Ask Me About My Uterus

by Abby Norman

  My mother’s anorexia meant that she had no menstrual map to give me. As an adult, I would look back and realize that even if she had been menstruating, she knew very little about her own body and wouldn’t have had much to offer me. Even if she had had any sentimentality about the clunky yet endearing bonding mothers and daughters generally partake in, she just didn’t know enough about herself, emotionally or physiologically, to guide me.

  Even without guidance, I was a keen observer, and I figured out the nuances of my cycle fairly quickly: my periods were essentially regular, but extremely heavy. Often they were painful enough for me to want to miss school—which was the first of many subconscious triggers that something wasn’t right. I had suffered some substantial illnesses and injuries, and never once had I wanted to miss school on account of them. To the contrary, the worse I felt, the more I needed school to lift my spirits. It was my entire network of love and support, not to mention food. But my periods, with their dizzying fatigue, nausea, and pain, seemed to be the one thing that could put my life on pause.

  Once I had left home and was spending my teenage years hopping from couch to couch, my relationship to my period became even more fraught. I knew I had a tendency to bleed through my clothes at night, and the harrowing prospect of bleeding onto the sheets or couches that people were so kindly letting me sleep on made me lie awake in fear many nights. It seemed that no matter how many pads I wore, I’d always end up with blood pouring out of me, either on bed linens or the middle of the bathroom floor.

  I tried valiantly to use tampons, but found them gasp-inducing, edge-of-sink-gripping painful. For many reasons, they would have been my preference—not least of all to end the locker room jeering I got for wearing pads. Still, no matter what I did, tampons would cause my entire pelvis to ache, as though the menstrual cramps were echoing, or the tampon a divining rod for pain.

  So, I stuck to pads. Or, rather, they stuck to me and everything else. I have, on more than one occasion, retrieved a notebook from my purse during a meeting only to find a panty-liner stuck to it. The foibles of needing to be ever-ready.

  Despite the fact that I suspected my periods might not be normal, I admitted that I didn’t really know what normal was. I reasoned that I just needed to toughen up about it, and composed rather eloquent and long Freudian explanations, writing in my journals that my periods were probably normal, but that my perception of them was skewed because I had not had a mother to put them into the grander context of my blossoming womanhood. In fact, she had gone so far as to instill in me a certain fear of my own body at an early age.

  Regardless, I have since discovered that the widely held belief that a normal menstrual cycle must be twenty-eight days, and that ovulation will occur mid-cycle around or on day fourteen, is not necessarily true. The study that provided the touted twenty-eight-day cycle meant it as an average. In fact, no woman in the study actually had a twenty-eight-day cycle. They all had cycles longer or shorter than twenty-eight days.

  These variations exist not only from woman to woman, but even within the same woman throughout the course of her life. A thirteen-year-old girl who has only just started menstruating may not be ovulating at all. Anovulatory cycles, where a woman has a period without ovulating at mid-cycle, can be normal, depending on the age of the woman’s menstrual life. But they can also be a sign of subfertility: a young teenager who is not ovulating would not be cause for concern, whereas an otherwise healthy woman in her early thirties should be ovulating quite regularly.

  For much of human history, females of the species were locked into near-constant cycles of pregnancy and breastfeeding. The act of breastfeeding suppresses ovulation and menstruation. This was kind of the nicest thing that evolution did for women of the ancient world, because it meant they wouldn’t immediately get pregnant while their newborn babies were still entirely dependent on them. Generally, by the time breastfeeding ceased, it meant that a child had (1) survived infancy, and (2) possessed enough independence from mom that she could become busy with a new baby and the child wouldn’t die from her negligence.

  When a woman breastfeeds, the suckling of the baby is actually what signals her body to start ovulating again. In the first few months of life, the intensity of the baby’s suckling action portrays desperation: without the mother at this point, the baby would die. As the baby gets older and enters toddlerhood, the amount of breastfeeding and the intensity of suckling gradually begin to ease off as the child gains more independence. When the suckling lessens, and eventually disappears, it signals the mother’s body that it would be okay to get pregnant again.

  The caveat? Research has indicated that this is really only protective for about the first six months postpartum. Some women certainly experience lactational amenorrhea for longer, but it’s not a sure thing. And these findings are pretty recent—only within the past thirty years. You can imagine that, at the turn of the century and before, women would have struggled to understand their fertility in the best of times, but the fear of getting pregnant so soon after giving birth was very real—in part because childbirth was, for most of history, a fairly dangerous, if not fatal, affair.

  IRVINE LOUDON, WHO PUBLISHED A paper on maternal mortality throughout the eighteenth century in 1986, referred to his research as the study of “a deep, dark and continuous stream of mortality.” Women who died in childbirth either had complications during delivery, such as hemorrhaging, or complications after, such as puerperal fever. The latter was called “childbed fever,” because women who had just delivered babies in “lying-in hospitals” seemed particularly vulnerable to it. The disease was actually sepsis, a potentially life-threatening infection of the blood, and it was caused by the very doctors who treated the women in hospital.

