Get Braver at the Gynecologist [Podcast]
Published June 2022
No stirrups, just straight-up talk. A Northwestern Medicine obstetrician-gynecologist demystifies your annual gynecology appointment.
Disclaimer: This podcast does not substitute for medical advice from a clinician.
Guest: Melissa A. Simon, MD, obstetrician-gynecologist, Northwestern Medicine
Russell [00:00:02] Let's get stronger.
Gates [00:00:04] Healthier.
Prickett [00:00:04] Calmer.
Russell [00:00:05] Smarter.
Gates [00:00:06] Better.
Russell [00:00:06] Living a healthier life is a journey, not a destination.
Gates [00:00:10] You can always get better.
Prickett [00:00:12] Let's get better together.
Russell [00:00:20] So what are we talking about today?
Prickett [00:00:21] Visiting the gynecologist.
Russell [00:00:23] Oh, yeah.
Gates [00:00:24] Fun, fun. Those are forbidden words to discuss.
Prickett [00:00:30] So many people have fears and discomfort just talking about biological functions and women and what is normal in women.
Prickett [00:00:38] I think it's one of those things that everyone wants to be on their best behavior. And sometimes you're on your too-best behavior, and you don't actually get to the meat of what's going on. And so we don't like to bring up things that are uncomfortable, but we need to because it's a big part of health care. So, I hope we can get to the bottom with talking to an expert about female reproduction to really say what's normal, what's abnormal? When do we — when do you see the doctor? What do we need to keep ourselves healthy? How do you have those conversations that can sometimes be difficult?
Gates [00:01:10] Absolutely. I'm raising a little girl, right? And so, I want to share with her what I didn't necessarily get, which was there's nothing to be ashamed about. And yes, there are some things that we have to do on a regular basis. Hopefully talking with the experts, yeah, we can really clear out some of the misinformation and get, you know, information that we all need.
Russell [00:01:33] And I think it will be helpful to you to talk to somebody who does gynecologic care just so people can hear what is a gynecologist thinking when they walk in the room to do just a normal, straight-up exam? Are they thinking, "I'm looking for certain appearance or changes," or "I'm looking for what is normal, abnormal?" What are they doing down there to give people context for when they go in for their own exam?
Prickett [00:02:02] And confidence, right?
Gates [00:02:02] Absolutely confidence. Looking forward to it, ladies.
Russell [00:02:19] We're joined today by Northwestern Medicine Obstetrician and Gynecologist Dr. Melissa Simon. Dr. Simon is the host of Skinny Trees, a podcast about health inequities in and around Chicago, which is part of the Center for Health Equity Transformation at Northwestern University Feinberg School of Medicine. Welcome, Dr. Simon.
Simon [00:02:38] Thank you. Thank you so much for having me.
Russell [00:02:40] So, let's first recognize that we're going to be talking about gynecologists. But reproductive screening may take place in other venues, such as internal medicine and family medicine clinics. So, with that in mind, when should routine gynecological screenings start, and who specifically needs to see a gynecologist?
Simon [00:02:57] Yeah, routine gynecologic care should start when you're early in your teenage years, and it should go pretty much every year for the rest of your life. I really see gynecologists as primary care providers, and we are the ones that can take care of you completely if you have female parts, if you identify as femme or you identify as being a woman. So, it's really important to understand that we can take care of yall of your primary care needs. However, some of us may be more comfortable referring you to another primary care doctor. So it is not uncommon for us to actually care for people with other primary care doctors or nurse practitioners or midwives as well, along your trajectory, across your lifespan. So, that's really what's important is that to understand: Every year is ripe for visiting the gynecologist. And if we feel like there is some kind of health need that you have that is beyond the scope of our practice, we would refer you to a family medicine provider, or internal medicine or an adolescent medicine or a geriatrician. It really depends on your age and your health care needs.
Russell [00:04:14] I feel like the gynecologist often is, like, a point person and an intro to medical care over the life span. Because for everybody who has a child, they hopefully will see somebody at that who has that expertise. And I'm glad that you're acknowledging that there's a lot of overlap between all those specialties. But we want to go back to the basics, because us, as pulmonary doctors, we learned about this stuff a long time ago. So, what can you expect during a standard gynecological appointment?
