Midwives of the Revolution

Explorations, analysis, and reflections on reproductive health, birth, and midwifery from a feminist, marxist lens

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Sad Vaginas

Vaginal infection is a major reason that women visit the gynecology office (Brown, Hess, Brown, Murphy, Waldman, & Hezareh 2013; Overman 1993). I knew that going into midwifery. But my god, I never thought I would see so many sad vaginas every clinic day. My patients have a lot of vaginal infections. I spend a lot of time with patients talking about why for optimum vaginal health, less is more. Many have heard before that they “shouldn’t” douche, from other healthcare providers — but even among those patients for whom this is not a new idea, they continue intravaginal practices and don’t necessarily know why they shouldn’t.

This raises two issues for me as a nurse midwife and a feminist — the social roots of intravaginal hygiene practices (IVHP) and how providers educate –or don’t- — their patients about their own health.

Why do women douche? 

Many women tell me they feel they need to get clean after menses. They don’t like the residual menses they feel might be hanging around when the bleeding stops, and in particular they worry about the smell. They also think it will help them prevent infections. Commonly, my patients douche because their mothers, sisters, and grandmothers had and taught them these practices. But as one patient asked me this week, “why would they sell all that stuff if it’s so bad for you?” Good question.

And since Summers Eve re-vamped and expanded their product line beyond simple douche products to an impressive array of “yoni” personal products, these commodities are hipper and more attractive to consumers than they have been in a long time. Image

In a small (141 participants) prospective cohort study of sexually active women 18-65 years old in Los Angeles, researchers found that 66% reported IVHP, 49% of whom admitted using an intravaginal product (other than tampons) and 45% of whom reported intravaginal washing (Brown et. al 2013). This washing could include vinegar, water, soap and water, or commercially available products (Brown et. al 2013). One 2004 pharmacy journal reports that the reasons for these IVHP vary according to geography, racial background, age group, and rates of sexual activity (Pray & Pray 2004). According to Pray and Pray, African American women inherit IVHP from their mothers, while white women learn these habits more from advertising.

There is nothing wrong with your vagina

Wherever women get the specific idea that they need to use special products and habits to keep the vagina clean, smelling like roses (or lilies or citrus or island splash!), no one who lives in a wretchedly sexist society should be surprised that any woman would get the general idea that there is something wrong with how her normal healthy vagina smells, tastes, etc. But if women in modern capitalism can’t be trusted to decide if, when, and under what circumstances she gets pregnant, labors/births babies, and parents — wherein, for instance abortion is expensive, unavailable, often provided under non-compassionate conditions, and women are shamed for considering or choosing abortion (and even using birth control, these days!) — why could they be trusted to take care of their own vagina they way nature made it?

As a matter of fact, the vagina has its own beautiful environment that does all the work you think a douche might do for you — keeping your vagina clean — all on its own, when you are healthy. The vagina likes to be nice and acidic, which is made possible by a wide variety of anaerobic and aerobic gena and species (Overman 1993). Acid-producing bacteria like Lactobacillus keep in check the more basic bacteria that cause the common infection bacterial vaginosis (Overman 1993).

When you douche, you are likely to wipe or wash away the “good” bacteria, leaving lots of room for the “bad” bacteria to take over, causing you bacterial vaginosis (BV). Studies have not shown a direct correlation between douching and BV — for instance, infrequent douching may not directly cause BV (Brown et. al 2013). Overall, however, douching may increase a woman’s risk of contracting a sexually transmitted infection, or HIV if she is exposed to those pathogens, developing pelvic inflammatory disease, or be associated with preterm labor and birth when performed during the second and third trimester of pregnancy (Brown et. al 2013; Pray & Pray 2004).

Then there are all the products designed to make the vagina smell like something it’s not. All the deodorants, sprays, wipes, external washes, creams, and powders designed for vulvar application may place you at risk for yeast infections or irritation, but even if they don’t, their very existence and success on the market contributes to the cultural perception that there is something wrong with your vagina in its natural state. And it makes individual women feel bad about their bodies in a very particular way. As this wonderful columnist for Essence wrote: “There is nothing wrong with the totally natural, completely unaltered smell of your va-jay-jay in its normal state. (Our “down under” isn’t supposed to smell like summer linen, fruits, or fresh mint)” (Lucas, D. L. 2011).

