Orchestrate your gynecological health

By Kerri S. Smith

Right now, as you read this, a hormonal symphony is playing in your body.

Perhaps it's the time in your monthly cycle when estrogen surges from the ovary, and is met by a hurrah from the brain's pituitary gland (prepare an egg!). Or maybe a concerto is building in your uterus, the notes swelling in a precise harmony (nest ready for an egg!).

Feeling reflective, teary or having lots of dreams? You may be in descending into the luteal phase between ovulation and menses, (the egg release and period onset). The notes are longer and softer now. It's interesting that several studies indicate that if your inner song is ignored, during this time you are more prone to mood swings, exhaustion and headaches.

After your period, as hormone levels rise, the melody builds again - which some women experience as an energetic, creative kick - eventually pouring out an extravaganza of notes that literally can waken new life.

But too many of us don't hear our inner song, or consider it discordant - a shrieking annoyance punctuated by cramps and the dreaded annual exam. That's partly due to our cultural heritage, writes Dr. Christiane Northrup of Yarmouth, Maine, author of the ground-breaking book, Women's Bodies, Women's Wisdom.

"The menstrual cycle is the most basic, earthy cycle we have," she says. Yet "instead of celebrating our cyclic nature as a positive aspect of our female being, our culture teaches us that we shouldn't acknowledge our periods at all, lest we neglect the needs of our spouses and children."

She's right. These attitudes are even reflected in the way we sometimes talk about feminine functions, referring to menstrual cycles as "going on the rag" or "the curse" or lamenting the swelling bosom, curving stomach and voluptuous hips that often follow childbirth.

Then there is our appalling lack of knowledge about how the whole magnificent system works. Generally, we know less about our female functions than we do about Ricky Martin's love life. For instance, the National Vaginitis Association recently asked 300 women to name the symptoms of the most common vaginal infection. Fewer than 20% of the women correctly pegged the symptoms. Faced with a pubic-area itch or off-cycle bleeding, too many of us grab an over-the-counter cream or douche, figuring "I'll call the doctor if it's not better next month."

That's not good. Add to the equation the fact that plus-size women often churn out extra hormones - which can upset the delicate chemical pitch necessary to keep the female system humming - and this issue's report on gynecological health is a must-read.

So pour a glass of lemonade, grab a paper and pen, snuggle into a comfy chair and let's take a brief tour of Female Land.

Mapping the Territory

Most of us start out with the same basic equipment: a vagina, which is like a muscular tube, linked to the donut-shaped cervix, which acts as a gateway to the fist-sized uterus. On either side of the uterus is an ovary, connected to the uterus by a fallopian tube. When everything is operating normally, rising hormone levels nudge one of the ovaries into maturing an egg. The mature egg pops out of the ovary near the entrance to the fallopian tube, where it is sucked into the tube and down toward the uterus. If the egg is fertilized by sperm, it implants itself in the cushiony, blood-engorged walls of the uterus; if not fertilized, it triggers a period. The whole thing really is like a well-rehearsed musical, with a conductor (hormones) leading the orchestra (female organs) and starring the lead singer (the egg).

Before reading any further, take a few minutes to graph the notes in your personal medley. Start by writing down how old you were the first time you got a period. This is your official "onset of menarche." Did you start earlier than your friends did? Plus-size girls often start menstruating early, because their extra fat cells spur puberty.

Now it's time to graph the frequency of your periods. Write down how many periods you have a year, and how far apart they are. Note how long they last. Everyone's different in this department. Most doctors consider a cycle normal if it occurs every 24 to 35 days. Some women can predict the very hour their cycle will kick in, month after month. Others report starting out regular, say, every 28 days, then seeing their cycles elongate after childbirth, weight gain, disease or other changes. Some women report cycle oddities when the seasons change, when they're ill, traveling or under unusual stress.

Skipping Periods

But there's a name for it when you routinely skip periods without being pregnant: "amenorrhea." It's a signal - a discordant note - indicating that something is not working right in your reproductive system. This condition is more common among very thin or very fat women.

"When you're 15% over or under the desired percentage of body fat, your periods may be affected," explains Dr. Barbara Deming, a gynecologist in Baton Rouge, Louisiana. Many of Dr. Deming's plus- or super-size patients have amenorrhea. In amenorrhic women who are fat, estrogen and progesterone levels shoot up and fluctuate abnormally. Instead of maturing and moving into the fallopian tubes, eggs wilt while still in the ovaries, creating tiny cysts. Off-note due to the abnormal hormone levels and denied an egg, the uterus does not flush itself. Instead, a thick lining of spongy blood builds.

