Woman

by Natalie Angier

  Ninety minutes pass. The surgeons are not tired, but I am tired for them. Finally they get to the point where they can start removing parts. The pieces are placed on a metal tray, and the nurse holds each one up for me to see. Phillips's cervix: a shiny, taffy-colored tubular structure that reminds me of the head of a penis. The fibroid: it is so big and purposeful in appearance that I can't believe it wasn't a functioning part of Phillips's anatomy. It looks like a turnip, a tough swirl of purplish tissue that Horbach says reminds her of brain tissue. The body of the uterus: at this point, not exactly photogenic. It is an unremarkable pouch about the size of a child's fist, a timorous adjunct to the fibroid that it sustained for so long.

  With the cervix and uterus gone, Phillips's vagina now opens directly into her abdominal cavity, so the surgeons stitch it closed. The vagina may not be as dirty as legend has it, but it is an orifice, and you don't want it to serve as a gateway between the public and the personal. Horbach makes sure there is no "schmootzy tissue" left behind, fibroid remnants that could serve as a source of infection. Finally, the doctors irrigate the excavated site with sterile water. Over time, Phillips's other viscera will reposition themselves and fill in the space where her reproductive organs once dwelled. The surgeons are ready to close up. Somebody changes the tape and the tempo. "Jazz is for opening, rock is for closing," Horbach says. The song that drifts out from the stereo is a lilting number called "Woman in Chains," which seems almost too blatantly appropriate. But is Phillips in chains, or is she being freed? The surgeons stitch up the layers they cut, working with firm delicacy. One of the residents does most of the stitching, and she clearly loves what she's doing. Her fingers fly. She looks like she's playing an instrument of sutures, fascia, fat, and skin. When the top layer of skin is sewn shut and the body restored to its preferred state of solitary confinement, Phillips's stomach looks surprisingly tidy, with no sign of the recent assault beyond a thin dark line. "We like to make the sutures as cosmetically good as possible, because that's what patients judge us on," says Horbach. "They never see all the hard work we do inside." See, no, but feel—how could they not?

  The womb does not define a woman, philosophically, biologically, or even etymologically. A woman does not need to be born with a uterus to be a woman, nor does she have to keep her uterus to remain a woman. We don't want to fall into the trap of womb-worship, or hope that men suffer from womb envy. Very few of them do, and when they are around pregnant women, none of them do. And yet most of us have grown up with the familiar medical image of the female reproductive tract, the O'Keeffeian ram's head, its face the body of the uterus, its beard the cervix, its horns the fallopian tubes. We see this image and we think of the female pelvis, how fine the fit, triangle within triangle. Aesthetically, at least, we own the uterus; we feel comfortable about it. For about thirty-eight years of our lives, from age twelve to age fifty, we experience the customary tug and flow of the uterus in the form of menstruation. So what is the uterus, and what is its essential geography? Why is it so temperamental, prone to spawning growths that look like tubers dug up from the garden? Let us be appreciative and precise but not obsequious. The nonpregnant uterus is the size of a small fist; let us see how much punch that fist can pack.

  In a sense, evolution adheres to the classic twelve-step program: it takes things one day at a time. It does not strive for perfection; it does not strive at all. There is no progress, no plans, no scala natura, or scale of nature, that ranks organisms from lowly to superior, primitive to advanced. A fly is brilliant at flydom, and wouldn't you love on occasion to see as a fly does, in all directions? If mammals strike us as higher and worthier and more compelling than insects, it helps to recall that this bias too is the result of evolution by natural selection. We tend to like that which seems most like us, because resemblance implies genetic relatedness, and we like our genes; they have given us us. The tendency to favor our personal gene pond over foreign waters is called kin selection, and it extends into many areas of our lives. It means that we will more readily help a relative than a stranger, and that we feel greater fellowship with a chimpanzee, or even a lion, than with some alien-looking organism that has an external skeleton, a segmented body plan, and appendages that bend backward. But just because we identify with hairy lactating warm-bloods doesn't mean that the mammalian order is any closer to the goddesshead.

