A no-holds-barred, totally frank guide to all of the things that go on down there


From your first period to your most recent orgasm, you've had one thing on your mind: What's going on down there? And just when you think you know everything about your lady parts, they surprise you. "Women in their 30s and 40s are often starting to experience medical conditions like fibroids or dryness that impact everything from their menstrual cycle to intercourse to simply how they feel about themselves," says Pamela Berens, MD, professor of ob-gyn at the University of Texas Health Science Center.
Don't worry: We're not going to make you get a hand mirror and examine yourself. But we're not going to tiptoe around gyno issues, either, and neither should you. Here are the best ways to handle menstrual mysteries, puzzling pains and other very personal problems.

Problem No. 1: Vaginitis

The lowdown: Got discharge and itching or burning? You probably have vaginitis—vaginal inflammation due to irritation or infection. The most common culprits are yeast infections, which are caused by fungus overgrowth, and bacterial vaginosis (BV), resulting from bacterial overgrowth. You may be particularly prone to vaginitis if you've recently finished a course of antibiotics (they can throw off the normal balance of microbes in your vagina), you have diabetes or your hormone levels are in flux, as happens around pregnancy and menopause, says Mary Jane Minkin, MD, an ob-gyn at the Yale School of Medicine.

What it feels like: You'll have irritation and extra discharge (grayish white and foul-smelling if it's BV; cottage cheese--like if it's yeast). It may also hurt to have sex, and you could see light vaginal bleeding or spotting.

Rx: If you think it's a yeast infection but over-the-counter meds don't work, see your doc. Yeast and BV are easily confused but have different remedies: A yeast infection is usually treated with an over-the-counter antifungal med such as Monistat; BV requires antibiotics.

Problem No. 2: Dryness

The lowdown: Low estrogen is the usual suspect for women over 35; levels of the hormone plummet during perimenopause, as well as when you're breast-feeding, making your vaginal tissue thinner and drier.

What it feels like: Vaginal itching, stinging, burning and soreness, in addition to pain or light bleeding during sex.

Rx: Pick up a vaginal moisturizer like Replens, plus a water-based lubricant such as Astroglide or K-Y Jelly to use during sex, advises Hilda Hutcherson, MD, professor of ob-gyn at Columbia University Medical Center. Nookie time in fact helps relieve dryness (the more activity down there, the more blood flow, which makes vaginal tissue more elastic). If dryness is still a problem, your ob-gyn can prescribe topical estrogen in the form of a cream, ring or tablet.

Problem No. 3: Fibroids

The lowdown: Up to 80 percent of women develop these noncancerous uterine growths. "A single cell in the muscle wall of the uterus divides again and again, forming a rubbery benign tumor," says Susan Haas, MD, clinician in residence at Northeastern University's Health Care Systems Engineering Institute in Boston. They seem to be hereditary and are most frequently diagnosed in your 30s and 40s, partly due to hormone production—progesterone is key to promoting fibroid growth. African American women are particularly susceptible; you're also more at risk if you're overweight or eat a diet high in red meat.

What they feel like: Usually nothing. But if they're large or in certain areas of the uterus, they can cause heavy and/or too-long periods, pelvic pain, pain during sex, frequent urination and back or leg pain.

Rx: Most of the time, no treatment is needed: Fibroids often shrink once you hit menopause, when your hormone levels are no longer high enough to fuel their growth. But if they're causing symptoms, or if you're having trouble getting pregnant, your gyno will need to take a closer look. If heavy bleeding is a problem, first-line treatment is usually birth control pills or a progestin IUD. Medications such as Lupron can shrink fibroids by blocking the production of estrogen and progesterone. (Since these drugs temporarily throw you into menopause, however, don't use them for longer than six months.) If medications aren't effective, you may need to undergo a more invasive procedure, such as uterine artery embolization, which eliminates fibroids by cutting off blood flow to them, or a myomectomy (surgical removal).

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Problem No. 4: Endometriosis

The lowdown: This disorder occurs when the tissue that normally forms the lining of your uterus—the endometrium—appears outside your uterus, usually ending up on your ovaries, bowels or somewhere else in your pelvis, says Taraneh Shirazian, MD, an ob-gyn at the Icahn School of Medicine at Mount Sinai in New York City. Genetics appear to play a role. And some researchers theorize that retrograde menstruation—which causes the uterine lining released during your period to flow backward into your abdomen—may be to blame.

What it feels like: The tip-off is severe pelvic pain around your period, since the excess tissue in your pelvis also sheds monthly. You may have pain during sex or while going to the bathroom. About one-third to one-half of women with endometriosis also experience infertility, according to the Mayo Clinic. (Inflammation can obstruct the fallopian tubes, preventing egg and sperm from meeting.) "I've seen patients who have had undiagnosed endometriosis for years," Dr. Shirazian says. "They'd just dismissed symptoms and weren't diagnosed until they had trouble conceiving."

