Ovaries

Today, I tackle a body part upon which I consider myself to be somewhat of an expert. Had my left ovary behaved years ago, I would not be typing this today–and I would still have both ovaries. Speaking with other women, it becomes obvious very quickly that we tend to know very little about our ovaries.  Hopefully, I will shed some light on this for you today!

Where are the ovaries?  It’s safe to say we know they’re in our pelvis, but where exactly?  A good estimate is to make a triangle with with your index fingers and thumbs and place that over your pelvis with the index fingers pointing downward.  In the upper corners is about where your ovaries are.  (They tend to be a bit lower and more centralized than most assume they are.)  The ovaries are held in place by a network of ligaments which also attach to the uterus and Fallopian tubes.  The ovaries are not connected directly to the Fallopian tubes.  Many diagrams shows the fimbriae (the leafy looking parts on the far left and right below) of the Fallopian tubes as been directly adjacent to the ovaries, which leads many to believe that the ovaries are directly attached to them.  They are not.  (Read more about the relationship between the ovaries and the Fallopian tubes in the section about Fallopian tubes.)


The ovaries are, ironically, shaped like eggs but are smaller than the chicken eggs that one typically purchases at the grocery.  The ovaries are about the size of a walnut, are slightly pearl colored, and have bumpy, soft surfaces.  The ovaries are responsible for producing a variety of sex hormones.  At birth, the ovaries of a healthy baby girl contain between one and two million eggs.  By the time puberty begins, most of these have wasted away leaving about 300,000 eggs–plenty for the reproductive lifespan.  Thus, a woman has a finite number of eggs, but men have a different mechanism that continually makes sperm.  This is why women have “childbearing” years, but men can father children throughout their adult lives.

The eggs have a complicated lifespan before they are even released for potential fertilization.  The term “egg” is generic and refers to a single cell’s journey through maturation.  Before maturation, the egg is referred to as an oocyte.  Once it finishes maturing (see diagram below), it becomes an ovum and three polar bodies.  The polar bodies are actually inside of the ovum and serve to “fuel” the egg once it is fertilized continuing cell division and replication before it implants in the uterine lining (where it forms a network of blood vessels that forms the placenta and umbilical cord).

Each month, the ovaries usually release one mature egg (not one from each).  The ovaries are covered in cells called follicles and within each follicle is a single egg.  Once an egg is matured, the process of ovulation can begin.  During this time, the follicle that houses the mature egg expands and eventually ruptures forcing the egg outward.  This rupturing is completely normal–it would be abnormal for ovarian follicles to never rupture, and in fact some women can actually feel a quick pain when the rupture occurs.  The diagram below is an illustration of the ovulation process, beginning in the upper-left hand corner and going clockwise.


Following a woman’s “childbearing” years, the ovaries continue to play an important role.  For years, many doctors prescribed a surgery called a hysterectomy to remove the ovaries (as well as the uterus and Fallopian tubes) once a woman was finished having children.  This was performed to prevent cancer from developing.  However, we now know that ovarian cancer can actually develop anyway after the ovaries have been removed.  This is because the ovaries share tissue with the internal cavity that remains following a hysterectomy.  Leaving the ovaries intact provides a number of hormonal benefits throughout menopause that are difficult to replace.  Thus, the benefits of leaving the ovaries intact often outweigh the drawbacks.  (This is something that should be discussed with a physician, because each individual has a different medical history that will affect any such decision.)

There is a lot more that could be said about ovaries, but let’s save that for another day.  Hopefully this gives you a better understanding of how the ovaries work!

The First Visit to the Gynecologist: A Guide (Part Two)

Finding Eve returns with Part Two of this first-timer’s guide.  (Click here for Part One.)

During your appointment:

  1. LISTEN!  You will be given a series of instructions throughout your appointment.  Things will generally be more comfortable for you if you follow them.  They may want the paper gown to open in the front or the back or the side.  They may want you sitting, standing, lying on your back.  Just pay attention and things will go much more smoothly.
  2. Be vocal.  Now that you’re getting into the stirrups and down to business, it’s up to you to make sure your doctor knows how you feel.  For example, if you have a bad back and lying a certain way hurts, let the doctor know she or he will usually be happy to accommodate.
  3. Remember your breasts.  Most, but not all, gynecologists will give your breasts a once-over to check for lumps, bumps, and irregularities.  So, be prepared for this.  This might be the most awkward you’ll feel since the doctor will be nearly face-to-face with you at this point.
  4. Be prepared for some unusual sensations.  No matter your level of comfort with your genitalia, your first appointment with the OB/GYN will be something new.  The doctor will need to insert a few things in your vagina.  It’s an unavoidably strange situation, but it doesn’t have to be a nightmare, so be prepared for the following:
  • The first thing in will generally be a speculum.  This is a device that goes in to spread the vaginal walls to allow the doctor to see in.  There will be bright lights focused on your vagina to aid in this.  While the doctor looks around, she or he will also use a swab to take a sample of cells from your cervix.  You’ll barely be able to feel the swab, so don’t be too worried about it.  The swab is then sent away for testing to see if you have (pre-)cancerous cells.  This is called a Pap smear.  REMEMBER, this only tests for one type of gynecologic cancer (cervical).  Keeping track of your periods and pelvic health is your best bet for detecting other types of cancer.
  • After the swab for the Pap smear has been collected the doctor will “manipulate” your pelvis.  That is to say, it’s time for the rough and tumble part of the exam.  Really, it is not as bad as it sounds or may look in the diagram below.  (Believe me, I have had several severe pelvic surgeries and I make it through the pelvic manipulation fine.)  This, to me, is the most important part of the exam.  The doctor is using her or his hands to “see” what’s inside you and to make sure all is well.  It’s normal to grimace.  It’s not the most normal feeling, but it will soon be over!
  • Ask questions!  Generally, after the manual exam, the doctor says you can sit up.  This is your invitation to ask questions.  Since this is your first time, you should ask as many questions as you want.  Many doctors’ offices will schedule first-timers with longer appointments because they expect the patients to have more questions.  Don’t be shy.  If there is any thing that you don’t understand or have reservations about below the belt, ASK!  The doctor will be able to help explain whatever it may be, and this will put your mind at ease.

    After your appointment:

  1. Follow through!  If the doctor recommends that you take care of yourself with some therapy, medicine, or change, do it.  If it is something drastic, feel free to go to another doctor for a second opinion.  It is your body, after all.
  2. If you are having testing for sexually transmitted diseases (STDs), you may be asked to make another appointment at a lab.  Larger doctors’ offices usually have their own lab, so you may be escorted across the hall to have blood taken.  If you’re afraid of having blood drawn, be prepared!  Drawing blood is crucial to many standard gynecological tests, so don’t be worried if you’re referred for blood work.
  3. Keep in touch.  You will most likely receive your test results (Pap smear, blood work, etc.) in the mail or over the phone in the subsequent two week.  If, after 2-4 weeks, you have not heard anything, call your doctor’s office!  You paid for those tests, so you have the right to know how they turned out.   Things can get lost in the mail or misplaced, so take the reins and find out.  The office staff won’t begrudge you at all.
  4. Remember to make an appointment for next year.  You should never go more than a year without a visit to the gynecologist’s.  Most insurance will only cover one visit in a 365 day period, so if you went on May 1st one year, you will have to wait until least May 1st of the next year.

Remember, this guide is intended as a rough guide to your first visit.  No two appointments will ever be identical.  It is important to do what is right for you.  Please feel free to add your comments and questions and thanks for reading!

The First Visit to the Gynecologist: A Guide (Part One)

A young woman’s first visit to the gynecologist can be daunting.  Women who have already been for a gynecological check-up generally report that it’s unpleasant.  So, naturally, this scares others and many avoid going until they have to.  BUT!  I’m here to help quell those fears and insist that all young women go for a check-up.  My first visit to the gynecologist was about as traumatic as possible, but I know that I might not be alive today if I had not gone.  So, it is of the utmost importance that you take your health seriously and face any fear you might have of going to the gynecologist.  Almost every young woman comes out after that first visit and says, “That wasn’t as bad as I thought it would be.”

Before your appointment:

  1. Do your research!  If you’re reading this blog, you’re off to a good start.  Continue on by finding a local gynecologist that you are comfortable visiting.  Many young women who nervous about their first appointment find it easier to visit a female physician.  It will serve you well to talk to friends about who they go to and why.  Also, look into insurance matters.  It can be really confusing, but ask the office staff of your doctor of choice to help you confirm what is or is not covered by insurance–they’re experts and can find out what you need to know.
  2. Monitor your period.  This is an important habit to keep up your whole life.  If you’ve never kept track of your periods before, start right now!  Keep a calendar record of when your periods begin and end and make notes about any irregularities (more pain, heavier flow, etc.).  You’ll be expected to know how regular (or irregular) your periods are at the doctor’s.
  3. Decide on a day and make the appointment.  Once you known when your “safe times”* are, call the doctor’s and make that appointment!  Just making the appointment is half the battle–the next half is keeping the appointment.  You can do it!