  Having said all that, I will now argue that the uterus was and is a magnificent invention, a revolution in physiology. I mentioned earlier that an internally conceived and gestated fetus is a protected fetus, and a protected fetus has the luxury of developing an elaborated central nervous system. The uterus and its attendant placenta mother the offspring as it will never be mothered again, not even by its own mother postpartum. The more mothered the animal is, the more apt it is to dominate its environment. At the moment, we placental mammals, we Eutherians, define the mammalian calling. Marsupial mammals certainly do a reasonable job of nurturing a larvalike fetus in their external pouch. Kangaroos are the deer of Australia, koala the squirrels. Here in the United States, opossums are a suburban staple—or thorn—and they are marsupials. Nevertheless, there are far more species of placental mammals than there are pouched ones, and Eutherians have populated far more habitats on earth. Could a humanlike brain have evolved in a species gestated in a pouch, or for that matter in a shelled egg? Probably not. The uterus in its bony and ligamentous pelvic cage is incomparably secure, and the placenta is incomparably nourishing. The womb may have nothing to do with the intellect of the woman who bears it, but it has everything to do with the brain of the fetus it bears.

  A fetus certainly knows how good its life is. It does not leave the womb until forced to do so by the gradual retrenchment of the placenta—the mother's body deciding, Enough, enough, we've done enough, out out damned tot! Sensing an impending drought, the fetus releases a series of biochemical signals that result in its expulsion from the only Eden it will ever know.

  The geography of the uterus, then, cannot be disengaged from the organ's role as primal mother, fetal tent and fetal supermarket. Consider the contradictory features the womb must embody. It must be labile yet stable. It must be rich yet affordable. It must be capable of growing in adulthood as no other organ grows. It must communicate with the rest of the body, to discern where it is in the do-si-do between ovulation and menstruation. The uterus is a part of the endocrine system, the macramé of glands, organs, and brain structures that secrete and respond to hormones. It is enmeshed biochemically with the adrenals, the ovaries, the hypothalamus, and the pituitary. At the same time it is a privileged place, a dome apart, where the fetus will not be ejected by the body's xenophobic immune cells.

  Structurally, the uterus is not complicated. In an adult woman who is not pregnant, it weighs about two ounces and is roughly three inches long. It has two parts, each making up about half its length: the body, or fundus, in which the fetus develops, and the cervix, which projects down into the vagina and opens slightly for the release of menstrual blood and more gapingly for the birth of a baby. If you look at the cervix from a gynecologist's-eye view, it resembles a glazed doughnut. A doctor who worked in a woman's health clinic once said that doing pelvic exams made her hungry, and she wasn't kidding or being lewd; she just liked doughnuts.

  In other ways the uterus is a sandwich, a muscle hero. The cervix and fundus are both composed of three tissue types. The meat in the middle is the thick myometrium, built of three inter-wrapping sheets of muscle. On the outside of the myometrium is a slick covering, the serous membrane, which is similar in texture and function to the sacs surrounding the heart and lungs. Like those sacs, the uterine serous membrane keeps the organ wet and cushioned.

  On the other side of the myometrium is the uterine lining, the endometrium. The body likes to work in threes, and so the endometrium is made of three layers of mucous membrane. Unlike serous membrane, mucous membrane breathes and snorts and secretes. It absorbs water, salts, and other compounds. It relea
ses mucus, a mixture of white blood cells, water, the sticky protein known as mucin, and cast-off tissue cells. Menstruation is in part a mucus discharge. During menstruation, two of the mucous sheaths are shed, thence to be reconstructed when the cycle begins anew. Like one who has reached enlightenment, the third, deepest endometrial layer escapes the wheel of death and rebirth, and it is to this stable foundation that a placenta moors itself if a fetus should be favored with a home.

  Hippocrates thought that the womb wandered, and he meant wandered, took a transcorporal journey up to the breastbone, even to the throat, becoming particularly frantic when it wasn't fed on a regular basis with semen. (By Hippocrates' estimation, the uterus of a whore would be far calmer than that of a virgin.) He was wrong, of course, but that does not mean the uterus is an immobile stone. In fact, it is springy and fungible. It is held loosely in its pelvic girdle by six ligaments, flexible bands of fibrous tissue that offer support for the organ and also enclose the blood vessels that nourish it. The position of the uterus shifts in the pelvis depending on whether you're prone or upright, your bladder is full or empty, and other such unremarkable circumstances. If you're sitting down now, not particularly in need of a toilet break, and not pregnant, your uterus is probably tipped slightly forward, its fundus leaning toward a spot an inch or two above your pubis, that hard bone in your crotch. If you were to stand up, again with an empty bladder, and push your shoulders back with military crispness, your uterus would assume a nearly horizontal position, like a pear that's fallen over.

