Seven months and five doctors later, I finally had an explanation of my symptoms. In the early months of summer 2017, I experienced deep hip pain with certain movements. After one hip intensive yoga practice, I noticed abnormal vaginal bleeding. Over time, the bleeding occurred whenever I performed any type of lower body movement.
June, 2017: “It’s just abnormal bleeding between periods.”
July, 2017: “Yup, weak pelvic floor. I am sending you to pelvic floor therapy. I doubt you have any fibroids or cysts, but I’ll still order the transvaginal ultrasounds.”
The physician’s assistant seemed impressed with my knowledge of the term “menarche,” the technical term for a woman’s first menstrual period. She felt around my pelvic floor and I immediately cringed in pain. I thought it was odd, but when I rose from the examination table, I knew for certain that something was awry. I gazed at a puddle of bright red blood. I know that some women bleed during PAP smears and pelvic exams, but I know my body, and this was an abnormal response for me. I was still bleeding three days later, and my calls to the gynecologists’ office were met with dismissals of normalcy.
August, 2017: “Since you brought up your previous eating disorder, I have significant reason to believe your bones may be the culprit for your hip pain. We’ll take an x-ray of your pelvis and order a round of physical therapy. I don’t do gynecology. You’ll have to see a gynecologist for bleeding. I don’t see a correlation.”
August, 2017: “As active as you are? There’s no way you have a weak pelvic floor.”
One urgent care practitioner, three gynecologists, and one female athletic specialist. Two PAP smears, two ultrasounds, and an x-ray. I found myself on a journey from one doctor to another, and I was fortunate enough to carry health insurance to support me. With nearly three months’ rest from weightlifting and yoga, I allowed my body time to heal. And it did. I never received a formal diagnosis for my hip pain, but despite the apparent setback, I was able to learn the value of rest, and just how much of it my body needed. As pain and recurrences of bleeding subsided, I began to work my way back into an exercise routine.
From September through November, things seemed relatively “normal.” Pain was absent, but bleeding reappeared around the holiday season. I downloaded a period tracker app, so that I could better differentiate what was happening when, to decipher the puzzle pieces of my body’s symptoms. This time, much of the bleeding occurred post intercourse. There was no associated pain, but when I got up, the sheets were shades of red and pink. I looked down and we both had smears of blood on our skin. The first time it happened, I was embarrassed. The second time, concerned. When the bleeding persisted into the New Year, I knew that I needed to make a visit to yet another gynecologist.
January, 2018: “You have cervicitis. It is very common, and can easily be alleviated through cryotherapy, if you choose to pursue that treatment route.”
I searched patient reviews on Google, Yelp, and ZocDoc, and finally settled on a gynecologist who patients reported as a great listener; someone who spent as much time as necessary with patients . While the previous doctors heard my immediate concerns and scanned the history disclosed on my intake sheet, this particular doctor was the only one who guided me into his office, took out a pen and paper, and wrote persistently while I recounted my body’s story. He picked up on my type-A tendencies, and how that trait potentially affects other habits, such as taking a birth control pill at the same time each day. He noticed how I knew the exact date that I was diagnosed with herpes, and how deeply that must have impacted me. He took time to get to know me, and most importantly, listen.
Seven months and five doctors later. Although I now had a more definitive diagnosis than I did seven months prior, I remained frustrated by the medical field. Why did it take so long for a diagnosis? Why did no one else take me seriously? Why did some doctors focus on only one part of my medical history? Why were my concerns of abnormality within my body brushed aside by practitioners? If this is so common, why did no one else investigate further?
Gynecology and Sexuality: A Dynamic Duo?
Membership in the human sexuality field includes stereotypes that are present across various disciplines and spheres. At first glance, sexuality and gynecology seem to couple well together, but as conversations progress, a power struggle is revealed. I typically preface my gynecologist visits by revealing my identity as a sexuality student and researcher, and my specified knowledge in herpes simplex. Although this disclosure creates space for a more specialized level of communication between patient and practitioner, it may be difficult for clinicians to navigate between their knowledge and mine. Perhaps doctors feel particularly threatened by my intellect on subject matter that is supposed to be their specialty. Thus, the relationship may feel imbalanced and becomes a battle for validity rather than a conversation of care.
In sharing my experience with women outside the field, I learned that I was not alone in my feelings. Women who felt their concerns were ignored and invalidated by their gynecologists. Women who were denied testing. Women who felt that their doctors did not address their concerns. Women who did not feel accepted. Women who did not feel valued as patients. Women who felt shame. Women who left the office with more questions than answers. I needed to dig deeper.
What Defines Gynecologists’ Training?
To preface, my research thus far is broad. I started with The American College of Obstetricians and Gynecologists (ACOG), and The American Board of Obstetrics and Gynecology (ABOG). ACOG has resourceful fact sheets and guidelines for patients with specific gynecological inquiries. ABOG defines obstetricians and gynecologists as “…physicians who, by virtue of satisfactory completion of an accredited program of graduate medical education, possess special knowledge, skills and professional capability in the medical and surgical care of women related to pregnancy and disorders of the female reproductive system. Obstetricians and Gynecologists provide primary and preventive care for women and serve as consultants to other health care professionals.”