* Many gynecologists will not perform an exam when a woman is menstruating since the blood may obscure their view of the vaginal structures–they look for any abnormalities that are visible to the naked eye.

The day of your appointment:

  1. Shower!  Or bathe!  Just get clean somehow.  Doctors encounter enough unpleasantness throughout a working day–they will thank you for not adding to it.
  2. Try to stay as calm as possible.  Being nervous and jumpy will make the appointment even more lousy.  Take deep breaths, listen to calming music, think happy thoughts.  It might be a good idea to take a friend with you if you’re really nervous.
  3. Get to your appointment on time!  Most doctors’ offices will give a recommendation of how early you should arrive.  Follow it.  If you have a bit of time to spare, you might even show up earlier than that.
  4. Almost across the board, a gynecological appointment requires the patient to provide a urine sample.  So, about an hour or so before your appointment start sipping on water (or your beverage of choice).  They will collect the sample before your actual appointment with the doctor begins and you’ll want to have something in your bladder to give.
  5. Be prepared to answer questions!  Each doctor’s office will ask a different set of questions, but here are some of the most common ones:  When was the first day of your last period (menses/menstruation/etc.)?  What medications are you taking?  (Don’t forget non-prescriptions like vitamins!)  Have you been experiencing any problems, pain, or irregularities?  Do you have a family history of cancer . . . anything?  Are you sexually active?  (BE HONEST!  If you’re nervous about a parent finding out, don’t be.  Doctors, by law, have to respect your confidentiality.)
  6. Wear clothes that are easy to remove.  Wearing clothes with lots of buttons and buckles and so on are a rookie mistake.  You’ll be glad to have a shift dress or sweatpants or what-have-you when they only give you 90 seconds to disrobe!  You might have more time than this, but more often than not I have been given very little time to climb out of my clothes and into the paper clothes.  (Also, wear nice socks.  You’ll want something warm on your feet when you rest of you is clothed in paper.  Your feet will be in the doctor’s face for much of the appointment, so pick nice ones.


The is just the first half of the guide!  Part Two will be published soon.  As always, feel free to add any comments, recommendations, or questions.

(Here is Part Two.)

Teen Pregnancy and the Rhythm Method

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

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

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

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

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

History of the IUD

Speaking of Dr. Ernst Gräfenberg, let’s talk about intrauterine devices (IUDs) since Dr. G is recognized as the first developer of the modern IUD.  IUDs, in a crude sense, have existed for an untold number of years.  Women and men have inserted various implements into human and animal uteri to prevent pregnancy for many years.  Forerunners to the modern IUD emerged in the beginning of the twentieth century with inventions such as the stem pessary.

The first true modern IUD was invented in the late 1920s by Dr. Gräfenberg when he was still practicing gynecology in Germany.  The IUD that Dr. G invented was, instead of the familiar t-shaped device, actually a circle-shaped device:  the Gräfenberg ring.  These rings were silk threads covered with fine silver wire.  The metal of this device caused an inflammatory response in the uterus thus creating hostile conditions for sperm.  He later found that some copper mixed with the silver aided in the contraceptive ability of the device.  (Of course, for a number of uteri in which these were inserted the inflammation was so great as to cause complications, though these were rarely severe.)  By the end of the 1930s, the Gräfenberg ring fell out of use mostly because of the eugenic policies implemented by Nazi Germany (in which all contraception was outlawed, as it was in Japan as well).  Gräfenberg himself left Germany in 1937 to escape persecution because of his Jewish heritage.

The modern plastic-based IUD began to take shape in the United States in the 1950s.  Lazar C. Margulies, an obstetrician in New York, is generally credited for pioneering plastic IUDs to help reduce the danger associated with previous IUDs.  In 1958 he introduced his version of the IUD, though it was not greatly successful because of its large size.  In 1962, Jack Lippes, a gynecologist also in New York, developed a smaller, plastic IUD that became more popular.  In the late 1960s, Howard Tatum, another New York obstetrician, developed a plastic-cased, cooper-based IUD that could be dramatically reduced in size without sacrifcing its effectiveness.  During the 1970s, in an effort to help cheaply curb reproduction and enforce the “one-child policy,” Chinese physicians developed the stainless-steel IUD, but banned them by early 1990s because of a 10% pregnancy rate due to steel’s lowered contraceptive capability.