  The uterus is at its most physiologically flamboyant when pregnant. An organ that weighs two ounces before pregnancy grows to two pounds by pregnancy's end, a gain that is independent of the weight of the fetus or placenta. Its volume increases a thousandfold. No other organ undergoes such dramatic changes in adulthood unless it is diseased. Yet give it a mere six weeks postpartum, and it has retreated to its fisty proportions. In effecting the changes of pregnancy, the myometrium does most of the heavy lifting. The muscle cells multiply at the beginning of pregnancy and then enlarge, or hypertrophy, in the second trimester, just as muscle cells elsewhere do if you diligently subject them to exercise. In the final trimester, the cells neither divide nor hypertrophy, but the whole uterine wall simply stretches and stretches and stretches, until you feel, mama, as though you might burst. In fact, rupture of the uterus during pregnancy is surprisingly rare. Placental mammals, after all, have been around for 120 million years, enough time to work out the bugs of the distendable womb.

  As happens so often in life, the problem of expansion is solved through harmonious apposition. The placid madonna, ha! A uterus in pregnancy is an arm wrestle between two well-matched, muscled dames. One arm starts to teeter, it pushes back upright, the other arm flags, and oomph into verticality again. Consider this: the uterus grows because during pregnancy your body is flooded with estrogen. Four thousand years ago, a woman wanting word of her condition mixed her urine together with barley seed; if the barley grew faster than usual, it signified pregnancy. No one knew it at the time, but the test probably worked because estrogen spurs the growth of many cell types—mammal, insect, grain. It is a potent biotroph, an ancient signal from organismic Babel, as I will discuss in detail later. For now, suffice it to say that estrogen stimulates myometrial cells to divide and enlarge.

  There's just one problem with the scheme. The hormone also throws muscle cells into a state of electrical excitation. It makes them twitch. A uterus that twitches too much is a uterus that expels a fetus. Therefore, even as it is urged to expand, the myometrium must be tranquilized. That is the job of progesterone, the so-called hormone of pregnancy; progesterone means pro-gestation. Progesterone inhibits the contractibility of muscle cells. Throughout the whole nine months of baby-baking, the negotiation between estrogen and progesterone is a dynamic one. Small, fleeting contractions pass over the swelling womb like local thunderstorms flickering over the desert. The more advanced the pregnancy, the more insistent these so-called Braxton Hicks contractions become. Mother of goddess, how extraordinary it is! Your belly is swelling, and you think, I will explode, I am a supernova. And then contractions seize you up and you think, No, I will collapse, I am a giant black hole.

  The uterus grows. The uterus retreats. It is not unlike the heart, a large, powerful muscle that swells, shrinks, twitches, and bebops. Oscillations and deep rhythms are the source of life, the principle of life; even cells work through pulsatile mechanisms. When radio astronomers first discovered pulsating signals coming from a distant neutron star, they thought they were detecting a message from an alien civilization. What but other living beings could emit such rhythmic signals? Only when the scientists determined that the signals were too regular, too mechanical, for life did they trace their source to the spinning core of the ultradense neutron star. If we respond to music viscerally, it is because our viscera are the original percussionists, and the heart and the uterus are among the most perceptible of our natural pacemakers.

  Beyond rhythmicity, the heart and the uterus share another quality, their association with blood. Not all women breed, but nearly all women bleed, or have bled. Jane Carden said that she regretted her inability to menstruate far more than she did her inability to become pregnant. In that way alone did she feel she was missing something extraordinary about the female odyssey. And she was. There is no clearer rite of passage, no surer demarcation between childhood and adulthood, than menarche, the first period. When people talk of the indelibility of a strong memory, they speak of recalling exactly where they were when Kennedy was shot or the Challenger space shuttle exploded. But what a woman really remembers is her first period; now there's a memory seared into the brain with the blowtorch of high emotion. With some exceptions, a girl loves getting her first period. She feels as though she has accomplished a great thing, willed her presence into being. Emily Martin interviewed a number of women from different social classes about their thoughts on menstruation, and all gave joyful accounts of menarche. One recalled bursting into song in the bathroom. Another rushed to tell her girlfriends in the school cafeteria that her period had just started, and they responded with a small celebration, buying her ice cream. Those who are too shy to celebrate publicly rejoice internally. In her diary, Anne Frank referred to those early periods of hers—and early ones is all she lived to have—as her "sweet secret." If a girl has cramps, she may even love them at first. They are proof of her body's power, the muscular flexes propelling her toward a destiny that looks, for the moment, as bright and as important as blood.