Well, society doesn’t really value anything “natural” about women except for our bodies’ ability to 1. sexually excite men and 2. bear and mother children. So, we are meant to buy cosmetics, sexy clothes, enjoy pole dancing for exercise, be ok with making less money than our male counterparts, do more housework, assume primary responsibility for childcare, etc.

So if we do everything else to bend to society’s desires for who we are as women, why shouldn’t our vaginas be part of that package? As the “EVEangelist” over at Summer’s Eve reminds us, ”It’s time for a shower inventory. If you’ve got a cleanser for everything but your vaginal area, it’s time to make room for our pH-balanced Cleansing Wash.” Products for everything! You are not good enough as you are!

(As an aside, a simple, non-scented soap to cleanse the vulva should do the trick! Avoid body washes and avoid washing in the vagina itself.)

Don’t get me started about the pseudoscience and fake pro-vagina crap over at that website…Barf.

…Until there is

Not all vaginas are going to be happy all the time. And vaginal health isn’t just about products you do or don’t put in them or any sexual pleasure/stimulation a vagina might be party to. Vaginas are part of the female body, which may have lots of experiences that can enhance or hurt vaginal healthy: like diet, exercise, sexual consent, history of abuse or assault, body size, and emotional stress.

But none of those things can be rapidly fixed with an over-the-counter product that makes claims that it will fix up your vagina, unless it is medicine designed to treat a real infection, like intravaginal treatment for yeast infections. And I am all for trying things yourself, DIY, and taking care of yourself using health knowledge grounded in non-commercially biased information like that which is found in, say, Our Bodies, Ourselves and Guide to Getting It On. But douching and using these so-called yoni products that are making some CEOs rich over at Hate Your Vagina, Inc. isn’t gonna help.

Where the provider comes in

I’m glad when patients come into the clinic for evaluation of vaginal discharge because it allows for patient education. I like talking to patients about the difference between healthy and abnormal vaginal discharge, and what a healthy vagina might look/smell like, versus what could put it at risk for infection.

And that’s why I’m glad I’m a midwife (do I say that in every post?). Midwifery is about meeting women where they’re at, and working with them to achieve desired health outcome. Women really are the best expert in their own body/experience, and I am just there to facilitate her reaching her optimum health. When women tell me anything about their health habits that I may think is unhealthy or possibly harmful, my first question is “tell me more about that.” If you want to help a patient/client change a health habit, you need to know what motivates her to either continue or change. This is what we do for smoking cessation, nutrition or exercise promotion, and especially for sexual health risk reduction.

This gets back to my initial observation that many patients know they “shouldn’t” douche (or do lots of other health behaviors deemed unsafe/unhealthy, but I digress), but most don’t know why. When I explain to a woman how wonderful her vagina is and how douching disturbs that beautiful environment, she is more likely to understand her own anatomy and how to promote her own health. My hope is that instilling pro-vagina sentiment can also clear the way for greater acceptance of vaginal delivery of medication and contraception and to an increased motivation to use condoms/protect the goods from more dangerous infections and disease. We shall see.

Really sad vaginas

 

A much riskier health habit than douching, though douching may compound the risk, is practicing unprotected sex with someone whose infection status you don’t know, or having multiple sexual partners, having a partner who has multiple partners, anonymous sex or sex when high or drunk. (You can look forward to my forthcoming Condoms, Part II post for more on that.)

Actually sad vaginas have infections like trichomonas, chlamydia, gonorrhea, herpes, warts, and syphilis. Many of these have no symptoms or barely noticeable symptoms, but none of those can be treated with douching, and all of them require diagnosis and treatment in clinic. And someone who gets one of those infections is at higher risk for sexual transmission of HIV and hepatitis.

I guess a part of me understands that when my patients who are at risk for STIs douche, they may be trying to cleanse themselves of STI risk. (Fortunately, the old myth that douching can prevent pregnancy is much less prevalent these days.) And even here, I can find a good instinct. Douching may not get the desired results (a healthier, happier vagina), but it is a health habit, and I think providers need to recognize that patients do want to be healthy.

