Women’s health: ask your doctor

health , women’s health , Tatyana Tsoy , gynecologist , interview , first-person reply

We interviewed Tatyana Tsoy, a gynecologist, we discussed women’s health in general and clarified the concept of “norm” in this area.


Presentation: Anastasia Karpushkina and Alena Rain
Interviewee: Tatyana Tsoy

Russian version

Hello, Tatyana. Browsing on the web we come across a lot of information about what should be considered abnormal in the field of women’s health. However, there is little information about the ranges of normality. Let’s talk about it. Tell us, please, how normal female genitalia should appear?

First of all, the core point: there is no standard!

We are all unique, so genitalia may differ in color, size, shape, asymmetry (we are all asymmetric by nature)-these characteristics are very specific fr om person to person.

There is a wonderful artist, Jamie McCartney. To my mind, his works are a sort of hymn to human body and its variety. For example, “The Great Wall of Vagina”, the correct name would be “The Great Wall of Vulva”, is a sculpture composed of 400 molds put together to form 10 blocks including 40 pieces. The models are women aged fr om 18 to 76, totally different, women before and after childbirth, mothers and daughters, identical twins and gender shifters. The author, therefore, calls women for leaving behind their anxiety and shame regarding the way their genitalia appear through showing their uniqueness. Another amazing work of Jamie-“Spice of Life” was created for the museum of sexual education in London. Its models are 18 men and women. Looking at similar works, we can see things real, full of diversity and “otherness”, instead of a synthetic image created by the porno industry.

Still, what should NOT be considered normal?

The situation when your usual appearance has changed: presence of rash, lumps (particularly painful ones), tumors, cuts and/or sores, reddening, enhanced asymmetry, blood-containing and/or green-yellow vaginal discharge-these are motives to see your doctor. By the way, the same is with female breast.

At what age can we detect unfavorable visual changes in external genitals?

At any age. In small children, vulva is monitored by their parents during intimate washing. Reddening, concretion of labia, change in skin color and/or appearance. A child should be examined by a pediatrician or a pediatric gynecologist. According the Ministry of Health, order № 514n, the age of examination is of: 3, 6, 14 and each year after 14. Up to 3 years old, the examination is made by a pediatrician. Adult women should estimate their vulva and breast’s look by themselves.

What age is considered normal for the first menstruation to come?

The coming of the first menstruation is called menarche. The age at menarche varies between 9 and 15-this variation is considered roughly normal and depends on many factors: genetics (the way menarche took place with mother and other females in the clan), health status (excessive thinness or diseases can delay menarche), doing sports (intensive physical activity and professional sport can also make menarche be late).

Some average height-weight indexes exist. Reaching these, menarche is to take place. For example, the height between 158-162cm. But! In families where everyone is short the girl won't ever grow beyond 157cm. Still, menarche comes although her height lies outside the “normal index”.

In my opinion, reaching certain body mass is a far more important index because fat is wh ere our body stores estrogen. Loosing significant amount of weight is unhealthy for women. For menarche to take place, the percentage of fat must reach at least 22% of the body mass.

Am I right to suppose that menarche occurring before 9 and after 15 years old is a reason to see a doctor?

Right. You should see a doctor. Such abnormality may be due to familial peculiarities (all women had early or late menarche) or some individual characteristics (the girls is engaged in professional sport-the fact that can make menarche come later). However, it is up to a healthcare specialist to consider it.

At what age does the cycle become regular in girls?

The first several cycles, during the first year, may be irregular because a girl’s reproductive system is making necessary settings. This process is similar to cogs in a watch, sometimes they fail to latch. It is worth mentioning that nutrition, physical activity, distress and other external stimuli can interfere in the process of setup causing positive or negative impact, e.g. strict diet, intensive exercise and a heap of extra classes can have negative impact on menstrual cycle's regularity.

The concept of ‘norm’ in gynecology is rather loose. Many factors can have an impact on our health and the processes within our body. Still, doctors need some supporting facts. That is why a research study was conducted and it showed that about 90% of women had a cycle as long as 21-35 days, while the period itself lasted from 3 to 7 days. This is the starting point to let doctors make assessments.

Important things to consider:
– regularity;
– duration;
– the amount of blood loss.

Normally, periods are repeated at regular intervals. Whether they are of 25, 35 or 42 days-there is no big deal. Plus or minus 2 or 3 days-it is still ok. If your mother and your grandmother always had a cycle of 42 days, this duration is ok for you too. This is your norm then.

Normally, a period lasts for not more than 7 days, with blood loss not more than 150-200 ml, with no severe pain. There must not be heavy pain or blood-like spotting between the periods.

Women know that during the first days of the cycle swelling, migraine and pain are possible. Which of these phenomena are considered normal among doctors?

These symptoms can be a sign of vascular or kidney diseases, for example. One shouldn't blame periods every time. If we suspect a gynecological disorder, one should keep a diary for 2 or 3 months describing the occurrence of these symptoms in relation to each day of the cycle. This helps diagnostics to confirm or disprove any relation between the symptoms and the cycle.

As for swelling, its intensity should be assessed. Retaining of liquids during the second phase of cycle is normal-this is our body's natural defense mechanism against dehydration during the period. Significant swelling (apparent sock foot, band mark left by clothes and/or underwear, ring mark on fingers) is a reason to see a urologist.

It is not so clear with pain. I need to know wh ere pain is located, the type of pain (nagging, dull or cramping, etc.), its intensity, whether there is a sensation similar to lumbago in some part of the body and so on. E.g. cramping sharp stabbing pain in lower abdomen, most likely, is a sign of bowel disorders while dull pain in lower back shooting up a leg is usually due to spine problems.

What is PMS? What causes it? What are the ways to control it?