Simon [00:04:44] So, a standard gynecological appointment really involves, first, the basics. You usually take some kind of a questionnaire when you get to the office, to the waiting room, and then we'll bring you back and have the usual vital signs. So, all of that stuff, weight, blood pressure, all of those things. And then we have a discussion, right? So there's a lot of talking that goes on around our visit, just like in any other primary care office. So, just to get to know you better, so that you get to know us better, we talk about all kinds of things, including not just your usual health things and your gynecological health things, but about your sexual health and making sure that you are doing well in all areas of your life with respect to your health. And that includes sexual health. It includes mental health. It includes your physical health. So, all of those things will be talked about. And then, we get you into that lovely gown. Now, what's important to understand is that you don't need a pelvic exam every year. And I know that's probably one of the scariest or the parts of that of the GYN clinic encounter that people dread most. But honestly, you don't need a pelvic exam every single year because a long time ago we used to say, "Oh, you need a pap test." And we don't do pap tests — which are a screening for cervical cancer — every year. We actually do it about every three years, and sometimes after the age of 30, we do it every five years, depending on how we're screening you, with either a pap test, the usual cytology pap test, or the HPV swab. Now, if you are symptomatic, if you have some discharge or something's not going right down there and you just want it checked out, there's a bump or something, then absolutely we would do that. And again, I want you all to know is that we don't judge. This is truly a no-judgment zone. When we're looking down there, we don't care about hair, we don't care about patterning, we don't care about dirty socks. We really don't care if you have your nails, your toenails done. I'm not looking. I don't even remember, to be honest with you. We are just going down there and looking and examining for anything that could be abnormal or normal, taking the swabs that we would normally take.
Russell [00:07:16] Well, that is reassuring to hear, because I think that is what a lot of people delay health care, especially gynecological exams, because there's concerns. And I think it's really just helpful to hear that it is a no-judgment zone. And just coming to see the gynecologist is really the first step. I can speak for myself. Again, I get pretty nervous when I have my annual exam. They put you in the room. You'll be in that tiny little paper gown. You seem like you're waiting forever. I know it's just a couple of minutes, but what do you recommend for people that do feel nervous, especially recognizing that some patients have gone through some prior, traumatizing experience? What are your recommendations? How can we alleviate some of those fears and make it a more comfortable experience?
Simon [00:08:00] Be open and honest. If you come in and you're in that paper gown or even not in the paper gown yet, and you've had experiences like a history of assault, it is really helpful for you to just be honest with that health care provider and say, "Look, I've had really bad experiences before with this. Can we take it slow?" And that is totally fair game. And you know what? If it is not the day to actually get the pelvic part of the exam and it needs to be done, we can reschedule and we can do it in two parts. We can do the talking part of the exam, the history in one visit, and then come back another day for the other visit, the actual exam. This is okay to take time. Sometimes, we are so routinized in what we expect or what we think we should do, that we forget that sometimes the cadence can change and that is perfectly okay. Things like allowing you to insert the speculum into your vagina by yourself is totally fair game too. I mean, there are many different things that we can do to try to make what is a very uncomfortable exam, at least a little more comfortable.
Russell [00:09:16] Talk a little bit about what you're actually doing down there because I went to medical school, so I have an idea, but I know a lot of people, they don't want to look. They don't want to see what you're doing. They don't want to, like, have a mirror to watch. But I think it might be helpful to people to know what you're actually doing and, kind of, the general of what you're looking for.