Rx: If your gyno suspects endo, she'll likely prescribe a progestin-based contraceptive, which slows the growth of endometrial tissue, or a short course of Lupron, which reduces estrogen levels. But if your pain persists, you may need a procedure called laparoscopy, in which your gyno makes a small incision near your belly button and peeks inside with a laparoscope to find—and remove—wayward endo tissue. (This is also the only way to definitively diagnose endometriosis.) "Laparoscopy relieves symptoms for about six months, so if a patient is trying to get pregnant, I usually advise her to be actively working on it during that time," Dr. Shirazian says.
A guide to your anatomy

Uterus: This expandable, pear-shaped organ houses a developing fetus. Each month you're not pregnant, it sheds its lining—that's when you get your period.

Mons veneris: The fatty, triangular tissue above the vulva that's covered by pubic hair and pads the pubic bone

Vulva: All the external parts of the female reproductive system, including the labia majora (outer lips); the labia minora, which cover the vaginal opening; and the clitoris

Fallopian tubes: The narrow channels through which eggs travel to the uterus

Ovaries: Small, oval glands that produce eggs and hormones

Cervix: The lower part of the uterus

Vagina: This canal connects the cervix to the outside of the body.
Decoding lumps and bumps

A small lump on your vaginal wall or lips
A cyst, which occurs when a gland or duct becomes clogged. It should disappear within a few weeks, but if it gets larger and uncomfortable, your ob-gyn can drain it or remove it surgically.

Flesh-colored, cauliflower-shaped bumps either in your vagina or on your vulva
Genital warts—caused by certain strains of human papillomavirus (HPV)—but they could also be skin tags or a condition called molluscum contagiosum. (See your ob-gyn to figure out which you've got.) Warts often disappear on their own, as your body fights off the virus. If not, treatments include topical meds, freezing or burning them off or injecting them with interferon, an immune-system-boosting drug. And don't freak: Generally, the strains of HPV that cause genital warts are different from the ones that lead to cervical cancer.

Red, pimplelike bumps around your bikini line
Ingrown hairs. Hair in this region tends to be coarse and curly, so it's more likely to get trapped under the surface of the skin, causing swelling and sometimes infection. Try washing the area with an over-the-counter antibacterial wash (like Cetaphil) and applying an over-the-counter hydrocortisone cream twice a day; if that doesn't bring relief within three days, see a derm or your ob-gyn for topical or oral antibiotics.

Could it be cancer?
Probably not, but just to be safe, see your doctor if you're noticing any of these symptoms, especially if you've hit menopause.

• Frequent bleeding after sex
• Bleeding between periods or after menopause
• Pelvic pain that lasts more than two weeks
• Significant bloating that lasts more than two weeks
• A change in bathroom habits for more than two weeks, such as having to pee very badly or very often or experiencing constipation or diarrhea
• Vulvar itching, burning or bleeding that doesn't go away
• Vulvar sores, lumps or ulcers that don't go away

[This article contains a table. Please see hardcopy of magazine or PDF.]



Have a Pap smear every three years from age 21 to 65; after age 30, you can extend it to every five years if you get a Pap plus an HPV test and both are normal.

Annually—while the American College of Physicians recently deemed it unnecessary, the American College of Obstetricians and Gynecologists still says it's a must-do.

Get screened for chlamydia and gonorrhea, specifically, every year if you've got multiple sexual partners or a new partner.

Think twice before getting this surgery
About 500,000 hysterectomies—in which the uterus is removed—are performed annually in the U.S., making it the second most frequently performed surgical procedure on women. But most hysterectomies treat conditions that are not life-threatening. Case in point: Around 60 percent of hysterectomies are done for fibroids or endometriosis, yet less invasive treatments exist. "There are almost always other options," says Charles Ascher-Walsh, MD, director of the gynecology and urogynecology division at Mount Sinai Hospital. "A hysterectomy is the most aggressive approach."

In some situations, a hysterectomy may be necessary, such as with certain cases of uterine or cervical cancer. But if your ob-gyn suggests it for a benign condition, get a second opinion. If surgery is needed, avoid the laparoscopic procedure known as morcellation, in which fibroids are removed by dividing uterine tissue into pieces—and, per a warning from the FDA, may spread cancerous tissue beyond the uterus.

Now, about your libido...
Just not feeling it between the sheets? "One of the biggest misconceptions I hear from my patients is that a low libido is an inevitable by-product of aging. But that is so not true!" says Dr. Hutcherson, who is also the author of Pleasure: A Woman's Guide to Getting the Sex You Want, Need and Deserve. Your sex drive may actually be taking a hit from something medical: anything from undiagnosed thyroid disease or diabetes to drugs you're taking, such as certain antidepressants. Sometimes the solution can be as simple as talking to your doctor about switching from one medication to another.

"If that doesn't work, I often pry a little more to see if there's an emotional cause behind the problem," Dr. Hutcherson explains. "For example, a lot of women don't realize that stress can have a huge impact on sex drive because anxiety makes it more difficult for you to relax and focus on pleasure." In many cases, good old-fashioned stress-management techniques—like exercising regularly and getting a better night's sleep—will help revive your drive.