If your menstrual history includes amenorrhea, pay attention. You need to see a doctor right away for a complete physical and lab tests. Tell the doctor you may have "polycystic ovary syndrome," which is an innocuous name for a very tricky condition. PCOS, as it's more commonly known, doesn't just jangle your reproductive system. Thought to be a genetic problem, PCOS affects the metabolic and reproductive systems. As many as 5 million American women may have it, experts say, and it is the leading cause of infertility today. Because PCOS upsets so many body processes, it is linked to diabetes, high blood pressure, obesity, heart disease and endometrial cancer. Women with PCOS also often report increased facial or body hair, thinning head hair, dark skin patches on inner thighs, underarms and neck napes, acne and mood swings.

How likely is it that you have it? According to Dr. John Nestler, endocrinology chairman at Virginia Commonwealth University in Richmond, Virginia, there's an 80-90% chance you have PCOS if you are plus size and have irregular periods.

The good news is that PCOS can be treated. The bad news is that so far it can't be cured. Treatment includes hormone therapy, most often in the form of birth control pills; diabetes drugs such as Metformin and Rezulin; testosterone-blocking drugs; fertility drugs for women trying to get pregnant; a low-carbohydrate diet and regular exercise.

If you have symptoms of amenorrhea or PCOS, write them down underneath the description of your cycles. Be sure to note your last period, including how long it lasted and whether you experienced any bleeding between cycles. And when discussing this with your doctor, if he or she seems to regard PCOS as a mild condition, find another doctor who takes it seriously.

Bleeding between cycles is another sign of trouble, says Nurse Practitioner Hilary Modell of Berkeley, Calif. Modell, who is also a registered nurse, is a member of an advisory committee studying ways to ensure that large-size women get good gynecological care.

"There is an increased incidence of abnormal vaginal bleeding in fat women because their fat tissue produces a form of estrogen; and this may or may not be linked to PCOS," Modell says. Abnormal bleeding can also be caused by severe anxiety or depression; thyroid disease; a pituitary tumor, uterine (endometrial) or cervical cancer and other conditions. She suggests seeing a gynecologist immediately for bleeding between cycles.

Annual Exams

Speaking of seeing a doctor, write down the date of your last gynecological exam and Pap smear. Has it been more than a year? Neglecting to get annual exams and pap smears is more common among large women; we avoid going in, because we are so often treated poorly in the doctor's office. "So many women have had a bad experience with their health care providers, because the providers can't see beyond the fat," says Modell with a sigh. "Women get turned off to health care."

But that means we risk our health - and it's part of the reason why plus-size women are more likely to die of reproductive-organ cancer. We don't go in for simple screenings, early conditions aren't caught in time or treated appropriately. By the time symptoms scare us into the stirrups, disease can be far advanced. So if it's been more than a year since your last pap smear, or it's possible you may have PCOS or another condition, write this down: MAKE AN APPOINTMENT WITH A DOCTOR THIS WEEK.

BBW asked Modell and a dozen other health care providers if doing a gynecological exam on a large woman is different from doing one on an average-size woman. Their answer: not by much, and everything is do-able, with a little patience and the right equipment. So if you're being treated disrespectfully or turned down for a Pap smear, quit going to that doctor, but don't quit getting the health care you need.

"That's the best thing to do, because some doctors are better at dealing with the large-size population than others," agrees Dr. Deming. "I don't think all of us are comfortable with every disease process or medical problem. Some are not willing to invest time and energy in the needs of a particular group. I say, find one who is."

Ask your friends if they know of a good gynecologist, then call and speak to the doctor's nurse. Be up front and say, "does the doctor have a problem working with a patient who weighs X?" Listen to how the nurse responds; if she seems hesitant, or offended, that's a tip - try another doctor.

What are the caveats in examining a large woman? Number one, it's harder for a doctor to manually feel whether or not your uterus and ovaries are the right size and free of cysts if there's a thick layer of abdominal fat covering the organs. Solution: ultrasound. "Ultrasound shows me the size and position of what's in there, and ultrasound shouldn't be more difficult to do on a fat woman than on a smaller woman," Modell adds. She likes to ultrasound any woman whose organs are difficult to feel, especially if they are over 40 or have irregular periods. Happily for us, ultrasound is painless and simple.

Chubby thighs are virtually never an issue because the stirrups can be adjusted so that the doctor has room to work. But access to the vagina and cervix is difficult in some large women, Modell admits. "It's a combination of the angle of the vagina, position of the cervix, whether they've had children and muscle tone of the vagina. Also, some women have fat deposits in the vaginal walls; it can be difficult to see or access the cervix," she explains. Solution: patience and long, slender speculums. This tool, when slipped into the vagina, gently holds the vaginal walls apart so the doctor can see and examine the vagina and cervix. Before going to a new doctor, ask if he or she has a long, slender speculum on hand.

Most gynecologists do a breast exam during the annual checkup. Dr. Lauren Hamilton of Charleston, South Carolina, says she takes extra care while palpitating larger patients, to make sure she doesn't miss anything. "It's not really harder, you just have to be more meticulous during the breast exam," she says. "As for the pelvic, you need to simply position them properly and use the right instruments, like the longer speculums. As for the rest, you can't feel as well with your hands, so you order more ultrasounds."

