The Vagina Bible - Dr. Jen Gunter

Last updated Jan 21, 2025

• Author: Dr. Jen Gunter
• Full Title: The Vagina Bible
• Category: #books

–Dr. Danielle Martin, author of Better Now: Six Big Ideas to Improve Health Care for All Canadians (Location 13)

This book reads like a film— and like a great filmmaker, Dr. Gunter has delivered an intimate and loving portrait of the vagina. (Location 16)

—Elaine “Lainey Gossip” Lui, author of Listen to the Squawking Chicken and co-host of The Social (Location 18)

—Miranda Esmonde-White, author of Aging Backwards (Location 22)

—Ami McKay, author of The Birth House (Location 25)

—Kevin Patterson, MD, and author of News from the Red Desert (Location 30)

—Carl Zimmer, author of She Has Her Mother’s Laugh: The Powers, Perversions, and Potential of Heredity (Location 42)

One of the core tenets of medicine is informed consent. (Location 145)

Pseudoscience and those who peddle it are invested in misinformation, but so is the patriarchy. (Location 152)

Medically, the vagina is only the inside, but language evolves and words take on new meaning. (Location 159)

The vulva is often neglected. A lot of this vulvar neglect is a result of patriarchal society’s lack of investment in and fear of female sexual pleasure. (Location 181)

the vulva is the outside (where your clothes touch your skin) and the vagina is the inside. The transition zone between the vulva and vagina is called the vestibule. (Location 184)

As there were no female physicians, everything first written about women’s bodies in ancient medical textbooks and taught to the first physicians was what women and midwives passed along to men, who in turn interpreted the information as they saw fit. (Location 201)

The clitoris, when it was considered by ancient physicians at all, was believed to be the female version of the penis. But lesser. (I’m sorry, but the organ, capable of multiple orgasms, that only exists for pleasure is not lesser. It is the gold standard.) (Location 213)

The vulvas of the time were but mysterious mounds concealed by crossed legs. (Location 216)

In 1938, a Los Angeles teacher, Helen Hulick, was held in contempt of court for daring to show up in pants to testify as a witness and for refusing to change into a dress when the male judge insisted. (Location 226)

A male-dominated profession, a male-dominated society with little interest in women’s experiences and opinions about their own bodies, a penis-centric view of female sexuality, and the belief propagated by Freud’s work that the clitoris was unimportant are a lot of obstacles to overcome. (Location 232)

Before the advent of MRI (magnetic resonance imaging), it wasn’t really possible to know exactly how the clitoris in a living woman was positioned or how it engorges with blood in response to sexual stimulation. (Location 237)

The clitoris has one purpose: sexual pleasure. It is the only structure in the human body solely designed for pleasure. (Location 245)

THE CRURA (“ CRUS” IS THE SINGULAR): The outside arms of the inverted Y (some people also describe them as looking like the arms of a wishbone). They are 5– 9 cm in length, (Location 258)

Because the clitoris is so intimate with the urethra and the lower walls of the vagina, many experts feel a better terminology is the clitorourethrovaginal complex. (Location 263)

All parts of the clitoris are involved in sexual sensation and all parts are erectile, meaning they can engorge with blood, becoming firmer. The glans has the highest concentration of nerves and the least amount of erectile tissue. The body and the crura have the most erectile tissue. (Location 264)

For some women the glans clitoris may not be the best pathway to orgasm, so moving sexual stimulation to other areas may help achieve orgasm. (Location 271)

The labia minora are filled with specialized nerve endings important for sexual response, especially along their edge. They are capable of distinguishing touch on a very fine scale. (Location 282)

Under the microscope, all skin looks like a brick wall— cells are stacked on top of each other in layers upon multiple layers. The very bottom layer has specialized cells called basal cells. Basal cells produce new skin cells that are pushed up towards the top, like a conveyor belt. The cells develop as they move upwards, producing a protein called keratin that serves as waterproofing and makes the cells tougher so they can resist injury. At the surface, the skin cells release fatty substances that provide protection against trauma and infection, as well as trapping moisture. The cells in the top layer are dead, and they are brushed off with everyday wear and tear, or with trauma. A new layer is replaced approximately every thirty days. (Location 287)

As each pubic hair is attached to a nerve ending, tugging or friction on the hair may have a role in sexual stimulation. (Location 294)

Pubic hair follicles also have specialized sweat glands called apocrine glands (also found in the armpit) that become active during puberty. They empty a specialized oily sweat with trace amounts of hormones and pheromones onto the hair shaft. Skin bacteria convert the secretions from apocrine sweat glands into odorous compounds, which are responsible for the typical, intense apocrine sweat smell. (Location 297)

The true function of the apocrine sweat glands is not known, but as they develop and become functional around puberty and secrete pheromones, it is likely they had or still have some role in sexual attraction. (Location 300)

Skin, hair, and the irises of your eyes all get their color from the pigment melanin, which is produced by specialized skin cells called melanocytes in the basal layer. (Location 307)

Medicine still can’t explain how your back has fewer melanocytes than your vulva but they end up the same or a very similar tone. (Location 310)

Technically the vestibule is external, but the skin is similar to what you would find in the vagina: it’s mucosal skin, meaning there is very little keratin and the cells are filled with glycogen, a storage sugar. (Location 315)

The anus has two muscular rings called the internal and the external sphincter. The mucosa of the anus is highly innervated (full of nerves) because the tissue has to distinguish between solid and liquid stool as well as gas, in addition to coordinating the socially appropriate time for emptying. (Location 321)

There is no “normal” size for labia minora and labia majora. (Location 330)

Labia minora, labia majora, and the mons contribute to both sexual pleasure and protection of the vagina opening. (Location 331)

The pH of the vulvar skin is acidic, between 5.3 and 5.6. (Location 332)

The vagina is a fibromuscular tube that connects the vulva with the cervix. (Location 336)

The hymen can tear from physical activity, and approximately 50 percent of teens who report sexual activity still have an intact hymen, meaning it is a highly unreliable “virginity indicator.” (Location 342)

it’s pretty clear that for the majority of women, their sexual debut is not painful enough that they are going to hold out for some hypothetical Mr. Right. (Location 348)

I believe the hymen was a pre-puberty physical barrier against dirt and debris. (Location 355)

In a fetus, the vagina starts as a solid tube. The cells from the inside gradually disappear— this proceeds from top (the cervix) to bottom. Any remnants that remain at the lower part of the vagina are the hymen, which can be a ring, crescent shaped, have holes, or even be absent altogether. (Location 358)

The presence of a septum should be considered for any teen who has not had a period by the age of sixteen, any women who is unable to insert a tampon, fingers, a penis, or have a speculum exam due to pain, and any woman who has a feeling of an obstruction with vaginal penetration. (Location 362)

Smooth muscle is a type of muscle not under voluntary control (your gut is also made of smooth muscle). (Location 368)

There is data that suggests that some women who have painful periods have more spasms or uncoordinated activity of their vaginal smooth muscle. (Location 371)

Everyone (okay, the patriarchy) seems very impressed with the ability of a penis to grow, but the few centimeters of change that a penis can muster up pales in comparison with the vagina’s ability to stretch. (Location 373)

The vaginal smooth muscle is surrounded by a network of blood vessels. The rich blood flow is one of the reasons the vagina typically heals well after injury. (Location 375)

The vagina gets wider as you move from the vaginal opening towards the cervix. (Location 378)

On average, the pelvic floor muscles contract 3– 15 times during an orgasm. (Location 381)

Weakness or tearing of the pelvic floor, most commonly caused by childbirth, can contribute to incontinence (both bladder and bowel) and pelvic organ prolapse (descending of the pelvic organs and structures). (Location 398)

They also have much less keratin than the vulva cells, making the surface of the vagina slightly less waterproof than the vulva. This allows a small amount of fluid to leave the bloodstream and leak between the cells of the vagina to become part of the vaginal discharge. This fluid is called transudate. The reduced waterproofing also means some substances can be absorbed from the vagina into the bloodstream. (Location 403)

These dead cells are filled with the storage sugar glycogen (made of thousands of glucose molecules), which feeds the bacteria that keeps the vagina healthy. (Location 413)

The dead cells floating in the vagina work like a decoy. They are the first cells encountered by pathogenic (potentially harmful) bacteria. (Location 416)

The vagina typically produces 1– 3 ml of discharge in twenty-four hours, but up to 4 ml has been reported as normal. (Location 422)

when I was in training everyone thought L. acidophilus was most common, but that was because it was one of the only types of lactobacilli that could be grown easily in a lab. (Location 437)

Each woman has one of five community states of vaginal bacteria. Four are dominated by Lactobacillus spp. (73 percent of women); the remaining 27 percent have few lactobacilli and instead have a diverse collection of other bacteria. (Location 442)

The more lactobacilli, the more acidic the vaginal pH, (Location 446)

Vaginal pH increases during menses due to the blood itself, which has a pH of 7.35. Blood also binds lactobacilli, so lactobacilli levels are reduced with bleeding. (Location 449)

If I took a picture of your hair at 4 P.M. one day, that would not be representative of how your hair looks day to day, nor would it tell me how to wash your hair or what hair-care products to choose. (Location 458)

The folds in the vagina are called rugae. (Location 465)

Sex is the designation of a person as male or female based on biological characteristics, such as anatomy and/ or hormones. Sex can be assigned at birth or changed. Gender is your sense of who you are— male, female, both, or neither. (Location 473)

Testosterone for transitioning can produce significant changes in the vulva and vagina. The clitoris will enlarge, from an average length of 1.5 cm to 4.5 cm. (Location 487)

Cervical cancer screening guidelines remain the same for trans men— screening should start at age twenty-one and continue until age sixty-five (screening can stop at sixty-five if the last three tests have been normal). (Location 503)

It is important for every person to get the HPV vaccine, but especially so for trans men who are at great risk for insufficient screening for cervical cancer and abnormal Pap smears. (Location 525)

as vaginal length is not related to sexual satisfaction, most surgeons aim for a vaginal length in the mid-range of 9– 10 cm. (Location 552)

A vagina constructed from penile skin is colonized with bacteria routinely found on the skin. (Location 555)

The advantage of colon and peritoneum tissue is that they are self-lubricating. (Location 562)

Complete hair removal can take up to a year, and electrolysis is the only truly permanent method. (Location 570)

All tobacco products impair wound healing, as they reduce blood flow in small blood vessels. (Location 573)

Many heterosexual women learn about sex from male partners, who are often uneducated or undereducated themselves about the mechanics of female orgasms. (Location 599)

women who have medical conditions that interfere with their sex life, typically conditions that cause pain with sex, end up minimized. Many women suffer for years not realizing they have a medical problem that has a diagnosis and treatment. (Location 612)

the average amount of time people spend having sex is about four minutes a day. (Location 619)