Simon [00:09:37] Yeah, great question. A lot of us, no matter what sex or gender we identify with and as, haven't looked down there regardless of what our parts are. And I think it's really important to be one with your body. I really think you should just dispel your own myths and perceptions and get a mirror and look, because it's important. The more you ignore that part of your body, the harder it is to present it to somebody else. And so, when you go into that clinical care situation and we have you naked, and we're looking at a part of your body that you probably haven't seen before, then it makes it even more uncomfortable because you have no idea what's going on down there because you don't even know what it looks like. So, that's the first thing I recommend is y'all look in the mirror. I can't emphasize that enough because we all look differently. Just feminine parts, like vulva, the external part of your vagina, they all look differently. They're not symmetrical. Almost nobody is symmetrical in the world with respect to vulva, and every vulva looks a little different and those are all almost always in range of normal variation. And that's something, again, not to be embarrassed about because that's just how it is. And if anyone ever judged you, like if you were having sexual intercourse and anyone ever judged you about having big labia or uneven labia or no labia — that's just wrong. It is wrong for so many reasons, and it makes stigma about our body parts even worse. And when we have stigma about our body parts, it makes getting to a doctor and having that exam even more difficult. So, that's why I really emphasize this no-judgment zone and really understand that we're just looking to make sure everything works within a range of normal. But what we're looking for is any abnormal bumps, bruising, cuts and little pimple-like things, rashes. Those are the things we're looking for. And then, if you have any pain, we're going to examine where you have pain to try to figure out why you're having pain. And then if you have something like discharge, we're taking samples with special Q-tips of the discharge to make sure that everything is normal. So, we'll send that out to a lab for tests or we'll do a test in-house in the clinic under a microscope. When we insert the speculum into the vagina, we're trying to do it as comfortably as we can, as slowly as we can. But again, this is such a uncomfortable exam at baseline, it makes it even harder. And what we're doing is as we're looking in the vagina, we're looking at the cervix, if you have one, and then taking samples from the cervix if you want. So, again, samples from the cervix would include things like a pap test for cervical cancer screening or an HPV, a human papillomavirus test for HPV screening, which is the virus that causes genital warts and it causes the majority of cervical cancers. And then we're looking for anything else. Like if you think you might have chlamydia or gonorrhea or Trichomoniasis or yeast or bacterial vaginosis, all of those things. That's what we're doing in that exam. Now, the next part of that exam involves the internal exam with our one finger or two fingers and a hand on top of your abdomen to really try to feel if we can feel any abnormal things like cysts on your ovaries or uterus being too big or it may have fibroids or if there's any pain, again, trying to figure out why you're having pain. And depending on the scenario, on the situation and your age, we may also be doing a rectal exam to, again, feel for anything that feels abnormal, either behind the uterus or in the rectum itself. And then we're just looking at the outside of your urethra where the urine comes out for any abnormal cysts or things like that. So, again, a lot of it is feeling, it's touching, it involves looking, and we're just trying to help and to make sure that you don't have anything that could harm you like a cancer or a sexually transmitted infection and trying to get you to feel better about yourself as well. Hopefully, that helps demystify the exam a little more.
Russell [00:14:09] Can you comment on what sort of things women postpartum should bring up with their gynecologist? Like, six months or a year out, when you're like kind of released back to your normal gynecologic care that you should bring up if you're noticing.
Simon [00:14:25] It is not uncommon, right after you give birth to be incontinent, to lose your urine, sometimes lose your bowel, and it can take a while to gain that continence back. We need to know about that. One really important topic that I don't think is discussed enough at a gynecologist office is continence, bladder issues, bowel issues. Those things need to come up if you're having anything because we have ability to refer you to physical therapy, and there's pelvic floor therapy. There are all kinds of things that we can do to help support that. Just because you have a baby, or many babies, doesn't mean you have to live with a bladder that just isn't working well for you or a bowel. Healing from any tears. It's not uncommon to have some level of tear on your perineum after a birth, a vaginal birth, trying to learn how to do Kegel exercises, or those pelvic squeezes, those pelvic floor squeezes. We can help teach you those. And if you don't understand how to do them, ask us to help you learn how to do them. And we can also refer you other things that are important. Vaginal dryness can be a real issue as your hormones fluctuate, especially postpartum. And if you are breastfeeding, your estrogen levels — which normally make your vagina very lubricated — naturally can go down, and it can make sexual intercourse postpartum six months, 12 months out, very uncomfortable. And so, we can prescribe some cream to help you with that. We can help you answer any of the questions that you have about your vagina. You may have different periods, you may have different discharge. And, like I said, you may have some dryness. That's not like it was before. Our bodies don't go back to normal or to baseline after having a pregnancy. Some things will go back to baseline, but some things won't. And that's a really important thing to understand, is that if you're not back to baseline, and if you think there is anything — just that's not normal, ask, you know, the worst thing that can happen is we say, "You know what? That's normal."
Russell [00:16:35] The gift that keeps on giving, for years and years (laughs).