  At that point in history, doctors were kind of jacks-of-all-trades: they delivered babies, treated the sick and injured, and conducted autopsies when necessary. The problem was, they weren’t washing their hands in between. So, a doctor might be conducting an autopsy and be called away to help deliver a baby. This was before germ theory, so it never occurred to a doctor to wash up beforehand. Essentially, doctors were transmitting any and all of the diseases or infections they encountered in their previous patients (living or dead) to new mothers and their babies.

  When women began dying from sepsis in London hospitals at a faster clip than women who delivered at home with midwives, a few pioneering physicians began to investigate (including Dr. Oliver Wendell Holmes, known best for his poetry, but who was also an accomplished physician). Once medical science discovered and began to actively crusade against transmissible infection, childbed fever all but evaporated. But there were still risks to childbirth, many of which were silent and pernicious.

  Eclampsia, a dangerous rise in blood pressure, can cause fatal seizures after a baby is born and may come on quite suddenly. The youngest daughter of the Crawley family on the beloved period drama Downton Abbey died of this when the two male doctors who were charged with treating her couldn’t agree on her course of treatment: a storyline that, unfortunately, is based on fact.

  Of course, for the vast majority of human history, women gave birth virtually anywhere but in a hospital: at home, at work in the fields, in a hut or a cave—and certainly these places weren’t the most sterile and safe environments. Yet humankind persisted.

  Just as childbirth can endanger a woman’s life, so, too, can menstruation. Women today have nearly four times as many periods in their lifetimes as their ancestors did—around 450 to 500. It might seem like an extremely high number, but consider the following: if a woman begins to menstruate at age twelve and ceases to menstruate at age fifty (averages that are hypothetically perfect but nonexistent in practice on both ends), and she has one period per month during that time, she’ll have had 456 periods in her lifetime. Factor in one pregnancy, where her periods would be absent for at least 9 months, or maybe a year if she breastfeeds on demand, and she’d only be down 12 to 15 periods. So even two or three preg
nancies would only save her maybe 50 periods in her lifetime. That’s still about 400 periods.

  Our ancestors didn’t have to confront these numbers, because they rarely lived into what we now consider to be middle age. The high end of their life expectancy topped out long before menstruation begins to taper off as women of the modern age enter perimenopause in their early fifties. The historical trend for menarche, meanwhile, has slunk downward. It wasn’t unheard of for young women of the Downton Abbey era to not begin menstruating until the age of fifteen or sixteen. A woman would likely only have a few years of her “monthlies” before she would marry and begin to have children. The reasons for the declining age at menarche are not yet fully understood, but if you can imagine it—diet, environment, genetics, plastic—someone, somewhere, has likely implicated it.

  Today, with menarche happening at age twelve, on average, and women choosing various methods to delay childbearing well into their twenties and thirties (or even longer!), women are having a lot of periods. And not only are they starting them earlier, but they’re having them longer (well into their forties and early fifties) largely because they are simply living longer.

  The big question is, do women need to menstruate so long? Other than to precipitate childbearing, does menstruation actually have any other purpose? Once a woman completes her childbearing, say, in her late thirties, can she safely stop menstruating? Can a young woman who wishes to delay childbearing for a decade, or indefinitely, use the various methods of hormonal contraception available to her to never have a period?

  Dr. Melanie Marin, one of the top gynecologic surgeons in New York, thinks she can—and in fact, that she should. Particularly if she has debilitating premenstrual symptoms or a condition like endometriosis that makes having a period excruciatingly painful.

  DR. MARIN ARRIVED TO MEET me in a café on the Upper West Side on her bicycle. She shook her neatly cropped blonde hair, a bit askew from her helmet, out of her eyes as she sat down. Dr. Marin struck me as being a serious, but not unfriendly, woman in her early forties with a verbal acuity mirroring the precision required of a surgeon. She’s affiliated with a group of doctors in New York but has surgical and admitting privileges at Mount Sinai, where she performs surgeries and oversees the work of her many residents.

  Dr. Marin was a young resident at Columbia during a decade when the crusade for laparoscopic gynecological surgery informed her education, and certainly it influenced her career as a surgeon. These methods are still doubted in the setting of grand rounds, but when it comes to time on the table versus time in recovery, Dr. Marin thinks the answer is pretty clear: do what’s best for the patient.

  I was eager to hear from a female physician on the subject of endometriosis and reproductive health, because even the most astute and competent male physician is still missing that experiential component of the menstrual cycle that breeds empathy. Although I acknowledge that physicians of any gender have to put limits on their empathy—too heavy a dose of it can greatly compromise their work—I also think that it has a place in the exam room. That being said, I personally have experienced a lack of empathy from both male and female physicians around menstruation: women who haven’t had bad periods can’t empathize any better with me than men who have never menstruated.

  Recent research from JAMA Internal Medicine revealed that patients have better outcomes when they’re treated by female physicians, including being less likely to die. This study, and ones like it, chalk it all up to differences in how men and women approach and practice medicine. Female doctors are more likely to encourage and prescribe preventative care measures and to use more patient-centered communication techniques. They also seem to have a better handle on what one would call “bedside manner.” But medicine on the whole is still a male-dominated profession: women make up just a third of all doctors in the United States. And certainly education, personality, motivation, resources, location, and many other socioeconomic factors that have nothing to do with gender account for how a particular physician practices. By and large, though, it does seem that much of what we consider traditional thought in medicine stems from its roots as a male-led vocation.

