can involve cystectomy (removal of the cyst) or oophorectomy (removal of the ovary).

8. Pelvic Floor Dysfunction: Muscles, Nerves, and Pain

Pelvic muscle spasm and pelvic dysfunction are extremely common causes of pain and bowel and bladder symptoms, but they are often missed.

Pelvic floor anatomy. The pelvic floor is a group of muscles that support the pelvic organs and control bladder and bowel function. Dysfunction of these muscles can cause a wide range of symptoms.

• The pelvic floor muscles include the levator ani, obturator muscles, coccygeus, and piriformis.
• These muscles connect to the lower back, hips, and legs.
• They help control urination, bowel movements, and sexual function.

Symptoms of dysfunction. Pelvic floor dysfunction can cause pain, muscle spasms, and problems with bowel and bladder control.

• Pain can be felt in the pelvis, lower back, hips, and legs.
• Muscle spasms can cause pain with sex or exercise.
• Bladder symptoms include urinary urgency, frequency, and incontinence.
• Bowel symptoms include constipation, pain with bowel movements, and rectal pain.

Diagnosis and treatment. Pelvic floor disorders are diagnosed with a combination of symptom evaluation and a physical exam of muscle strength, tone, and tenderness. Treatment primarily involves pelvic floor physical therapy.

• Pelvic PT can include stretching, strengthening, and retraining the muscles.
• Medications such as muscle relaxants, nerve pain medications, and vaginal suppositories may be used as adjuncts to PT.
• Trigger point injections and botulinum toxin injections may also be helpful.

9. Pelvic Organ Prolapse and Urinary Incontinence: Common but Treatable

Up to half of all women and up to 70 percent of postmenopausal women experience urinary incontinence.

Pelvic organ prolapse (POP). POP occurs when the pelvic organs (uterus, bladder, rectum) drop into the vagina due to weakened support structures. It can cause vaginal pressure, pain, and difficulty with sex or exercise.

• Risk factors include pregnancy, childbirth, menopause, and chronic strain.
• Types of prolapse include cystocele (bladder), rectocele (rectum), and enterocele (intestines).
• Treatment options include pelvic floor PT, pessaries, and surgery.

Urinary incontinence. Urinary incontinence is the loss of bladder control, affecting up to half of all women. It can be caused by weakened pelvic muscles or bladder dysfunction.

• Stress incontinence is leaking with coughing, laughing, or exercise.
• Urge incontinence is leaking associated with a sudden need to urinate.
• Overflow incontinence is leaking due to incomplete bladder emptying.

Treatment options. Treatment for urinary incontinence includes lifestyle modifications, pelvic floor PT, pessaries, medications, and surgical procedures.

• Lifestyle changes include limiting caffeine and alcohol and bladder training.
• Medications include vaginal estrogen, anticholinergics, and beta-3 agonists.
• Surgical options include urethral bulking, slings, and neuromodulation.

10. Sexual Dysfunction: A Spectrum of Issues, Many Solutions

Sexual health is influenced by a complex interplay of physical, mental, emotional, and social factors.

Understanding sexual dysfunction. Sexual dysfunction encompasses a range of issues that can affect libido, arousal, orgasm, and pain with sex. These issues are common and can significantly impact quality of life.

• Pain with sex (dyspareunia) can be caused by various factors, including hormonal changes, injuries, and nerve irritation.
• Low libido or desire can be influenced by stress, mood disorders, and hormonal changes.
• Arousal problems can be related to both mental and physical factors.
• Orgasmic disorders involve difficulty achieving orgasm despite feeling aroused.

Diagnosis and evaluation. Diagnosis of sexual dysfunction involves a thorough evaluation of symptoms, medical history, and physical exam. Questionnaires can help identify specific issues.

• Doctors will ask about pain, desire, arousal, and orgasm.
• A physical exam may assess for vulvar or vaginal abnormalities.
• Hormone levels and other medical conditions may be tested.

Treatment options. Treatment for sexual dysfunction is often multidisciplinary and may include sex therapy, pelvic floor PT, stimulatory devices, lubricants, and medications.

• Sex therapy can help with communication, skills, and emotional issues.
• Pelvic PT can address muscle spasms and pain.
• Stimulatory devices can help with arousal and orgasm.
• Hormonal medications and antidepressants may be used to treat low libido.

11. Vulvovaginal Conditions: Beyond Yeast Infections

The vulva and vagina are very sensitive and complex structures that are affected by an enormous range of different conditions that cause very similar symptoms.

Vulvovaginitis. Vulvovaginitis is inflammation of the vulva or vagina, often caused by infections such as yeast, bacterial vaginosis (BV), or STIs. It can cause itching, burning, discharge, and pain.

• Yeast infections are caused by candida and can cause a white, curdy discharge.
• BV is caused by an imbalance of bacteria and can cause a fishy odor.
• STIs such as chlamydia, gonorrhea, and trichomonas can also cause vaginitis.

Vulvar skin conditions. Vulvar skin conditions can cause itching, irritation, and changes in the appearance of the vulva.

• Vulvar dermatitis is caused by irritants such as soaps and fragrances.
• Lichen simplex, lichen sclerosus, and lichen planus are chronic skin disorders.
• Vulvar squamous intraepithelial lesions (VSIL) are precancerous changes caused by HPV.

Vulvodynia. Vulvodynia is chronic vulvar pain without a known cause. It can cause burning, stinging, and throbbing pain.

• Vestibulodynia is pain at the entrance of the vagina.
• Treatment may include physical therapy, medications, and nerve blocks.

Genitourinary syndrome of menopause (GSM). Low estrogen levels in menopause can cause vaginal dryness, pain with sex, and urinary symptoms.

• Vaginal estrogen is an effective treatment for GSM.
• Laser and radiofrequency devices are not yet proven to be effective.

Vulvovaginal hygiene. Douching, feminine sprays, and washes can cause irritation and vaginal infections. The vulva should be washed with water or fragrance-free soap.

12. PMS, PMDD, and Menopause: Hormonal Shifts and Their Impact

Periods are an indicator of not only gynecologic health but also overall health and well-being.

Premenstrual syndrome (PMS). PMS is a common condition that causes physical, emotional, and mental symptoms before or during periods.

• Physical symptoms include cramping, bloating, and breast tenderness.
• Emotional symptoms include mood swings, irritability, and anxiety.
• PMS is diagnosed based on a pattern of symptoms over at least three cycles.

Premenstrual dysphoric disorder (PMDD). PMDD is a more severe form of PMS, with debilitating mood symptoms such as depression, anxiety, and anger.

• PMDD can significantly impact daily functioning and relationships.
• It is considered a mental health disorder and requires specialized treatment.

Menopause. Menopause is the end of menstrual cycles, usually occurring around age fifty. It is marked by a decline in ovarian hormones and can cause a range of symptoms.

• Vasomotor symptoms include hot flashes and night sweats.
• Mood changes, sleep disturbances, and cognitive issues are common.
• Genitourinary syndrome of menopause (GSM) can cause vaginal dryness and urinary problems.

Treatment options. Treatment for PMS, PMDD, and menopause includes lifestyle modifications, medications, and sometimes surgery.

• Medications include hormonal birth control, antidepressants, and GnRH agonists.
• Holistic options include exercise, dietary changes, and mental health care.
• Hysterectomy and oophorectomy may be considered in severe cases of PMDD.

Last updated: February 3, 2025