Toward a world with happier vaginas

I don’t blame individual women for buying into the crap that the vaginal hygiene industry sells them, any more than I blame women for using makeup, enjoying fashion, partaking in gossip and petty shit among women, or being in abusive relationships, for instance. These are all symptoms of a sexist society, and individual women who make these “choices” are operating in a false set of choices we are allowed to make in capitalism. Sexual liberation (or for the sake of this post, happier vaginas belonging to happier female bodied people) is about a lot more than lack of vaginal infection/STIs, but I do think that would be a good start.

Health care providers–not just midwives–can play a role in that by promoting and practicing in line with Dr. George Tiller’s call to trust women. We need to stop blaming women when they make “poor” choices about their health in a society full of so much sexism, racism, and class inequality. And we can take part in every social movement that confronts sexism, misogyny, and inequality, because health isn’t just about what happens in the exam room — it is determined by the world we live in, and we have to fight for a world that values women and allows for people to make the best possible real choices about our lives and our health.

References:

Brown, J. M., Hess, K. L., Brown, S., Murphy, C., Waldman, A. L. & Hezareh, M. (April 2013). Intravaginal practices & risk of bacterial vaginosis & candidiasis infection among of cohort of women in the United States. Obstetrics & Gynecology 121(4), 773-780. doi: 10.1097/AOG.0b013e31828786f8

Lucas, D. L. (July 21, 2011). Real talk: feminine care 101. Essence. Retrieved 04/14/2014 http://www.essence.com/2011/07/20/real-talk-feminine-care-101/

Overman, B. A. (May-June 1993). The vaginal as an ecologic system. Journal of Midwifery & Women’s Health 38(3), 146-151. doi : 10.1016/0091-2182(93)90038-I

Pray, W. S., & Pray, J. J. (2004). Douching: perceived benefits but real hazards. US Pharmacist 29(1). http://www.medscape.com/viewarticle/490338


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Tears

Some days, I come home on the verge of tears. This is my body’s way of telling me that I am soaking up a bit of secondary trauma. I am good at being an emotional sponge, but that is not going to work for me long term. Here is a short list of some things my patients shared with me, that made me tear up at work and once away from work in the last two weeks:*

  • Partner being incarcerated during her entire pregnancy
  • Being set up and attacked by a group of people that she thought were her friends
  • Being intentionally burned as a small child
  • Child sexual abuse
  • Partner sabotaging her birth control
  • Being told that since she had two abortions, she wouldn’t be able to have healthy pregnancies

There is a choice that caregivers must make when witnessing others’ trauma — we can absorb others’ trauma/let it overwhelm our own emotions, we can distance ourselves from it/numb ourselves, or we can find a middle way, to walk with the trauma.

I aim to walk that middle way.

And it’s really not taught in nursing or midwifery school. If we are lucky, a friend, classmate, or colleague tells us about theoretical and practical work around secondary trauma, compassion fatigue, vicarious traumatization, and trauma stewardship. These are all different ways to say that people who take care of people that experience trauma also need to be taken care of. I am lucky that I learned about this field of research/practice among caregivers some years ago.

…Because if you don’t realize how bearing witness to others’ trauma impacts you, and work on it, it can take over. One who was once empathic, laughing easily, and finding meaning in life and work can fade into someone cynical and burnt out…someone who is ultimately not only unhappy in life but also an ineffective caregiver. In other words, it should be taught in nursing/midwifery/medical/PA/education/PT/OT etc. school — and supported by healthcare (and other) institutions.

I’m glad I’m tuning into this two weeks into seeing patients, and not, say, two months or two years. Because I have my emotional work cut out for me, not to mention clinically, as I develop competencies as a new provider — and I’m ready for it.

And that’s why I love and am honored to be a midwife. 

*I also laughed and smiled with loads of patients, and many told me they hoped I’d be there to catch their baby or to see them in clinic next time. So it’s gratifying in fun ways too!


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Condoms. The Why.

I am working in a part of the city where bacterial sexually transmitted infections (STIs) are unfortunately endemic. They are easily prevented by condom use, yet for a wide variety of social reasons, the majority of my patients who are at risk for STIs report to me that they use condoms sometimes or never. These same patients often present to the office not only to be tested for STIs but also to report bothersome vaginal discharge that may or may not be related to STIs. Condoms are readily available in my office — in a basket in each exam room, or in paper bags of 15 of them that we can give out, or even by prescription at the pharmacy on site.

