The V Book: A Doctor's Guide to Complete Vulvovaginal Health

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Chapter One

The Mind Why V Health Starts Here

Vagina is hardly a household word. Vulva and clitoris might as well belong to another language. They are blushers, vaguely subversive, not ready for prime time. They hide behind pet names and euphemisms ("my privates," "Pookie," "down there") if they're called anything at all. And then there's vestibule. That word's easy to say only because 99 out of 100 women have no idea that they have one, let alone where it is or what it does. (Don't worry. I'll show you later.) I feel pretty sure that a man would not allow some important part of his terrain to go uncharted for so long.

Believe it or not, even medical professionals can be uncomfortable about V terms. My own vulvar specialty practice in Boston is called the Stewart-Forbes Specialty Service. It's named after me and my nurse-practitioner partner, Diana Parks-Forbes, because at the time we were deliberating about what to call it, no one in the medical group's administration wanted the word vulva or vagina in the name. As a result, I surprise many new patients when I first walk into the exam room. "You're a woman!" they'll exclaim. They expected a gentleman named Stewart Forbes. The practice's vague name is hardly helpful to me professionally, either. Whenever I write a business letter or call a colleague, I always have to clarify that I represent the Stewart-Forbes Vulvovaginal Specialty Service. (Even so, Dr. Stewart Forbes gets lots of letters!)

I wish everyone could be matter-of-fact about the Vs. How much better my life-and your health-might be.

The first step to being comfortable with your body, after all, is being comfortable thinking about it (if not talking about it). That's why I say that V health starts in your head. As a physician, I'm a big believer in "liberation biology," to use the term coined by Mary Carlson, associate professor of psychiatry and neurobiology at Harvard Medical School. That means using biological information to help you understand your body, shake your hang-ups, and take charge of your full potential as a woman. In V terms, that means recognizing that the vulva and vagina are healthy parts of the body to be protected from disease, explored and treasured in responsible sexual life, esteemed for childbearing. I'd like for every woman to feel free enough to learn her way around her own body, free enough to talk easily to her doctor if a problem crops up.

Why are we so awkward about such commonplace body parts? Reticence about the vulva and vagina is nothing new. I'm no anthropologist or historian, but I do know that a veil has been draped over these parts for not merely a few generations but thousands of years. Knowing this past helps explain where our collective mind-set is today. Moreover, such information points the way to where our thinking ought to go.

So let's start at the beginning.

A short history of the Vs

Once upon a time people did not feel negatively about the vulva and vagina. Tens of thousands of years ago, the beautiful design of the vulva was something celebrated, even revered. The yoni, a symbol of the female genitalia, took many forms. Flowers, fruits, a triangle, and a double-pointed oval shape were all used to depict the vulva. Yoni is a Sanskrit word for "womb, origin, source, sacred place"-honoring the vulva's role as birthplace, bringer of life. Today the word yoni enjoys a renaissance as a way to refer to female genitalia, although its use is hardly widespread.

For a time, this symbol was worshiped as more powerful than its male counterpart, the phallus.1 This was a time when the basic facts of biology that we take for granted today were yet unrecognized. That women were fertile year round, unlike the rest of the animal kingdom, inspired awe. Menstruation-painless bleeding-was a mystery. A woman's periods, not a man's sperm, were linked to the miracle of birth. Women seemed to give birth by their own divine power.

Rock carvings and chiseled figurines of ancient goddesses, their vulvas prominent, have been found dating back as much as thirty thousand years. People are thought to have worn amulets featuring the yoni both to protect them and to bring fertility. They conducted celebratory and fertility rituals at natural rock formations that seemed to echo the shape of the vulva. Some of these sites can still be seen today, in such places as lower Yemen; Tongariro National Park in New Zealand; Koh Samui, Thailand; and the southern California desert. Sheila-na-gig statues-stone carvings of a squatting or reclining naked woman prominently displaying her vulva-have been found in old churches or buried in churchyards throughout Ireland and in parts of Scotland, England, and France. Their purpose is unknown. It's been speculated that the Celtic or pre-Celtic statues-many of which were buried or disposed of during the prudish Victorian era-were protectors from evil, bringers of luck, or fertility goddesses.

Many historians suggest that this veneration of the vulva-and in turn of the woman who is able to produce a child from those inner secret places-led to fear of her goddesslike power. Eventually, everything associated with the goddess was denigrated.2 Goddess worship came to an end around the globe, replaced by the male-oriented cultures, religions, and mythologies we're familiar with today.