The second generation of plastic-copper IUDs came around in the 1970s.  These IUDs increased the surface area of the devices and increased their effectiveness above 99%.  Today, in the United States, this type of IUD and one other type are available.  The copper IUD available in the United States is called ParaGuard and is effective for twelve years.  The other type of IUD available in the United States is a hormone-based IUD, called Mirena, that functions in a few ways.  This IUD first creates a hostile environment for sperm, much like copper-IUDs by thinning the uterine lining making it highly unlikely a fertilized egg could implant in the uterus.  Second, the hormones involved create a thicker cervical plug making it less likely that sperm will enter the uterus to begin with.  Finally, the hormone-IUD in some instances stops the ovary from releasing an egg, though this is less likely than the other two functions.  Hormone-based IUDs were developed in the 1970s, but have not been popular in the United States until recently because of ad campaigns for Mirena (though they remain relatively very unpopular compared to condoms and the pill).

This is all a sort of background to understanding the IUD.  Hopefully, in a later entry we can better address the scientific and medical aspects of IUDs in their modern form.  Do you have something to say about IUDs?  Or anything else?  I yield the floor.

Diaphragms

Diaphragms are a popular type of contraception that consist of a sheath of silicone or latex around a
circle-molded spring that is placed in the vagina prior to intercourse to prevent sperm from entering the uterus.  Having discussed with many women my age various types of contraception, the diaphragm is probably one of the least discussed among us.  I have always had the impression that only “older” women use diaphragm.  (I use “older” lightly, meaning simply women who are about 35 or older.  There is nothing old about these women, of course, they are simply more sophisticated.)  So what’s the deal with diaphragms?

Forerunners of the diaphragm have been around since time immemorial.  Ancient peoples used various implements to function as a proto-diaphragm such as lemon slices and paper leafs stuck to the cervix using honey (a natural anti-bacterial and antiseptic).  The modern diaphragm began to take shape in the nineteenth century when vulcanization processes allowed for rubber contraceptive devices to be used.  Margaret Sanger promoted the use of such rubber devices as early as 1916 and helped introduce them en masse to the United States.  By the 1940s nearly one-third of all married couples in the United States used diaphragms as a primary method of contraception.  However, the introduction of intrauterine devices (IUDs) in 1960s and the popularity of oral contraceptives (the pill) greatly reduced the use of the diaphragm.  By 1965, fewer than 10% married couples were using diaphragms.  Following safe sex campaigns of the 1980s and 1990s, condom use increased greatly and now less than 2% of married couples in the United States use diaphragms.

Diaphragms have several advantages.  Many women prefer diaphragms to oral contraceptives because pills generally require daily use and it can be difficult to always remember to take it.  One advantage for women is that they can be inserted hours before sexual intercourse allowing it to progress without having to stop to put on a condom.  Because diaphragms are meant for somewhat longterm reuse, they oftentimes end up costing less than other forms of contraception.  Also, some types of diaphragms are designed to collect menstrual blood though they are not usually used primarily for this reason (i. e., they are used to allow sexual intercourse without having to worry about blood).  Diaphragms, when properly used, are 94-95% effective in preventing pregnancy.  However, with “typical” use this rate drops to about 85%.

One drawback to diaphragms is that they do not fully protect against sexually transmitted diseases (STDs).  Used in conjunction with spermicides, diaphragms do offer some protection against these diseases but are not 100% effective.  (The effectiveness of diaphragms in preventing STDS is debated by scientists.  The cervix is especially prone to contracting STDs, so protecting it with a diaphragm may impede the transmission of some STDs but certainly not all.)  Another drawback is toxic shock syndrome, though this is more likely to occur with use of tampons.  There is also an associated risk of urinary tract infections, though if properly used diaphragms usually do not cause this.  And of course, women who are allergic to latex should not use latex-based ones and should warn partners ahead of time in case they are allergic to latex.

Having never used a diaphragm myself, I cannot deliver a personal opinion though they seem like something worth trying if you are interested in different methods of birth control.  Of course, I recommend using them in a monogamous relationship because of their decreased ability to prevent STDs.  If you are having sex outside of a monogamous relationship, you should always use a condom–still the most effective means of preventing the transmission of STDs.  So, do you have something to say about diaphragms or maybe have a question?  I’m all ears.