I want to share my top five reasons I encourage condom use for my patients and others who are at risk for either STIs like chlamydia or gonorrhea but also for this bothersome discharge known as bacterial vaginosis.

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1. Safety

Starting with the most obvious/boring/basic/duh. If you have sex with someone who has one of these infections, or HIV, or even HPV, you greatly reduce your risk of being exposed to their infections by correctly and consistently using condoms with those partners. Great for casual encounters, someone you don’t want to or can’t talk to about their risk factors for STIs, or someone known to have these infections. 

2. Less Mess!

Let’s face it, male-bodied people are messy when it comes to sex. Their ejaculate can get all over you if they pull out or if they come in you or during other sexual play. It’s nice when you wrap it up that if you/he removes the condom appropriately after coming, that mess stays put in that condom and not all over you/your sheets/car/bathroom/couch/wherever you are.

3. (Added) Contraception

If you are trying to avoid pregnancy and have sex with a male bodied person, using condoms for penis-in-vagina sex is a great primary or secondary family planning/contraceptive method. If you *always* use condoms correctly, this method is 98% effective — meaning that if 100 women are using this method correctly all of the time, only 2 of them will get pregnant. Of course, not using it correctly every time is less effective — but still 82% effective. This is great added protection from pregnancy if you use another method, like the pill, the patch, the ring, or the shot. 

4. Fewer vaginal infections

That thin, white, fishy smelling discharge known as bacterial vaginosis can be prevented with good vaginal hygiene and by using condoms. This helps keep the environment of the vagina nice and acidic. Your vagina has this lovely acid-producing bacteria (the “good” bacteria) that can get disrupted by semen/cum, which is very basic (going back to some chemistry here…). If the semen isn’t hanging out in the vagina, it doesn’t have a chance to change the vaginal environment, so you can keep it acidic in there. (Then, don’t douche or use those other “feminine” products…more on that later!)

5. It involves your dude!

Unlike most birth control methods or things women/female bodied people do to keep ourselves safe and free from pregnancy, etc., condom use directly involves your guy. This may not always be possible, if he hurts you or wants you to get pregnant when you don’t, or he wants to have other control over you. But in a safe and healthy relationship, talking about condom use and safety can add intimacy and a shared commitment to your safety. 

Now…the HOW of condom use is another thing. If it were as easy as telling people WHY we probably wouldn’t have such high rates of STIs and unplanned pregnancies. So, that’s for another day.


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“[Knock on wood]…So if I got pregnant and you took care of me, you would come to my house for the delivery?”

#1 myth about midwives:

We only/always attend birth at home.

So…more on this later. But (for better or worse) the vast majority of midwives (particularly nurse-midwives) in the US attend births in the hospital–including me. We can take care of low risk pregnant women — meaning, we need to consult or co-manage your care with a physician if you have an issue like gestational (or pre-existing) diabetes, hypertension in pregnancy, twins/multiples pregnancy, preterm birth, or need an instrument (vacuum or forceps) or surgical (c-section) birth. Otherwise, we are all yours for the normal stuff!  

One day, women will be healthier, birth will be less risky for many women, we will have single payer or nationalized healthcare, and birth can again commonly take place in the home, for women who want it. And then or perhaps before that day (but when I have lots more experience under my belt), I will attend home birth. Until then, my nurse-midwife sisters (and a few brothers!) will take care of you in the clinic/office for your gynecology and prenatal care needs and in the hospital or out of hospital birth center when you need to deliver your baby. 


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Orientation Time: The Cervix!

I’m on orientation for two weeks — I get 4 patients in the morning, and 4 in the afternoon. That’s supposed to give me lots of time to get to know my patients, the charting system, and how things work in the organization with patient flow and all.

It’s been a year and a half since I graduated. The only other times I’ve laid hands on “patients” is when I have been doula to the friends and family that asked for pregnancy, birth, and postpartum support. So here I am, getting the hang of using the speculum again, and I’m having to figure out simple things like how to best help a patient sit up on the table after a bout in the stirrups. Other things, like listening to women, talk before touch, and explaining what I’m doing, haven’t changed.