A sexless relationship, meaning no sex in the past 6– 12 months, affects up to 15 percent of couples. There is less data on non-marital relationships. (Location 630)

the area in the brain that responds to nipple stimulation overlaps with the area that responds to clitoral stimulation. (Location 636)

many reasons women report wanting sexual intimacy: for example, emotionally connecting with their partner, trust, affection, safety, and respect. (Location 640)

A circular model has been proposed (by Dr. Rosemary Basson in 2000) that endorses the concept that a satisfying sexual encounter does not require starting with a spontaneous sexual drive or desire. (Location 641)

The circular model accepts that women may not always have a high spontaneous libido and that some women engage in sexual activity initially to feel intimacy or connectedness, and desire kicks in after arousal. (Location 644)

I often tell women to focus less on the idea of spontaneous libido and more on the idea of satisfaction (emotional and physical)— and, of course, fun and sexual pleasure. (Location 648)

I prefer to think of sex as a party. It doesn’t matter if you received an engraved invitation or were invited by text. It doesn’t matter if you took a limo, drove your car, took the subway, or walked. What matters is you were at the party and you had what you consider to be a good time. (Location 650)

Orgasm is the rhythmic contractions of the muscles that wrap around the vagina (the pelvic floor muscles). (Location 656)

Contracting your pelvic floor muscles voluntarily (Kegel exercises) doesn’t trigger orgasm, but many women find that purposely contracting these muscles can increase arousal. (Location 659)

Female orgasm— the contractions of the pelvic floor muscles— typically lasts 5– 60 seconds. The muscle contractions occur at approximately 0.8-second intervals (so one right after the other), and for many women each successive contraction is longer, but weaker. The general range of contractions, number-wise, is 3– 15. Orgasm is accompanied by a feeling of well-being and/ or release of tension. What is fascinating is that both women and men describe the feeling of an orgasm with almost identical terminology. (Location 662)

a penis is in no way required for satisfying sex, nor is it the judge of female sexual satisfaction. (Location 673)

The ideal duration of penile penetration during heterosexual sex according to a survey of U.S. and Canadian sex therapists was 3– 7 minutes (Location 674)

In one study, heterosexual couples reported an average of 11– 13 minutes of foreplay and 7– 8 minutes of intercourse, and men thought both the foreplay and the penetration lasted longer than the women did. (Location 676)

Only one third of women are capable of achieving orgasm with penile penetration alone (meaning hands off, penile thrusting only), (Location 681)

It is not surprising to me when I hear of women who fake orgasms with male partners. After all, they have been led to believe that a female orgasm should be reached with a penis by way of an imaginary spot. (Location 692)

MRI studies looking at anatomy during heterosexual sex reveal that the clitoris can be compressed by the penis, which is why some women can orgasm with penile penetration. (Location 693)

The clitoris is the pleasure aggregator and amplifier. Basically, all pleasure roads lead to the clitoris. (Location 698)

There is a pair of glands on either side of the urethra (the tube that drains the bladder) called Skene’s glands. These are about the size of a pea or smaller, and they are sometimes referred to as the female prostate because their secretions contain traces of prostate-specific antigen (PSA), a protein found in the male prostate. Skene’s glands can secrete a small amount of fluid, perhaps 1– 2 ml at most, during sexual activity. (Location 708)

It is possible when women report squirting that they are simply having an orgasm strong enough for the pelvic floor muscles to empty their bladder, which is why it is associated with heightened pleasure. It is also possible that a more intense sexual response could result in a faster filling of the bladder. It is also possible that some women have a lot of transudate— meaning they get very wet— during sex. When they orgasm, that fluid could come out all at once. (Location 720)

A good sexual encounter is not about optics that make a man (it’s usually a man in this scenario) feel as if he has achieved something. A good sexual encounter is about pleasure. (Location 730)

the class of drugs that includes sildenafil (VIAGRA) works for men by increasing blood flow to the penis. One study indicated that these medications do increase clitoral blood flow for women who report difficulties feeling aroused, but that did not translate into a feeling of sexual arousal. One possibility is the feeling of arousal is not just dependent on blood-flow-induced changes, but the brain needs to perceive that sensation as sexually pleasurable. (Location 743)

pornography is acting and not documentary filmmaking. Sex in porn is about as realistic as driving is in car chase scenes in action movies. (Location 753)

It is important when we discuss anal sex as a society that we do not trivialize or normalize this behavior. (Location 757)

Studies indicate that approximately 50 percent of women who have anal intercourse find it arousing, although pain is often an issue. (Location 763)

Anal sex is the most efficient way to sexually transmit HIV (human immunodeficiency virus), due to the combination of microtrauma and the specific cells in the anus being more susceptible to infection with the virus. (Location 767)

If you plan to also have vaginal sex, you need one condom for anal and another for vaginal penetration. (Location 771)

An anal vibrator or dildo should have a flared base so it cannot move up inside the rectum. Every general surgeon I know has taken someone to the operating room to remove toys that have become lodged— this can result in very serious bowel injury, so choosing a medically safe anal vibrator is essential. (Location 779)

There is no specific G-spot; the sensitive area that many women describe just inside the vagina is part of the clitoral complex. (Location 789)

Knowing what to expect after you are finished expecting is very helpful, both so you have a realistic baseline, but also so you know when there is a medical concern and should ask for help. (Location 798)

Changes to the cervix, vagina, and vulva can start as soon as 4– 5 weeks into the pregnancy. (Location 805)

A pregnant woman with group B strep who does not receive antibiotics has a 1 in 200 chance that her baby will develop the infection, but if she is treated that risk drops to 1 in 4,000. (Location 815)

women with a low-risk pregnancy who have no symptoms of a vaginal or cervical infection are at no higher risk of having a premature delivery if they are sexually active. (Location 821)

Most studies show that heterosexual sex has no effect on triggering labor or on reducing the risk of cesarean section. (Location 824)

It’s recommended to avoid sexual activity for women in some higher-risk situations, such as ruptured membranes, placenta previa (where the placenta implants over or next to the cervix), and those who have a high risk of premature delivery (for example, twins or a previous preterm delivery). (Location 827)

An air embolism is a stroke or heart attack due to a large air bubble entering an artery or vein and traveling to the brain, heart, or lungs. (Location 830)

Air embolism is described in fewer than one in a million pregnancies, so it is hard to give science-based recommendations. It is best to avoid blowing air into the vagina during oral sex, (Location 833)

if the person delivering your baby supports a practice that is more than twenty-five years out of date, such as shaving or enemas, I might wonder about the currency of other aspects of their medical care. (Location 839)

It’s best not to shave yourself before labor either, as this causes microtrauma and may increase your risk of infection. (Location 841)

A single stitch can be run like a hem and close a large tear. Multiple tiny stitches may be needed to repair a much smaller laceration to achieve the best cosmetic result. (Location 849)

A first- or second-degree laceration has no increased risk of urinary or anal incontinence, but the risk is increased with third- and fourth-degree tears. (Location 860)

Episiotomy is associated with a larger injury and an increased risk of incontinence. In general, an episiotomy is only indicated in an urgent or emergent situation. (Location 864)

The risk of tearing during a vaginal delivery ranges from 44 to 79 percent— any provider who tells you they can guarantee no tears is not being honest. (Location 867)

Perineal massage starting at 34– 35 weeks. Women or their partners insert one or two lubricated fingers vaginally about two inches into the vagina and apply pressure downward for two minutes, then on each side for two minutes, for a total of ten minutes at least one or two times a week. Coconut oil, olive oil, and lubricant for sex can all be used. (Location 871)

Warm compresses on the perineum during pushing may reduce third- and fourth-degree lacerations. (Location 881)

Swelling, bruising, tearing of muscles and skin, need for stitches, and hemorrhoids can all contribute to pain after a delivery. (Location 887)

Another unique factor is how your baby is doing— the stress of a sick newborn may affect how you process pain. (Location 892)

ICE PACKS: Reduce swelling and pain, especially when applied for 10– 20 minutes immediately after delivery. (Location 904)

The biggest issue with a stool softener is people think they are taking something effective when they are not, and then they wonder why they are still constipated. (Location 920)

Incontinence immediately after delivery is uncommon, so if this happens make sure to tell your doctor or midwife. (Location 925)

If your pain was improving and then takes a turn for the worse, do not assume that it is normal. Check with your doctor or midwife. Potential reasons could be stitches coming apart or an infection. (Location 926)

Opioids are medications such as morphine, hydrocodone, hydromorphone, or codeine. They are often called narcotics, but that is not a medical term. (Location 929)

Opioids are also transferred into the breast milk. (Location 931)

There is valid concern that opioids are overprescribed to women after delivery. (Location 933)

It takes two doses of an opioid to develop physical dependence, meaning when the medication is stopped, physical symptoms of withdrawal, like feeling unwell and pain, appear. (Location 938)

It is easy to mistake symptoms of withdrawal as a false sign that the opioids were helping, and so these symptoms can lead people to restart the opioid medications under the false belief that they need them medically. (Location 939)

Children, especially teens, are curious about medications, and taking leftovers found in the medicine cabinet accidentally or on purpose could lead to an overdose or start an addiction. (Location 942)

Vaginal bleeding after delivery is called lochia. (Location 945)

It is normal to have a heavy, mucusy, blood-tinged, brownish, pretty gross discharge for up to eight weeks after delivery. I remember thinking this was going to go on forever, but it didn’t. You shouldn’t wear a tampon or menstrual cup for this bleeding until you get the all clear from your provider. (Location 947)

(WHO) guidelines recommend four checkups after delivery. (Location 951)

Pelvic floor physical therapy should not start sooner than two months after delivery, to allow for the tissues to heal and return to baseline. (Location 969)

Women who have persistent urinary or fecal incontinence at three months after delivery should be offered pelvic floor physical therapy. (Location 971)

Most health care providers recommend waiting 4– 6 weeks after an uncomplicated vaginal delivery before resuming sex. (Location 977)

If you have pain with sex that persists beyond three months after a vaginal delivery, then you should be evaluated. (Location 981)

LOW ESTROGEN LEVELS IN THE VAGINA: This is almost exclusively seen in women who are breastfeeding, which can stop ovulation. (Location 984)

If a woman feels too tight after a delivery and/ or has persistent pain with sex, it is usually the result of muscle spasm. (Location 1009)

There are so many variables in sexual functioning, but a caring partner who you love and who is a good lover (meaning the kind of lover you need) is probably the most important. (Location 1016)

Sexual function just isn’t about a body part, it’s about you as a whole person. (Location 1021)

To put it in perspective, changes in libido, sexual priorities, and satisfaction with their sexual relationship also happen to gay men who adopt a baby. (Location 1022)

Breastfeeding is associated with pain during sex for the first six months. (Location 1028)