Dr. Hamilton is used to hearing stories about patients' negative experiences with fat-phobic doctors, but believes most physicians today are more understanding about diversity of size in their patients.

"Every patient needs to be respected regardless of their weight or other status," she says. "At the same time, it is a doctor's responsibility to be honest about the role of weight in medical problems. I don't believe in diet pills but do counsel patients about exercise. I also screen my larger patients for specific, weight-related problems, like abnormal bleeding and diabetes."

Shy about shivering on the examining table in a too-small gown? Call the doctor before your appointment to ask how roomy their gowns are, or order one in your size from NAAFA, a non-profit size acceptance organization. Gowns - which are perfect for exams, mammograms, ultrasounds, even beauty shop appointments - are available up to size 10X and cost $19.95-$29.95. For information, visit www.naafa.org.

Infections

During the exam the gynecologist might mention seeing a yeast infection in the skin folds between your thighs and vulva. The yeast organism grows naturally in women's vaginas and rectums. Large women often have an overgrowth of yeast in skin folds, because the organism is happy in damp, warm places such as the groin, under the belly flap (the "panniculus") and below the breasts. Yeast is white, like cream cheese, and causes a red, itchy rash that should be treated with an anti-fungal medication. To keep it from growing back, keep skin folds dry. Set your blow dryer to "cool" and dry skin fold areas before dressing. Wear cotton-crotch panties and pantyhose. Avoid powdering the area, as powder can cause other problems. Modell tells some clients to wedge clean cotton balls or gauze under their bra, etc. to stay dry during the warm months.

Sometimes a skin-fold yeast problem is connected to a vaginal yeast infection. In that case, the yeast fungus, candida albicans, takes root because the vagina's natural pH balance is off. This may have happened because you are taking birth control pills, antibiotics, are stressed or pregnant. Symptoms are intense itching and white, curd-like discharge. Over-the-counter creams like Monistat may get rid of it, but stronger cases will require prescription drugs. To avoid re-infection, take off a wet swimsuit once you're out of the pool, avoid deodorant tampons and douches and wear pantyliners only when necessary, not every day.

Bacterial vaginosis is another mild infection, this one in the vagina. It is caused by a bacterium called an "anaerobe" that grows naturally in the vagina; when too many anaerobes grow, it causes an infection. The condition is more common among sexually active women but can occur in everyone. Symptoms include a clear or colored vaginal discharge, often with a fishy smell. It is treated with antibiotic pills or vaginal creams.

Trichomoniasis is another unpleasant infection, caused by a single-cell parasite. It is transmitted through intercourse and symptoms include a yellow-green, frothy vaginal discharge. It may smell fishy, and your vagina may burn or itch, and it may hurt to urinate or have sex. Antibiotics are required to clear this up.

Endometriosis

Have bad period pain? Get checked out for endometriosis. This painful condition occurs when pieces of the uterine (endometrial) lining somehow escape the uterus and grow outside the organ, usually in the pelvis. Then, when your hormones start singing "build up a thick lining for an egg!" these little pieces of tissue swell, too, causing pain and hampering fertility. Typically endometrial tissue will settle behind the uterus and rectum, which may cause pain during sex or bowel movements.

A few women with endometriosis don't complain of pain, and only find out they have the condition when getting fertility treatment. Bad cases are treated through laproscopic surgery, during which the doctor removes the tissue. Keep in mind that many surgeons won't do laproscopic surgery on patients with lots of abdominal fat. The problem is keeping the abdominal skin/fat layer elevated during surgery; doctors pump gas into the abdominal cavity and say in very large people, the layer is too heavy for the gas cloud. But one woman interviewed by BBW for this story reports having successful laproscopic surgery recently at 350-plus pounds. She said her anesthesiologist claims laproscopic surgery is possible for very large people, but requires a particularly skilled and patient doctor.

OK, so have you written down the dates and details of any infections you've had? Described the symptoms of what might be endometriosis? Is there a pattern - for instance, are you one of the many women who frequently juggle yeast infections? If so, you may want to discuss this with your doctor, who may have ideas on preventing them. Also be sure your doctor screens you for STDs (sexually transmitted diseases, which is too big a topic for today's story) if you are sexually active. And make a note on your page if you've had an STD, even if it was 20 years ago. The information is part of the overall gynecological health portrait you're drawing.

Now sit back and scan your page. What do you see? Regular periods, normal bleeding, no symptoms that need explanation, a recent exam by a skilled doctor, A-OK Pap smear report? Congratulations! You don't need to make any changes. If not - well, you know what to do. Get yourself to a skilled, patient, accepting doctor and get fixed up.

We close with yet another quote from Dr. Northrup's wonderful book: "Some women require big bodies - for reasons that are mysterious to me. In certain large women, their bodies - all of them - are filled with energy and vitality. They like themselves, and this self-love permeates their flesh."

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