PMS, or pre-menstrual syndrome, refers to lack of balance between cyclical changes of the hormone during the menstrual cycle and the reaction of both the central nervous system (serotonin, gamma amino acid, adrenaline, noradrenaline, dopamine, endorphins) and the autonomic nervous system (vessels, internal organs, metabolic processes).

This kind of imbalance is manifested through a number of symptoms during the II phase of the cycle-from ovulation to the period (approximately 8-14 days depending on the total duration of the cycle):
– mood swings;
– sleep disturbance;
– faint, fatigue;
– decreased concentration and short attention span;
– sexual disorders (decreased libido, altered sensation, changes in natural lubricating secretion, orgasmic disorder, etc.);
– migraine, headaches, dizziness;
– nausea, vomiting, constipation and/or diarrhea;
– palpitation, tachycardia, increased blood pressure;
– swelling;
– sweating;
– thirst;
– weight gain;
– decreased urination.

These symptoms are not necessarily manifested all together, they can go hand-in-hand, a few at once or multiple.

What's important is that all these symptoms are cyclical and there is a clear connection between these symptoms and the menstrual cycle: they surge prior to the period (a few days and up to two weeks before), otherwise we cannot diagnose PMS.

Another thing to consider: no PMS can occur without ovulation! Ovulation is a result of proper hormonal fluctuations during the cycle. If these are absent, no ovulation follows, therefore no inadequate response of both the central and the autonomic nervous systems can occur.

The risk factors include:
– infections (of pelvic floor or central nervous system organs, etc.);
– frequent changes of climate;
– stressors (physical and psychological);
– alcohol intake or abuse;
– deficiency in calcium, magnesium, vitamin B6;
– dietary excesses (lots of salty, greasy, spicy food, caffeine, particularly in the II phase of the MC);
– genetic predisposition;
– mental disorders (anorexia, bulimia, depression).

How do I know it is PMS?

One should keep a diary during 2 or 3 cycles, writing down the occurrence of symptoms and indicating the day they occur. If the connection between the occurrence of symptoms and the II phase is obvious, you can be sure it is PMS.

Are there any coping methods for such days?

1. Daily regime to regulate activity, rest and sleep.
2. Diet: cutting down fast carbohydrates, salty, greasy, spicy food, caffeine during the II phase of the cycle.
3. Physical activity-yoga, light stretching, intimate exercises. Refrain from CrossFit or strength-training.
4. Minimizing stressors.

Starting sex life. At what age is the body ready for it?

The question is controversial since there are many factors to consider. Biologically, girls are considered to be sexually matured since menarche has come-the first ovum is matured, so procreation can be launched. As I said earlier, it can happen between the age of 9 and 15.

Medically, such a young woman is not ready for gestation and childbirth. Even the first several cycles can be irregular. Up to 18-20 years old the body is ready for such a large load.

To my mind, a more concerning point is the legal aspect of this issue.

Penal Code contains such notion as “the age of consent” – the age when a person is thought to be able to express informed consent to sexual intercourse with another person.

In some countries, the legislation additionally contains the notion of ‘the age of sexual consent’ in situations when adults find themselves in dominant position towards the younger one (teachers, doctors, instructors, law enforcement officers, members of family).

The age of consent doesn't necessarily coincide with the age of majority or the age of marriage. In the Russian Federation, according to part 1, article 13 of the Family Code, the age of marriage is of 18 years old (while the age of consent is of 16.) It was legally established since October, 1st, 2012, when Russia signed the European Convention on protection of children from sexual exploitation and abuse. For example, in Quatar, Saudi Arabia and North Korea, the legal concept of the age of consent does not exist, however, being married is mandatory. In Yemen, the age of consent is of 9 years old.

According to the articles 134,135 of Penal code, sexual conduct, even non-violent, initiated by a person of 18 years old towards a person under 16, is a criminal offence. Sexual relationship between people under 18 is not regulated by law, but criminal responsibility for sexual abuse begins at the age of 14.

Psychologically, whether one is ready or not for ethical and ecological sexual relationship does not depend as much on age as on the type of education both partners have had, their awareness and personal responsibility.

How often should a girl see a gynecologist?

Since the age of 14, it is recommended to see a pediatric gynecologist annually, and visit a gynecologist every year since the age of 18. In our country, these two specialties are separated by law. As a gynecologist, I am not authorized to attend under-age patients. If the advice above has not been followed, the first visit should be made after the first sexual intercourse, the following visits are to be made annually unless health problems occur.

I do recommend finding a gynecologist a girl could feel at ease with, feel safe. It must be someone pleasant to deal with.

What type of tests a woman is to take during regular visits to a gynecologist?

The annual visit to a gynecologist includes:

– a chair exam (mirroring and manual examination);
– breast examination;
– microflora exams;
– cervical cytology;
– a sonogram of pelvic organs and mammary glands.

Additional advice includes taking annual tests for sexually transmitted diseases (chlamydia, gonorrhea, mycoplasmosis), blood tests for HIV, Hepatitis B, C and syphilis. These are particularly recommended if partners do not use barrier methods of contraception. Unfortunately, using condoms and/or oral dams cannot guarantee 100% protection.

Negative tests, obtained once, for example, at the beginning of a relationship, may not prove safety. This is not so much a matter of fidelity as of particularities of laboratory diagnostics. The previous results might have been obtained too soon or the infection was at its latent stage.

Who needs surgical defloration?

Surgical defloration is recommended:
– to girls with complete atresia of hymen, when the latter (the vaginal corona as they call it nowadays) has no openings-the fact that makes menstrual blood accumulate in the vagina, or if the hymen is very dense and rigid and it won't stretch and/or rupture during penetration;
– during medical procedures requiring access to the vagina (e.g. polyp removal), in women who have never had penetrative sex.

Thank you for conversation!