Pelvic floor PT is definitely recommended if you have incontinence; in other situations, Kegel exercises are likely as effective. (Location 1029)

The vulva and vagina do not require regular checkups. (Location 1036)

A screening test is done when there are no symptoms of a condition— the idea is that finding and treating before there are symptoms will reduce complications and even save lives. (Location 1042)

A diagnostic test, on the other hand, is done to help identify the cause of symptoms. (Location 1048)

Menstruation is the shedding of the lining of the uterus (the endometrium) when a pregnancy has not occurred. (Location 1057)

The average age of menarche— the first menstrual cycle— is 12– 13 years. The first day of the menstrual cycle, or day 1 of your cycle, is the first day of bleeding (so the first day of your period). Menstrual bleeding typically lasts 3– 7 days (Location 1058)

The corpus luteum can only produce progesterone for approximately 14 days unless it gets a signal from a pregnancy. Without fertilization, the corpus luteum shrinks and the progesterone is rapidly withdrawn and this causes the lining of the uterus to come out as a period. (Location 1070)

A screening visit regarding reproductive preventive health care is recommended between the ages of thirteen years and fifteen years. (Location 1079)

A pelvic exam has two components: looking inside the vagina with a speculum to see the vagina and cervix, and touching inside with gloved and lubricated fingers of one hand into the vagina (the other hand may press down on the lower abdomen to feel the uterus and ovaries). (Location 1092)

aware of physical cues that might suggest the exam has become painful and knows to stop and reaffirm that it is okay to proceed or make adjustments as necessary. (Location 1113)

The first speculum may date back to Roman times (one was excavated at Pompeii), and a vaginal speculum was in use by surgeons in 1818, (Location 1128)

WHAT IF SPECULUM EXAMS ARE ALWAYS PAINFUL? There are two reasons: you have a medical condition or your provider has poor technique. (Location 1137)

I often wonder if an annual check-in by phone would be helpful, so a gynecological provider can hear a woman’s story and let her know if she needs STI testing outside of the routine screening recommendations, ask about sexual health or other vulvar and vaginal concerns, and provide any age-specific reproductive health advice. (Location 1162)

If a speculum exam is necessary, narrow Pedersen or Cusco speculums are the smallest and are often all that is needed. (Location 1169)

The only regular evaluations related to vaginal health are cervical cancer and STI screenings. (Location 1171)

the idea of eating food to change the way a vagina smells supports the tired and destructive trope that there is something wrong with a normal, healthy vagina. (Location 1180)

(orthorexia is an eating disorder with extreme attention to foods perceived as healthy and avoidance of foods believed to be harmful). (Location 1183)

The biggest contributors to vaginal scent are substances produced by the lactobacilli, (Location 1191)

While the actual mechanism is still not known, most researchers think some people metabolize asparagusic acid from asparagus into a sulfur smelling compound that is excreted in the urine. Approximately 40 percent or so of people can smell these unpleasant metabolites. (Location 1200)

Kidneys and breast tissue actively concentrate certain metabolites, so it makes sense that if you eat enough garlic, a malodorous metabolite could be concentrated in urine or breast milk and impact smell. The vagina does not concentrate metabolites. (Location 1204)

Your vagina needs sugar, and the levels in your vagina have nothing to do with food. (Location 1214)

Yeast infections are a major issue in the intensive care unit. We all have yeast in our bowel, vagina, and on our skin, so when we have invasive procedures that break the skin barrier, the normal, minding-its-own-business yeast can now enter the bloodstream. This is a systemic yeast infection, and it is very serious. Without intravenous therapy, it is fatal. (Location 1215)

When women empty their bladders, there is a microscopic mist of urine that gets on the skin. While the vagina evolved to tolerate sugar, the skin of the vulva has not, and glucose exposure here can favor the growth of yeast, leading to vulvar yeast infections. Some of that yeast may make it into the vagina, leading to a vaginal infection. (Location 1225)

“nocebo effect,” which is a negative effect on health due to negative expectations (basically an unpleasant placebo response). It is the result of conditioning, specifically the belief that something negative will happen. (Location 1235)

trans fats, which are modified fats linked with inflammation and heart disease. Avoid these for all kinds of health reasons (this means saying goodbye to icing from a can). (Location 1261)

Eating at least 25 g of fiber a day is the best preventative health advice I can offer vagina-wise, as fiber is a prebiotic, meaning it feeds good bacteria in the bowel. Fiber also draws water into the stool, softening it and helping it move along more quickly, thereby preventing constipation. (Location 1274)

fiber count, meaning writing everything down that you eat for 1– 2 days and then checking the fiber count so you know how much you are eating and can make changes if necessary. (Location 1277)

I just eat a cereal with 8– 13 g of fiber a serving most days, so I know I’m one third to one half of the way there before I’ve even started my day. (Location 1279)

Fermentation enhances the nutritional value of vegetables and may increase the iron that is available for absorption. (Location 1283)

Having fermented foods if you are on antibiotics is probably not a bad strategy to try to lessen the impact of antibiotics on your gut bacteria (this is a cause of antibiotic-related diarrhea). (Location 1286)

When something bad happens, like vulvar or vaginal irritation, people are more likely to remember things they feel could be related than those who have not had the same bad experience. This is called recall bias. (Location 1314)

For underwear to cause an issue, it would have to change the ecosystem (perhaps by altering the pH of the skin), trap excess moisture, or cause friction. The combination of moisture and friction can cause microtrauma, which could allow the normal yeast on the skin to cause an infection. (Location 1318)

The only thing that can change the pH and microenvironment of the vulva is something occlusive— think waterproof, like plastic or latex. This can be an issue for women who have to wear waterproof incontinence underwear daily. (Location 1323)

runners put petroleum jelly between their thighs before a long run, to prevent the maceration from friction and sweat. (Location 1334)

The vagina doesn’t like oxygen, or even air. (Location 1339)

most vulvar skin infections start because there was a break in the skin, allowing the normal yeast or bacteria on the skin to breach the first line of defense. (Location 1353)

Perfumes and fragrances are known irritants (it doesn’t matter if they are botanical or lab made), and so it is best to avoid them in products that touch your skin, especially underwear, as the vulva is more prone to irritant reactions. (Location 1356)

Fabric softener and dryer sheets can also cause irritant reactions, so I recommend avoiding them. A capful of white distilled vinegar in the fabric softener dispenser works well in the washing machine to soften clothes cheaply, and it’s likely better for the environment. (Location 1363)

It’s also important to use lubricant with condoms as it reduces condom breakage— and no, saliva does not count, as it’s not a great lube. (Location 1381)

The most common cause is menopause, but other causes of vaginal dryness include a yeast infection, breastfeeding, hormonal birth control that doesn’t have estrogen (for example, the Depo-Provera injection and the implant Nexplanon), and muscle spasm around the vagina (the tightness causes more friction, and it can be perceived as dryness). (Location 1386)

it’s not how you got to the party, it’s that you were at the party and had a good time! (Location 1396)

There are several categories of lube: water based, silicone, hybrid (silicone and water), oil based, and pure oil (think olive or coconut). (Location 1400)

Silicone lubricants stay around longer on the tissues versus water-based lubes, so you may need to reapply less and they can be used in the shower or bath. Some people find silicone harder to clean up than water based. Oil also has a lot of staying power and many people prefer the feel, but it can also stain sheets. (Location 1401)

make sure your lubricant doesn’t irritate the vaginal tissues or negatively affect the healthy bacteria. (Location 1408)

(WHO) has guidelines for water-based lubricants. Specifically, they recommend a pH of 3.5– 4.5 (the same as the vaginal pH) and an osmolality of less than 380 mOsm/ kg (the concentration of molecules in water; low osmolality means fewer molecules (Location 1409)

The osmolality of vaginal secretions is 260– 280 mOsm/ kg. If the osmolality of the lube is higher, it can pull water out of vaginal tissues, potentially causing irritation and increasing microtrauma, and theoretically increasing the risk of contracting an STI if exposed. (Location 1411)

oil-based lubricants can weaken latex condoms. Silicone and water-based are fine. You can use any lubricant with polyurethane condoms. (Location 1415)

capsaicin (what makes chili peppers burn, (Location 1437)

“Natural” or “plant-based” does not mean safe. (Location 1438)

For the average person trying to get pregnant, the science behind special lubricant seems iffy at best, but avoiding a lubricant with a high glycerin content is best for your vagina, so avoid those regardless. (Location 1468)

If a male partner says lube affects his sexual performance he, not you, should see a doctor. (Location 1475)

Avoid water-based lubricants with an osmolality > 1,200 mOsm/ kg. (Location 1477)

Dr. Kegel developed what he called a perineometer, a compressible bulb that went in the vagina attached to a dial, like a blood pressure cuff without the part that goes around your arm. Women inserted the bulb vaginally and squeezed with their pelvic floor muscles, and the dial provided visual feedback on the strength of the squeeze. (Location 1493)

Relaxation and injury of the pelvic floor, most commonly tearing of the muscles during childbirth, can lead to incontinence and prolapse, as well as reduced orgasm strength. In addition, we lose muscle mass with age, (Location 1501)

Pelvic floor muscle (PFM) exercises can be part of the therapy for urinary incontinence, difficulties achieving orgasm or weak orgasm, pelvic organ prolapse, and fecal incontinence. (Location 1505)

If it makes you feel as if you are taking care of yourself by doing them, that is okay, too— as long as you are doing the exercises correctly and you don’t get discouraged if they don’t make an observable difference. (Location 1512)

As some women can have trouble isolating their pelvic floor, a prompt, like asking you to pretend you are out in public and squeezing as if you are trying to hold in gas, can be helpful. (Location 1519)

There are two types of exercises— sustained contractions and quick flicks: (Location 1556)

It will take 6– 12 weeks to see improvement. Like all exercises, consistency is the key. After 4– 5 months of daily practice, you will have achieved the most benefit. At this point, you can back off to three days a week. (Location 1567)

Physical therapists also have other tools, like biofeedback machines and even electrical stimulation, which delivers a small, painless current to the pelvic floor muscles to increase blood flow and make them contract, helping your brain learn to isolate the muscles. (Location 1576)

the idea that these jade eggs are somehow known to a for-profit business in California yet unknown to scholars is, shall we say, somewhat suspect. (Location 1601)

PFM can be hard to do, biomechnically speaking. Even with instruction many women will contract the wrong muscles. (Location 1613)

The vulva, like most of the body, medically requires very little, if any, cleaning. (Location 1621)

The only parts of your body that medically need regular cleaning are your teeth and your hands. (Location 1623)

the concept of female cleanliness has largely been driven by a male-dominated society that for centuries, if not longer, has decided normal female genitals and secretions are “dirty.” (Location 1629)

Healthy vulvas don’t smell any more than any other body part. (Location 1635)