  The more physicians and patients I talked to, the more I began to realize that while there are some overarching patriarchal themes, they aren’t solely perpetuated by men. Women do it too: every time a mother tells her daughter that bad cramps are just a part of life, or just part of being a woman, she’s reinforcing something she’s come to understand as fact.

  Dr. Marin would beg to differ—on the nature of menstruation, not the patriarchy. Regarding the latter, as we stood to depart at the end of our interview, she glanced down at my notepad where I’d scribbled something about the patriarchy of medicine. She pointed to it and just gave me a simple, but bold and resounding, “Yes.”

  “I think perhaps my biggest take as a woman is that I have so many people come to me who are willing to tolerate so much, or they have tolerated so much,” Dr. Marin began in our discussion of female pain. “Either because no one was willing to listen to them, or just because they thought it was normal, or that was the price of being a woman—that they don’t have to tolerate.”

  Although I presumed that she doesn’t have endometriosis herself and told her as much, she added, “I have no idea if I have endometriosis or not. But I always had horrible cramps. With the heating pad on my back, lying on the couch and crying. Heavy periods. Once I realized I didn’t have to have a period, I never had a period again.”

  I actually felt myself staring at her, unsure if I’d heard her correctly. She then went on to say that she hasn’t had a period in twenty years. Her menstrual cycle impacted her life so negatively that she—in what I can only describe as enviable pragmatism—took control by using a mix of continuous hormonal birth control options to permanently suppress her period, except for when she wanted to become pregnant.

  “You don’t have to have a period, ever,” she told me unflinchingly. “You should never have a period, unless you’re trying to get pregnant. And even then, maybe not. You don’t have to have a period. You don’t have to have cramps. You don’t have to bleed. You don’t have to. You ought not to.”

  She’s never looked back, and when it comes to her patients—many of whom are debilitated by their periods because of endometriosis or fibroids—she recommends the same path. It’s not uncommon for women to balk at the suggestion: many have asserted that not having a period would feel “unnatural.” Dr. Marin acknowledges this, but counters, “We don’t know what it means for periods to be ‘natural.’”

  Dr. Marin, and others, have suggested that the idea that menstruation is the only natural course for a woman is outdated. “People think it’s not natural not to bleed—well, it’s not natural to bleed,” she said. “Until the past century or so, women couldn’t control their own fertility. For most of human history, monthly periods for thirty or forty years were not the norm. It’s only in the past eighty to one hundred years that women have had enough control over their fertility that they’ve had periods for so long. And the average lifespan of a woman was not eighty-six a thousand years ago. It was thirty-six.” Therefore, most women weren’t living long enough to achieve what we now commonly refer to as menopause.

  As much of history has been penned by men, our framework for studying menstruation historically is kind of limited. A lot of what we know, or think we know, comes from pulling back the curtain on the proverbial Red Tent, which is not something lost to ancient history. The practice of sequestering women away to menstruate is still very much in practice all over the world. Menstrual huts are still prevalent in some parts of India, and attempts to ban these gaokors, as they’re called, have been unsuccessful. The National Human Rights Coalition visited well over two hundred of them in 2015 and found that since they’re public property, no one specific is responsible for their maintenance. Most of them lack a proper bed. They’re also typically placed in fairly remote settings, and should a woman end up there alone fo
r the duration (as is often the case), she’s vulnerable to predators. This practice begins as soon as a young woman gets her first period, and therefore, 23 percent of girls in India drop out of school when they start menstruating.

  Although the most obvious justification for hiding menstruating women away comes straight from the biblical “periods make you unclean” narrative, anthropologists and sociologists have also suggested that husbands can exact more control over their wives and daughters through enforcing their menstrual hut stay: they know exactly where they are, because they’ve disallowed them from being anywhere else for at least five days of the month.

  The biblical passage most often cited is Leviticus 15:19. Depending on which translation you’re reading, menstruation is referred to as “discharge,” “regular flow of blood,” “menstrual period,” a woman’s “impurity,” or, in the King James—her “issue.” The warning being that if anyone (read: a man) touched a woman during the week she was bleeding, he’d be unclean for the rest of the day. The specificity is interesting here: women certainly don’t consistently bleed for seven days; it can be more or less by a rather large margin. And why would the person touching the woman only be made dirty “till the evening”? The Bible also notes, in nearby passages, that a woman who bears a male child is unclean for seven days after the birth, and that when she’s on her period, everything she comes into contact with is also made filthy. Like some kind of Menstrual Midas Touch.

  What’s important to keep in mind here is that it wasn’t really about the blood itself—no one’s really worried about staining chairs. The problem is where the blood’s coming from. I mean, if a gladiator shed his blood on your recently swept kitchen floor, you’d feel blessed. But, quite literally, God forbade a woman’s menstrual effluent from touching you or anything you loved.