We don't know what happened in the centuries after the fall of the yoni culture. Though the vulva was no longer venerated, it may not have been off-limits to medical minds. Evidence from ancient Greece and other civilizations reveals that physicians of these times knew a surprising amount of gynecology.3 From the time of Hippocrates (c. 460-c. 377 bce), such things as dilatation of the cervix, uterine infections and prolapse, ovarian cysts, and pelvic infection were accurately described. How much vulvovaginal knowledge existed is unclear. Maybe not a lot, but things such as growths and inflammatory conditions of the vulva were documented.

Methods of examination that women are familiar with today existed long ago too. The Egyptians practiced vaginal examination long before the time of Hippocrates. The position of a woman on her back, knees flexed and legs separated (called lithotomy), for the investigation of gynecological troubles was described by a famous Greek surgeon, Archigenes, who practiced in Rome around 120 ce. We don't have any record of what Greek and Roman women thought of pelvic exams, but I can guess, can't you? Not all cultures were comfortable with genital anatomy and examinations: In ancient China, the diagnostic dolls used for the female patient to discreetly point out the location of her symptoms had no vulva.

Unfortunately, gynecology's early sophistication didn't continue. Thanks to the lack of free communication between various countries, the scanty dissemination of knowledge by means of books, and the overthrow of nations by war, medical knowledge was not transmitted from one generation to another, as it is today. For centuries there was a yawning lack of information; by the beginning of the nineteenth century, Europeans had only a fraction of the gynecological knowledge that had been attained by the Greek and Arabian masters.5

Even during the time women's gynecological problems were being treated in ancient Greece, its practitioners were flying a bit blind. No thorough knowledge of anatomy, male or female, existed until the time of Claudius Galen, court physician to Marcus Aurelius, who lived 130-200 ce. A leading medical authority of antiquity, Galen's fame rests solely on his dissections and descriptions of the female genitalia in animals.6 He never worked on a woman. Along with his successors for the next two thousand years, he thought the human body was basically unisexual and that the two sexes were inside-out versions of each other. The male was primary, and the woman was described based on him. Here's how Galen made his point: "Think first, please, of the man's [external genitalia] turned in and extending inward between the rectum and the bladder. If this should happen, the scrotum would necessarily take the place of the uterus with the testes lying outside, next to it on either side.

"Think too, please, of . . . the uterus turned outward and projecting. Would not the testes [ovaries] then necessarily be inside it? Would it not contain them like a scrotum? Would not the neck [the cervix and vagina], hitherto concealed inside the perineum but now pendant, be made into the male member?"

No, it would not, of course. You'd think that by being sexually active themselves, Galen and his contemporaries would have known that women were not inside-out versions of men, but remember that human anatomy wouldn't be perfected for hundreds of years. Galen's faulty logic-of a woman's body being the exact reverse of a man's, like a sock taken off in a hurry-persisted for generations.7 Following that line of thinking, the uterus was thought to be the female equivalent of the scrotum, the ovaries were like testicles, the vulva was the foreskin, and the vagina was like the penis. The names used for female organs reflect their supposed similarity to the male: Galen called the ovary by the same name he used for the male testes, orcheis. Thinking of a woman as merely an inverted man made her automatically secondary and had long-standing repercussions: Why study her very closely if you could derive your basic knowledge by studying men?

Accurate descriptions of female anatomy were a long time in coming. Not until the fifteenth and sixteenth centuries were human dissections systematically done in order to chart the interior of the human body. But they were performed only on male prisoners who had died or had been executed. Andreas Vesalius (1514-1564), a professor of anatomy at the University of Padua, conducted painstaking investigations, resulting in his epochal text De Corporis Humani Fabrica (The Makeup of the Human Body). To gynecology Vesalius contributed fairly accurate descriptions of much of the genital tract. He perpetuated one very big mistake, though: Women's organs were still represented as versions of man's.

Two of Vesalius's students made progress when they began identifying the distinct parts of female genitalia. Gabriele Fallopio of Modena (1523-1562) named the Fallopian tubes and accurately described the hymen. Matteo Realdo Colombo (1516-1559) was the first to use the term labia for structures that he considered essential to protect the uterus from dust, cold, and air. He also introduced the word vagina.8 Not only did Colombo identify the soft inner folds of the vagina and name them rugae (the term still used today), but we can also thank him for being the first to describe the clitoris in detail.