Menstrual blood also reacts with lipids on the surface of the skin, oxidizing the iron molecules in the hemoglobin and producing the distinct metallic smell of blood. (Location 1639)

Washing is most important for women with moderate to severe urinary incontinence and fecal incontinence. Urine and feces can damage the acid mantle of the skin and lead to skin inflammation and injury, (Location 1642)

not put any cleaning product between the labia minora, but water is fine. (Location 1649)

Soap strips away part of the acid mantle— the natural oils and bacteria that are an important part of the skin’s defense. If a product is called soap, I don’t care how gentle it claims to be— it can dry the skin, which can leave you feeling irritated and possibly more susceptible to microtrauma. (Location 1661)

Cleansers are not soap; they are synthetic surfactants and other chemicals designed to strip away dirt and leave the acid mantle intact. (Location 1664)

I use cleansers only except on my hands, which get alcohol-based sanitizer or soap. I use the same cleanser for my face, body, and vulva because I am lazy, (Location 1665)

Fragrance is a common source of irritation and allergy. (Location 1674)

Skin loses moisture with age, so if you are using soap you may want to think about a cleanser as a preventative measure. (Location 1682)

IF IT IRRITATES, DON’T USE IT: Really, you don’t need to get used to it. (Location 1697)

IF YOU PREFER SOAP TO A CLEANSER: Use an unscented product. One option is liquid castile soap (Location 1700)

The moisture in the vulva skin is a protective mechanism, and a hair dryer can damage the acid mantle and overdry the skin, even on a cool setting. (Location 1704)

wipes are useful for babies who are incontinent and wear diapers, which are occlusive and keep the stool smushed against the skin. (Location 1712)

The rectum is a storage pouch that sits just above the anal canal. Rubbing or stimulating the external anal sphincter— with aggressive wiping, for example— triggers a reflex that causes the sphincter to relax, and a small amount of stool will be released from the rectum. (Location 1735)

Overcleaning can be a source of irritation, as it can damage the skin’s acid mantle. (Location 1743)

Many cultures have long-standing practices of vaginal astringents and antiseptics to dry the surface of the vagina so men can enjoy “dry sex.” (Location 1760)

By the time you’ve grabbed the douche, enough sperm has already made it past the cervix and is well on its way to the fallopian tubes. Douching also doesn’t make it past the cervix. (Location 1769)

Women who douche also tend to start young, with 80 percent starting before they are twenty years old. They are also more likely to use other products for vaginal cleaning. (Location 1800)

More than 50 percent of women who clean intravaginally report they are encouraged to do this by their sexual partner. (Location 1807)

Wipes, sprays, and odor-control suppositories could very easily kill good bacteria and irritate the mucus and the lining of the vagina in the same way as douches. (Location 1816)

believe they are safe— because otherwise why would stores sell them? Stores also sell cigarettes. (Location 1837)

(we shouldn’t lecture, we should inform), (Location 1839)

Your vagina is a self-cleaning oven. (Location 1845)

Anyone who suggests vaginal cleaning or tightening is recommended is wrong. (Location 1846)

Vaginal cleaning will damage the good bacteria and mucus, increasing a woman’s chance of odor, bacterial vaginosis, and sexually transmitted infections. (Location 1847)

Vaginal steaming, ozone, and “ancient” tightening products are equally as harmful as anything from a drugstore. (Location 1849)

It develops during puberty, and its function is likely protecting the vulva by providing physical protection, trapping microscopic dirt and debris, and maintaining humidity (if you remember, the vulvar skin has a high moisture content). (Location 1854)

The amount of pubic hair and the thickness of each hair does decrease with age, and it also grays. (Location 1866)

Pubic hair removal has been around for a long time. (Location 1874)

The first depiction of female pubic hair in Western art wasn’t until Goya’s The Naked Maja in the late 19th century, and this was apparently outrageous even though just a few wisps are barely visible. (Location 1883)

Visible pubic hair was often the definition of public nudity, (Location 1885)

Pubic hair removal is a cause of injury— (Location 1895)

Women who have their partner perform their grooming on them are more likely to experience injury. (Location 1901)

This has not been studied, but using an antibacterial wipe or washing with an antibacterial soap is probably a good idea before any method of hair removal. (Location 1902)

Women with diabetes who have elevated blood sugar and women who have a suppressed immune system should skip hair removal, as any injury is much more likely to develop into a serious infection. (Location 1905)

There is data that says the first naked genitals that you see prime you to consider them as your baseline for “normal” or typical. (Location 1918)

two main types: depilation and epilation. Depilation involves removing the hair at the surface or just below the surface, and epilation involves removing the entire hair shaft and bulb. (Location 1928)

Shaving is the technique of using a razor to cut the hair at or just below the skin surface. (Location 1944)

minimizing trauma (razor burn is a painful rash due to skin trauma) and not breaking or cutting the hair below the skin surface, as this increases the risk of ingrown hairs. (Location 1947)

USE A PRODUCT TO PREP YOUR SKIN: This means shaving cream, not a quick pass with a bar of soap in the shower. This minimizes microtrauma. (Location 1952)

SHAVE IN THE DIRECTION OF THE HAIR GROWTH: This reduces the risk of the hair shaft breaking beneath the skin’s surface. (Location 1954)

USE A RAZOR WITH A SINGLE BLADE: With a double blade, the first blade pulls the hair up and the second cuts it, but the lower the cut, the deeper the hair shaft retracts into the hair follicle— and the greater the risk of an ingrown hair. (Location 1956)

The pain of pulling the hair out can be lessened somewhat by applying a hand firmly and immediately to the area after removing the wax. (Location 1982)

Laser is not technically considered a permanent method, as the hair follicle can recover. Different lasers are better for different skin colors and types of hair, so I recommend seeing a board-certified dermatologist or plastic surgeon with a large cosmetic practice— they have the most experience, and you want someone who has more than one kind of laser. (Location 1990)

Electrolysis is the only truly permanent form of hair removal. This procedure involves inserting a tiny probe into the hair follicle and passing an electric current to damage the follicle so the hair cannot grow back. (Location 1994)

Ingrown hairs occur when the hair breaks just below the surface and inflammation or trauma blocks the opening of the follicle or causes a hair to bend back on itself and grow into the skin. Very curly hair has the highest risk, as it is predisposed to curling back on itself— this is why you likely never get ingrown hairs on your legs, but you do in your bikini area. (Location 2002)

Ingrown hairs typically work their way out. If you can see the bump well and it is not right next to your labia minora or anus, you can apply some 5 percent or 10 percent benzoyl peroxide cream to dry the area and reduce inflammation and bacteria. (Location 2018)

not remove pubic hair on my labia majora or around the anus. The closer you get to mucosa, the greater the risk of irritation. (Location 2031)

I clean the area a few hours before with an antibacterial skin wipe. This could irritate the vagina and anus, so I would not use them on the labia minora or around the anal area. (Location 2038)

I avoid cleaning or trauma to the area for the rest of the day. The next day, I start using my moisturizer (coconut oil) and cleanser again on my vulva, and a week later I start using salicylic acid pads every few days to loosen sebum and prevent any occlusion of hair follicles. (Location 2042)

A moisturizer is a topical substance that increases the hydration of skin by protecting and repairing the skin’s outer layer, the stratum corneum. (Location 2064)

Moisture loss in the vulva skin can lead to symptoms of dryness, irritation, and increased susceptibility to microtrauma. (Location 2076)

Medications can also lead to dry skin and may not be possible or practical to stop, including chemotherapy for cancer or oral retinoids for severe acne. (Location 2081)

downsides to moisturizing? Some products can block pores and lead to folliculitis (basically acne on the vulva). (Location 2097)

Some researchers have suggested virgin coconut oil, obtained without chemicals or heat, might offer even more anti-inflammatory activity, but there is no good data to support that hypothesis. (Location 2108)

BABY OIL OR MINERAL OIL: These are by-products of distilling petroleum. (Location 2114)

The product claims to be “chemical-free,” which is disingenuous as nothing is chemical free, not even water. (Location 2129)

While unstudied topically, when taken orally in doses of > 400 IU/ day, vitamin E increases the risk of death from any cause. (Location 2133)

Do not use creams and ointments with salicylic acid or retinol (common in face creams) as they could be irritating. Avoid any product that claims to brighten the vulva— (Location 2138)

Topical skin lightening products work by affecting the production of melanin, the pigment that produces skin color. They typically contain one or more of the following: ascorbic acid (vitamin C), retinoic acid, alpha hydroxy acid, or salicylic acid. (Location 2140)

When you bathe, you do not get a douche. (Location 2164)

the male adolescent, many of whom seem as averse to water as the Wicked Witch of the West. If bath bombs are what get my teenage son to rinse the testosterone-fueled sebum-fest off his skin, then bath bombs it is! (Location 2168)

Before puberty, girls are at higher risk of irritant reactions, as their labia are very small and don’t cover the vestibule (vaginal opening), and the mucosa at the vaginal opening doesn’t have estrogen. (Location 2172)

temporary relief from itch can sometimes break the cycle. (Location 2187)

Mosturizers can be useful on the vulva, especially during menopause, for dry skin, and with incontinence. (Location 2197)

There are some cheap, homemade options with a lower risk of irritation for those who can give up big bubbles. (Location 2203)

Toxic shock syndrome, or TSS, is a severe response to a toxin that has entered the bloodstream. A toxin is a substance made by an organism— bacteria, plants, and animals can all make toxins. (Location 2216)

The symptoms of mTSS are fever, a sunburn-like rash that peels, low blood pressure, vomiting, and diarrhea. Organs can shut down, and lack of blood flow to limbs can even lead to amputations (fortunately, this is very rare). (Location 2223)

just because you can eat something does not make it safe for the vagina!) (Location 2245)

Menstrual products in the U.S. are regulated by the FDA (Food and Drug Administration) as medical devices, and any product that differs substantially from what is on the market needs to submit studies for review or they cannot be marketed. Technically, menstrual products are reviewed, not approved, by the FDA. (Location 2248)

Rely was pulled from the market on September 22, 1980, and cases of mTSS started to drop. Polyacrylate was removed from tampons in the U.S. in 1985. (Location 2255)

BE MINDFUL OF TRAUMA WITH INSERTION AND REMOVAL: Using a less-absorbent tampon on lighter days may help. (Location 2295)

HAVE TWO CUPS, AS THE MANUFACTURER INSTRUCTIONS FOR RINSING BETWEEN EMPTYING ARE NOT SUFFICIENT TO KILL TSS-1: The cups should be boiled between insertions, (Location 2306)

A sea sponge is an aquatic organism made of spongin. (Location 2309)

Cleaning a sponge appropriately is also a challenge. When they are used in the kitchen, they need to be washed on hot in the washing machine with detergent and bleach to kill bacteria, (Location 2314)