  After the heady triumph of menarche, most of us soon begin thinking of menstruation as a hassle, a mess, an embarrassment. We try to be cavalier, and we try to scold ourselves into pragmatism, yet still we feel uncomfortable paying for a box of tampons or napkins when the salesclerk is male. There are innumerable myths and taboos surrounding menstruation, some, not surprisingly, attributable to our familiar medicine men, Hippocrates, Aristotle, and Galen (most easily remembered by the acronym HAG). Hippocrates argued that fermentation in the blood precipitated menstruation, because women lacked the male ability to dissipate the impurities in the blood gently and sweetly through sweat; to him, menstrual blood had a "noisome smell." Galen believed that menstrual blood was the residue of blood in food that women, having small and inferior bodies, were unable to digest. Aristotle assumed that menses represented excess blood not incorporated into a fetus.

  The notion that menstrual blood is toxic has pervaded human thinking, west to east, up to down. Given the noxious fumes they exude, menstruating women have been said to make meat go bad, wine turn sour, bread dough fall, mirrors darken, and knives become blunt. Menstruating women have been confined to huts, to home, to anywhere but here. Some anthropologists have suggested that hunting societies have been particularly stringent in keeping women quarantined during their monthly flow, in part because of fears that menstrual odor attracts animals. Even today, women are warned not to go camping in grizzly country if they
are menstruating, lest a very large ursine nostril pick up the scent. Whether the warning has merit remains unclear. When biologists in North Carolina recently tried to determine the best way to lure a bear, they found menstrual blood to be of almost no use. Some men, bearlike or otherwise, claim that they can smell when a woman is on her period, but no study has ever borne out that charming if rather smug conviction, and this writer has certainly not found it to be true even when cohabiting with said sensitive fellows. Certainly men who continue to hold ritualistic prejudice against menstruation don't rely on their olfactory powers to distinguish the clean from the soiled. It is not unusual for an Orthodox Jewish man, for example, to refuse the ministrations of a female physician, on the chance that the doctor may be menstruating and pollute him more profoundly than the disease from which he suffers.

  In fairness, views of menstruation have not been uniformly negative, and the same potent ingredients that menstrual blood supposedly carries have on occasion been considered therapeutic. Moroccans have used menstrual blood in dressings for sores and wounds, while in the West blood has been suggested as a treatment for gout, goiter, worms, and, on the theory of using fire to fight fire, menstrual disorders. The ancient practice of bloodletting, which dominated medicine for hundreds of years, may well have been a mimic of menses, although the fact that women shed blood naturally did not spare them from extraphysiologic drainings whenever they fell ill.

  We may be amused or angry at the variations on the theme of the bloody succubus, but how much better are we? We modern women too think of menstrual blood as dirty, much filthier than blood from a cut on the arm; which would you rather put in your mouth? Camille Paglia, that most noisome and antifeminist of self-proclaimed feminists, expressed in her book Sexual Personae an attitude toward menstruation that is no more inspired than the HAG's. "Menstrual blood is the stain, the birthmark of original sin, the filth that transcendental religion must wash from man," she writes. "Is this identification merely phobic, merely misogynistic? Or is it possible there is something uncanny about menstrual blood, justifying its attachment to taboo? I ... argue that it is not menstrual blood per se which disturbs the imagination—unstanchable as that red flood may be—but rather the albumin in the blood, the uterine shreds, placental jellyfish of the female sea. We have an evolutionary revulsion from slime, our site of biologic origins. Every month, it is woman's fate to face the abyss of time and being, the abyss which is herself." Placental jellyfish? Forget the menstrual hut—this woman needs to be confined to an aquarium.