From there, I learned that there are six gynecologic sub-specialties: (1) critical care medicine, (2) female pelvic medicine and reconstructive surgery, (3) gynecologic oncology, (4) hospice and palliative medicine, (5) maternal/fetal medicine, and (6) reproductive endocrinology/infertility. To become certified in one of these specialties, physicians must be Board Certified by ABOG and complete additional training beyond the basic ABOG certification. According to the ABOG website, Board Certified obstetricians/gynecologists’ training consists of:
- four years of residency training in preconception health, pregnancy, labor and delivery, postpartum care, genetics, genetic counseling and prenatal diagnosis;
- women’s general health (reproductive organs, breasts and sexual function);
- screening for cancer;
- hormonal disorders, infections, surgery to correct or treat pelvic organ and urinary tract problems; and
- preventative health care.
Although reproductive health and sexual functions are addressed, from my research, sexual wellness appears absent from the gynecological education experience. The American Sexual Health Association (ASHA) defines sexual health as “…the ability to embrace and enjoy our sexuality throughout our lives. Being “sexually healthy” means:
- understanding that sexuality is a natural part of life and involves more than sexual behavior;
- recognizing and respecting shared sexual rights;
- having access to sexual health information, education, and care;
- making an effort to prevent unintended pregnancies and STDs and seek care and treatment when needed;
- being able to experience sexual pleasure, satisfaction, and intimacy when desired; and
- being able to communicate about sexual health with others including sexual partners and healthcare providers.
A 2009 study by Kershnar, R., Hooper, C., Gold, M., Norwitz, E.R., and Illuzzi, J.L. sought to investigate the attitudes, training, and experience of pediatric, family medicine, and obstetric-gynecology residents with regard to adolescents. “Of 87 respondents (31 OB/GYN, 29 FM, and 27 Pediatric), most residents from all three fields felt that the full range of adolescent preventative and clinical services…fell under their scope of practice.” The study concluded that residents are not “optimally prepared to provide the full range” of care and services to adolescents that their disciplines expect of them. Interestingly, over 90 percent of residents in the study felt well-prepared to counsel STI risk and prevention, but are practitioners just as prepared to discuss living with an STI?
J. Dennis Fortenberry, MD, an ASHA Board member and professor of pediatrics at Indian University believes that “sex is still primarily seen as a set of risk factors that [physicians] counsel against.” He is “convinced that this perspective on sex and sexuality as “risk” legitimates the stigma associated with sexually transmitted infections and contributes to our society’s poisonous intolerance of sexual diversity.” Considering Dr. Fortenberry’s words in relation to gynecological standards set by ACOG and ABOG, much of the guidelines prescribed for gynecologists to counsel is risk prevention-based. Prestigious gynecological boards are advocating for STI prevention, rather than validating their inevitability. According to The World Health Organization (WHO), more than one million STIs are acquired every day across the globe. This is not a matter of “if,” it’s a matter of “when.”
Disclosing STIs to Professionals
Testing for herpes simplex virus (HSV) can be challenging. When I encountered a false-positive IGM result in 2013, the notification of results was not carried out well. I received a phone call while I was on vacation. The doctor simply said, “Your test yielded positive results for genital herpes.” Her delivery lacked resources, emotional compassion, and understanding. Given the materials referenced above, it is unsurprising that the doctor’s counsel was negligent—her training taught her how to counsel prevention, not how to live life with an STI.
Additional IGG serological testing by my primary care provider showed that I was indeed, negative for herpes in 2013, and had a false-positive IGM read. My 2015 diagnostic visit was met with concern, heartache, and reassurance by the nurses. Since then, my herpes disclosure at introductory gynecological check-ups have been brushed aside as, “Oh almost everyone has that. It’s more common than you think.” Although true, not everyone knows that, or has completed enough research to be satisfied with that statement. People want to know how to move forward from an STI diagnosis. How to tell their current and future partner(s). How to find love. How to feel normal (whatever that is!). How to navigate sexuality with something that is so demonized by our society.
The Price of Honesty
Although my most recent gynecological concerns were not herpes-related, I view my abnormal bleeding experience as a gateway into expanding my research into gynecology and working to better the patient/practitioner relationship. I learned just how little doctors listened to me, or valued my knowledge and experience of my body. How easily I was dismissed when presenting my own scholarly research. How different sub-specialties of gynecology could structure how doctors shaped their diagnosis. Considering that I am a white, straight, cisgender woman, I can only begin to imagine the experiences that other races, ethnicities, and gender identities encounter. ACOG has several LGBT fact sheets dedicated to adolescents and women, but I am curious to know how extensive gynecologists' training is in these populations.
People want honesty from their doctors. People want real answers. People want to be heard and valued. I doubt that the gynecology field is equipped to provide that level of transparency and acceptance. There is an apparent disconnection between the patient and gynecologist relationship that warrants further deconstruction and analysis. We are more than our body parts, more than another pair of feet in the stirrups. It is difficult enough to strip down for an annual appointment, but to share vulnerable parts of our identities and health stories only to be dismissed and chastised makes us question, "Is it worth being honest?"
ABOG Certification - American Board of Obstetrics and Gynecology
ACOG - The American College of Obstetricians and Gynecologists
ASHA - American Sexual Health Association
WHO - Sexual Health