Evaluation of sea sponges by the FDA in the 1990s revealed the nooks and crannies were filled with microscopic dirt and debris (not surprising, as they filter the ocean). (Location 2320)

Rare events are very hard to study, prevention-wise, although it doesn’t mean companies shouldn’t try. (Location 2342)

Do not assume menstrual cups are safer than tampons. (Location 2352)

Fear sells. (Location 2359)

Being registered with the FDA means these products are subject to manufacturing oversight, and complaints and adverse events must be tracked. (Location 2362)

Unscented pads and scented pads using materials that have been studied and previously cleared by the FDA are Class I medical devices, (Location 2364)

Scented pads using new materials and any device inserted vaginally (for example, tampons and menstrual cups) are Class II medical devices. (Location 2367)

there still are traces of dioxin in tampons, pad, and disposable diapers, even those made of 100 percent cotton. Not because of problematic manufacturing, but because dioxin is everywhere in the raw materials, be it cotton or wood pulp, due to pollution. (Location 2386)

The FDA requires tampons be free of herbicide/ pesticide residue (or have such low levels that they are not medically relevant)— no manufacturer makes this raw data available about their product. (Location 2409)

Most so-called “organic” tampons have not submitted their own safety data; they are cleared for use based on tampons that have already been cleared by the FDA. (Location 2413)

The average menstrual fluid loss is 30– 50 ml a day (1 to almost 2 ounces). Over a period, which typically lasts seven days or fewer, a woman loses an average of 80 ml of blood, but it can range from 13 ml to 217 ml. (Location 2425)

Women with medically heavy periods (menorrhagia) can sometimes bleed up to 400 ml per period, which is a lot! (Location 2427)

studies tell us what women find most distressing is not the volume of blood, but the fact that the blood has leaked onto their clothes. (Location 2428)

Menstrual blood has venous blood (what you normally bleed when you are cut) as well as vaginal discharge and cells from the lining of the uterus (called the endometrium). It can look like blood, it can look like red mucus, it can be almost black, and it can be clotted— none of that is abnormal medically. (Location 2437)

Sometimes menstrual blood can even look so much like tissue, it could be confused with a miscarriage. This medical phenomenon is called a decidual cast, which occurs when a large portion of the endometrium comes off at once. (Location 2439)

excessive menstrual blood loss is often defined as soiling clothes, not volume of blood. If a woman is leaking blood onto her clothes because she is using a product that is ill-fitted or not designed for her blood loss, she may think she is bleeding heavily and seek medical and even surgical intervention (like a hysterectomy), when really what she has is a product problem. (Location 2446)

In the U.S., about 12 billion disposable pads are used each year, (Location 2453)

Perforated top sheets may help reduce wetness by allowing some airflow. (Location 2458)

Some have wings to wrap around your underwear to hold the pad in place and catch side leaks. (Location 2470)

Pads with odor control may have fragrance or absorbent mineral particles in the core that trap volatiles. (Location 2481)

Vulvar skin issues usually arise when moisture is retained against the skin for extended periods of time— as from a soaking wet pad or underwear. (Location 2490)

If you prefer daily pantyliners and have no vulvar concerns, there is no data to suggest they will cause harm. (Location 2501)

There is also a “feel” factor involved in comfort. Some women prefer the feel of fabric, and others find fabric pads are too damp as there is no top sheet to keep wetness from flowing backwards. (Location 2510)

The range for period underwear absorption-wise is anywhere from 5 ml to 25 ml. (Location 2517)

Women have used a variety of vaginal products for centuries, but the first U.S. patent for a tampon was in 1933 (Location 2532)

Modern tampons absorb primarily lengthwise; if they absorbed width-wise, they could cause pain and potentially microtrauma with removal. (Location 2534)

What a tampon can hold in the lab may be different from what it can hold in a vagina without leaking. (Location 2539)

When a tampon is positioned correctly, it shouldn’t be felt. (Location 2550)

Tampons are fine to wear during oral sex. (Location 2552)

Tampons can be left behind. Sometimes people can’t get their tampon out and are too embarrassed to go to the doctor, and sometimes people forget. (Location 2554)

The most common sign of a forgotten tampon is a foul-smelling discharge, as the tampon becomes a perfect place for bacteria to overgrow. (Location 2557)

If you are tense, the pelvic muscles can contract, and you will feel as if you are hitting a wall and the tampon may not go in or may come right back out. (Location 2570)

women can have a septum (extra hymenal tissue in the vagina) that is blocking the path. (Location 2578)

If insertion is painful at any point, then stop. It is better to get some advice from a woman’s health care provider. (Location 2579)

Irritation and difficulties with insertion were most common in the first two cycles, by the third cycle few problems were noted (this is a similar ease-of-use trajectory to that found for the female condom). (Location 2597)

as a cup is larger, you need to ensure it is in far enough that you don’t feel it while sitting. (Location 2600)

There are sites where women have compiled all the available cups and sizes for comparison, so for a cup novice that might be a place to start. One site with lots of aggregated information is putacupinit.com. (Location 2605)

A cup should be comfortable to insert, and when you are wearing it, you should not feel it and should be able to empty your bladder without difficulty. (Location 2612)

Menstrual cups may be a little tricky the first few cycles, but by the third cycle they are rated very favorably. (Location 2640)

menopausal, meaning they are one year from their last menstrual period or they have had their ovaries removed before the onset of menopause. (Location 2646)

The average age of non-surgically-induced menopause is fifty-one years. (Location 2647)

With age, the ability of the follicles to produce estrogen declines, so the brain produces higher levels of FSH in an attempt to stimulate the ovaries (Location 2654)

The transition to menopause in the forties and early fifties can be a meandering descent with years of unreliable menstrual cycles or a precipitous crash— (Location 2663)

adipose tissue (fat), as that can convert other hormones into estrogen using an enzyme called aromatase. (Location 2666)

Estrogen increases blood flow to the tissues and helps maintain tissue strength and elasticity. (Location 2677)

Pubic hair graying is age-related and not hormone-related. It is due to a loss of melanin production. (Location 2682)

The lack of estrogen affects glycogen deposition in the vaginal mucosa. The cells lose volume and there is less glycogen to feed lactobacilli, so they begin to die and different populations of bacteria can be established. (Location 2689)

Loss of tissue support can cause cells of the urethra to protrude and become irritated— this is called a caruncle. (Location 2698)

Vaginal dryness is the number one symptom, but others include a sandpaper feeling in the vagina, vaginal irritation, a change in discharge, decreased lubrication, pain with sex, bleeding after sex, burning on urination, increased urgency (need to empty your bladder urgently), and bladder infections. (Location 2703)

With medicine, it is always important to put things in personal perspective. (Location 2723)

I went through menopause at the age of forty-nine, and regular heterosexual intercourse offered no protection. Within a year, I needed pharmaceuticals. (Location 2739)

(the body’s response to injury is to send more blood to the injured site). (Location 2741)

This spasm can narrow the vaginal opening and feel like a roadblock, making pain with sex worse and giving the sensation that the vagina has closed. (Location 2762)

used to treat women with certain kinds of breast cancer. Aromatase inhibitors block the production of estrogen in every tissue because they block the enzyme aromatase, (Location 2774)

Tamoxifen, another breast cancer medication, blocks the effect of estrogen on tissues. Tamoxifen acts like an antiestrogen on some tissues, and on others it can act like an estrogen. (Location 2780)

Physical changes of menopause affect the clitoris, labia, vagina, urethra, and bladder. (Location 2788)

Symptoms related to genitourinary syndrome of menopause, or GSM, are experienced by 50 percent of women. (Location 2789)

The most common symptom of GSM is vaginal dryness. (Location 2791)

Most women are not asked about symptoms of GSM, so self-advocacy is important. (Location 2793)

Symptoms of GSM (genitourinary syndrome of menopause) affect approximately 50 percent of women. (Location 2797)

It can be hard to know which symptoms are due to GSM and which are due to other causes, so it is very reasonable to start with treatment for GSM and then reevaluate after 6– 8 weeks to see what bothersome symptoms remain. (Location 2804)

Regardless of your symptoms, good vulvar skin care is an important foundation, as the loss of moisture associated with aging can aggravate symptoms of GSM. (Location 2819)

IF YOU HAVE URINARY INCONTINENCE, USE INCONTINENCE PADS, NOT MENSTRUAL PADS: The average episode of incontinence is often more volume of liquid than an overnight pad is designed to hold. The fluid also comes out all at once, not over twenty-four hours. (Location 2826)

Vaginal moisturizers are supposed to rehydrate vaginal tissues and replace lubrication. They are used regularly, not just during sex. (Location 2837)

Vaginal estrogen is considered the gold standard for GSM. (Location 2858)

For all of the estrogen regimens, with the exception of the ring, the dose is nightly for two weeks and twice a week after that. (Location 2875)

Risks with the topical estrogen products are low. There is no increased risk of breast cancer, heart attack, or stroke, despite the package labeling. (Location 2884)

the FDA rules require that if the risk is seen with one form of the drug, it must appear on the labeling for all forms. (Location 2888)

With intravaginal DHEA, the hormone is absorbed by the vaginal mucosa, where it is converted to testosterone and estradiol, although the exact hormone that exerts the effect on the vaginal mucosa is not known. Blood levels of testosterone and estradiol do not increase, so it appears that all the hormone that is produced acts locally. (Location 2905)

So-called “bioidentical hormones” are not safer. They may even have higher risks, as some data shows they can have up to 30 percent more estrogen than advertised. (Location 2921)

women who start their periods early are at a higher risk of breast cancer, specifically because they have had a longer exposure to the natural hormones made by their ovaries. (Location 2923)

What matters is if a medication is safe and effective. (Location 2924)

If the alternative is to go without, then compounded estradiol may be considered if there is informed consent about the possibility of inaccurate dosing. (Location 2931)

For women who dislike vaginal application or who find vaginal application painful, 60 mg of oral ospemifene a day is an option. As it acts like estrogen on the uterus, women who have not had a complete hysterectomy (meaning uterus and cervix removed) will also need to take the hormone progesterone (or a similar drug) to protect against endometrial cancer. (Location 2939)

Many women with breast cancer can safely use the lower doses of estrogen vaginally. (Location 2977)

Like a lot of “next great ideas,” there is some basic biologic plausibility, little hard science, and a lot of hype. (Location 2986)

We have receptors for cannabinoids not because we evolved to consume cannabis, but rather because our bodies make our own (or endogenous) cannabinoids called endocannabinoids. (Location 2994)

A medical motto that governs much of what I do, especially when something is understudied, is “we don’t know what we don’t know.” (Location 2997)

the experience of feeling more sexually aroused while sexual performance is actually physically reduced by a substance is a well-known phenomenon— the most notable example is alcohol. (Location 3016)

cannabis is an endocrine disruptor, meaning a substance that isn’t an estrogen but acts like one, just like BPA in plastics. (Location 3068)

