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

something wrong with their daughters because they are only having periods every two or three months. But this is quite common when your periods start because the hormone cycles are still synchronising, and also coming up to the menopause when you have fewer eggs left, meaning you’re less likely to ovulate as easily. Cycles are typically shortest and most regular in your twenties and thirties. Any variation in the length of the cycle at any age will be due to changes in the follicular phase because the length of the luteal phase is pretty standard being dictated by the lifespan of the corpus luteum.³ (See Chapter 4 for other factors affecting cycle length besides age.)

       Menstrual cups, tampons, pads … ?

      There are an overwhelming number of ‘menstrual-hygiene’ products on the market; I’m not hugely keen on the term because I think it perpetuates the myth of periods being ‘dirty’.

      Menstrual cups, tampons, pads … I’m constantly asked which are ‘the best’, and, to be honest, from a health point of view there is no shining star – so I’d advise you to use whichever makes you feel most comfortable.

       Menstrual cups

      There may be a few furrowed brows at the mention of ‘menstrual cups’. If you are wondering, they are small and egg-cup-shaped and made of a soft silicone, which you insert into your vagina, where they sit collecting blood as it comes out of the cervix. There’s only one small study that has ever compared tampons and cups head to head and actually found greater satisfaction with cups compared to tampons, but it didn’t find any difference in terms of infections⁴ and there don’t appear to be any clear health benefits. The main advantage is that they are probably better for the environment and will definitely save you money in the long run. But don’t feel you have to use them. I don’t recommend them for the squeamish, as you have to be quite cool about putting your fingers into your vagina to insert them (they don’t come with an applicator like tampons), and it takes a bit of patience to learn how to remove them. After writing an Instagram post on menstrual cups I received a flurry of messages from women sharing the horror stories and proud moments of their first time. The most common initial problem seems to be difficulty removing it. Do not underestimate the strength of the vacuum that a menstrual cup can make with the cervix. However, you’ll quickly learn how to break the vacuum and remove it like a pro.

      I’m frequently asked if it’s OK to use them with a contraceptive coil. Different manufacturers have different ideas on this, some saying it’s OK, others saying it should be avoided. This is because theoretically you could dislodge your coil with the aforementioned vacuum effect – something that has, in fact, been confirmed by several women who have contacted me via social media saying they managed to suction out their coil: ‘Anita, I’ve saved my coil, can you put it back in?’ was one SOS message I recently received from a friend. But while I’m all for recycling, you can’t reuse a coil, so I promptly replied, ‘Sorry, darling, you need a fresh one!’ If you do choose to use a cup with a coil, I would advise checking the strings at the end of your period. If you feel they are lower than normal, you can feel the rod of the coil or you can’t feel any strings at all, I would use condoms until you’ve had it checked by a doctor to ensure it’s still in the right place to give you full contraceptive protection.

       Tampons

      Just as menstrual cups may not be for everyone, the same goes for tampons. Some women just don’t feel comfortable putting something inside themselves. Others find it too painful. This may be due to tight pelvic-floor muscles or not being relaxed enough or, in my experience, endometriosis, probably due to inflammation and scarring in the pelvis. One study suggested that tampon use is protective against endometriosis,⁵ but I think this finding is skewed by the fact that a lot of patients with endometriosis don’t use tampons because it’s too uncomfortable to put them in or because their period is so heavy that a tampon isn’t going to cut it.

       Toxic-shock syndrome

      Toxic-shock syndrome (TSS) is caused by bacteria and has nothing to do with any kind of chemical that is in the tampon itself. Staphylococcus aureus is a type of bacteria commonly found on the skin, and a particular form can produce a toxin called TSST-1. On entering the bloodstream, this can cause a massive inflammatory reaction, usually characterised by a really high fever, vomiting, skin rashes and aching muscles. But, unhelpfully, it doesn’t always lead to any symptoms ‘down there’ which would make it easier to identify the cause. It can be life-threatening and requires urgent medical attention. It’s also incredibly rare, with only about forty cases per year in the UK, around half of which are thought to be related to tampon use (the other half are seen in children, men and older women, and are typically associated with skin burns and infections).

      The ways that tampon use can potentially increase the risk of TSS include:

       collecting blood and increasing vaginal pH to create a breeding ground for bacteria

       causing tiny little micro-tears in the vaginal wall on insertion and removal, which allow bacteria to enter the bloodstream (it has been suggested that menstrual cups are safer in this regard, although I disagree; there has been a reported case of TSS with menstrual-cup use,6 probably because it too can cause vaginal abrasions and potentially create the right bacterial breeding ground.

      On balance, I don’t think there’s any reason for the social media-based frenzy related to tampons, or enough evidence for changing your practices, especially because TSS is so rare.

       Pads

      Let’s not forget pads now. They might not be the sexy option these days, but they’re still incredibly useful, especially for light days, and a godsend to the many women who don’t like tampons or cups. To be clear, you don’t need the scented ones, which some women find cause irritation to the delicate vulval tissue. Reusable pads, as well as periods pants, with an inbuilt absorbable pad, are also increasingly popular. These are better for the environment, and there’s no difference between them and disposable pads from a health perspective.

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

       Should I track my menstrual cycle?

      I’m a massive fan of cycle tracking and usually recommend the Clue app (see Resources). It stops you being caught short without pads or tampons and can be really useful in helping you to recognise patterns in symptoms that you might get at particular times of the month. I breathe a sigh of relief when a patient gets her phone out to tell me all about her periods because it makes things so much easier to pinpoint; and if you haven’t been doing it, we will often give you a menstrual-cycle tracking chart to fill in for the next few months.

      I started tracking my period as a way of reassuring myself that the pain in my side every month was ovulation pain and not some dreadful case of appendicitis; all doctors are hypochondriacs to some extent. I did my medical-school elective on a tiny island in Fiji, where I had what I now realise was terrible ovulation pain, but at the time I was panicking and planning how I would get airlifted out to get my appendix removed because I didn’t want to undergo surgery in our operating theatre, which was essentially a shed with a bright light. It was the worst twelve hours of my life! (And I’ve also seen the occasional woman arrive at A&E with the same fear.)

       What is a fake period?

      I’ve heard people referring to periods on the Pill as ‘fake periods’, which can cause a bit of anxiety. What they mean is that the bleeding is due to the hormones in the Pill, unlike a ‘true period’, in which the bleeding is caused by your body making the necessary hormones. When you stop taking your Pill it mimics the last few days in your cycle where the corpus luteum is dying away, so the levels of synthetic hormones from the Pill are dropping, which causes the lining to fall away.

      I’m often asked: ‘If it’s a fake period,