Prickett [00:16:42] And I don't think we talk about it enough. People talk about pregnancy and it's such this wonderful gift, which it is. But we don't talk about all the things that come with it. We don't talk about how common spontaneous abortions are. We use the term miscarriage, it's this euphemism, but miscarriage, no one carried anything wrong. It was a spontaneous abortion, and it's part of health care. So, I think I had heard is one in five pregnancies can end with spontaneous abortions. Is that a true statement? Is that about what we expect?
Simon [00:17:13] Yeah. So, on average across this country, we have about 20% of all pregnancies have some kind of bleeding, OK? And about half of those definitely end in miscarriage or spontaneous abortion. That's an important framing. So it's not something that you did yourself, especially if this happens, you know, in the first trimester or the second trimester. It's not you. It most likely is either the chromosomes of the fetus just weren't viable and your body just naturally knows this and then expels the pregnancy. So, again, it's no-judgment zone. And those are the one thing that's, like, one thing in the clinical care setting that I see the most remorse, shame, guilt in a clinical encounter, and that is around a miscarriage. I can't tell you how many times when a person comes in having bleeding, they're blaming themselves for something they did.
Prickett [00:18:14] I think that's the experience I've had, not as a physician, but just as a woman. People, it's so common, and it's something that we can support each other with.
Russell [00:18:22] So what if you're not interested in pregnancy at the moment? I know there are a lot of options out there for birth control. What are some of the options and how can our listeners decide this with their physician, or what sort of things do they bring to the table in that discussion?
Simon [00:18:36] There is a wide range of things, so there's things that are used daily, which are pills, and there is different kinds of pills. There's pills that contain estrogen, and pills that just contain progesterone. So, people who have migraines with auras or have had a history of blood clot or have a history of high blood pressure or smoke cigarettes should be steered away from the estrogen containing. Then we have things like the ring, which are every three weeks to four weeks. So it's a vaginal ring. It kind of looks like those old school gummy bracelets and you fold it up and you inserted into the vagina and it's out of your mind for three weeks. And then you take it out for one week and have a menstruation and then put a new one in. There's also the patch, which is like a sticker patch. That is the only form of birth control really that is dependent on weight. And so we don't recommend anyone over 190-ish pounds, regardless of your height, to take a patch because the patch is not effective, really not effective after about 190-ish pounds. But that is a sticker that goes on your body for one week and then comes off and you exchange it every — you change it every week. And then, we have things like longer-acting contraceptives. First is the Depo shot that many people are familiar with. It's every three months. And then there is longer-acting, reversible contraception like IUDs — intrauterine devices — and the next one, a rod. It's one rod that we put in your arm, your upper arm, and it lasts for up to three years. Now, your IUDs are not like your grandmother's or your mother's IUDs. These are a lot more safe, a lot more effective. And there's a wide range of them. There's one that lasts for only a few years. There's one that lasts for five to seven years, and there is one that lasts for 10 to 12 years. And there's ones with hormones in them, just the progesterone, those last like five to seven years or two to five years. And then there's the 10-year to 12-year ones that are copper that don't have any hormones in them. So there's a wide range of options for birth control. And it's really important to recognize that if one doesn't work for you, come back and we'll try another one.
Russell [00:20:57] So, I think we're coming close to the end of our time. But is there anything else you'd like to add?
Simon [00:21:01] I think the most important points are: There is no shame. And if you don't feel comfortable with the provider that you have: Change. If you're not feeling comfortable at any point you have the right to verbalize that. There is no shame. I don't care what your socks look like. I don't care what your manicure looks like, or none. You don't have to worry about odor or anything. Your vagina has its own ecosystem. It is like a forest. Really, it is. The vagina is meant to take care of itself and it's meant, it cleans itself. And so it's important to understand that you have to be one with your vagina when it comes down to it.
Russell [00:21:44] This has been so much fun. Dr. Simon, thank you so much for being here. We would love to have you back to talk more about women's health, reproductive health, probably menopause too. That's going to be on our list of future questions. But so nice just to talk about what is normal and have open conversations to normalize women's health care. So, thank you so much for joining us today.
Simon [00:22:07] Thank you for having me.
Russell [00:22:12] Thanks for listening to Get Better.
Gates [00:22:14] We hope you'll leave this podcast better than when you started.
Russell [00:22:17] For more information, visit NM.org/healthbeat.