The impact of cannabis on the vagina is poorly tested. The scant data we have strongly suggests a link with yeast and a negative impact on hormones. (Location 3074)

The method of contraception that you choose has to actually work for you. (Location 3086)

if you partner with either men or women, condoms are the very best thing that you can do for your vagina. (Location 3091)

women who have low or no levels of good bacteria are four times more likely to catch gonorrhea or HIV if exposed. (Location 3099)

If you find condoms irritating, make sure they are spermicide-free and lubricant-free and use your own lubricant. (Location 3104)

Biofilms are protective coatings that bacteria and yeast can make that allow them to avoid detection from the immune system and escape antibiotics or antifungals (yeast medication). (Location 3116)

70 percent of women who think they have a vaginal infection are misdiagnosed, (Location 3129)

a link may simply imply correlation (today it is sunny, and I read the newspaper— two events that happened on the same day, but no cause and effect) versus causation (it is sunny so I am wearing sunglasses— direct cause and effect). (Location 3145)

The estrogen-containing birth control pill increases healthy vaginal bacteria, but it may be associated with a small increased risk of yeast. (Location 3166)

If you need antibiotics, you need them. If you don’t, you don’t. (Location 3177)

If you don’t take the entire course of antibiotics— 43 percent of people do this, for a variety of reasons— you risk not only getting sicker when your partially treated infection returns, but you also paradoxically contribute to the development of resistant organisms that could harm you and other people. (Location 3179)

Medically, the most appropriate course of action is to make sure you really need those antibiotics to begin with (this is called antibiotic stewardship). (Location 3184)

The prevailing belief is that antibiotics lead to yeast infections by killing the lactobacilli (good bacteria) in the vagina, as well as killing the pathogenic (harmful) bacteria that they were prescribed to treat. The temporary drop in lactobacilli allows yeast, which is often normally present, to overgrow. (Location 3195)

When getting an antibiotic, ask if this is the narrowest-spectrum antibiotic you can have for this infection. Most doctors I know would be thrilled to be asked! (Location 3210)

Clindamycin cream and suppositories have mineral oil, so they are not compatible with latex condoms— (Location 3230)

probiotics are live microorganisms that, when administered in adequate amounts, confer a health benefit on the host. (Location 3246)

If you are feeling well and have no symptoms, probiotics are unlikely to enhance or improve your gut bacteria. (Location 3253)

Other reasons why the data on probiotics has been discouraging include studying the wrong strains (the strains that we believe to be most important for vaginal health are difficult to grow outside the vagina) and that women may need strains individualized for their own flora or specific medical condition. (Location 3264)

The biggest issue is they may not help and you have wasted money in addition to the frustration of committing to a regimen. (Location 3270)

The most concerning health risk with probiotics is that bacteria might inadvertently get into the bloodstream, causing a serious infection. (Location 3278)

If you have any significant immune-system problems or are taking medications that suppress your immune system, you should check with your doctor before starting probiotics. (Location 3281)

Mislabeling and unknown ingredients are unfortunately common in the supplement industry. (Location 3289)

As the ingredients, purity, and doses for supplements— including probiotics— in the United States are on the honor system, it is very much buyer beware. (Location 3292)

Basically, the weeds grew faster with the enhanced food source than the flowers. (Location 3301)

information we miss because negative studies are less likely to get published. Everyone wants to find a cure, not show that something is ineffective, even though they are both very important information. (Location 3302)

Some basics are 1– 2 servings of fish a week, no trans fats, no fast food, and 25 g of fiber a day. (Location 3304)

Approximately 23 percent of women will develop a yeast infection after antibiotics. (Location 3323)

Some antibiotics have a very low/ no risk of causing vaginal yeast infections. (Location 3324)

Boric acid does not work by acidifying the vagina; it is cytotoxic (kills cells). (Location 3327)

When it comes to procedures, words like “rejuvenation” and “renewal” are medically meaningless. I would steer clear of any procedure marketed with that terminology. (Location 3336)

This surgery for reducing and/ or reshaping the size of the labia minora is on the rise. (Location 3346)

seeking surgery for reducing the labia minora used to be confined to women with a significant size discrepancy, typically relating to a previous vaginal delivery or significant weight loss, where one labia minora is significantly larger in width (meaning 3– 4 cm larger) than the other. (Location 3349)

There is an African culture where women practice labial elongation, as it is a desired sexual characteristic with no associated negative symptoms or sexual difficulties. (Location 3355)

50 percent of women have labia minora that protrude beyond the labia majora, (Location 3360)

seeing images of surgically or naturally smaller labia minora in pornography can alter women’s perception of what is typical. (Location 3363)

some people call this look “camel toe,” but I prefer “labial cleavage,” and the answer is not surgery— it is better-fitting athletic wear. (Location 3380)

can’t imagine a similar industry for men that profits from surgically trimming penises so they look better in tight jeans. (Location 3383)

The gender and specialty of the doctor a woman sees for consideration of labial surgery make a difference in whether the surgery is recommended. (Location 3385)

Stem cells are cells with the ability to differentiate or turn into other cells. Stem cells can be harvested from several sources, such as the umbilical cord, the bone marrow, and even fat (adipose tissue). (Location 3416)

The biggest reason to be worried by stem-cell injections is that they can cause unregulated growth— (Location 3424)

If you feel that your vagina is looser after delivery, the answer is usually Kegel exercises and physical therapy, not surgery. (Location 3434)

multicenter randomized, double-blinded placebo-controlled trial (Location 3452)

Under no circumstances can I recommend the G-shot, the O-shot, or stem-cell injections. (Location 3462)

Laser to treat GSM and incontinence is understudied, and there is no data about using these devices to “tighten” the vagina. (Location 3464)

Approximately 80 percent of women who have ever been sexually active with a man will have had at least one sexually transmitted infection (STI). (Location 3470)

almost all STIs increase the risk of acquiring HIV (human immunodeficiency virus) if exposed, (Location 3474)

Some STIs can even be transmitted by non-penetrative sexual activities, like genital rubbing. (Location 3478)

BACTERIAL VAGINOSIS (BV): This indicates low levels of protective bacteria. (Location 3489)

Knowing your risk factors can help you decide if you should advocate for more testing. (Location 3499)

exchanging messages may provide an illusion that you know someone so the first time you meet it feels as if you’ve already had ten dates. (Location 3515)

OVERRELIANCE ON CONDOMS: Condoms are not a “Get out of Jail Free” card. They reduce STIs in the same way that seat belts reduce death in car accidents. (Location 3520)

Male condoms are used about 3 percent of the time in heterosexual porn, and dental dams are almost never used. (Location 3525)

when discussing STIs. Incidence is the number of new cases and prevalence is the number of total cases. (Location 3530)

HIV for sexually active individuals is recommended annually until you are sixty-five years of age. (Location 3539)

While you should be tested if you have concerns about exposure, STI testing is recommended for women if they have had more than one partner or a new partner in the previous year or if their partner has had other partners. (Location 3540)

Home testing for STIs is used routinely in many countries, such as Sweden, Denmark, the United Kingdom, and the Netherlands. (Location 3572)

You can be tested for most STIs free or for very low cost at a health department. Planned Parenthood and a variety of community clinics also have low-cost or sliding-scale options. (Location 3576)

guttmacher.org, which provides a wealth of information about reproductive health care laws. (Location 3586)

It’s not just STIs; many infections and health conditions that have nothing to do with sex, like tuberculosis and elevated lead levels in children, are reportable. (Location 3589)

There are services that will anonymously notify your sex partner for you, such as inspot.com and STDcheck.com. (Location 3606)

Anyone who has ever had sex of any kind is at risk for STIs, (Location 3614)

Bacterial vaginosis, a bacterial imbalance of the vagina, increases your risk for STIs if exposed. (Location 3616)

There are many places you can get screened: at a provider, the health department, and even at home. (Location 3617)

In the United States, you do not have to be eighteen to consent to testing, but in some states the provider can legally contact your parent or guardian if they choose to. (Location 3619)

There are highly effective vaccines for two STIs: hepatitis B (HBV) and human papilloma virus (HPV). (Location 3632)

HBV can remain infectious on surfaces for seven days and it is highly infectious— even microscopic blood on a shared toothbrush can potentially transmit the infection. (Location 3641)

The CDC recommends universal vaccination against HBV at birth, (Location 3644)

If you don’t know if you have been vaccinated, ask your doctor for a blood test for antibodies to HBV. If it is negative, get the vaccine. (Location 3649)

The HPV vaccines are approved in the United States up to the age of forty-five. This has nothing to do with safety; the studies submitted to the Food and Drug Administration (FDA) involved this age range. (Location 3653)

The other benefit of vaccinating early is there is a stronger immune response. (Location 3663)

many do not realize the burden of precancerous changes, including the stress of abnormal results and the physical and emotional pain of biopsies and procedures to remove precancerous changes. (Location 3667)

Vaccinating kids does not make them more likely to have risky sex. This has been proven by studies. (Location 3678)

The Panic Virus by Seth Mnookin). (Location 3682)

Almost every substance is dangerous at some level and safe at others. (Location 3685)

thehotline.org. (Location 3711)

Sheepskin condoms are not effective for STI prevention, as the pores in the material are large enough that viruses can pass through. (Location 3716)

Hold the tip to leave space for the ejaculate as you roll on the condom. (Location 3749)

Make sure the condom is unrolled completely on the penis: (Location 3750)

Use lubricant: this reduces breakage and makes sex more comfortable for the female partner. (Location 3751)

Grasp the base of the condom during withdrawal so it doesn’t slip off. (Location 3755)

Erectile dysfunction (ED) prevents many men from using condoms. The incidence of ED climbs with age, (Location 3758)

Don’t double up using a male and female condom. This causes more friction and can lead to condom failure. (Location 3763)

Dental dams are a square sheet of latex to cover the vulva or anus before oral sex. (Location 3772)

Dental dams have to be held in place, although there are harnesses to purchase. The taste of latex can be a little clinical, so there are flavored products. Putting lubricant on the person on the receiving end improves the sensation. They are single use only; (Location 3774)

PrEP involves taking medications every day to prevent HIV. In many ways it is like a vaccine. (Location 3779)

PrEP is for HIV-negative individuals at high risk of acquiring HIV. It is well over 90 percent effective at preventing HIV infection if exposed (some newer data suggests when prescribed and taken appropriately it is close to 100% effective). (Location 3783)

In the United States, most private health insurance policies and Medicaid cover PrEP. (Location 3791)

To start PrEP, you must be HIV negative and get tested every three months— if you become HIV positive, different medication is needed. (Location 3793)

Make sure you are vaccinated against HBV, and ask your sexual partners if they have been vaccinated. (Location 3802)