The breakthrough in getting the complete landscape of a woman's body right didn't occur until the seventeenth century, when female cadavers were at last dissected along with men's. That's when Regnier de Graaf (1641-1673) mapped all the anatomic structures of the female genitalia, which, with few exceptions, serves well today.9 His detailed medical text contained separate brief chapters on the external genitalia, the clitoris, the mons, the hymen, the urinary opening, the vagina, and the internal pelvic organs. Hurrah!

Understanding all the V parts and knowing how to help them were two different matters, though. No great advances followed from this new knowledge about the most female parts of the female body. Instead, growing demureness seems to have crept in.

All the way through the nineteenth century, gynecology texts made little mention of the vulva. Dr. Thomas Denman, the leading English practitioner of gynecology in 1805, mentions only clitoral enlargement, hardly a common problem, in his textbook.10 Bimanual examination at this period was unknown. Vaginal examination was resorted to only on urgent indication, and even then it took place under protective drapes that effectively concealed the patient's genitals from the examiner's eyes. Even once vaginal exams were recognized as useful, toward the end of the 1800s, Victorian discretion often got in the way of effective treatment. Students of Dr. William Goodell (1829-1894) at the University of Pennsylvania, for example, were counseled to keep their eyes fixed on the ceiling while making vaginal evaluations.11 An upholstered examining chair with concealed stirrups continued the sense of propriety.

Physicians were as clueless about effective therapies as they were about insightful exams. By the early twentieth century, the treatment for yeast infection-and, in fact, any of the itching and redness collectively known as vaginitis-was the same: bed rest. Warm-water vaginal injections medicated with opium and belladonna were given every four hours. Opium rectal suppositories were given at bedtime to bring on sleep. Narcotics and rest surely eased the pain, but the actual problem was left unaddressed.

It wasn't until 1923 that an American physician, Frederick Taussig, published the first medical book exclusively about the vulva, Diseases of the Vulva, which became the standard medical text in the United States.

In fact, aside from that work and another published in England nearly twenty years later, there was startlingly little accurate information available to physicians, and in turn their patients, until 1969. That year-well after the birth of such female cultural icons as the tampon, the pill, and Barbie-Americans Herman Gardner and Raymond Kaufman published a groundbreaking book that finally covered all aspects of vulvar and vaginal problems in detail, Benign Diseases of the Vulva and Vagina.

Even today, the total number of texts about the vulva and vagina in print wouldn't fill a bookshelf-fewer than a dozen. (Compare that with more than four hundred for the heart.) There is no medical journal devoted to the vulva and vagina. Research is sparse; dozens of papers have been published on the yeast Candida albicans, but they deal with the myriad other problems associated with yeast besides vaginitis. Bacterial vaginosis is receiving a lot of attention not because of the miserable discharge and odor it causes but because of its connection with premature labor.

It's not surprising, then, that popular thinking has mirrored the medical community's indifference. For much of the twentieth century, women's genitals remained mired in ignorance and shame, as had been the case for hundreds of years. The vagina was sexual, and you didn't talk about sex. Touching yourself might lead to masturbation; women have had the clitoris removed for that since ancient Egyptian times and are still taught that touching themselves is wrong.12 The vagina was a birth canal, of concern only to the midwife or doctor attending you. Mothers whispered the facts of Kotex to their daughters at the time of menstruation, and the facts of life on the eve of their weddings-if they told them anything at all. There were no books a woman could consult, only her friends or relatives, should she muster the nerve. Until only recently, women's magazines brought their readers little genital health information alongside the latest fashions and recipes. Into the vacuum of silence fell folklore, misconceptions, and dirty jokes.

Snickers and embarrassed silence are a long way from the primitive celebration of the yoni.

The power of positive thinking

Culturally ingrained habits are hard to change. If, at the dawn of the twenty-first century, you're comfortable with the skin you're in, good for you. It's simply healthy, both mentally and physically, to think about your genitals as yet another intricate part of your human machinery, with important diverse functions, and worthy of considerate care. If you can talk to your doctor about your vulva and vagina without embarrassment, if you can look at your parts and understand what they're for and when something might be amiss, then you're in charge of yourself-and that's a good place to be.