As I am getting oriented to the organization and to my patients, and getting used to being in charge (not a student any more!), I am trying to also orient my patients to their own bodies.

Today, I found Nabothian cysts on two patients. I actually had not seen any on any patients while a student, so both times, they threw me off — sending me to investigate first with my heavy edition of Varney’s Midwifery and then to consult with my collaborating physician (OB). 

First, you have to get a good view of the cervix. The cervix is at the “back” of the vagina. In some women, it may be tilted down (toward the back) or tilted up (toward the abdomen). In many people, it can be found “midline,” or straight to the back if you are looking into the vagina head-on. The cervix is the mouth to the uterus — it’s where the sperm has to travel to get into the uterus in order to pass to the fallopian tubes for fertilization to occur. Most of us think about the cervix because of the pap smear, HPV, and cervical cancer. It’s also the opening that will dilate when a pregnant woman is in labor, so the baby can pass through the uterus to the vagina and out into the world. 

So…to find the cervix on an exam. We usually do the speculum exam before anything else, so as not to mess anything up first by stirring the pot. This has a disadvantage, however. If you haven’t done a digital (finger) exam first, you don’t necessarily know where to look for the cervix. It could be in any of the three positions I mentioned, and you really can’t tell from looking at a patient where her cervix might be found. You also may not know what size speculum she may need. 

“M’am, please place your feet on the stirrups here. Good! Now, keep your feet here, and try to flop your knees out toward the wall. Wiggle your toes to relax your bottom. Great! Now, here is my hand [touches back of left hand to patient’s inner right thigh]. I’m going to place the speculum now. Lots of pressure.”

Placing the speculum at a 30* angle to the floor of the vagina and pressing down ensures you aren’t putting pressure on the bladder or clit. From there…you have to kind of wiggle the speculum toward the back of the vagina, then open slowly while trying to visualize the round shiny part with the little opening. Flat if she’s had babies; small and round if she has not.

Then: what is that? You want it to be round, shiny, and pink. Some might have an area of pink around the os (inner hole) — “ectropian.” Cervicitis, or inflammation of the cervix, can be seen with sexually transmitted infections chlamydia or gonorrhea, and usually comes with discharge escaping from the os. 

What I wasn’t expecting today was present for two women I cared for: 1-2 centimeter bumps on the cervix; round to more ovoid, white with pink/reddish edges, and non-tender when touched with the fox swab (giant Q-tip). To give you a visual, here is a “normal” versus a cervix where there are Nabothian cysts:

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Of course, these are cartoon drawings…but you get the idea. After I took samples from the os for a pap test, STI screen, and a culture of the bump, I did a “bimanual” exam — meaning, I checked her pelvic organs using both hands. Internally, I found her cervix with my right hand. There was a hardened area on her lower cervix, but it was not tender or painful for her as I moved the cervix with one hand internally and then pressed the uterus down with my other hand. 

Nabothian cysts usually resolve on their own, and are considered a benign condition. You can read more about them on this delightful website: http://www.beautifulcervix.com/nabothian-cyst/

I had the pleasure of learning alongside my patients today…and now have the pleasure of sharing with you, dear reader. Now: tell your friends! Get to know your cervix. Find out what size speculum works best for finding your cervix, so you can tell future health care providers which size they should reach for when doing your exam. 

And…be nice to your cervix! Protect it from possible exposure to HPV by getting the HPV vaccine; by using condoms if you are at risk for STIs; and by following pap guidelines for prevention of cervical cancer. Talk to your partner(s) about it, and ask your health care provider for more information or for help navigating your sexual health and safety. 


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Another Beginning

I started seeing patients today…on my own. 

I have been through many beginnings, from deciding to become a nurse, to attending community college for my prerequisites, to moving to a new city for nursing school, to deciding to become a midwife, to being a student midwife, to working as a nurse, and now, beginning my new practice. 

I am thanking all my life midwives as I transition…my mother, my teachers, my mentors, my patients. 

I hope to use this space as my professional life grows to share my journey and my own and others’ analyses and thoughts about the world of women’s health.