The human papilloma virus (HPV) is the most common sexually transmitted infection (STI) in the world. (Location 3811)

Up to 80 percent of American and Canadian women will have at least one infection with HPV in her lifetime (Location 3817)

A virus is a tiny organism made of genetic material within a protective membrane that depends on the host for food, energy, and reproduction. (Location 3829)

It is parasitic, meaning dependent on a host to live, but not a true parasite. A parasite reproduces outside our cells, (Location 3830)

HPV has evolved to match the life cycle of skin cells. It infects the basal (bottom) layer of skin cells and then inserts itself into the nucleus, which is the command center of a cell. (Location 3832)

HPV hijacks the cell’s DNA to make more HPV and instructs the cell to assemble the DNA into new viral particles. (Location 3835)

HPV types are highly adapted to specific skin cells, which is why plantar warts (also due to HPV) do not grow on the vulva and genital warts do not grow on the feet. (Location 3837)

High-risk HPV can also cause cancer of the mouth and throat. (Location 3846)

Oncogenic HPV types interfere with a specific repair mechanism, so mutations go unchecked and are more likely to become cancer. (Location 3848)

cigarette smoking significantly increases the risk that an HPV infection will progress to cancer. (Location 3857)

Cervical cancer is the fourth most frequent cancer among women worldwide and the second most common cancer among women of reproductive age (15– 44). (Location 3859)

The bulk of this cancer burden is for women in countries with no access to the HPV vaccine, screening for precancer, or treatment for precancer or cancer. (Location 3861)

In the United States, cervical screening starts at twenty-one years of age and continues to sixty-five years of age. (Location 3868)

Women with a history of negative tests can stop screening after sixty-five years of age. (Location 3874)

a good unwritten rule in medicine— if the test is not going to change the plan, don’t order it! (Location 3876)

during pregnancy some women who have never tested positive for HPV can develop an HPV infection. Pregnancy suppresses the immune system, which may allow a latent virus to reactivate. (Location 3890)

If you have anal symptoms, for example a persistent itch or irritation, then you need a rectal exam. (Location 3898)

If you partner with men, as men do not get screened for genital HPV, some women feel at a disadvantage with disclosing. We generally recommend that honesty is the best policy. (Location 3912)

A wart can look flat or raised. Often it looks thickened because the virus triggered additional production of the protein keratin. (Location 3930)

Warts do not become cancer, but a precancer of the vulva or vagina could be misdiagnosed as a wart as they look similar. (Location 3932)

Failure to clear an oncogenic or cancer-causing strain of HPV is the risk factor for cervical cancer. (Location 3974)

HPV may persist on sex toys, even after cleaning. (Location 3979)

There are over one hundred different kinds of herpesviruses, but only eight cause infection in humans. Two are sexually transmitted: herpes simplex virus 1 (HSV-1) and herpes simplex virus 2 (HSV-2). (Location 3982)

Almost everyone has one or more herpesviruses in their body. (Location 3989)

Women are more likely to acquire herpes through sexual contact than men because women have more microtrauma during heterosexual sex and the mucosa (skin) of the vagina is more susceptible to infection than the penis. (Location 3991)

the symptoms are easily mistaken for a different infection. The sores or lesions of herpes can also be misdiagnosed, for example as an ingrown hair. (Location 4027)

if you have had a history of genital herpes, make sure to tell your OB/ GYN, family doctor, or midwife and report any new genital symptoms during a pregnancy so you can be evaluated and treated appropriately. (Location 4039)

Whether or not you decide to get a blood test for herpes depends on how you and/ or your health care provider will act on the results. Think about how the results will change what you do. (Location 4053)

A lot of women are also reassured when they learn herpes does not cause cancer, recurrent sores are uncommon, and there are medications to reduce outbreaks as well as strategies to reduce the risk of transmission and minimize any harm in pregnancy. (Location 4091)

HSV-1 can cause both oral and genital herpes; recurrences of HSV-1 on the genitals are uncommon. (Location 4096)

The most serious consequences of genital herpes are an increased risk of HIV transmission and risks to a pregnancy during vaginal delivery. (Location 4100)

There are disproportionately higher rates of gonorrhea among African American versus white women in the United States— seventeen times higher. (Location 4111)

Both gonorrhea and chlamydia can only live in specific kinds of skin (epithelial) cells called columnar and transitional cells. (Location 4113)

Infants can also acquire vaginal and rectal chlamydia during birth from exposure to infected vaginal secretions. (Location 4127)

Pregnant women should also be screened, as both chlamydia and gonorrhea are associated with complications during pregnancy and for the baby after birth. (Location 4146)

As gonorrhea and chlamydia are associated with other STIs (they tend to travel in packs), if you screen positive, it is generally a good idea to get tested for syphilis, trichomoniasis, and HIV as well, and make sure your cervical screening is up to date. (Location 4147)

In supposedly monogamous heterosexual relationships, approximately 23 percent of men and 19 percent of women admit to sexual infidelity. (Location 4160)

The emergence of resistance has often been very rapid, taking less than twenty years for some classes of antibiotics. The pace at which gonorrhea is defeating antibiotics far outstrips our ability to develop new classes of antibiotics. (Location 4174)

It is important to know what works locally, as resistance patterns can vary from country to country. (Location 4176)

Gonorrhea can cause a heavy discharge or burning with urination, but only 20 percent of women have symptoms. (Location 4189)

Spotting after sex can be a symptom of chlamydia. (Location 4190)

As symptoms are uncommon with both gonorrhea and chlamydia and untreated infections have serious consequences, screening is essential. (Location 4191)

Gonorrhea resistance is a significant problem, and treatment options are limited. (Location 4192)

Trichomoniasis is an infection caused by a protozoan, meaning a single-celled microscopic animal. (Location 4196)

They are not parasites, as they reproduce outside human cells, but trichomoniasis is a parasitic infection, meaning it gets its nutrients from the host— in this case, the storage sugar, glycogen, that is found in the vagina. It attaches to the cells with a barb in the tail and causes an intense inflammatory reaction. (Location 4199)

The most common symptoms are a yellow-green discharge, pain with urination, odor, itching, and irritation (of the vulva and/ or vagina). Some women can have so much inflammation that they can have a small amount of bleeding from the vaginal walls, which presents as spotting. The most common symptoms of trichomoniasis are symptoms seen with many conditions, so they are nonspecific, (Location 4215)

85 percent of women with a trichomonas infection have no symptoms and by six months only 40– 50 percent of women have symptoms, so relying on symptoms to identify trichomoniasis is not sufficient. (Location 4219)

The intense inflammation of trichomoniasis particularly facilitates the transmission. In the United States, it is estimated that 6.5 percent of HIV infections in women happen because of trichomoniasis. (Location 4223)

Trichomoniasis is also associated with premature delivery and lower birth weights. (Location 4225)

If you have not been sexually active and are diagnosed with trichomoniasis, it is important to remember that false positives with most testing methods can occur. (Location 4281)

Unlike other STIs, the risk of acquiring trichomoniasis increases for women over forty years of age. (Location 4300)

Testing for trichomonas is often not included in standard STI screening, so if you want to be tested ask specifically. (Location 4302)

While technically it is possible to catch trichomonas from nonsexual activity, this requires very close, wet contact— such as sharing a basin for washing the vulva. (Location 4304)

Pubic lice are insects called Pthirus pubis, commonly called crabs due to their crab-like appearance under the microscope. Technically they are parasites, meaning their entire life cycle is dependent on the host (Location 4308)

They have specific hair preferences due to the spacing of the hair follicles— pubic hair follicles (and other coarse hair follicles) are about 2 mm apart, which is the distance between the louse’s hind legs, allowing it to crawl from hair to hair. Lice also like a humid environment, so pubic hair is the ideal habitat. (Location 4311)

There is also an incorrect belief that pubic lice are associated with being dirty or unclean. They are not. (Location 4316)

Lice feed on blood, and the reaction to the bite causes intense itching— essentially an allergic reaction. (Location 4321)

The first time you catch lice, the itching may be delayed for up to four weeks, as it takes a few weeks after first exposure to get sensitized and develop the reaction. (Location 4323)

They are harder to see unless combed out with a nit comb (a very fine-tooth comb that can snag the nits and pull them off). (Location 4327)

There is an oral medication called ivermectin. It definitely does not kill nits, so you have to repeat the treatment two weeks later. (Location 4343)

if you have acquired pubic lice, you have a higher risk of also being exposed to other STIs. (Location 4345)

To kill lice on your clothes, towels, and bedding, machine-wash everything and anything that has been worn or slept in for the past 2– 3 days in hot water (50 ° C or 122 ° F) and/ or machine-dry on hot. Dry cleaning is also an option. Place any clothes or bedding that cannot be washed in a sealed plastic bag for three days (European guidelines). (Location 4353)

pubic lice can’t live for more than two days without blood. (Location 4356)

Pubic lice are parasites uniquely adapted for pubic hair. (Location 4358)

There are over-the-counter treatments— you have to make sure you get all the nits as well as killing the lice. (Location 4362)

Many women are plagued for years with a seemingly untreatable yeast infection, when they really are suffering from something else. (Location 4370)

Colonization by yeast (so yeast is present, but there are no symptoms) drops with menopause for women who do not use estrogen. (Location 4380)

When yeast overgrows, it causes an inflammatory reaction, which causes swelling, redness, itching, burning, and pain. (Location 4426)

Yeast on the skin causes a red rash that may be itchy or tender to the touch. The rash classically has what we call satellite lesions— small islands of rash next to the larger area. (Location 4439)

Oral fluconazole has a lot of drug interactions, (Location 4481)

Garlic may have soil bacteria, (Location 4527)

TEA TREE OIL: This can cause nasty allergic reactions on the vaginal mucosa. It is also an endocrine disruptor (Location 4530)

Yeast is a normal part of the vaginal microbiome. (Location 4542)

Most yeast infections are due to C. albicans, but an increasing number are due to non-albicans species. (Location 4544)

If your yeast medication fails, do not call in for treatment; get a culture. (Location 4547)

BV is associated with an increase in bacteria that produce compounds called cadaverine and putrescine that have a musky, fishy smell. When they mix with the alkaline (or elevated) pH of ejaculate, these compounds become volatile and are much easier to smell. (Location 4554)

Lactobacilli bind to red blood cells. (Location 4569)

once women become sexually active, their lactobacilli start to risk compromise. (Location 4584)

There is some data that suggests some men may have biofilms with Gardnerella and other pathogenic bacteria on their penis and theoretically could be transmitting this bacteria, the biofilm, or the ability to make biofilms to their female sexual partners. (Location 4587)

Strategies for recurrent BV suppress the pathogenic bacteria while trying to encourage lactic acid– producing bacteria to grow. (Location 4663)

