The Gynae Geek: Your no-nonsense guide to ‘down there’ healthcare. Dr Mitra Anita

mind once I’ve explained that it’s not harmful. As one patient once said to me, ‘If it’s nothing sinister, I’ll take a few harmless drops of blood over a barbecue on my cervix any day.’

       Cervical polyps

      These are little ‘skin tags’ that can be found in the cervix. Many women have them and never know, but in some they cause symptoms of abnormal discharge (a change in colour, texture, amount or bloodstained), bleeding in between periods, after sex or after a gynaecological examination, which makes them super annoying, and a potential source of worry. They may also be found by chance during a routine examination such as a smear test. They can be removed easily in clinic, and it’s quick and painless, but if they’re not causing symptoms this is unnecessary, as they are always benign (non-cancerous) and don’t increase the risk of any kind of disease or trouble in the future.⁵

       Nabothian follicle

Also called mucus-retention cyst, this is where the mucus that is made as part of the healthy function of the cervix becomes trapped underneath the surface of the cervix. Most often, these cysts are just an incidental finding when you’re having a speculum examination, and they’re usually too small to be felt, although if you touch your cervix, you may be able to feel the little lumps. They are completely normal and don’t increase the risk of any kind of gynaecological disease, nor are they anything to do with sexually transmitted infections. A patient once told me that another doctor described them as spots/whiteheads on her cervix, and she had thought it was because she wasn’t washing her vagina enough; so she went to town with various feminine-hygiene products, which didn’t make them go away and just gave her terrible vaginal irritation. If you have them, you can’t do anything to make them go away and you don’t need to either.

       Fallopian tubes

      You have two fallopian tubes – one on the left and one on the right, coming off the top of your uterus like long ears that flap around and pick up eggs from the ovaries. I recently scanned a lady who was ecstatic to find out she was seven weeks pregnant. I showed her the pregnancy in the uterus with a heartbeat and told her I could see the egg had come from the left ovary. She looked baffled and said it wasn’t possible because she’d had her left tube removed three years before due to an ectopic pregnancy (where the fertilised egg implants itself outside the uterus, usually in one of the tubes). However, your tubes are incredibly mobile – like a motorbike courier, they’ll pick up from any location if the goods are ready and waiting. So even with one tube, eggs can still be picked up from either ovary. The tubes contain tiny little finger-like projections called cilia, which help to sweep the eggs along into the uterus. However, they are not directly attached to the ovaries, and open into the pelvic cavity, which can serve as a route for infections to spread from your vagina, which is how sexually transmitted infections in particular can spread and cause pelvic inflammatory disease (see Chapter 9).

Ovaries

      You have two ovaries, which are held close to your uterus by two ligaments – one that attaches to the wall of the inside of your pelvis and one that attaches to your uterus. The ovaries are home to a woman’s egg supply, which is complete at birth (about 2–4 million). The number of eggs decreases gradually as we age, with about three to five thousand ultimately making it to the point of being released. This is called ovulation and usually happens about once a month. The eggs live in little sacs called follicles, which go through several days of maturation to eventually form a cyst: a fluid-filled sac which bursts and releases an egg which may or may not then be fertilised.

      Your ovaries are also a major site of hormone production, making the following:

       Oestrogens Oestrogens, of which there are three types (oestrone, oestrodiol and oestriol), are not only responsible for your menstrual cycle, but also play a role in memory, heart health, bone strength and even the immune system.

       Progesterone The major site of progesterone production is from the corpus luteum – this is the ‘shell’ that is left behind in the ovary after ovulation. If you don’t ovulate, very little progesterone will come from the ovaries themselves and the adrenal glands. (These glands sit above your kidneys and are responsible for making small amounts of progesterone along with a whole host of other very important hormones.) Levels are highest seven days after ovulating – that is Day 21 if you have a twenty-eight-day cycle – so if you’re having blood tests to see if you’re ovulating, this is what will be checked. If your level is low, you either didn’t ovulate or the timing of the test was wrong. The latter is surprisingly common, and a lot of scared patients come to clinic worried that they’re not ovulating. On further questioning, they do describe all the signs of ovulation (see Chapter 3), and I’m then able to help them work out when to do the test, after which they come back very happy with a nice high progesterone reading.

       Inhibin This hormone sends a message from the ovaries back to the brain saying, ‘We’re being stimulated enough, thanks’.

       Relaxin This is a hormone which causes the joints and ligaments to soften during pregnancy to prepare the body for labour. It’s also responsible for the joint pain that pregnant women often experience.

       Testosterone This is usually associated with men, but believe it or not, women need it too – not just to promote sex drive, but also for bone and muscle strength, as well as brain function.

       THINGS YOU’VE ALWAYS WANTED TO KNOW, BUT WERE TOO AFRAID TO ASK

       What is a retroverted uterus and will it affect my chances of getting pregnant?

      Also known as a tipped/tilted uterus, it means the uterus points backwards (retroverted) instead of forwards (anteverted). Between 20 and 30 per cent of women have this and in many cases, it is just how they were born and bears no impact on their health. In some women, however, it may be due to conditions such as endometriosis (see here), fibroids (see here) or the presence of scar tissue that pulls the uterus backwards. The actual position of the uterus does not affect your chances of getting pregnant because sperm is able to swim in all directions; however, any one of the underlying conditions above may cause problems. It also doesn’t cause pain, but again, if it’s due to an underlying disease, that may do so.

      A retroverted uterus can make your cervix a little trickier to find when you have a smear test, which can be slightly uncomfortable. But we know plenty of tricks to make it easier and less painful. I often use the ‘make-fists-and-put-them-underneath-your-bottom’ position – if you know, you know! But the smear itself shouldn’t be any worse than normal.

      As the uterus increases in size in pregnancy, it will gradually flip forward, and by twelve weeks – when most women are having their first scan – a retroverted uterus may have corrected itself, so that many women never even find out they had one.

       Why do I bleed after sex?

      Also called post-coital bleeding, bleeding after sex can have many causes, including:

       cervical ectropion (see here)

       cervical and endometrial polyps (see here)

       infections such as chlamydia, or even something simple like thrush, which causes irritation of the vagina and cervix and the added friction of sex can be enough to make it bleed

       vaginal dryness (lack of lubrication, which can make the vaginal tissue more sensitive to friction in particular)

       skin conditions such as psoriasis or lichen schlerosus – these can make the skin more delicate and increase the chance of getting small skin tears

       cervical