WOMEN WHO PARTNER WITH WOMEN: Do not share sex toys and consider having your partner tested for BV and treated if appropriate. (Location 4678)

BV is a common cause of vaginitis— classic symptoms include irritation, discharge, and an odor. (Location 4697)

Recurrent BV can be a challenge— this is a time to see a practitioner with extensive experience. (Location 4702)

Provoked vulvodynia means the pain is not noticeable until the area is touched or provoked in some way. (Location 4709)

Stress is bad for every medical condition— many of the chemical changes in the nervous system with stress can lower the threshold for pain conditions. (Location 4756)

Just getting a diagnosis can help women with vulvar pain. (Location 4782)

Giving women a name for their condition and validating that it is real is empowering and can be very helpful. (Location 4784)

BIOFEEDBACK: A technique where you learn to control your body’s functions, typically heart rate and breathing. (Location 4807)

the illusory truth effect (meaning mistaking repetition for fact). (Location 4827)

Vulvodynia is a common and frequently undiagnosed cause of vulvar pain. (Location 4838)

Depression and lack of sleep are accelerants that can make the pain worse. (Location 4842)

pelvic floor muscle spasm, or PFMS, when the muscles are constantly tight, and this can cause vaginal pain, pain with sexual activity, and the urge to empty your bladder. (Location 4848)

Pain primes the nervous system for more pain. Part of this is a result of microscopic changes to the nervous system, and part is anticipation. (Location 4863)

Anticipating negative experiences causes muscles to spasm and primes the nervous system to experience more pain. (Location 4869)

Pain is very complex, and much of the pain experience— meaning what you feel— depends on how your nervous system processes pain signals (Location 4887)

Women with persistent genital arousal disorder, or PGAD, a rare condition with a sensation of constant sexual arousal, should be evaluated for pelvic floor spasm. (Location 4906)

Some women tell me the physical bonding is worth the pain, but many have not been able to tell their partners about their pain. A sex therapist or other psychologist may be helpful in explaining the pain situation to a partner. (Location 4952)

If sex is “twist a nipple and stick it in,” that would hurt most women. Use plenty of lubricant and focus on areas that do not hurt, such as the clitoral glans and labia. Aim for an orgasm (or more than one) before any penetration. (Location 4954)

book She Comes First— (Location 4956)

Some women find after an orgasm or two their pelvic floor begins to relax, and then penetration is easier. (Location 4956)

Dilator exercises depend on forming muscle memory; it is more important to do them 5– 10 minutes a day every day than thirty minutes once a week. (Location 4965)

Pelvic floor muscle spasm is a common cause of vaginal pain and pain with sex. (Location 4986)

This further traumatizes the skin and primes the nervous system to feel even itchier. Scratching and rubbing can produce redness and thickening of the vulvar skin. (Location 5039)

Scratching, when deep enough, can damage the bottom layer of skin cells (the basal layer). This can lead to scarring, and it can cause the melanocytes to release pigment, leading to flat, dark areas called melanosis. (Location 5044)

Hidradenitis suppurativa is a chronic inflammatory condition of the hair follicle that, while uncommon, often goes undiagnosed— early intervention may improve outcomes. (Location 5137)

Bladder cancer is much less common in women versus men, and it is rare under the age of fifty-five. If you are forty or older and have symptoms suggestive of PBS, especially if you have blood in your urine, you should ask about being screened for bladder cancer. (Location 5226)

Pelvic organ prolapse means part of the vagina and/ or the cervix/ uterus is dropping down towards or even through the vaginal opening. (Location 5347)

There can be a lot of crossed signals, and symptoms are often not what they appear to be. In addition, many things that women have been taught about their bodies and medical conditions that affect the vulva and vagina are incorrect. (Location 5359)

If you experience a painful symptom, your nervous system may turn the volume up on the nerves in the same region, so subsequent stimuli are more painful. This is called windup. (Location 5386)

Anxiety, stress, worry, relationship or financial issues, and lack of sleep can all lower tolerance and so symptoms become more bothersome. (Location 5407)

confusing. I’m an expert, and my symptoms were in no way classic. I couldn’t do a proper self-exam, and my pain and recall biases led me to believe the sugaring was at fault. (Location 5436)

Think about your bother factor— say it out loud or write it down so the word choice feels correct to you. (Location 5474)

Lead with your symptoms when communicating with providers, not your suspected diagnosis. (Location 5475)

Pain with sex is a medical condition. It is not normal to have pain with sex. (Location 5481)

Anxiety, stress, and sadness all make pain worse. They don’t cause it, but they are fuel on the fire, (Location 5487)

A practitioner who is experienced in diagnosing and treating pain with sex can learn a lot from very little. (Location 5498)

Sometimes with muscle spasm there can be so much pressure at the vaginal opening that it can lead to splits in the skin, which are painful. These splits or tearing can sometimes heal in such a way that a web of tissue forms and traction during sex is painful. (Location 5551)

many women do not get enough foreplay. Watching a video about the mechanics of good sex and female orgasm might be helpful. A sex therapist is another option. (Location 5577)

Pain with sex is not normal— tell your provider, and if they don’t listen get another provider. (Location 5582)

about 50 percent of the time doctors make the diagnosis of vaginitis without doing the correct testing, and sometimes without any testing at all. Self-advocacy to ensure you are getting the appropriate tests is important. (Location 5604)

It is valid to ask what tests your doctor is going to do to diagnose your symptoms. (Location 5635)

If you are allergic to poison ivy, always wash your hands well after eating mango, as mango skin contains the same allergen as poison ivy— urushiol. (Location 5726)

LOW IRON: This can lead to intense itching that can start on the vulva. This is also a cofactor for yeast infections. (Location 5734)

Once an irritant reaction starts, it can be like a snowball rolling down a hill. The trigger may have been a small thing, but your skin, immune system, and nerves turned it into a bigger thing. (Location 5742)

ANAL PRECANCER AND CANCER: If there is persistent itching and no identifiable cause, then an exam to rule out anal precancer or cancer is indicated. (Location 5766)

Intense vulvar itch without significant redness or skin changes is usually lichen simplex chronicus. (Location 5774)

You can develop an allergic reaction to any product at any time, even after years of use. (Location 5775)

Low iron can be a cause of chronic itch. (Location 5777)

Acute conditions can be missed and end up becoming chronic issues. (Location 5793)

Cancer of the vulva is only painful once it gets large enough that it starts to ulcerate or grow into nerves. (Location 5830)

When lactobacilli levels drop, there is an increase in odor-producing bacteria. (Location 5855)

If you do not have the odor when you see your doctor, there is a greater chance they will be unable to make a diagnosis. (Location 5896)

Pyridium is a pain medicine for bladder infections that turns urine orange. (Location 5916)

When I do not detect an odor, my next step to take a swab from the vagina, smell it, and then hand it to the patient to smell. This way we are both smelling the same thing. (Location 5925)

it could be harmful to your good bacteria or the protective mucus. Give douching with water a pass. (Location 5951)

Antibiotics and antifungals (especially when not indicated), overcleaning, douching, and odor-control products can paradoxically lead to odor. (Location 5959)

In gynecology, a concerning blood loss is usually one soaked pad an hour for two hours. (Location 6010)

When there is a lot of blood, the cause is almost always trauma or cervical cancer, although it is usually trauma. (Location 6014)

Bleeding with sex happens to about 5 percent of women. (Location 6071)

A FACIAL CLEANSER WITH A PH AROUND 5: I use this sparingly on my vulva (and on my body and my face). Right now, I am using CeraVe Foaming Facial Cleanser for dry skin. (Location 6090)

It is important to know what you will and will not do— meaning not what you are planning to do in your head, but what you are actually willing to execute. (Location 6105)

Medication is absorbed more slowly from ointments and often penetrates better, so they are very useful for chronic conditions. (Location 6133)

DOUCHES: These are cigarettes for your vagina. (Location 6145)

If you have soap, I am not going to take it away if you have no symptoms and you like what you are using. If you are using it sparingly then it is probably fine. However, you must promise to throw it away at the first sign of itch and irritation. (Location 6168)

If you are a hair-removal devotee, give a trimmer a try. (Location 6175)

Ditch the douches and odor-control products. (Location 6178)

predatory journals— medical publications that accept low-quality studies for profit. (Location 6194)

the illusory truth effect: when incorrect information is repeated, it is more likely to be accepted as truth. (Location 6199)

bookmark the National Library of Medicine. It is a great place to start any health research. (Location 6205)

the first piece of information sticks the most, so you want to stack the odds in your favor and make sure the first thing that reaches your eyeballs is high quality. (Location 6205)

DO A BROWSER SEARCH: Type in the name of the organization and the subject, and see what comes out. You can also add the term “patient handout.” (Location 6223)

Universities have bias, whether they admit it or not. Every organization does. They want to promote their own work. (Location 6229)

Does your doctor get money from Big Pharma? You can look them up on Dollars for Docs, a service from ProPublica. (Location 6237)

Women are constantly fed lies about toxins in their periods or that the vagina is dirty. “Pure,” “clean,” and “natural” are just modern riffs on that destructive messaging. They also do not mean anything medically. You want sound hypotheses and clinical evidence, not patriarchy’s dog whistle. (Location 6247)

The phrase “100 percent successful” means “high probability of scam.” (Location 6254)

Do not read the comments. Ever. A negative comment about the author can change what you think of the quality of the information. Even one ad hominem attack in the comments changes a reader’s perception of what they read. (Location 6261)

Take the National Library of Medicine tutorial “Evaluating Internet Health Information.” (Location 6272)

Start your search with a professional medical society and expand outwards. (Location 6273)

Any site that sells product or uses nonmedical words, such as “detox” or “pure,” is more heavily invested in selling you magic than providing useful medical information. (Location 6274)

Before we had microscopes and testing, before we had X-rays or other imaging, we struggled to make real medical diagnoses. (Location 6281)

As women were denied an education and because of the social mores could not get an exam from a male physician, they often had to make do with female healers who likely did the best with what they had. (Location 6295)

the illusory truth effect (repetition being mistaken for accuracy) (Location 6302)

The man who wrote the book that started the alkaline trend received jail time for practicing medicine without a license. (Location 6337)

HORMONAL CONTRACEPTION CAUSES “INFERTILITY”: Nope, but the patriarchy trying to scare you away from controlling your reproductive health is invested in this myth. (Location 6345)

A vagina does not make you a woman, how you feel inside does. (Location 6360)

Therapeutic magnets are a multibillion dollar industry and there is no evidence they do anything but lighten your wallet. (Location 6373)

Tea tree oil is an endocrine disruptor and a common cause of irritation. (Location 6404)

Anything offered to tighten your vagina is an astringent and will damage the mucosa and your mucus. (Location 6413)

True choice— weighing your personal risk-benefit ratio and making a decision for your body based on that information— requires facts. (Location 6435)